Exercise for osteoarthritis of the hip

Clinical Practice Guideline: Total Hip Replacement for Osteoarthritis–Evidence-Based and Patient-Oriented Indications

BACKGROUND

Total Hip Replacement (THR) belongs to the most common inpatient operations in Germany, with over 240 000 procedures performed per year. 90% of the artificial joints are still functional at 15 years, and up to 60% at 20 years after surgery. It is essential that the indications for such procedures should be uniform, appropriate, and patient-oriented.

METHODS

This review is based on publications retrieved by a systematic literature search for national and international guidelines and systematic reviews on the topic of hip osteoarthritis and THR.

RESULTS

THR should be performed solely with radiologically demonstrated advanced osteoarthritis of the hip (Kellgren and Lawrence grade 3 or 4), after at least three months of conservative treatment, and in the presence of high subjective distress due to symptoms arising from the affected hip joint. Contraindications include refractory infection, acute or chronic accompanying illnesses, and BMI ≥ 40 kg/m2. Patients should stop smoking at least one month before surgery. In patients with diabetes mellitus, preoperative glycemic control to an HbA1c value below 8% is advisable. It is recommended that patients should lower their weight below a BMI of 30 kg/m2.

CONCLUSION

The decision to perform THR should be taken together by both the physician and the patient when the expected treatment benefit outweighs the risks. Evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome.

Total hip arthroplasty versus progressive resistance training in patients with severe hip osteoarthritis: protocol for a multicentre, parallel-group, randomised controlled superiority trial

INTRODUCTION

Hip osteoarthritis (OA) is the leading cause for total hip arthroplasty (THA). Although, being considered as the surgery of the century up to 23% of the patients report long-term pain, and deficits in physical function and muscle strength may persist after THA. Progressive resistance training (PRT) appears to improve multiple outcomes moderately in patients with hip OA. Current treatment selection is based on low-level evidence as no randomised controlled trials have compared THA to non-surgical treatment. The primary aim of this trial is to investigate whether THA followed by standard care is superior to 12 weeks of supervised PRT followed by 12 weeks of optional unsupervised PRT for improving hip pain and function in patients with severe hip OA.

METHODS AND ANALYSIS

This is a protocol for a multicentre, parallel-group, assessor-blinded, randomised controlled superiority trial conducted at four hospitals across three healthcare regions in Denmark. 120 patients aged ≥50 years with clinical and radiographic hip OA found eligible for THA by an orthopaedic surgeon will be randomised to THA followed by standard care, or 12 weeks of PRT (allocation 1:1). The primary outcome will be change in patient-reported hip pain and function, measured using the Oxford Hip Score, from baseline to 6 months after initiating the treatment. Key secondary outcomes will be change in the Hip disability and Osteoarthritis Outcome Score subscales, University of California Los Angeles Activity Score, 40 m fast-paced walk test, 30 s chair stand test and occurrence of serious adverse events. Patients declining participation in the trial will be invited into a prospective observational cohort study.

ETHICS AND DISSEMINATION

The trial has been approved by The Regional Committees on Health Research Ethics for Southern Denmark (Project-ID: S-20180158). All results will be presented in peer-reviewed scientific journals and international conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT04070027).

The effect of a multidisciplinary lifestyle program for patients with rheumatoid arthritis, an increased risk for rheumatoid arthritis or with metabolic syndrome-associated osteoarthritis: the "Plants for Joints" randomized controlled trial protocol

Low-grade inflammation and metabolic syndrome are seen in many chronic diseases, including rheumatoid arthritis (RA) and osteoarthritis (OA). Lifestyle interventions which combine different non-pharmacological therapies have shown synergizing effects in improving outcomes in patients with other chronic diseases or increased risk thereof, especially cardiovascular disease. For RA and metabolic syndrome-associated OA (MSOA), whole food plant-based diets (WFPDs) have shown promising results. A WFPD, however, had not yet been combined with other lifestyle interventions for RA and OA patients. In this protocol paper, we therefore present Plants for Joints, a multidisciplinary lifestyle program, based on a WFPD, exercise, and stress management. The objective is to study the effect of this program on disease activity in patients with RA (randomized controlled trial [RCT] 1), on a risk score for developing RA in patients with anti-citrullinated protein antibody (ACPA) positive arthralgia (RCT 2) and on pain, stiffness, and function in patients with MSOA (RCT 3), all in comparison with usual care.We designed three 16-week observer-blind RCTs with a waiting-list control group for patients with RA with low to moderate disease activity (2.6 ≤ Disease Activity Score [DAS28] ≤ 5.1, RCT 1, n = 80), for patients at risk for RA, defined by ACPA-positive arthralgia (RCT 2, n = 16) and for patients with metabolic syndrome and OA in the knee and/or hip (RCT 3, n = 80). After personal counseling on diet and exercise, participants join 10 group meetings with 6-12 other patients to receive theoretical and practical training on a WFPD, exercise, and stress management, while medication remains unchanged. The waiting-list control group receives usual care, while entering the program after the RCT. Primary outcomes are: difference in mean change between intervention and control groups within 16 weeks for the DAS28 in RA patients (RCT 1), the RA-risk score for ACPA positive arthralgia patients (RCT 2), and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score for MSOA patients (RCT 3). Continued adherence to the lifestyle program is measured in a two-year observational extension study.

Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

Introduction

The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.

This work aimed to agree clear statements for use by healthcare professionals about medical risks of physical activity for people living with LTCs through expert consensus. These statements addressed the following questions: (1) Is increasing physical activity safe for people living with one or more LTC? (2) Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels? (3) What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTCs to increase their physical activity levels?

Methods

Statements were developed in a multistage process, guided by the Appraisal of Guidelines for Research and Evaluation tool. A patient and clinician involvement process, a rapid literature review and a steering group workshop informed the development of draft symptom and syndrome-based statements. We then tested and refined the draft statements and supporting evidence using a three-stage modified online Delphi study, incorporating a multidisciplinary expert panel with a broad range of clinical specialties.

Results

Twenty-eight experts completed the Delphi process. All statements achieved consensus with a final agreement between 88.5%–96.5%. Five ‘impact statements’ conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty.

Conclusion

Clear, consistent messaging on risk across healthcare will improve people living with LTCs confidence to be physically active. Addressing the fear of adverse events on an individual level will help healthcare professionals affect meaningful behavioural change in day-to-day practice. Evidence does not support routine preparticipation medical clearance for people with stable LTCs if they build up gradually from their current level. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms. As part of a system-wide approach, consistent messaging from healthcare professionals around risk will also help reduce cross-sector barriers to engagement for this population.

Physical activity on prescription in patients with hip or knee osteoarthritis: A randomized controlled trial

OBJECTIVE

To evaluate whether physical activity on prescription, comprising five sessions, was more effective in increasing physical activity than a one-hour advice session after six months.

DESIGN

Randomized, assessor-blinded, controlled trial.

SETTING

Primary care.

SUBJECTS

Patients with clinically verified osteoarthritis of the hip or knee who undertook less than 150 minute/week of moderate physical activity, and were aged 40-74 years.

INTERVENTIONS

The advice group (n = 69) received a one-hour session with individually tailored advice about physical activity. The physical activity on prescription group (n = 72) received individually tailored physical activity recommendations with written prescription, and four follow-ups during six months.

MAIN MEASURES

Patients were assessed at baseline and six months: physical activity (accelerometer, questionnaires); fitness (six-minute walk test, 30-second chair-stand test, maximal step-up test, one-leg rise test); pain after walking (VAS); symptoms (HOOS/KOOS); and health-related quality of life (EQ-5D).

RESULTS

One hundred four patients had knee osteoarthritis, 102 were women, and mean age was 60.3 ± 8.3 years. Pain after walking decreased significantly more in the prescription group, from VAS 31 ± 22 to 18 ± 23. There was no other between groups difference. Both groups increased self-reported activity minutes significantly, from 105 (95% CI 75-120) to 165 (95% CI 135-218) minute/week in the prescription group versus 75 (95% CI 75-105) to 150 (95% CI 120-225) in the advice group. Also symptoms and quality of life improved significantly in both groups.

CONCLUSION

Individually tailored physical activity with written prescription and four follow-ups does not materially improve physical activity level more than advice about osteoarthritis and physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02387034).

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

The effects of race/ethnicity and physician recommendation for physical activity on physical activity levels and arthritis symptoms among adults with arthritis

BACKGROUND

Among U.S. adults with physician-diagnosed arthritis, we examined the association of 1) participant race/ethnicity with meeting physical activity guidelines and arthritis symptoms, and 2) the association of receipt of a physician exercise recommendation with physical activity levels and arthritis symptoms, and whether race/ethnicity moderates these associations.

