Strategies for the prevention and management of osteoarthritis of the hip and knee

Osteoarthritis (OA) is one of the most common forms of musculoskeletal disorders and incurs significant economic, social and psychological costs. OA increases in prevalence and also progresses with aging. Clinically OA is characterised by joint pain, crepitus, stiffness after immobility and limitation of movement. Many cases are 'idiopathic' (disease or condition of unknown course or which arises spontaneously), but OA can also be the end result of several other conditions or due to the combination of several other factors. There are various lifestyle factors that increase the risk of developing OA. Preventable or modifiable risk factors include obesity, occupational factors, sports participation, muscle weakness, nutritional factors and hormonal influence. Pharmacological therapies reduce pain and may reduce joint damage. Surgical interventions correct altered biomechanics to prevent OA. For severely damaged joints, partial or total replacement of the joint is possible for all of the large joints that are commonly affected by OA. OA is commonly associated with a limited function that can be improved with a wide variety of rehabilitative interventions: joint specific exercises, physical fitness, physical modalities. Education and self-management are very important to prevent overuse and to use the joints in the most adequate way.

Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee

AIM

This paper reports a study of the effects of aquatic exercise on physical fitness (flexibility, strength and aerobic fitness), self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee.

BACKGROUND

Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement. Exercise is important for preventing and/or managing the functional limitations associated with joint disease. Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis; however, few studies have examined the effects on people with osteoarthritis, and these have yielded inconsistent results.

METHODS

A two-group randomized controlled trial with a convenience sample was used. Participants were recruited from community sources and randomly assigned to a 12-week aquatic programme or a non-exercise control condition. Data for 38 participants were collected at baseline, week 6, and week 12 during 2003 and 2004. Instruments were a standard plastic goniometer, a handheld dynamometer, the 6-minute walk test, the multidimensional Health Assessment Questionnaire, and a visual analogue scale for pain.

RESULTS

Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility, strength and aerobic fitness, but had no effect on self-reported physical functioning and pain. The exercise adherence rate was 81.7%, and no exercise-related adverse effect was observed or reported.

CONCLUSIONS

Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee. Although the programme may not offer pain relief or self-reported improvements in physical functioning, results suggest that aquatic exercise does not worsen the joint condition or result in injury. Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients.

Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis?

Background

Patient education and self-management programs are offered in many countries to people with chronic conditions such as osteoarthritis (OA). The most well-known is the disease-specific Stanford Arthritis Self-Management Program (ASMP). While Australian and international clinical guidelines promote the concept of self-management for OA, there is currently little evidence to support the use of the ASMP. Several meta-analyses have reported that arthritis self-management programs had minimal or no effect on reducing pain and disability. However, previous studies have had methodological shortcomings including the use of outcome measures which do not accurately reflect program goals. Additionally, limited cost-effectiveness analyses have been undertaken and the cost-utility of the program has not been explored.

Methods/design

This study is a randomised controlled trial to determine the efficacy (in terms of Health-Related Quality of Life and self-management skills) and cost-utility of a 6-week group-based Stanford ASMP for people with hip or knee OA.

Six hundred participants referred to an orthopaedic surgeon or rheumatologist for hip or knee OA will be recruited from outpatient clinics at 2 public hospitals and community-based private practices within 2 private hospital settings in Victoria, Australia. Participants must be 18 years or over, fluent in English and able to attend ASMP sessions. Exclusion criteria include cognitive dysfunction, previous participation in self-management programs and placement on a waiting list for joint replacement surgery or scheduled joint replacement.

Eligible, consenting participants will be randomised to an intervention group (who receive the ASMP and an arthritis self-management book) or a control group (who receive the book only). Follow-up will be at 6 weeks, 3 months and 12 months using standardised self-report measures. The primary outcome is Health-Related Quality of Life at 12 months, measured using the Assessment of Quality of Life instrument. Secondary outcome measures include the Health Education Impact Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (pain subscale and total scores), Kessler Psychological Distress Scale and the Hip and Knee Multi-Attribute Priority Tool. Cost-utility analyses will be undertaken using administrative records and self-report data. A subgroup of 100 participants will undergo qualitative interviews to explore the broader potential impacts of the ASMP.

