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Keywords:

  • Joint lavage;
  • Osteoarthritis;
  • Video;
  • Information

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Objective

To investigate the impact of video information on preoperative anxiety of patients scheduled to undergo joint lavage for knee osteoarthritis, and tolerability of the lavage.

Methods

A video film on joint lavage (duration 4 minutes, 20 seconds) was made by medical communication professionals, based on recommendations of the medical and paramedical staff of the Institute of Rheumatology. Patients diagnosed with knee osteoarthritis and scheduled for lavage were assigned, using a preestablished list of randomization, to either the video group or the no-video group. In the operating room, preoperative anxiety level was measured on a 100-mm visual analog scale (VAS), and tolerability was assessed using a 4-grade scale.

Results

One hundred twelve patients (56 patients in each group) were included and completed the trial. Preoperative anxiety was lower by half for patients who had viewed the video (VAS 13 ± 20 versus 26 ± 27; P = 0.0056). Tolerability of knee lavage was also significantly better in the video group (very tolerable 91% versus 48%; P < 0.0001).

Conclusion

This prospective, controlled, randomized study confirms the usefulness of video information prior to an invasive rheumatology procedure.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Osteoarthritis (OA) of the knee is one of the most common forms of arthritis and a major cause of pain and disability (1). The results of several prospective, controlled studies have suggested that joint lavage, commonly performed under local anesthesia using a 1- or 2-cannulae technique, may be beneficial and can relieve such symptoms as pain in knee OA (2–4). However, joint lavage is an invasive procedure that can be stressful and painful (4).

Providing information before a medical or surgical procedure has proved to reduce anxiety in such situations as colonoscopy (5, 6), heart catheterization (7, 8), dental surgery (9), radiation therapy (10), and bone scan imaging (11). However, the ideal means of providing preoperative information is still unclear. Verbal information given by the clinician is the most common method. The use of other media, such as written information (11), brief or detailed verbal descriptions (12), leaflets (13), booklets (14), audiotapes (9), or videotapes (5, 7, 12), have been proposed. In a randomized controlled trial evaluating information before colonoscopy, the use of a videotape alone was significantly more efficient in reducing anxiety than an in-person discussion by the physician, and was as effective as video plus discussion (5).

The effect of information on the tolerability of invasive procedures has not been extensively studied. The aim of this trial was to investigate the impact of video information on preoperative anxiety of patients scheduled to undergo joint lavage for knee OA, and on tolerability of the lavage procedure.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Patients

All patients with knee OA who were scheduled for knee joint lavage in the Day Unit of Cochin Hospital were considered for enrollment. Joint lavage was indicated in the presence of inadequate pain control and/or persistence of chronic joint effusion with prior failure of intraarticular glucocorticoid injection, physical exercises, analgesics, and nonsteroidal antiinflammatory drugs.

Study design

The study was prospective, monocenter, and controlled. Before hospitalization, the patients received verbal information on joint lavage from their own rheumatologist. This information included the fact that a previous study conducted in our department had shown that lavage plus corticosteroid injection was superior to corticosteroid injection alone (4). No separate, verbal or written standardized information on the procedure of lavage was given to the patients. On arrival at the Day Unit on the day of their lavage, patients were assigned, using a preestablished list of randomization, to video or no-video groups. All patients were in an individual room of our Day Unit waiting for the lavage, which was performed in an operating room of our department. Patients assigned to the video group were invited to watch the video in a specific room of our department.

The anxiety level of all patients entering the operating room was measured on a 100-mm visual analog scale (VAS) in which 0 indicates the absence of anxiety and 100 the most severe anxiety. At the end of the lavage, while the patient was still lying on the operating table, tolerability of the procedure was similarly assessed using a 4-grade scale: very tolerable, tolerable, hardly tolerable, intolerable. This information was collected by a single observer for all the patients, i.e., the nurse working in the operating room. The nurse was not aware of the group to which the patient was assigned. However, during the procedure and/or during the time the nurse was collecting the information related to the outcome measures, the patient might discuss the different elements he/she had seen during the video.

Video information on joint lavage

The video film (4 minutes, 20 seconds in length) used in this trial was made by medical communication professionals, based on recommendations of the medical and paramedical staff of the Institute of Rheumatology. Nonmedical language was used to explain briefly the normal and osteoarthritic structures of the knee joint, the indications of joint lavage, its modes of action, and its effectiveness, with a mention of the superiority of lavage plus corticosteroid injection compared with corticosteroid injection alone (4). The joint lavage procedure was shown in detail, including its various steps. Preparation of the patient was shown, including wearing of mask and cap, and shaving of the knee. Aseptic conditions were shown, including sterile dressing of the operator, disinfection of the skin of the knee with iodine, and sterile draping of the knee. Intraarticular procedures were shown, including arthrocentesis of the knee, evacuation of joint effusion, local anesthesia (1% lidocaine) of the lateral and medial suprapatellar portals with mention of the possibility of pain during the anesthesia, introduction of the two cannulae (14-gauge), connection of one cannula (medial) to an extension line and infusion set containing 1 liter of sterile normal saline, evacuation of saline by the other cannula (lateral) with manual compression of the distended joint cavity, injection of corticosteroids through one cannula at the end of the lavage, and wound closure with sterile adhesive dressing. Finally, postoperative care was shown, including bed rest for 2 hours, authorized walk afterwards, duration of hospitalization (1 day or 1.5 days), and clinical improvement starting during the first postlavage week with the possibility of a long-lasting effect until 1 year.