METHODS

Retrospective, cross-sectional study of National Health Interview Survey pooled data from 2002, 2006, 2009, and 2014 from 27,887 U.S. adults aged ≥18 years with arthritis. Outcomes were meeting aerobic (yes/no) and strengthening guidelines (yes/no), arthritis-associated activity limitations (yes/no) and arthritis-related pain (0-10; higher score = more pain). Predictors were race/ethnicity (White, African American, Latino, and Asian) and receipt of physician recommendation for exercise (yes/no). Covariates included demographic and health characteristics.

RESULTS

Adjusting for covariates, African Americans were more likely (AOR = 1.27; 95% CI 1.12, 1.43) and Asians were less likely (AOR = 0.75; 95% CI 0.61, 0.92) than Whites to meet muscle strengthening activity guidelines. Compared to Whites, African Americans (B = 0.48; 95% CI 0.24, 0.72) and Latinos (B = 0.44; 95% CI 0.15, 0.72) reported more severe, while Asians reported less severe (B = -0.68; 95% CI -1.22, - 0.14) joint pain. Controlling for covariates, physician exercise recommendation was associated with meeting aerobic (AOR = 1.20; 95% CI 1.11, 1.30) and strengthening (AOR = 1.21; 95% CI 1.11, 1.33) guidelines, regardless of race/ethnicity except for a weak negative association with meeting strengthening guidelines (AOR = 0.85; CI 0.74-0.99) among Latinos.

CONCLUSIONS

Disparities in pain exist for African Americans and Latinos with arthritis. Physician exercise recommendation is critical among patients with arthritis to relieve symptom burden.

Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review

OBJECTIVE

Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use.

METHODS

A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded.

RESULTS

After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA.

CONCLUSION

Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.

'Function First': how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods

OBJECTIVES

To develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory.

DESIGN

Realist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation.

RESULTS

A taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions.

ABRIDGED REALIST PROGRAMME THEORY

Routinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy.

CO-DESIGN

The programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change.

CONCLUSIONS

Previous physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

Mesenchymal Stem Cells: Current Concepts in the Management of Inflammation in Osteoarthritis

Osteoarthritis (OA) has traditionally been known as a “wear and tear” disease, which is mainly characterized by the degradation of articular cartilage and changes in the subchondral bone. Despite the fact that OA is often thought of as a degenerative disease, the catabolic products of the cartilage matrix often promote inflammation by activating immune cells. Current OA treatment focuses on symptomatic treatment, with a primary focus on pain management, which does not promote cartilage regeneration or attenuate joint inflammation. Since articular cartilage have no ability to regenerate, thus regeneration of the tissue is one of the key targets of modern treatments for OA. Cell-based therapies are among the new therapeutic strategies for OA. Mesenchymal stem cells (MSCs) have been extensively researched as potential therapeutic agents in cell-based therapy of OA due to their ability to differentiate into chondrocytes and their immunomodulatory properties that can facilitate cartilage repair and regeneration. In this review, we emphasized current knowledge and future perspectives on the use of MSCs by targeting their regeneration potential and immunomodulatory effects in the treatment of OA.

Experts prioritize osteoarthritis non-surgical interventions from Cochrane systematic reviews for translation into "Evidence4Equity" summaries

OBJECTIVE

Osteoarthritis generates substantial health and socioeconomic burden, which is particularly marked in marginalized groups. It is imperative that practitioners have ready access to summaries of evidence-based interventions for osteoarthritis that incorporate equity considerations. Summaries of systematic reviews can provide this. The present study surveyed experts to prioritize a selection ofinterventions, from which equity focused summaries will be generated. Specifically, the prioritized interventions will be developed into Cochrane Evidence4Equity (E4E) summaries.

METHODS

Twenty-seven systematic reviews of OA interventions were found. From these, twenty-nine non-surgical treatments for osteoarthritis were identified, based on statistically significant findings for desired outcome variables or adverse events. Key findings from these studies were summarised and provided to 9 experts in the field of osteoarthritis.. Expert participants were asked to rate interventions based on feasibility, health system effects, universality, impact on inequities, and priority for translation into equity based E4E summaries. Expert participants were also encouraged to make comments to provide context for each rating. Free text responses were coded inductively and grouped into subthemes and themes.

RESULTS

Expert participants rated the intervention home land-based exercise for knee OA highest for priority for translation into an E4E summaries, followed by the interventions individual land-based exercise for knee OA, class land-based exercise for knee OA, exercise for hand OA and land-based exercise for hip OA. Upon qualitative analysis of the expert participants' comments, fifteen subthemes were identified and grouped into three overall themes: (1) this intervention or an aspect of this intervention is unnecessary or unsafe; (2) this intervention or an aspect of this intervention may increase health inequities; and (3) experts noted difficulties completing rating exercise.

