Conservative management of a young adult with hip arthrosis

STUDY DESIGN

Case report.

BACKGROUND

Clinical practice guidelines regarding the conservative management of degenerative hip conditions in older adults routinely incorporate therapeutic exercise and manual therapy. However, the application of these recommendations to young, active adults is less clear. The purpose of this case report is to describe the management of a young adult with advanced hip arthrosis using a multifaceted rehabilitation program.

CASE DESCRIPTION

A 28-year-old female with severe left hip degeneration, as identified with diagnostic imaging, was referred to physical therapy. Reduced hip range of motion and strength, sacroiliac joint asymmetries, and a modified Harris Hip Score of 76 were observed. She was seen for 12 visits over a 3-month period and treated with an individualized program including manual therapy, therapeutic exercise, and neuromuscular re-education.

OUTCOME

Substantial improvements were noted in pain, hip range of motion, and strength and function (modified Harris Hip Score of 97). In addition, she discontinued the use of anti-inflammatory medications and returned to her prior level of activity. Improvements were maintained at a 3-month follow-up, with symptom recurrence managed using a self-mobilization technique to the left hip and massage to the left iliopsoas.

DISCUSSION

Degenerative hip conditions are common among older adults but are relatively rare in the younger population. Although it is likely that this patient will experience a return of her symptoms and functional limitations as her hip disease progresses, the immediate improvements may delay the need for eventual surgical management. These outcomes suggest that physical therapy management should be considered in those with an early onset of degenerative hip disease and are consistent with results previously reported in the older population.

LEVEL OF EVIDENCE

Therapy, level 4.

Activity Increase Despite Arthritis (AIDA): design of a Phase II randomised controlled trial evaluating an active management booklet for hip and knee osteoarthritis [ISRCTN24554946]

BACKGROUND

Hip and knee osteoarthritis is a common cause of pain and disability, which can be improved by exercise interventions. However, regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement. The best method of encouraging increased activity in this patient group is not known. A booklet has been developed for patients with hip or knee osteoarthritis. It focuses on changing disadvantageous beliefs and encouraging increased physical activity.

METHODS/DESIGN

This paper describes the design of a Phase II randomised controlled trial (RCT) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs, and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour. A computerised search of four general medical practice patients' record databases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months. A random sample of 120 will be invited to participate in the RCT comparing the new booklet with a control booklet, and we expect 100 to return final questionnaires. This trial will assess the feasibility of recruitment and randomisation, the suitability of the control intervention and outcome measurement tools, and will provide an estimate of effect size. Outcomes will include beliefs about hip and knee pain, beliefs about exercise, fear avoidance, level of physical activity, health status and health service costs. They will be measured at baseline, one month and three months.

DISCUSSION

We discuss the merits of testing effectiveness in a phase II trial, in terms of intermediate outcome measures, whilst testing the processes for a larger definitive trial. We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24554946.

Rehabilitation after total hip arthroplasty: a systematic review of controlled trials on physical exercise programs

Total hip arthroplasty (THA) has revolutionized the care of patients with end-stage joint disease, leading to pain relief, functional recovery, and substantial improvement in quality of life. However, long-term studies indicate persistence of impairment and functional limitation after THA, and the optimal rehabilitation protocols are largely unknown. The aim of this paper was to systematically review the controlled trials published on the effectiveness of physical exercise programs after THA. Nine studies were retrieved from MEDLINE and reviewed. Results show that the physical exercise protocols most frequently used after THA in the early postoperative phase are neither supported nor denied by clinical controlled trials. Convincing evidence for the effectiveness of single interventions in addition to usual exercise programs exists for each of the three following options: treadmill training with partial body-weight support, unilateral resistance training of the quadriceps muscle (operated side), and arm-interval exercises with an arm ergometer. In the late postoperative phase (operation interval > 8 weeks) exercise programs consistently improve both impairment and ability to function. Weight-bearing exercises with hip-abductor eccentric strengthening may be the crucial component of the late-phase protocols. Substantial limitations were found in the nine studies, including small sample size, patient selection, heterogeneity of outcome assessments, and potential sources of variability not investigated. Despite limitations, we conclude that three main suggestions emerge from controlled trials on physical exercise after THA: early postoperative protocols should include additive interventions whose effectiveness has been shown. Late postoperative programs are useful and should comprise weight-bearing exercises with hip-abductor eccentric strengthening.