Discussion

Using an innovative design combining both quantitative and qualitative components, this project will provide high quality data to facilitate evidence-based recommendations regarding the ASMP.

No difference in health-related quality of life in hip osteoarthritis compared to degenerative lumbar instability at pre- and 1-year postoperatively: a prospective study of 101 patients

BACKGROUND

Total hip replacement (THR) is a very successful and refined surgical procedure when compared to crude bony fusion in degenerative lumbar segmental instability (LF). We compared the pre- and postoperative health-related quality of life status of THR and LF patients.

PATIENTS AND METHODS

We prospectively studied 51 THR patients and 50 LF patients. The outcome parameters were SF-36 and Oswestry Disability Index (ODI), measured preoperatively and at 1 year postoperatively. The status of the patients was compared to that of an age-matched healthy control group.

RESULTS

The preoperative SF-36 and ODI scores were similar between the groups, except for the subscale role emotional. One year postoperatively, only the differences in 3 subscales (physical functioning, role physical, and role emotional) and in the standardized physical component reached statistical significance; the THR-patients scored worse than the LF-patients. The improvements in SF-36 and ODI reached statistical significance in both groups.

INTERPRETATION

The differences in quality of life between the THR and LF patients were similar pre- and postoperatively. The quality of life of both cohorts improved considerably and significantly after the treatment, but they remained at a level significantly below that of a general age-matched population.

Predictors for response to rehabilitation in patients with hip or knee osteoarthritis: a comparison of logistic regression models with three different definitions of responder

OBJECTIVE

To identify pre-treatment predictors of who will benefit from a 3-4-week comprehensive rehabilitation intervention in patients with osteoarthritis (OA) of the knee or hip.

METHODS

A prospective cohort study with assessments at admission to the clinic and after 6 months was conducted. Two hundred and fifty patients from the rehabilitation clinic Rehaclinic Zurzach, Switzerland, were included. Three different measures of response to a 3-4-week comprehensive rehabilitation intervention were used: one indirect measure (minimal clinically important difference (MCID) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global score=18% improvement), one direct measure (transition question) and a combination of both criteria. Responders were predicted by a sequential logistic regression analysis with nine personal variables, five lifestyle risk factors, seven psychological status variables and the WOMAC global baseline score.

RESULTS

The set of statistically significant predictors was dependent on the definition of response. The comparison of predictors that were statistically significant in any of the prediction models showed similar odds ratios (ORs) for the majority of predictors across three regression models with the different response definitions as dependent variable. Female gender, absence of depressive symptoms (dep), history of complementary medicine (cm) and low comorbidity (com) were the most stable predictors and had ORs above 2.0 (female) and above 1.5 (dep, cm, com) across the three regression models with different response definitions.

CONCLUSION

A set of predictors for the outcome of rehabilitation in patients with OA was identified. If these predictors could be confirmed in future research, this knowledge might help to adopt and individualize the treatment of patients who are, at present, less likely to respond.

Evidence-based clinical guidelines: a new system to better determine true strength of recommendation

RATIONALE, AIMS AND OBJECTIVES

Clinical practice guidelines often grade the 'strength' of their recommendations according to the robustness of the supporting research evidence. The existing methodology does not allow the strength of recommendation (SOR) to be upgraded for recommendations for which randomized controlled trials are impractical or unethical. The purpose of this study was to develop a new method of determining SOR, incorporating both research evidence and expert opinion.

METHODS

A Delphi technique was employed to produce 10 recommendations for the role of exercise therapy in the management of osteoarthritis of the hip or knee. The SOR for each recommendation was determined by the traditional method, closely linked to the category of research evidence found on a systematic literature search, and on a visual analogue scale (VAS). Recommendations were grouped A-D according to the traditional SOR allocated and the mean VAS calculated. Difference across the groups was assessed by one-way ANOVA variance analysis.

RESULTS

Mean VAS scores for the traditional SOR groups A-D and one proposition which was 'not recommended' showed significant linearity on one-way ANOVA. However, certain recommendations which, for practical reasons, could not assessed in randomized controlled trials and therefore could not be recommended strongly by the traditional methodology, were allocated a strong recommendation by VAS.