CONCLUSION

The list of priority interventions and corresponding expert commentary generated information that will be used to direct and support knowledge translation efforts.

The quality of intervention reporting in trials of therapeutic exercise for hip osteoarthritis: a secondary analysis of a systematic review

BACKGROUND

Therapeutic exercise is recommended as a core treatment for hip osteoarthritis (HOA). Whilst it is widely accepted that exercise can improve pain and disability, optimal type and dose of exercise are yet to be agreed upon. This may, in part, be attributed to the wide variation and inadequate reporting of interventions within the literature. This study evaluates the quality of intervention reporting among trials of therapeutic exercise in HOA.

METHODS

Randomised controlled trials (RCTs) were sourced in a systematic review, completed in August 2020. Two raters independently used the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT) to evaluate intervention reporting. Correlations between quality assessment scores and CERT and TIDieR scores evaluated the relationship between internal validity and external applicability. The year of publication was compared to the quality of reporting scores.

RESULTS

Fourteen RCTs were included in the analysis. On average, studies were awarded 9.43 ± 1.95 out of 12 points for the TIDieR checklist (range 4-12) and 13.57 ± 4.01 out of 19 points for the CERT (range 5-19). Pearson's correlation coefficient suggested that the quality of reporting had improved over time and that there was a fair, positive relationship between internal validity and external applicability.

DISCUSSION

Whilst the quality of intervention reporting is improving, many RCTs of therapeutic exercise in HOA lack the detail necessary to allow accurate evaluation and replication. Researchers are encouraged to utilise the standardised reporting guidelines to increase the translation of effective interventions into clinical practice.

Prognostic Factors for Health Outcomes After Exercise Therapy and Education in Individuals With Knee and Hip Osteoarthritis With or Without Comorbidities: A Study of 37,576 Patients Treated in Primary Care

OBJECTIVE

To identify prognostic factors for health outcomes following an 8-week supervised exercise therapy and education program for individuals with knee and hip osteoarthritis (OA) alone or with concomitant hypertension, heart or respiratory disease, diabetes mellitus, or depression.

METHODS

We included individuals with knee and/or hip OA from the Good Life With OsteoArthritis in Denmark (GLA:D) program. GLA:D consists of 2 patient education sessions and 12 supervised exercise therapy sessions. Before GLA:D, participants self-reported any comorbidities and were categorized into 8 comorbidity groups. Twenty-one potential prognostic factors (demographic information, clinical data, and performance-based physical function) gathered from participants and clinicians before the program were included. Outcomes were physical function using the 40-meter Fast-Paced Walk Test (FPWT), health-related quality of life using the 5-level EuroQol 5-domain (EQ-5D-5L) index score, and pain intensity using a visual analog scale (VAS; range 0-100) assessed before and immediately after the GLA:D program. Within each comorbidity group, associations of prognostic factors with outcomes were estimated using multivariable linear regression.

RESULTS

Data from 35,496 (40-meter FPWT) and 37,576 (EQ-5D-5L and VAS) participants were included in the analyses. Clinically relevant associations were demonstrated between age, self-efficacy, self-rated health, and pain intensity and change in 40-meter FPWT, EQ-5D-5L, or VAS scores across comorbidity groups. Furthermore, anxiety, education, physical function, and smoking were associated with outcomes among subgroups having depression or diabetes mellitus in addition to OA.

CONCLUSION

Age, self-efficacy, self-rated health, and pain intensity may be prognostic of change in health outcomes following an 8-week exercise therapy and patient education program for individuals with OA, irrespective of comorbidities.

Aerobic capacity and fatigability are associated with activity levels in women with hip osteoarthritis

Physical activity is important for physical function and pain relief in people with lower extremity osteoarthritis (OA). Unfortunately, people with OA are not as active as their peers without OA. The objective of this study was to determine whether aerobic capacity and fatigability are associated with physical activity in women with hip OA. We conducted a cross-sectional analysis of 36 women with hip OA. We assessed aerobic fitness as predicted VO₂ max from a 6-min walk test. We assessed fatigability using a treadmill test. Finally, we assessed self-reported physical activity using the UCLA activity scale and quantified steps per day and activity intensity using accelerometers. We used Pearson correlations to determine associations. We used regression analysis to determine whether fatigability mediated the association between aerobic fitness and physical activity. On average, subjects were moderately active via the UCLA score (5.2 ± 1.3 out of 10). Aerobic fitness (R = 0.582, p < .001) and fatigability (R = 0.516, p =.003) were significantly correlated with UCLA scores. However, aerobic fitness was the best predictor of UCLA scores, as well as sedentary time, and time spent in light activity. Fatigability was not a mediator between aerobic fitness and UCLA scores. Aerobic fitness and fatigability may be modifiable barriers to physical activity in people with OA. Future interventional studies should examine whether improving aerobic fitness improves physical activity or fatigability.

