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Objective: Exercise is effective in producing a wide range of beneficial health outcomes. To ensure safe and effective exercise, guidance has been developed for seemingly healthy people and for people with a single disease. Unfortunately, similar guidance is not yet available for people with comorbidity in addition to the index disease or for people with multimorbidity. However, researchers have recently started to explore the application of exercise in people with comorbidity or multimorbidity, and these innovative applications of exercise have produced encouraging results: Exercise was shown to be safe and effective. The objective of the present article is to identify the underlying principles of exercise in people with comorbidity or multimorbidity., Method: We perform a narrative review of applications of exercise in people with comorbidity or multimorbidity., Results: Principles of exercise in people with comorbidity or multimorbidity appear to include (a) a rigorous assessment of health status, (b) the adaptation of exercise to comorbidity or multimorbidity, (c) the application and integration of behavior change techniques into the exercise plan, and (d) clinical reasoning to support the application of exercise by health professionals., Conclusions: We posit that these 4 principles provide a framework for the successful development of exercise guidance for people with comorbidity or multimorbidity. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose: Exercise therapy is effective in a wide range of chronic diseases. Comorbid disease necessitates adaptations to exercise therapy. Guidance on how to develop such adaptations is currently not available. We present an innovative strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease., Method: We previously developed comorbidity-related adaptations to exercise therapy in osteoarthritis. We now broaden this approach into a general strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease., Results: The i3-S strategy consists of four steps. The first three steps involve creating an inventory of comorbid disease, an inventory of contraindications and restrictions on exercise therapy, and an inventory of potential adaptations to exercise therapy. In the fourth step, this information is synthesized into guidance on comorbidity-related adaptations to exercise therapy in the index disease. The adaptations concern physiological, behavioural and environmental factors., Conclusion: In view of the general effectiveness of exercise therapy and the high prevalence of comorbidity in older people, there is a great need for comorbidity-related adaptations to exercise therapy. We recommend to use and evaluate the i3-S strategy in future research., Implications for Rehabilitation: Exercise therapy is effective in a wide range of chronic diseases. Comorbid disease necessitates adaptations to exercise therapy. Guidance on how to develop such adaptations is currently not available. We present an innovative strategy for the development of comorbidity-related adaptations to exercise therapy in an index disease. Researchers and clinicians can use this strategy to develop guidance on the adaptation of exercise therapy to comorbidity.

Although much research has been done on the impact of chronic illness on quality of life, still relatively little is known about the role of comorbidity. Given the growing number of (older) people with multiple chronic conditions, more information is needed on the effects of specific disease combinations for preventive purposes. In a nationwide representative sample of 1673 non-institutionalized chronic disease patients (recruited in 56 general practices) in The Netherlands, we assessed the separate and joint effects of cardiovascular disease, cancer, arthritis, chronic respiratory disease, diabetes mellitus, and thyroid dysfunction on physical and mental functioning. Data on medical diagnoses were provided by the general practitioners; data on physical and mental functioning were collected by a patient survey (SF-36). Compared to reference data of the general population, physical functioning appeared to be worse in all six diagnostic groups, whereas mental functioning was more or less comparable. Patients with arthritis or those suffering from comorbidity reported the lowest levels of physical functioning. Synergistic effects of combinations of diabetes, cardiovascular disease and/or chronic respiratory disease were found, indicating that patients suffering from these disease combinations run a higher risk of physical disability than could be expected from their separate effects.