A computer-adaptive disability instrument for lower extremity osteoarthritis research demonstrated promising breadth, precision, and reliability

OBJECTIVE

To develop and evaluate a prototype measure (OA-DISABILITY-CAT) for osteoarthritis research using item response theory (IRT) and computer-adaptive test (CAT) methodologies.

STUDY DESIGN AND SETTING

We constructed an item bank consisting of 33 activities commonly affected by lower extremity (LE) osteoarthritis. A sample of 323 adults with LE osteoarthritis reported their degree of limitation in performing everyday activities, and completed the Health Assessment Questionnaire-II (HAQ-II). We used confirmatory factor analyses to assess scale unidimensionality and IRT methods to calibrate the items and examine the fit of the data. Using CAT simulation analyses, we examined the performance of OA-DISABILITY-CATs of different lengths compared with the full-item bank and the HAQ-II.

RESULTS

One distinct disability domain was identified. The 10-item OA-DISABILITY-CAT demonstrated a high degree of accuracy compared with the full-item bank (r=0.99). The item bank and the HAQ-II scales covered a similar estimated scoring range. In terms of reliability, 95% of OA-DISABILITY reliability estimates were over 0.83 vs. 0.60 for the HAQ-II. Except at the highest scores, the 10-item OA-DISABILITY-CAT demonstrated superior precision to the HAQ-II.

CONCLUSION

The prototype OA-DISABILITY-CAT demonstrated promising measurement properties compared with the HAQ-II, and is recommended for use in LE osteoarthritis research.

A trial of the use of pedobarography in the assessment of the effectiveness of rehabilitation in patients with coxarthrosis

BACKGROUND

Pedobarography is an evidence-based diagnostic method that allows quantitative, qualitative and repeatable measurement of pressures on every square centimetre of the sole area of the foot as well as centre of gravity sway, with graphic and numerical recording of results. The aim of the study was to assess the progress of a selected model of rehabilitation on the basis of subpedal pressure distribution and centre of gravity sway in pedobarographic examination as well as to evaluate changes in pain intensity in patients with a history of coxarthrosis.

MATERIAL AND METHODS

The study included 21 patients with Altman grade 2 coxarthrosis. A postural pedobarographic examination was performed immediately before and after a 15-day course of rehabilitation with a PEL 38 electronic pedobarograph and computer image analyser with TWINN 99 software, version 2.08.

RESULTS

Following the rehabilitation, the study group displayed a statistically significant reduction in pain intensity, improved balance between the average and maximum subpedal pressures of both feet as well as a decrease in the velocity of centre of gravity sway.

CONCLUSIONS

1. A correlation between reduced pain intensity and improved balance of loads on both feet, as well as decreased velocity of centre of gravity sway were observed in the study group after the rehabilitation. 2. The pedobarographic examination may become a new method of diagnosis and follow-up in rehabilitation. 3. Pedobarography, owing to its ease of repeatability and non-invasiveness, may constitute a valuable attempt at objective monitoring of the progress of rehabilitation and its results. 4. The study results encourage further research based on a larger cohort of patients and a control group with a multi-stage prospective design.

[Rehabilitation of patients with post-traumatic coxarthrosis]

This paper reports the results of rehabilitative treatment of 102 patients with post-traumatic coxarthrosis. The data obtained during clinical and instrumental examination provided a basis for the development of a diagnostic algorithm that allows for objective verification of ethiopathogenesis of structural and functional disturbances in the supporting organ. An original approach is proposed based on distinguishing the principal clinical syndromes associated with post-traumatic coxarthrosis. Ways and means for medical rehabilitation of patients with post-traumatic coxarthrosis are reviewed with special reference to the mechanism of action of various therapeutic agents. Their combined application permitted to achieve a synergistic effect and thereby improve the functional outcome of remedial measures.

International Classification of Functioning, Disability and Health (ICF) core sets for osteoarthritis. A useful tool in the follow-up of patients after joint arthroplasty

AIM

The first aim of this study was to verify the applicability of the International Classification of Functioning Disability and Health (ICF) core set for osteoarthritis (OA) as an outcome tool after the total hip arthroplasty (THA) and total knee arthroplasty (TKA), in order to follow the changes of the profile of functioning after joint arthroplasty.

METHODS

Seventy-two OA inpatients were consecutively enrolled during the first three days of rehabilitation after THA (34.7%) or TKA (65.3%) and were evaluated of the ICF Core Set for OA. Patients were interviewed at the beginning of the study one month prior to surgery, at the end of the rehabilitation treatment lasting on average three weeks and three and six months after their discharge.