Willingness to Undergo Joint Surgery Following a First-Line Intervention for Osteoarthritis: Data From the Better Management of People With Osteoarthritis Register

OBJECTIVE

To assess the proportion of participants reconsidering their willingness to undergo surgery after 3 and 12 months. Secondary aims were to analyze and compare the characteristics of individuals willing and unwilling to undergo joint surgery for osteoarthritis (OA) before a first-line intervention, and to study the association between pain intensity, walking difficulties, self-efficacy, and fear of movement with the willingness to undergo surgery.

METHODS

This was an observational study based on Swedish register data. We included 30,578 individuals with knee or hip OA who participated in a first-line intervention including education and exercise.

RESULTS

Individuals willing to undergo surgery at baseline showed a higher proportion of men (40% versus 27%) and more severe symptoms and disability. Respectively, 45% and 30% of the individuals with knee and hip OA who were willing to undergo surgery at baseline became unwilling after the intervention. At the end of the study period (12 months), 35% and 19% of those with knee and hip OA, respectively, who were willing to undergo surgery at baseline became unwilling. High pain intensity, walking difficulties, and fear of movement were associated with higher odds of being willing to undergo surgery at both follow-ups, while increased self-efficacy showed the opposite association.

CONCLUSION

A first-line intervention for OA is associated with reduced willingness to undergo surgery, with a greater proportion among patients with knee OA than hip OA. Due to its temporal variability, willingness to undergo surgery should be used with care to deem surgery eligibility.

The Effects of Visuomotor Training on the Functional Recovery of Post-Surgery Musculoskeletal Conditions: A Randomized Controlled Trial

(1) Background: Musculoskeletal conditions show increasing prevalence and high economic/human burden. Recovery for hip or knee surgery may require more than 26 weeks, while universally accepted rehabilitation guidelines are missing. Provided that multisensory-based training enhances motor learning, the study aims to verify if visuomotor training accelerates the recovery of lower limb motor function after orthopedic surgery. (2) Methods: Post-surgery subjects were randomly assigned to receive visuomotor training as an add-on to the conventional physical therapy (VTG), or receive the conventional therapy alone (CG). Subjects performed 40 one-hour training sessions in 8 weeks. The primary endpoint was the improvement in the Lower Extremity Functional Scale (LEFS) over the minimally clinical important difference (MCID) at 4 weeks post-randomization. The secondary endpoint included pain reduction. (3) Results: Eighteen patients were equally distributed into the VTG and CG groups. While LEFS and pain scores significantly improved in both groups, the VTG exceeded the LEFS MCID by 12 points and halved the pain value after the first 4 weeks of treatment, while the CG reached the endpoints only after treatment end (p = 0.0001). (4) Conclusions: Visuomotor training offers an innovative rehabilitation approach that accelerates the recovery of lower limb motor function in patients undergoing orthopedic surgery.

Immediate outcomes following the GLA:D® program in Denmark, Canada and Australia. A longitudinal analysis including 28,370 patients with symptomatic knee or hip osteoarthritis

OBJECTIVE

To report outcomes across three countries for patients with symptomatic knee or hip OA attending the evidence-based education and exercise therapy program Good Life with osteoArthritis from Denmark (GLA:D®).

DESIGN

GLA:D® is a structured treatment program including 2-3 patient education sessions and 12 supervised exercise sessions delivered over 8 weeks by certified health care practitioners. The program was introduced in Denmark in 2013, in Canada 2015 and in Australia 2016. Absolute mean change in pain intensity, number of chair stands in 30 s, 40 m walk test time and Knee injury and Osteoarthritis Outcome Score (KOOS)/Hip dysfunction and Osteoarthritis Outcome Score (HOOS) QOL subscale scores from baseline to immediately after treatment were reported as means and 95 % CIs and proportion of responders for each country.

RESULTS

Patients from the three countries improved 26-33% in mean pain intensity, 8-12% in walking speed, 18-30% in chair stand ability and 12-26% in joint-related quality of life from baseline to immediately after treatment, with no clinically relevant differences between patients with hip and knee OA. These improvements correspond with moderate to large within-group effect sizes and 43-47 % of the patients experienced clinically relevant pain reductions.