The present study examined the prevalence and pattern of comorbidity among Chinese patients with first-ever acute ischemic stroke, and assessed the associations of specific comorbidity patterns with physical and cognitive functioning after stroke occurrence. A hospital-based cross-sectional study was conducted among 2,151 patients with first-ever ischemic stroke (age ≥40 years; 64.2% men) who were admitted to two university hospitals in Shandong, China between 2016 and 2017. Data on demographics, lifestyles, chronic health conditions, and use of medications were collected through in-person interviews, clinical examinations, and laboratory tests. Physical functioning was assessed by the Barthel index (BI) and the modified Rankin Scale (mRS) while cognitive functioning was assessed by the Montreal Cognitive Assessment test. The results showed that comorbidity was present in 90.9% of the stroke patients (women vs. men: 95.2 vs. 88.7%, P < 0.001). Exploratory factor analysis identified three patterns of comorbidity, i.e., patterns of degenerative-cardiopulmonary, heartgastrointestinal-psychiatric, and metabolic-kidney diseases. The number of comorbidities was significantly associated with a higher likelihood of moderate-to-severe physical dependence [odds ratio (95% CI) = 1.15 (1.06-1.25) for BI and 1.12 (1.04-1.21) for mRS, all P < 0.01] and cognitive impairment [odds ratio (95% CI) = 1.11 (1.02-1.20), P = 0.017], after adjusting for multiple covariates. Almost all the three comorbidity patterns were associated with increased likelihoods of physical dependence (range for odds ratios: 1.26-1.33) and cognitive impairment (range for odds ratios: 1.25-1.34). No significant association was found between degenerative-cardiopulmonary pattern and mRS. These findings suggest that comorbidity is associated with poor physical and cognitive functioning during the acute phase of ischemic stroke. Routine assessments of comorbidity and cognitive and physical function among patients with acute ischemic stroke should be considered in stroke research and clinical practice. [ABSTRACT FROM AUTHOR]

Abstract Background The objective of the study was to determine whether psychological and social factors predict the course of limitations in activities in elderly patients with osteoarthritis of the hip or knee, in addition to established somatic and cognitive risk factors. Methods A longitudinal cohort study with a follow-up period of three years was conducted. Patients (N = 237) with hip or knee osteoarthritis were recruited from rehabilitation centers and hospitals. Body functions, comorbidity, cognitive functioning, limitations in activities and psychological and social factors (mental health, vitality, pain coping and perceived social support) were assessed. Statistical analyses included univariate and multivariate regression analyses. Psychological and social factors were added to a previously developed model with body functions, comorbidity and cognitive functioning. Results In knee OA, low vitality has a negative impact on the course of self-reported and performance-based limitations in activities, after controlling for somatic and cognitive factors. In hip OA, psychological and social factors had no additional contribution to the model. Conclusion Low vitality predicts deterioration of limitations in activities in elderly patients with osteoarthritis of the knee, in addition to established somatic and cognitive risk factors. However, the contribution of vitality is relatively small. Results of this study are relevant for the group of patients with knee or hip OA, attending hospitals and rehabilitation centers.

Objective: The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage. Method: The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews. Results: Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians. Conclusion: A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients. [ABSTRACT FROM AUTHOR]

Purpose: Exercise therapy is an effective intervention in a variety of chronic diseases. The prescription of exercise therapy is usually directed toward an index disease. The presence of comorbidity may require adaptations to the exercise program as intended for the index disease. This paper aims to structure the clinical reasoning process of health professionals when prescribing exercise therapy for the individual patient with an index disease and comorbidity. Methods: We adapted the previously published strategy for developing guidelines and protocols on comorbidity-adapted exercise to a version that can be used for individual exercise prescription. Results: Essential steps and considerations involved in prescribing an exercise program to an individual patient with comorbidity are described. A case description is used as an example of how the proposed strategy leads to clinical decisions. Conclusions: The proposed strategy may have a role in educational and professional development. The advanced clinical expertise needed for safe and effective exercise therapy in patients with a complex health status is emphasized. The presence of comorbidity may require adaptations to exercise therapy. We describe the essential steps and considerations involved in prescribing an exercise program to an individual patient with an index disease and comorbidity. The proposed strategy can be used to structure the clinical reasoning process of health professionals. [ABSTRACT FROM AUTHOR]

Background: As the population ages, the number of people with chronic diseases increases. Frequently, older people suffer from joint pain together with other chronic diseases, which can lead to decreased physical functioning.Aims: To investigate the associations of the changes in cognitive appraisals, coping strategies and pain with the change in physical functioning in older people, who have chronic pain and chronic diseases.Methods: Elderly persons (n = 407, mean age 77 years, and 62% female), with self-reported joint pain and at least two chronic diseases, filled in questionnaires about cognitive appraisals, coping strategies, pain intensity and physical functioning at baseline, at 6- and 18-month follow-ups. The associations of change in physical functioning with changes in cognitive appraisals, coping strategies and pain were modelled using generalized estimating equations (GEE).Results: Increase in pain, in negative thinking about the consequences of pain, and in activity avoidance and decrease in self-efficacy beliefs were associated with a decline in physical functioning.Discussion: Observed mean changes were small but large inter-individual variability was seen. This shows that cognitive appraisals and coping strategies are malleable. Statistical model of change clarifies the direction of longitudinal associations.Conclusions: The longitudinal findings suggest that joint pain, cognitive appraisals and coping strategies may determine physical functioning in older people who have chronic pain and comorbidity. [ABSTRACT FROM AUTHOR]