RESULTS

The ICF core set data comparison showed many significant differences among the four evaluations with a significant improvement in many categories assessed. At the six months interview activity limitations and participation restrictions were still reported, even if with a lower percentage as compared to the first evaluation.

CONCLUSION

The ICF core set for OA resulted an interesting outcome tool after the THA or TKA, even if more research is needed, mainly on data reliability and category definition. Even tough problems in the administration were encountered, the ICF core set allowed to focus on issues and aspects of patient's every day life usually not taken into account or not codified in the usual care assessment.

The benefit of modified rehabilitation and minimally invasive techniques in total hip replacement

INTRODUCTION

We wished to assess if an intensive rehabilitation regimen alone, or one combined with modified anaesthetic and surgical techniques, can change the speed of rehabilitation or the length of hospital stay after total hip replacement.

PATIENTS AND METHODS

We compared 44 patients who had followed a traditional care pathway, with 38 patients who had rehabilitated under a new rehabilitation protocol, with 40 patients who had also received modified, minimally invasive techniques. The speed of rehabilitation was measured in terms of three specific milestones accomplished on the day after surgery.

RESULTS

We found a statistically significant improvement in the day after surgery each activity was possible. The length of hospital stay was reduced from 6.5 days to 5.4 days to 4.1 days, a difference which was also statistically significant.

CONCLUSIONS

The data support the view that a new rehabilitation protocol alone can reduce the length of hospital stay and hasten rehabilitation. The combination of modified anaesthetic and minimally invasive surgical techniques with the new rehabilitation regimen can further improve short-term outcome after total hip replacement.

Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review

OBJECTIVE

To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee.

METHODS

We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings.

RESULTS

Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function.

CONCLUSION

The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term.

Perceived exertion and rehabilitation with arm crank in elderly patients after total hip arthroplasty: a preliminary study

This preliminary study examined, in a restricted randomized trial, the effects of a 6-week arm-crank rehabilitation training program in elderly osteoarthrosis patients after total hip arthroplasty, first on physiological and perceptual responses and second on physical function. Two groups of patients were studied: a training group (N = 7, mean age = 74.9 yr, standard deviation [SD] = 5.0 yr) who followed a training program in addition to traditional rehabilitation, and a control group who followed traditional rehabilitation only (N = 7 mean age = 75.4 yr, SD = 5.1 yr). At the beginning of the training program, the heart rate and the perceived exertion were not significantly correlated during the exercise session. However, at the end of the training program, five patients had a significant heart rate/perceived exertion relationship (p < 0.05). Furthermore, positive effects of the arm-crank rehabilitation training program were observed on cardioventilatory and functional responses in the training group compared with the control group. These results suggest that after an habituation period, most of our elderly osteoarthrosis patients experienced physical sensations that were connected to physiological responses. Therefore, perceived exertion could be useful in these patients to regulate exercise intensity, especially at the end of and after the rehabilitation period.

Establishing recommendations for physical medicine and rehabilitation: the SOFMER methodology

OBJECTIVE

The development of a rigorous methodology based on published results of clinical trials, evaluation of daily practice in France and multidisciplinary expert opinion to elaborate recommendations for rehabilitation interventions.

METHODS AND RESULTS

The following describes the methodology of SOFMER (Société Française de Médecine Physique et de Réadaptation [French Society of Physical Medicine and Rehabilitation]) for developing recommendations for rehabilitation interventions. The test case was developing recommendations for rehabilitation in hip or knee osteoarthritis (OA) and hip or knee arthroplasty. Physicians in rehabilitation, orthopedic surgery and rheumatology identified, synthesized, and analyzed data from the literature by use of the usual French system of grading trials (the French Agency for Accreditation and Evaluation in Healthcare [ANAES] scale). The data were published results of comparative controlled studies such as randomized controlled trials, controlled clinical trials, cohort studies, case control studies, reviews of clinical trials, and case series, as well as uncontrolled cohort studies. The resulting recommendations were presented to the three annual French national congresses of rehabilitation, rheumatology, and orthopedic surgery for comment and for adapting to French professional practice. Finally, a panel of multidisciplinary experts (physicians in physical medicine and rehabilitation, rheumatologists, orthopedic surgeons, general practitioners, physical therapists, social workers, podologists, occupational therapists, nurses, and patients) validated the recommendations.

CONCLUSION

The SOFMER methodology could be an interesting tool for use in developing recommendations elaborated by all the concerned medical and surgical specialists in the wide domain of rehabilitation.

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.