CONCLUSION

About half or more of patients across the three countries were categorized as responders for pain and objective function following the implementation of GLA:D®. These findings indicate positive patient outcomes associated with GLA:D® participation across varying health care systems from implementation of guideline-based patient education and exercise therapy for knee and hip OA.

Associations between comorbidities and immediate and one-year outcomes following supervised exercise therapy and patient education - A cohort study of 24,513 individuals with knee or hip osteoarthritis

OBJECTIVE

To investigate if comorbidities are associated with change in health outcomes following an 8-week exercise and education program in knee and hip osteoarthritis (OA).

METHODS

We included 24,513 individuals with knee or hip OA from the Good Life with osteoArthritis in Denmark (GLA:D®). GLA:D® consists of two patient education sessions and 12 supervised exercise sessions. Before the program, individuals self-reported having one or more of 11 common comorbidities. Physical function was assessed using the 40-m Fast-Paced Walk Test (FPWT, m/sec) before and immediately after the program. Pain intensity and health-related quality of life was self-reported before, immediately after, and at 12 months post-intervention using a visual analogue scale (VAS, 0-100) and the EQ-5D-5L index (-0.624 to 1.000), respectively. Associations of comorbidity combinations with change in outcomes immediately and at 12 months was estimated using mixed linear regression.

RESULTS

Individuals with OA improved on average 0.12 m/s (95%CI 0.12 to 0.13) in 40-m FPWT, -12.7 mm (95%CI -13.2 to -12.2) in VAS, and 0.039 (95%CI 0.036 to 0.041) in EQ-5D-5L from before to immediately after the intervention with minor additional improvements at 12 months. Despite that individuals with comorbidities had worse baseline scores in all outcomes than individuals without comorbidities, they had similar levels of improvement immediately and 12 months after the intervention.

CONCLUSION

Comorbidities are not associated with worse nor better health outcomes following an 8-week exercise and education program in individuals with OA, suggesting exercise as a viable treatment option for individuals with OA, irrespective of comorbidities.

A SYSTEMATIC REVIEW AND META-ANALYSIS OF COMMON THERAPEUTIC EXERCISES THAT GENERATE HIGHEST MUSCLE ACTIVITY IN THE GLUTEUS MEDIUS AND GLUTEUS MINIMUS SEGMENTS

Background

The gluteus medius (GMed) and gluteus minimus (GMin) muscle segments demonstrate different responses to pathology and ageing, hence it is important in rehabilitation that prescribed therapeutic exercises can effectively target the individual segments with adequate exercise intensity for strengthening.

Purpose

The purpose of this systematic review was to evaluate whether common therapeutic exercises generate at least high ( > 40% maximum voluntary isometric contraction (MVIC)) electromyographic (EMG) activity in the GMed (anterior, middle and posterior) and GMin (anterior and posterior) segments.

Methods

Seven databases (MEDLINE, EMBASE, CINAHL, AusSPORT, PEDro, SPORTdiscus and Cochrane Library) were searched from inception to May 2018 for terms relating to gluteal muscle, exercise, and EMG. The search yielded 6918 records with 56 suitable for inclusion. Quality assessment, data extraction and data analysis were then undertaken with exercise data pooled into a meta-analysis where two or more studies were available for an exercise and muscle segment.

Results

For the GMed, different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all segments. The dip test, and isometric standing hip abduction are other options to target the anterior GMed segment, while isometric standing hip abduction can be used for the posterior GMed segment. For the middle GMed segment, the single leg bridge; side-lying hip abduction with hip internal rotation; lateral step-up; standing hip abduction on stance or swing leg with added resistance; and resisted side-step were the best options for generating at least high activity. Standing isometric hip abduction and different variations of the hip hitch/ pelvic drop exercise generated at least high activity in all GMin segments, while side-lying hip abduction, the dip test, single leg bridge and single leg squat can also be used for targeting the posterior GMin segment.

Conclusion

The findings from this review provide the clinician with confidence in exercise prescription for targeting individual GMed and GMin segments for potential strengthening following injury or ageing.

Level of Evidence

Level 1.

What is known about the subject

Previous reviews on GMed exercises have been based on single electrode, surface EMG measures at middle GMed segment. It is not known whether these exercises effectively target the other segments of GMed or the GMin at a sufficient intensity for strengthening.

What this study adds to existing knowledge

This review provides the clinician with confidence in exercise prescription of common therapeutic exercises to effectively target individual GMed and GMin segments for potential strengthening.

Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews

BACKGROUND

Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes.