CONCLUSIONS

This new system of grading strength of SOR is less constrained than the traditional methodology and offers the advantage of allowing SOR for procedures which cannot be assessed in RCTs for practical or ethical reasons to be upgraded according to expert opinion.

Osteoarthritis of the knee and hip and activity: a systematic international review and synthesis (OASIS)

The goal of this study was to determine which activities in four domains, daily life, exercises, sports and occupational activities, should be recommended, in favor or against, for the patient suffering from knee or hip OA.

METHODS

Scientific literature was searched in Medline, Embase and Cochrane databases for articles in French or English, reporting original data. The articles were evaluated with standardized epidemiological criteria. Seventy-two articles were retained. Recommendations were graded according to the level of scientific evidence (A high, B moderate, C clinical consensus) and were formulated for primary care.

CONCLUSIONS AND RECOMMENDATIONS

For activity of daily life (ADL), the OASIS group states with a moderate level of scientific evidence, that ADL are a risk factor for knee OA and that risk increases with intensity and duration of activity. The group concludes that healthy subjects as well as OA patients in general can pursue a high level of physical activity, provided the activity is not painful and does not predispose to trauma (grade B). Radiographic or clinical OA is not a contraindication to promoting activity in patients who have a sedentary lifestyle (grade C). For exercises and other structured activities pursued with a goal of health improvement, the group states with a high level of scientific evidence that they have a favourable effect on pain and function in the sedentary knee OA patient. The OASIS group recommends the practice of exercises and other structured activities for the sedentary patient with knee OA (grade A). Static exercises are not favored over dynamic exercises, availability, preference and tolerance being the criteria for the choice of an exercise (grade A). As results deteriorate when exercises are stopped, they should be performed at a frequency of between one and three times per week (grade B). Professional assistance can be useful in improving initial compliance and perseverance (grade B). There is no scientific argument to support halting exercise in case of an OA flare-up (grade C). For sports and recreational activity, the group states with a high degree of scientific evidence, that these activities are a risk factor for knee and hip OA and that the risk correlates with intensity and duration of exposure. The group also states, with a high degree of scientific evidence, that the risk of OA associated with sport is lesser than that associated with a history of trauma and overweight. No firm conclusion could be drawn about the possible protective role of sports such as cycling, swimming or golf. The OASIS group recommends that athletes should be informed that joint trauma is a greater risk factor than the practice of sport (Grade A). The high level athlete should be informed that the risk of OA is associated with the duration and intensity of exposure (Grade B). The OA patient can continue to engage regularly in recreational sports as long as the activity does not cause pain (Grade C). The OA patient who practices a sport at risk for joint trauma should be encouraged to change sport (Grade C). For occupational activity, the OASIS group states with a high level of scientific evidence that there is a relationship between occupational activity and OA of the knee and hip. The precise nature of biomechanical stresses leading to OA remains unclear but factors such as high loads on the joint, unnatural body position, heavy lifting, climbing and jumping may contribute to knee and hip OA. The group recommends that taking an occupational history should always be part of managing the OA patient (Grade B). In the knee or hip OA patient, work-related activity that produces or maintains pain should be avoided (Grade B). Physicians should be alerted by the early knee and hip signs and symptoms in workers exposed to stresses that are known or supposed to favour knee or hip OA (Grade C).

Evaluierung des XSMFA-D an Patienten mit Erkrankungen des Bewegungsapparates und operativer oder konservativer stationärer Therapie

AIM

The present study had the objective of evaluating the psychometric characteristics of the shortened 16-item version of the German Short Musculoskeletal Function Assessment questionnaire (XSMFA-D), which was designed for routine assessment of functional capacity in patients with various orthopaedic disorders treated either surgically or medically.

METHODS

A total of 382 patients from seven different samples with either osteoarthritis of the knee, osteoarthritis of the hip, rheumatoid arthritis or rotator cuff tear treated either in surgical hospitals or rehabilitation settings were assessed both before and after treatment. The XSMFA-D was compared with both questionnaires measuring similar constructs and widely accepted indicators of health status in musculoskeletal disorders. Psychometric characteristics were computed.