Purpose:Delivery of exercise interventions to patients with early-stage breast cancer undergoing chemotherapy requires complex clinical decisions. The purpose of this study was to develop a framework to support clinical decisions for tailoring exercise interventions to common comorbidities and cancer treatment-induced adverse effects. Method:Tailored exercise prescriptions were developed in four steps, following the i3-S strategy. All steps were based on current best available evidence, complemented with expert opinions. First, common comorbidities and treatment-induced adverse effects were identified. In the subsequent steps, contra-indications and restrictions for exercise were described, along with possible exercise adaptations. In the final step, the obtained information was synthesized into a framework. Results:Prevalent comorbidities were hypertension, heart disease, diabetes mellitus, (osteo)arthritis, chronic obstructive pulmonary disease, and obesity. Adverse effects included conditions induced by pretreatment (e.g., lymphedema as a result of surgery) or by chemotherapy (e.g., reduced blood cell counts). Adaptations to the recommended exercise program were related to exercise tolerance, safety, and hygiene. A framework was proposed to guide clinical decisions during the exercise intervention. Conclusion:Comorbidities and adverse effects of breast cancer treatment require exercise adaptations. The proposed framework provides guidance on tailored exercise prescriptions in patients with breast cancer undergoing chemotherapy.Implications for RehabilitationExercise is recommended for patients with breast cancer undergoing chemotherapy, but requires complex clinical decisions of the health professional.We identified the most important comorbidities and adverse effects of breast cancer treatment, and the resultant contra-indications and restrictions to exercise.We incorporated these findings into a clinical decision framework that provides suggestions for exercise adaptations in patients with breast cancer undergoing chemotherapy. [ABSTRACT FROM PUBLISHER]

Objective: To evaluate the efficacy on physical functioning and safety of tailored exercise therapy in patients with knee osteoarthritis (OA) and comorbidities.Methods: In a randomized controlled trial, 126 participants were included with a clinical diagnosis of knee OA and at least 1 of the following target comorbidities: coronary disease, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, or obesity (body mass index ≥30 kg/m2 ), with severity score ≥2 on the Cumulative Illness Rating Scale. The intervention group received a 20-week, individualized, comorbidity-adapted exercise program consisting of aerobic and strength training and training of daily activities. The control group received their current medical care for knee OA and were placed on a waiting list for exercise therapy. Primary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, subscale physical functioning (WOMAC-pf), and the 6-minute walk test (6MWT). Measurements were performed at baseline, after 20 weeks (directly posttreatment), and at 3 months posttreatment.Results: Statistically significant physical functioning differences over time were found between the intervention and control group (WOMAC: B = -7.43 [95% confidence interval (95% CI) -9.99, -4.87], P < 0.001; and 6MWT: B = 34.16 [95% CI 17.68, 50.64], P < 0.001) in favor of the intervention group. At 3 months followup, the mean improvements in the intervention group were 33% on the WOMAC scale and 15% on the 6MWT. These improvements are of clinical relevance. No serious adverse events occurred during the intervention.Conclusion: This is the first study showing that tailored exercise therapy is efficacious in improving physical functioning and safe in patients with knee OA and severe comorbidities. [ABSTRACT FROM AUTHOR]

Background: Substantial variation exists in physical functioning (PF) among patients with comparable pain severity, which may be partly explained by underlying psychological processes, like cognitive appraisal of pain and coping with pain. It remains unclear to what extent such determinants contribute to changes in PF over time, especially in older populations. Therefore, we examined longitudinal associations of cognitive appraisals and coping strategies with PF, in older adults with joint pain and comorbidity.Methods: A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over 18 months, with 6 month time-intervals. We measured PF (RAND-36), five cognitive appraisals (consequences, concerns, emotional representations, self-efficacy, catastrophizing), four coping strategies (ignoring pain, positive self-statement, increasing activity levels, activity avoidance) and three time-dependent covariates; pain intensity, anxiety and depressive symptoms. Longitudinal associations were analyzed with Generalized Estimated Equations (GEE), by testing auto-regressive models, adjusted for covariates.Results: More negative thoughts about consequences of pain (β = -0.54, 95% CI = -1.02; -0.06), more catastrophizing (β = -0.67, 95% CI = -1.26; -0.07) and more activity avoidance (β = -0.32, 95% CI = -0.57; -0.08) were significantly associated with subsequent deterioration in PF, whereas higher perceived self-efficacy (β = 0.22, 95% CI = 0.12; 0.31) was associated with subsequent improvement in PF. Neither concerns, emotional representations, ignoring pain, positive self-statement nor increasing activity levels were longitudinally related to PF.Conclusions: More negative thoughts about consequences of pain, more catastrophizing and more activity avoidance contributed to deteriorated PF, whereas higher perceived self-efficacy contributed to improved PF. This knowledge may contribute to future management of functional limitations in older adults with joint pain and comorbidity. [ABSTRACT FROM AUTHOR]