METHODS

Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised.

RESULTS

Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions.

CONCLUSION

There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns.

TRIAL REGISTRATION

Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.

Responders to Exercise Therapy in Patients with Osteoarthritis of the Hip: A Systematic Review and Meta-Analysis

The Outcome Measures in Rheumatology workgroup (OMERACT), together with the Osteoarthritis Research Society International (OARSI) developed the OMERACT-OARSI responder criteria. These criteria are used to determine if a patient with osteoarthritis (OA) 'responds' to therapy, meaning experiences a clinically relevant effect of therapy. Recently, more clinical OA trials report on this outcome and most OA trials have data to calculate the number of responders according to these criteria. A systematic review and meta-analysis were performed on the response to exercise therapy, compared to no or minimal intervention in patients with hip OA using the OMERACT-OARSI responder criteria. The literature was searched for relevant randomized trials. If a trial fit the inclusion criteria, but number of responders was not reported, the first author was contacted. This way the numbers of responders of 14 trials were collected and a meta-analysis on short term (directly after treatment, 12 trials n = 1178) and long term (6-8 months after treatment, six trials n = 519) outcomes was performed. At short term, the risk difference (RD) was 0.14 (95% confidence interval (CI) 0.06-0.22) and number needed to treat (NNT) 7.1 (95% CI 4.5-17); at long term RD was 0.14 (95% CI 0.07-0.20) and NNT 7.1 (95% CI 5.0-14.3). Quality of evidence was moderate for the short term and high for the long term. In conclusion, 14% more hip OA patients responded to exercise therapy than to no therapy.

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee and/or hip osteoarthritis: protocol for a systematic review and meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) and knee and hip osteoarthritis (OA) are prevalent conditions in the aging population and published literature suggests they share many symptoms and often are present at the same time in patients. However, no prevalence estimates of multimorbid LSS and knee and/or hip OA are currently available. The primary objective of this systematic review is therefore to estimate the prevalence of multimorbid LSS with knee and/or hip OA using radiological, clinical, and combined case definitions.

METHODS

This systematic review protocol has been designed according to the guidelines from the Cochrane Collaboration and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. A comprehensive search will be performed in the following databases: MEDLINE, EMBASE, CENTRAL, and CINAHL. Forward citation tracking will be performed in Web of Science. No restriction for publication date and language will be applied in the literature search, but only articles in English will be included. The search strategy will include the following domains: LSS, knee OA, and hip OA. Retrieved citations will be screened by two authors independently. Disagreements will be discussed until consensus, and a third reviewer will be consulted if consensus cannot be reached. Data extraction and assessment of risk of bias assessment will be done by two authors independently, using a standardized data extraction form and a modified risk of bias tool for prevalence studies. Meta-analysis estimating prevalence with 95% CI will be performed using a random effects model. Meta-regression analyses will be performed to investigate the impact of the following covariates: LSS clinical presentations, sample population, healthcare setting, risk of bias, and other patient characteristics on prevalence estimates for multimorbid LSS and knee and/or hip OA.

DISCUSSION

The results of this review will provide the first estimates of the prevalence of multimorbid LSS and hip and knee OA based on various case definitions. The impact of covariates such as LSS clinical presentations, sample population, healthcare setting, risk of bias, and patient characteristics on prevalence estimates will also be presented.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, awaiting registration.

A Review of Non-Surgical Pain Management in Osteoarthritis

Osteoarthritis is a prominent cause of disability in older adults, especially with an increasingly obese and aging population. Clinical management of pain secondary to osteoarthritis should focus on education and self-management with exercise and weight management as a priority. Surgical intervention should only be considered once conservative measures have failed. This review provides a clinical update on the pathogenesis, diagnosis, and management of osteoarthritis.

Systematic review of economic evaluations investigating education, exercise, and dietary weight management to manage hip and knee osteoarthritis: protocol

BACKGROUND

International guidelines recommend education, exercise, and dietary weight management as core treatments to manage osteoarthritis (OA) regardless of disease severity or co-morbidity. Evidence supports the clinical effectiveness of OA management programs, but the cost-effectiveness of core treatments remains unclear. We will systematically review, synthesize, and assess the literature in economic evaluations of core treatments (education, exercise, and dietary weight management) for the management of hip and/or knee OA.