RESULTS

The internal consistency (Cronbach's alpha) exceeded 0.90 in most cases for the function index and was between 0.80 and 0.90 in most cases for the bother index of the XSMFA-D. Retest-reliability was between 0.80 and 0.95 for the function index and between 0.60 and 0.92 for the bother index. Correlations between the XSMFA-D subscales and the other questionnaires were substantial, showing construct validity. Criterion validity was also demonstrated as significant relationships with accepted external parameters such as function tests, judgements by physicians, pain self-ratings by patients and disease severity scores were found. Sensitivity to change was as high as for the other assessment instruments used in this study.

CONCLUSIONS

The XSMFA-D, a very short assessment instrument, proved to be practical, reliable, valid and sensitive to change among the various patient samples studied. It may be recommended for the assessment of patients' state as well as the evaluation of treatments.

Reducing incision length or intensifying rehabilitation: what makes the difference to length of stay in total hip replacement in a UK setting?

Minimal-incision surgery for hip arthroplasty and intensive post-op physiotherapy have both been shown to allow early mobilisation and to reduce hospital stay. Forty-five patients undergoing primary total hip arthroplasty using a standard posterior approach were compared with 51 patients using a minimal incision. In both groups, physiotherapy involved either a routine or intensive regime. Patients were matched in age, sex and body mass index. There was no significant difference in blood loss, post-operative stay and change in Oxford hip scores at one year between the mini- and standard-incision groups. There was a significant difference (P=0.003) in length of stay between routine- and intensive-physiotherapy groups (11.4 vs. 7.9 days). The dislocation rate was higher in the mini-incision group. This study suggests that in a standard UK setting, intensive physiotherapy can significantly decrease in-patient stay, but reducing the incision length does not.

Test methods to detect hip and knee muscle weakness and gait disturbance in patients with hip osteoarthritis

OBJECTIVE

To evaluate test methods for hip and knee muscle weakness and gait disturbance.

DESIGN

Test-retest.

SETTING

Orthopedic university clinic.

PARTICIPANTS

Ten young (age, 36+/-6 y) and 13 elderly (age, 69+/-8 y) healthy volunteers and 11 patients (age, 69+/-8 y) with unilateral hip osteoarthritis (OA) were tested for muscular strength. Twenty-five volunteers (age, 42+/-14 y) underwent gait analysis.

INTERVENTIONS

A dynamometer assessing maximal voluntary isometric force of hip and knee muscles and an optosensor walkway detecting limp were developed. Tests evaluated reproducibility and tolerance in patients with OA and elderly subjects.

MAIN OUTCOME MEASURES

Relative coefficient of variation (CV%) and force (in newtons).

RESULTS

CV% for unilateral strength measurements ranged from 7% to 12% for specific muscle groups. CV% for gait parameters ranged from 4% to 8%, except for the double-support phase. Tests were well tolerated, and no patient had to discontinue because of fatigue. Differences related to sex, age, and disease were detected.

CONCLUSIONS

Our dynamometer system provides reliable measurements of hip and knee muscle strength in young and old people, and variation is comparable to previous data. Our photocell technique for gait analysis is reliable in people with normal gait. Both methods are attractive because they are affordable, nonstationary, and easy to use.

Acupuncture for osteoarthritic pain: an observational study in routine care

OBJECTIVE

To investigate characteristics and outcomes of patients undergoing acupuncture treatment for osteoarthritic pain under conditions of routine care in the framework of statutory health insurance in Germany.

METHODS

Patients with chronic pain due to osteoarthritis (ICD-10 diagnoses M15 to M19) treated with acupuncture as the leading form of therapy were included in an observational study. Detailed questionnaires including instruments to measure pain intensity (numerical rating scales from 0 to 10), disability (Pain Disability Index) and quality of life (SF-36) were filled in before treatment, after treatment and at 6 months. Patients suffering from osteoarthritis of the knee and hip also filled in the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index questionnaire.