Background: Exercise therapy is generally recommended for patients with osteoarthritis (OA) of the knee. Comorbidity, which is highly prevalent in OA, may interfere with exercise therapy. To date, there is no evidence-based protocol for the treatment of patients with knee OA and comorbidity. Special protocols adapted to the comorbidity may facilitate the application of exercise therapy in patients with knee OA and one or more comorbidities. Purpose: The purpose of this study was to develop comorbidity-adapted exercise protocols for patients with knee OA and comorbidity. Method: Several steps were undertaken to develop comorbidity-adapted protocols: selection of highly prevalent comorbidities in OA, a literature search to identify restrictions and contraindications for exercise therapy for the various comorbid diseases, consultation of experts on each comorbid disease, and field testing of the protocol in eleven patients with knee OA and comorbidity. Results: Based on literature and expert opinion, comorbidity-adapted protocols were developed for highly prevalent comorbidities in OA. Field testing showed that the protocols provided guidance in clinical decision making in both the diagnostic and the treatment phase. Because of overlap, the number of exercise protocols could be reduced to three: one for physiological adaptations (coronary disease, heart failure, hypertension, diabetes type 2, chronic obstructive pulmonary diseases, obesity), one for behavioral adaptations (chronic a-specific pain, nonspecific low back pain, depression), and one for environmental adaptations (visual or hearing impairments). Evaluation of patient outcome after treatment showed significant (P<0.05) and clinically relevant improvements in activity limitations and pain. Conclusion: Comorbidity-adapted exercise protocols for patients with knee OA were developed, providing guidance in clinical reasoning with regard to diagnostics and treatment. To evaluate the effectiveness of treatment in line with our protocols, a randomized clinical trial should be performed. [ABSTRACT FROM AUTHOR]

Background In clinical settings, it is important for health care providers to measure different aspects of functioning in older adults with joint pain and comorbidity. Besides the use of distinct measures, it could also be attractive to have one general measure of functioning that incorporates several distinct measures, but provides one summary score to quantify overall level of functioning, for example for the identification of older adults at risk of poor functional outcome. Therefore, we selected four measures of functioning: Physical Functioning (PF), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and participation, and tested the possibility to aggregate these measures into one general measure of functioning. Methods A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided baseline data (n = 407) consisting of PF (PF subscale, RAND-36; 10 items), ADL (KATZ index; 6 items), IADL (Lawton index; 7 items) and participation (KAP; 6 items). We tested two models with confirmatory factor analysis: first, a bifactor model with all four measures and second, a bifactor model with PF, ADL and IADL and a correlated but distinct subgroup factor for participation. Several model fit indexes and reliability coefficients, such as explained common variance (ECV) and omega's, were computed for both models. Results The first model fitted the data well, but the reliability analysis indicated multidimensionality and unique information in the subgroup factor participation. The second model showed similar model fits, but better reliability; ECV = 0.67, omega-t = 0.94, low omega-s = 0.18- 0.22 on the subgroup factors and high omega of 0.82 on participation, which all were in favour of the second model. Conclusions The results indicate that PF, ADL and IADL could be aggregated into one general measure of functioning, whereas participation should be considered as a distinct measure. [ABSTRACT FROM AUTHOR]