Statistical analysis

Statistical analysis was performed to compare anxiety and tolerability in the video and no-video groups. Student's t-test was used for continuous variables (anxiety) and the chi-square test for categorical variables (tolerability). Statistical analysis was also used to examine the relationship between the anxiety score and the tolerability of joint lavage on one hand, and the patient's sex, age, and previous experience of joint lavage on the other.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Patient characteristics and study course

From May 4, 1999 to September 22, 1999, 112 patients were included and completed the trial according to assignment. Assignment to video or no-video groups was randomized, with 56 patients in each group. There was no difference in baseline characteristics between the 2 groups (Table 1).

Table 1. Baseline characteristics
VariableVideo group (n = 56)No-video group (n = 56)
Demography  
 Age, years64 ± 1564 ± 15
 Sex, F/M35/2136/20
Previous lavage  
 Yes45
 No5251

Impact of video information

Preoperative anxiety was less for patients who had viewed the video; this difference was statistically significant with an anxiety score lower by half (Table 2). Tolerability of knee lavage was also significantly better in the video group (Table 2).

Table 2. Effect of video information on prelavage anxiety and tolerability
ParametersVideo group (n = 56)No-video group (n = 56)P
  • *

    Anxiety determined on a 100-mm visual analog scale. Values are mean ± SD (median).

  • Student's t-test

  • Values are number of patients (%).

  • §

    Chi-square test

Anxiety*13 ± 20 (6)26 ± 27 (18)0.0056
Tolerability   
 Intolerable0 (0)0 (0) 
 Hardly tolerable0 (0)0 (0)< 0.0001§
 Tolerable5 (9)29 (52) 
 Very tolerable51 (91)27 (48) 

Influence of age, sex, and previous lavage

There was a negative statistically significant correlation between age and anxiety in both groups and in the total population: video group r = −0.36 (P = 0.0058); no-video group r = −0.30 (P = 0.0217); total population r = −0.31 (P = 0.0007). Prelavage anxiety decreased with increasing age.

A tendency to better tolerate lavage was found in older patients. The mean age of the patients who considered the procedure very tolerable was 65 ± 15 years (n = 78), and 60 ± 15 years (n = 34) for those who considered the lavage tolerable (P = 0.087).

Prelavage anxiety was significantly higher in women (VAS 24 ± 27; n = 71) than men (VAS 11 ± 17, n = 41; P = 0.003). At variance, tolerability of joint lavage was not influenced by sex (data not shown). Previous experience of joint lavage did not affect the anxiety or tolerability scores (data not shown).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES

Our study confirms the usefulness of video information prior to an invasive procedure in rheumatology. This study suggests that such information not only decreases the preoperative level of anxiety, but can also improve the tolerability of the procedure.

Trials evaluating nonpharmaceutical treatments are more difficult to perform than those evaluating the use of drugs. In the present study, we tried to diminish the potential bias by using identical verbal information concerning the potential benefit of the lavage for the entire group of patients, and identical management of the patients while they were in the 1-day hospital unit. However, we cannot exclude a potential bias due to the discussion existing between the patient and the nurse who was in charge of collecting the outcome measures.

In this study, both the level of anxiety and the tolerability were evaluated by using simple tools such as a VAS for anxiety and a Likert scale for tolerability. We admit that a proper measure of the state of anxiety has powerful psychometric properties. Nevertheless, the results obtained in our study are from a monocenter study using a single observer. This design suggests that the information provided by the patient, not taking into account the multidimensional meanings of the emotion, is probably mostly related to the domain “anxiety.”

As previously reported in other medical procedures (5, 11), video information clearly decreases preoperative anxiety, but our study also points out the beneficial impact of video information on the tolerability of the procedure. In gastroenterology, Morgan et al (15) reported that provision of congruent information reduced anxiety and the observed indices of pain in colonoscopy.

Demographic parameters seem to affect prelavage anxiety, with a positive influence of higher age and a negative influence of female sex. Nevertheless, the beneficial influence of age was not found in the study of Luck et al (6) on precolonoscopy anxiety. At variance, several studies (6, 9, 12, 16, 17) have pointed out that female patients have the highest anxiety score. The beneficial influence of previous experience of the procedure, clearly determined for precolonoscopy anxiety, was not confirmed in our study, but previous experience of joint lavage is much less frequent than colonoscopy and cannot be considered a relevant parameter. Our study suggests that younger women are most likely to benefit from video information before lavage. However, this study shows that video information decreases preoperative anxiety in all patients.

Randomized prospective studies have indicated that video information could be more effective than a personal discussion with the doctor, with (7) or without written information via a leaflet (5). Because video seems to work as well for various invasive medical procedures, it could become an important component of preoperative preparation while laying a foundation for a more personalized discussion with the patient. In addition, future studies should compare the effects of video to other techniques, such as music, relaxation, meditation, and others.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. REFERENCES