RESULTS

A total of 736 patients were included in the main analysis. Seventy (10%) patients and 278 (38%) patients, respectively, suffered exclusively from primary osteoarthritis of the hip or knee, 239 (33%) from another type of osteoarthritis and 149 (20%) had more than one affected joint. On average, patients received 8.7 +/- 3.1 acupuncture treatments. Statistically significant and clinically relevant improvements were seen in all subgroups both after treatment and at 6 months in all major outcome measures. In patients with osteoarthritis of the hip, the WOMAC sum score was 47.9 +/- 20.7 at baseline, 34.8 +/- 20.0 after treatment and 33.1 +/- 22.2 at 6 months. The respective values in patients with osteoarthritis of the knee were 51.7 +/- 20.9, 34.1 +/- 23.3 and 34.6 +/- 25.1.

CONCLUSIONS

In this study, patients with chronic pain due to osteoarthritis reported clinically relevant improvements after acupuncture treatment. Due to the uncontrolled design and the high proportion of patients lost to follow-up, the study findings must be interpreted cautiously.

Mini-incision total hip arthroplasty: a quantitative assessment of laboratory data and clinical outcomes

In this study, we used laboratory data and clinical outcomes to evaluate the degree of approach-related trauma in mini-incision arthroplasty. In 94 patients (8 male and 86 female), a total of 100 osteoarthritic joints were replaced using total hip arthroplasty (THA). The level of serum C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured 1 week postoperatively in both the standard group and a mini-incision group. The serum CRP level (mean +/- standard deviation) was 3.3 +/- 2.6 mg/dl in the standard incision group compared to 1.8 +/- 1.2 in the mini-incision group. The ESR level was 66 +/- 22 mm/h in the standard incision group and 52 +/- 20 mm/h in the mini-incision group. The ratio of the level of creatine phosphokinase (CPK) measured postoperatively/preoperatively was 4.7 on the first postoperative day in the standard incision group and 3.6 in the mini-incision group. On the basis of the CRP and ESR levels, the mini-incision THA was considered to be less invasive. However, there was no significant difference in the day 1 CPK ratios between the two groups, suggesting that the degree of muscle trauma was similar.

Responsiveness and clinically important differences for the WOMAC and SF-36 after hip joint replacement

OBJECTIVES

To study responsiveness and establish the minimal clinically important differences (MCID) and minimal detectable change (MDC) in patients undergoing total hip replacement (THR) using the Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

METHODS

We conducted a prospective observational study in three public hospitals of all consecutive patients with a diagnosis of hip osteoarthritis (OA) on waiting lists to undergo THR. Patients completed the SF-36 and the WOMAC (subscales transformed to 0 to 100), which measured the health-related quality of life (HRQoL), before intervention and 6 months and 2 years later, and additional transitional questions, which measured the changes in the joint 6 months postoperatively.

RESULTS

Improvements at 6 months after a THR were between 37 (stiffness) and 39 points (pain), depending on the WOMAC domain. The SF-36 domains also showed improvements: physical function (31.91), physical role (33.71), and bodily pain (29.77). From 6 months to 2 years, improvements ranged from 2 to 5 points, except for role physical (13.25). A ceiling effect was detected on some WOMAC domains as well as a floor effect on the SF-36. The MCID ranged from 25.91 (stiffness) to 29.26 (pain) on the WOMAC and from 10.78 (physical role) to 20.40 (physical function) on the SF-36. The MDC ranged from 21.38 (pain) to 27.98 (stiffness) on the WOMAC and from 18.99 (physical function) to 42.05 (social function) on the SF-36.

CONCLUSIONS

These values indicate expected gains after THR. However, the MCID and MDC values must be viewed cautiously due to the uncertainty of these estimators and should not be considered as absolute thresholds.

Assessment of the Lequesne index of severity for osteoarthritis of the hip in an elderly population

OBJECTIVE

To assess the measurement properties of the Lequesne index of severity for osteoarthritis of the hip (LISOH) together with its overall usefulness with reference to the original stated aims.

METHOD

Postal questionnaire was sent to a random sample of 5500 Oxfordshire residents, aged 65 and above. Respondents with hip symptoms at baseline (but without verification of a diagnosis) were sent an identical follow-up questionnaire 12 months later. The questionnaire included a general health section, including the Short Form-36 survey, and a hip section which began with a screening question about hip pain. Respondents who reported having a prolonged episode of hip pain were asked to complete the LISOH.