Background: Osteoarthritis (OA) has a very high rate of comorbidity. Exercise therapy is recommended in current guidelines on the management of OA of the hip and knee. Unfortunately, current protocols and guidelines for exercise therapy in OA of the hip and knee do not offer advice concerning comorbidity-associated adaptations for exercise therapy in OA patients. Because of the high prevalence of comorbidity in OA, it is important to establish when exercise therapy for OA of the hip and knee should be adapted when patients have one or more comorbidities. Objective: To identify restrictions and contraindications for exercise therapy for common comorbidities (cardiac diseases, hypertension, type 2 diabetes, obesity, chronic obstructive pulmonary disease (COPD), depression, chronic pain, low back pain (LBP), visual or hearing impairments, and chronic cystitis) in hip and knee OA patients. Major findings: Cardiac diseases, hypertension, type 2 diabetes, COPD, and chronic cystitis are associated with restrictions resulting from physiological impairments. Conversely, LBP, chronic pain syndromes, and depression are associated with psychological and behavioural restrictions to exercise therapy. Visual and hearing impairments result predominantly in environmental restrictions to exercise. Obesity is associated with restrictions resulting from physiological and psychological impairments and behavioural barriers. Several absolute contraindications exist and patient safety cannot be guaranteed when these are not taken into account during exercise therapy. Conclusion: Restrictions and contraindications for exercise in patients with OA of the hip and knee and comorbidity have been identified. This overview is helpful in decisions on the treatment of patients and will be instrumental in the development of a protocol for comorbidity related adaptations in exercise therapy for OA patients. [ABSTRACT FROM AUTHOR]

Objective. To describe the relationship between comorbidity (absolute number as well as the presence of specific comorbidities) and pain, physical functioning and mental health status of participants with early symptomatic OA of the hip or knee.Methods. In the Netherlands, a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association in participants with early symptomatic OA of the hip or knee: CHECK (Cohort Hip and Cohort Knee), which consists of 1002 individuals. At baseline, linear regression analysis was used to determine the influence of comorbidity on the outcome variables: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, WOMAC physical functioning, Medical Outcomes Study Short Form 36 (SF-36) Physical Component Summary and Mental Component Summary.Results. Of 979 subjects, 67% reported one or more comorbidities. After controlling for age, gender, social status and severity of radiographic OA (Kellgren and Lawrence score), back disorders have the largest effect on WOMAC pain and physical functioning, and one of the largest effects on physical status of SF-36, besides obesity. Mental status was negatively influenced by the additional presence of duodenal ulcer, thyroid disease, and migraine or chronic headache.Conclusion. In early stage of OA, the presence of additional problems in the musculoskeletal system and of obesity have a negative effect on pain and physical health status. Also mental status is affected in early symptomatic OA by the presence of specific comorbidities. Comorbidity should be assessed and treated to improve the burden of illness in patients with early symptomatic OA. [ABSTRACT FROM PUBLISHER]

Abstract: van Dijk GM, Veenhof C, Spreeuwenberg P, Coene N, Burger BJ, van Schaardenburg D, van den Ende CH, Lankhorst GJ, Dekker J, on behalf of the CARPA Study Group. Prognosis of limitations in activities in osteoarthritis of the hip or knee: a 3-year cohort study. Objective: To describe the course of limitations in activities in elderly patients with osteoarthritis (OA) of the hip or knee over a follow-up period of 3 years, and to identify prognostic factors of the course of limitations in activities, focusing on body functions, comorbidity, and cognitive functioning. Design: A longitudinal cohort study with 3 years of follow-up. Measurements were conducted annually. Statistical analyses included t tests, univariate regression analyses, and multivariate regression analyses. Setting: Rehabilitation centers and hospitals (Departments of Orthopedics, Rheumatology, and Rehabilitation) in The Netherlands. Participants: Patients (N=237) with hip or knee OA. Interventions: Not applicable. Main Outcome Measures: Patient-perceived change, self-reported limitations in activities measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and observed limitations in activities (timed walking test). Prognostic factors: demographic data, clinical data, body function (pain, muscle strength, range of motion [ROM]), comorbidity, and cognitive functioning (cognitive decline, memory, attention). Results: Self-reported limitations in activities measured by the WOMAC improved slightly after 3-year follow-up. In knee OA, reduced ROM at 1-year follow-up (β=.120), increased pain at 1-year follow-up (β=−.177), and higher morbidity count (β=−.180) predicted worsening of self-reported limitations in activities. In hip OA, reduced ROM at 1-year follow-up (β=.201 for hip external rotation and β=.144 for knee extension), increased pain at 1-year follow-up (β=−.134), higher morbidity count (β=−.220), or the presence of moderate to severe cardiac disease (β=−.214) and poorer cognitive functioning (β=.181) predicted worsening of self-reported limitations in activities. Performance-based limitations in activities measured by the timed walking test did not change after 3 years of follow-up. In knee OA, decreased muscle strength at 1-year follow-up (β=−.272) and higher morbidity count (β=.199) predicted worsening of performance-based limitations in activities. In hip OA, better ROM (β=.182), higher morbidity count (β=.232), or the presence of moderate to severe cardiac and eye-ear-nose-throat disease (β=.210 and β=.188, respectively) and older age (β=.355) predicted worsening of performance-based limitations in activities. Conclusions: Overall, at the group level, limitations in activities of patients with OA of the hip or knee recruited from hospitals and rehabilitation centers seem fairly stable during the first 3 years of follow-up. However, at the level of individual patients, considerable variation occurs. Prognostic factors for worsening of limitations in activities include increased pain, reduced ROM, and decreased muscle strength at 1-year follow-up; higher morbidity count; and to a lesser extent poor cognitive functioning. [Copyright &y& Elsevier]