RESULTS

At baseline, response rate of 66.3% (3341/5039) was obtained from eligible participants; 19.2% (610/3175) of respondents reported having hip pain. Internal reliability (Cronbach's alpha) was 0.84 (95% CI: 0.81-0.86) for all 11 items of the LISOH; however, factor analysis identified two factors (sub-scales): "function and mobility" and "pain and discomfort". Rasch analysis revealed that the two factors were only unidimensional when applied to sub-groups of respondents. Convergent validity of the LISOH was questionable, as the "function and mobility" factor was more highly correlated with SF-36 bodily pain score than was the "pain and discomfort" factor. The assessment of sensitivity over time was problematic due to changing patterns of symptomatic weight-bearing joints over time.

CONCLUSIONS

The current study identifies major limitations with the LISOH--particularly if used as a single composite measure.

Perceived self-efficacy gained from, and health effects of, a rehabilitation program after hip joint replacement

OBJECTIVE

To examine whether a routine multidisciplinary inpatient rehabilitation program can increase patient self-efficacy, and to investigate the effects of high self-efficacy at admission, and increases in self-efficacy, on health changes in patients who undergo such rehabilitation after hip joint replacement.

METHODS

Participants in this longitudinal study were 1,065 patients who underwent inpatient rehabilitation after hip joint replacement. Questionnaires were administered at admission, discharge, and 6-month followup. The main outcome variables were disability, pain, depressive symptomatology, and self-efficacy to cope with disability and pain.

RESULTS

Significant improvements from admission to discharge from the inpatient rehabilitation program in disability, pain, depressive symptoms, and self-efficacy were found. In addition, higher levels of self-efficacy at admission and larger increases in self-efficacy over the course of the program predicted larger health changes (i.e., greater decreases in disability, pain, and depressive symptoms). Results were generally similar for health changes from discharge to 6-month followup.

CONCLUSION

A routine multidisciplinary inpatient rehabilitation program after hip joint replacement can result in enhanced self-efficacy.

Evaluation and cultural adaptation of a German version of the AIMS2-SF questionnaire (German AIMS2-SF)

OBJECTIVES

The aim of the study was to examine the validity of a translated and culturally adapted version of the Arthritis Impact Measurement Scales 2, Short Form (AIMS2-SF) in patients suffering from osteoarthritis (OA) in primary care.

METHODS

A structured procedure was used for the translation and cultural adaptation of the AIMS2-SF into German. The questionnaire was administered to 220 primary care patients with OA of the knee or hip. Test-retest reliability was tested in 35 randomly selected patients, who received the questionnaire a second time after 1 week. The physical scale of the original AIMS2-SF was divided into an 'upper body limitations' scale and a 'lower body limitations' scale.

RESULTS

With values ranging from 0.52 to 0.97 for Pearson's r, item-scale correlations were reasonably good. The discriminative power of separate scales was also good, reflected in low values for correlation between different scales, indicating little redundancy. Only two items (13 and 15) referring to the symptom scale showed item-scale correlation of r = 0.72 and r = 0.67, respectively with the lower body limitation scale. The assessment of internal consistency reliability also revealed satisfactory values: Cronbach's alpha was > or =0.83 for all scales, except for the social interaction scale (0.66). The test-retest reliability, estimated as the intraclass correlation coefficient (ICC), exceeded 0.85 except for the affect scale (0.72). Substantial floor effects occurred in the upper limb scale (33.8%). Principal factor analysis confirmed the postulated three-factor structure with physical, physiological and social dimensions, explaining 49.8, 14.1 and 6.4% of the variation, respectively. The assessment of external validity revealed satisfactory correlations with the corresponding WOMAC (Western Ontario and McMaster Universities Arthrosis Index) scales. As expected, correlations with radiological grading were moderate to low. The correlation with the physician's assessment was high in the scales that were dominated by physical factors, but rather low in the areas of health, which were found to be dominated by psychological or social factors.

CONCLUSION

The German AIMS2-SF is a reliable and valid instrument to assess the quality of life in primary care patients suffering from OA. When addressing the different impacts of OA, the physical scale should be divided into an upper body scale and a lower body scale. The floor and ceiling effects revealed are in accordance with the disease characteristics of the study sample and do not limit the significance of the questionnaire.

The effects of an exercise program for older adults with osteoarthritis of the hip

OBJECTIVE

. Evaluation of an 8-week exercise program with strength training and lifestyle advice for older adults with osteoarthritis (OA) of the hip. Outcome measures were pain, hip function, disability, quality of life (QOL), and body mass index (BMI).

METHODS

Inclusion criteria for this randomized controlled trial were: age >or=55 years, clinical diagnosis of OA according to American College of Rheumatology criteria, and living independently. Interview and physical data were collected at baseline, post-test, and followup (3 mo) by trained interviewers and physical therapists with validated instruments: Harris Hip Score, Sickness Impact Profile, Groningen Activity Restriction Scale, functional tests (walking, timed Up & Go, ascending and descending stairs, and toe reaching), and visual analog scales (pain and QOL). Data were analyzed on an intention-to-treat basis. Effect sizes were calculated.

RESULTS

There were 109 participants (55 experimental, 54 controls). The 15 participants who dropped out were characterized by less tolerance to pain and younger age. The program had a positive effect on pain (moderate effect at post-test and small effect at followup), hip function (small effect at post-test), self-reported disability (small effect at followup), and the timed Up & Go test (small effect at followup). It did not affect QOL, other measures of observed disability, or BMI.

CONCLUSION

The exercise program had positive effects on pain and hip function, which are important mediators of disability. This study fulfilled a need for older adults with hip OA and provides evidence of the benefit of exercise in the management of hip OA.

Physical therapy and rehabilitation programs in the management of hip osteoarthritis

Nonpharmacological treatment programmes are as important as drug treatment in hip osteoarthritis (OA). Drugs (analgesic and nonsteroidal anti-inflammatory drugs) should not be used as sole treatments in hip OA. Patient education and weight reduction are the primary therapeutic approaches. Different types of exercises are beneficial for patients with hip OA. Occupational therapy plays a central role in the management of hip OA patients with functional limitations. More and better-designed trials are needed to evaluate the efficacy of nonpharmacological treatment programmes used in hip OA.

Manual therapy in osteoarthritis of the hip: outcome in subgroups of patients

OBJECTIVE

To investigate whether manual therapy has particular benefit in subgroups of patients defined on the basis of hip function, range of joint motion, pain and radiological deterioration.

METHODS

The study was performed in the out-patient clinic of physical therapy of a large hospital. Data on 109 patients with OA of the hip (clinical ACR criteria) participating in a randomized clinical trial on the effects of manual therapy were used. The outcomes for hip function (Harris hip score), range of joint motion (ROM) and pain (VAS) were compared for specific subgroups. Subgroups were assigned by the median split method. The interaction effect between subgroup and treatment was tested using multiple regression analysis.

RESULTS

No differences were observed in the effect of manual therapy in specific subgroups of patients defined on the basis of baseline levels of hip function, pain and ROM. On the basis of radiological grading of osteoarthritis (OA), we found that patients with severe radiological grading of OA had significantly worse outcome on ROM as a result of manual therapy than patients with mild or moderate radiological grading of OA.

CONCLUSION

A significant interaction effect was found for only 1 out of 12 hypotheses investigated. Therefore, we conclude that there is no evidence for the particular benefit of manual therapy in subgroups of patients.

Condition-specific Western Ontario McMaster Osteoarthritis Index was not superior to region-specific Lower Extremity Functional Scale at detecting change

OBJECTIVE

We determined whether the sensitivity to change of the Western Ontario McMaster Osteoarthritis Index (WOMAC) physical function (PF) subscale, a condition-specific measure for persons with osteoarthritis of the hip or knee, was superior to a lower extremity region-specific measure, the Lower Extremity Functional Scale (LEFS), in persons with osteoarthritis of the hip or knee undergoing total joint arthroplasty.

METHODS

The WOMAC and LEFS were administered to 102 patients with osteoarthritis preoperatively, within 16 days of surgery, and >20 days after the first postoperative assessment. These time points enabled the assessment of deterioration and improvement. Two timed performance measures (40 m walk test and the timed-up-and-go test) were also assessed. Change was quantified by the standardized response mean (SRM).