Background: This study aims to contribute to the knowledge of the influence of comorbidity in OA. The objectives of the study were (i) to describe the prevalence of comorbidity and (ii) to describe the relationship between comorbidity (morbidity count, severity and the presence of specific diseases) and limitations in activities and pain in elderly patients with knee or hip OA using a comprehensive inventory of comorbidity. Methods: A cross-sectional cohort study was conducted, in which 288 elderly patients with hip or knee osteoarthritis were included. Apart from demographic and clinical data, information about comorbidity, limitations in activities (WOMAC, SF-36 and timed walking test) and pain (VAS) was collected by questionnaires and tests. Statistical analyses included descriptive statistics, multivariate regression techniques, t-tests and one-way ANOVA. Results: Almost all patients suffered from at least one comorbid disease, with cardiac diseases, diseases of eye, ear, nose, throat and larynx, other urogenital diseases and endocrine/metabolic diseases being most prevalent. Morbidity count and severity index were associated with more limitations in activities and with more pain. The presence of most of the moderate or severe diseases and obesity was associated with limitations in activities or with pain. Conclusion: The results of this study emphasize the importance of comorbidity in the rehabilitation of elderly patients with osteoarthritis of the hip or knee. Clinical practitioners should be aware of the relationship of comorbidity with functional problems in OA patients. [ABSTRACT FROM AUTHOR]

The article presents the authors' reply to the commentary on their article which discusses the restrictions and contraindications on exercise therapy for hip and knee osteoarthritis (OA) patients. Topics discussed include adherence to exercise program, guidelines for hip and knee OA management, and comorbid diseases.

The article presents a response to a commentary on the article "Restrictions and contraindications for exercise therapy in patients with hip and knee osteoarthritis and comorbidity" by M. de Rooij and colleagues. It discusses contraindications for osteoarthritis (OA) exercise therapy for people with cardiac diseases, hypertension, type 2 diabetes and chronic obstructive pulmonary disease. The article also discusses the development of a patient-specific comorbidity-adapted exercise protocol.

Objective: Major depressive disorder (MDD) is common in patients with multiple sclerosis (MS) but may remain unrecognized because of overlapping symptoms and different presentation due to its specific MS-related neurobiological aetiology. We aimed to investigate the clinical profile of MDD in MS.Methods: In a sample of MDD patients with MS (n=83) and without MS (n=782), MDD characteristics, 30 depressive symptoms, and sum scores of cognitive, somatic, atypical and melancholic symptom clusters were compared using logistic regression analyses and analysis of co-variance.Results: MDD in MS was characterized by older age of onset (p<0.001), and fewer comorbid anxiety disorders (37% versus 72%; p<0.001). The symptom 'future pessimism' was more common in MS patients (OR=1.62; 95%CI=1.02-2.59). 'Diminished capacity for pleasure/enjoyment' (OR=0.44; 95%CI=0.24-0.78), 'increased appetite' (OR=0.40; 95%CI=0.19-0.85), 'arousal symptoms' (OR=0.49; 95%CI=0.28-0.84), and 'panic/phobic symptoms' (OR=0.49; 95%CI=0.29-0.84) were less common in MS patients. Twenty-five symptoms (83%) out of 30, including depression's core symptoms (sadness and loss of interest) were not differentially associated with MS and no differences existed for the symptom clusters.Conclusion: Only subtle differences in depressive symptom profiles existed between MDD patients with and without MS. The clinical profile of depression remains valid among MS patients, although it presents with diminished anxiety distress and comorbidity. [ABSTRACT FROM AUTHOR]

Objective: Increased knowledge about predictors of the course of persistent physical symptoms (PPS) is needed to identify patients at risk for long-term PPS in clinical settings. Therefore, we developed prediction models for the course of PPS in terms of symptom-severity and related functional status during a 2-year follow-up period.Methods: We used data of the PROSPECTS cohort study, consisting of 325 PPS patients from several health care settings. Symptom severity (PHQ-15), physical functioning (RAND 36 PCS) and mental functioning (RAND 36 MCS) were assessed at baseline and 6, 12 and 24 months afterwards. We applied mixed model analyses to develop prediction models for all outcomes, using all follow-up measurements. Potential predictors were based on empirical and theoretical literature and measured at baseline.Results: For symptom severity, physical functioning and mental functioning we identified predictors for the adverse course of PPS included physical comorbidity, higher severity and longer duration of PPS at baseline, anxiety, catastrophizing cognitions, embarrassment and fear avoidance cognitions, avoidance or resting behaviour and neuroticism. Predictors of a favourable course included limited alcohol use, higher education, higher levels of physical and mental functioning at baseline, symptom focusing, damage cognitions and extraversion. Explained interpersonal variance for all three models varied between 70.5 and 76.0%. Performance of the models was comparable in primary and secondary/tertiary care.Conclusion: The presented prediction models identified several relevant demographic, medical, psychological and behavioural predictors for adverse and favourable courses of PPS. External validation of the presented models is needed prior to clinical implementation. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to identify and characterize homogeneous subgroups of individuals with distinct trajectories of physical functioning (PF) and to examine prognostic indicators of deterioration in PF in a highly heterogeneous population of older adults with joint pain and comorbidity. Study design A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over a period of 18 months, with 6 month time-intervals. We used latent class growth modelling (LCGM) to identify underlying subgroups (clusters) with distinct trajectories of PF. Next, we characterized these subgroups and applied multivariable logistic regression analysis to identify prognostic indicators for deterioration in PF. Main outcome measures We measures PF with the RAND-36 PF subscale and several potential sociodemographic, physical and psychosocial prognostic indicators. Results LCGM identified three clusters. Cluster 1 'good PF' contained 140 participants with good baseline PF and small improvements over time. Cluster 2 'moderate PF' contained 130 participants with moderate baseline PF and deterioration over time. Cluster 3 'poor PF' contained 137 participants with poor baseline PF and deterioration over time. After backward selection, the final model that could best distinguish between improved participants (cluster 1) and deteriorated participants (cluster 2-3) included the following prognostic indicators: higher age, more depressive symptoms, less perceived self-efficacy and more activity avoidance. Conclusions Older adults with joint pain and comorbidity either improved or deteriorated in PF over time. The prognostic model facilitates the classification of patients, the provision of more accurate information about prognosis and helps to narrow the focus to the high risk group of poor PF. [ABSTRACT FROM AUTHOR]

Abstract: Older adults with joint pain and comorbidity are especially at risk of becoming functionally impaired. Therefore, we studied the frequency and severity of functional limitations and identified potential modifiable determinants that may reduce functional limitations. A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided cross-sectional baseline data (n =407). Based on the International Classification of Functioning, Disability and Health (ICF) model, we measured Physical Functioning; PF, (Instrumental) Activities of Daily Living; (I)ADL, and participation. Apart from examining the frequency and severity, we identified determinants of functional limitations with multivariate regression analyses, by adding determinants in two steps: (1) only physical determinants, (2) physical and psychosocial determinants. Limitations in PF, ADL, IADL and participation were present in 66%, 31%, 61% and 47% of the participants, respectively. About 22% reported limitations on all four measures. Of the physical determinants, especially frailty and higher pain intensity were related to functional limitations. Remarkably, adding psychosocial determinants to the model weakened some of these relations. The psychosocial determinants were especially related to poor PF (i.e. anxiety symptoms, activity avoidance and poor general health perception) and participation restrictions (i.e. depressive symptoms, less social support). An inverse relation was present between self-efficacy and both outcomes. In conclusion, our sample reported substantial levels of functional limitations. More depressive symptoms, more activity avoidance and less social support were indicative of more functional limitations, whereas higher perceived self-efficacy was indicative of better functioning. Such psychosocial determinants should receive more attention in research. [Copyright &y& Elsevier]