RESULTS

WOMAC PF SRMs were not greater than the LEFS SRMs. Performance measures' times increased significantly over the deterioration interval and decreased over the improvement interval. The WOMAC PF and LEFS demonstrated significant improvement over the second assessment interval; only the LEFS showed significant deterioration over the first assessment interval. WOMAC PF scores seem to be strongly influenced by pain.

CONCLUSION

The findings do not support the hypothesis that the WOMAC PF subscale is superior to the LEFS in detecting change.

OAKHQOL: A new instrument to measure quality of life in knee and hip osteoarthritis

OBJECTIVE

To develop a questionnaire with which to measure quality of life (QoL) in patients with knee and hip osteoarthritis (OA).

STUDY DESIGN AND SETTING

Thirty-two caregivers and 96 OA patients were interviewed individually (using cognitive and face-to-face techniques) and in focus groups. A group of experts working independently at first and then consensually used the interview transcripts to generate a 46-item questionnaire.

RESULTS

Analysis of questionnaires completed by 263 patients with hip or knee OA resulted in the exclusion of three items (two because of low reliability and one because of a low response rate). Principal component analysis revealed four factors: physical activity, mental health, social functioning, and social support. A pain dimension was individualized. Preliminary testing showed the reliability of the five dimensions to be satisfactory (intraclass correlation coefficients: 0.70-0.85), construct validity was adequate when correlated with the SF36 (Spearman correlation coefficients: 0.43-0.75), and discrimination was satisfactory. The osteoarthritis knee and hip quality of life questionnaire (OAKHQOL) consists of 43 items in five dimensions and three independent items.

CONCLUSION

The OAKHQOL is the first specific knee and hip OA quality of life instrument. Its development followed an a priori structured strategy to ensure content validity. It meets psychometric requirements for validity and reliability.

High independence level in functional activities reduces hospital stay after total hip arthroplasty regardless of pain intensity

OBJECTIVE

The purpose of this study is to investigate the relationship between independence level in functional activities and pain, and length of hospital stay in the early postoperative period in patients with total hip arthroplasty (THA).

METHODS

The study was performed over 26 end stage hip arthritis patients who were hospitalized in the Department of Orthopedics and Traumatology, Hacettepe University Hospital, Ankara, Turkey, between January 2000 and July 2003 for THA and operated with the same surgical technique by the same surgeon. All patients were mobilized in the first postoperative day and a standard rehabilitation protocol was applied to all patients. The independence level in functional activities of the cases was assessed with Iowa Level of Assistance Scale (ILAS). Iowa Ambulation Speed Scale (IASS) was used to evaluate the speed of ambulation in the early postoperative period. Pain was assessed with visual analogue scale (VAS).

RESULTS

There was no statistically significant relation between pain intensity and independence level in functional activities on the second and sixth postoperative days (p>0,05), but independence level scores in functional activities on the second and sixth days were correlated with hospital stay length (p<0.05).

CONCLUSION

The results of this study indicate that in patients with THA, pain does not affect the independence level in functional activities in the early postoperative period. In the same period as the independence level improves, the hospital stay length decreases. This is an important factor that may reduce both the hospital costs and the possible complications due to prolonged hospital stay.

Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus

OBJECTIVES

Exercise is an effective and commonly prescribed intervention for lower limb osteoarthritis (OA). Many unanswered questions remain, however, concerning the practical delivery of exercise therapy. We have produced evidence-based recommendations to guide health-care practitioners.

METHODS

A multidisciplinary guideline development group was formed from representatives of professional bodies to which OA is of relevance and other interested parties. Each participant contributed up to 10 propositions describing key clinical points regarding exercise therapy for OA of the hip or knee. Ten final recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of two categories: (1) strength of evidence and (2) strength of recommendation.

RESULTS

The first round of the Delphi process produced 123 propositions. This was reduced to 10 after four rounds. These related to aerobic and strengthening exercise, group versus home exercise, adherence, contraindications and predictors of response. The literature search identified 910 articles; 57 intervention trials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence to support each proposition is presented.

CONCLUSION

These are the first recommendations for exercise in hip and knee OA to clearly differentiate research evidence and expert opinion. Gaps in the literature are identified and issues requiring further study highlighted.