METHODS

We will search the following elecftronic databases (from inception onwards): MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), National Health Services Economic Evaluation Database, and EconLit. Economic evaluations alongside randomized or nonrandomized clinical trials investigating OA education, exercise, and dietary weight management interventions will be included. Title, abstract, and full text of relevant publications will be screened independently by two reviewers. A content matter expert will resolve any conflicts between two reviewers. Key information from relevant papers will be extracted and tabulated to provide an overview of the published literature. Methodological quality will be evaluated using the Consensus on Health Economic Criteria list. A narrative synthesis without meta-analysis will be conducted. Subgroup analysis will attempt to find trends between research methods, intervention characteristics, and results.

DISCUSSION

The findings of this review will evaluate the breadth and quality of economic evaluations conducted alongside clinical trials for core treatments in OA management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020155964.

Musculoskeletal pain reported by mobile patients with chronic kidney disease

BACKGROUND

Musculoskeletal pain has been reported as a clinical problem in patients with chronic kidney disease (CKD). The purpose of this study was to compare the frequency of musculoskeletal pain in patients with CKD and no mobility problems with a general population and to investigate the impact of pain on quality of life (QOL), physical activity and physical function.

METHODS

Patients with CKD Stages 4 and 5 with or without a dialysis treatment and no mobility problems were included. Musculoskeletal pain in the shoulder/neck, back/low back and limbs and level of physical activity were measured using the Danish Health and Morbidity Survey and coded into dichotomous answers. QOL and physical function were measured using the kidney disease QOL questionnaire and the 30-s chair stand test, respectively. Data for the general population were collected in national registers and adjusted for age, gender and region.

RESULTS

The patients (n = 539) had a mean age of 66 [95% confidence interval (CI) 65-67] years, 62% were men and they were treated with haemodialysis (HD) (n = 281), peritoneal dialysis (n = 62) or without dialysis (n = 196). The frequency of reported musculoskeletal pain in the patients did not exceed pain reported by the general population [e.g. pain in the limbs in patients undergoing HD versus a matched general population, 61% versus 63% (P = 0.533), respectively]. Pain in all measured body sites was associated with reduced QOL [e.g. pain in the limbs associated with a physical component scale β of -8.2 (95% CI -10.3 to -6.0), P < 0.001]. Pain in the limbs was associated with a reduced number of repetitions in the 30-s chair stand test [mean -1.7 (95% CI -3.0 to -0.4), P = 0.009]. Pain in the shoulder/neck was associated with reduced odds of being physically active [odds ratio 0.6 (95% CI 0.4 to 0.9); P = 0.022].

CONCLUSIONS

Musculoskeletal pain was not more frequently reported by patients with CKD and no mobility problems compared with the general population. However, as musculoskeletal pain was reported by up to two-thirds of the patient sample, healthcare professionals should remember to focus on this issue. The patients' pain was associated with negative impacts on QOL, level of physical activity and physical function.

The Active with OsteoArthritis (AktivA) Physiotherapy Implementation Model: A Patient Education, Supervised Exercise and Self-Management Program for Patients with Mild to Moderate Osteoarthritis of the Knee or Hip Joint. A National Register Study with a Two-Year Follow-Up

BACKGROUND

Recent systematic reviews and international guidelines recommend patient education, exercises, and weight control (if overweight) as first-line treatment for patients with hip or knee osteoarthritis (OA). The Active with osteoArthritis (AktivA) program is a physiotherapy model for the implementation of these guidelines into clinical primary care practice. The purpose of the present study was to evaluate the long-term effects of and adherence to the AktivA program for patients with mild to moderate knee or hip OA.

METHODS

The AktivA program includes three modules: a physiotherapy certification course, a patient education and exercise program and an electronic quality register. An electronic questionnaire including questions about, pain, quality of life, physical activity, self-efficacy and satisfaction with the AktivA program are sent to the participants at inclusion and after 3, 12 and 24 months. A linear mixed model for repeated measurements was used to assess the difference between the follow-up times.

RESULTS

Until January 2020, 6245 patients were included in the register. The response rates were 98%, 86% and 63% at 3, 12 and 24 months, respectively. After participating in the AktivA program, the patients reported decreased pain and increased health-related and disease-specific quality of life at three months and the positive effect was maintained up to two years after inclusion. The proportion of patients reporting to be inactive or having a low physical activity level was reduced from 43% to 22%. After two years, more than 80% of the participants reported to use what they have learned from the AktivA program at least once a week.

CONCLUSIONS

Two years after inclusion in the AktivA physiotherapy program, the patients still report reduced pain, increased quality of life and higher activity levels.

Patients use fewer analgesics following supervised exercise therapy and patient education: an observational study of 16 499 patients with knee or hip osteoarthritis

OBJECTIVES

To investigate changes in analgesic use before and after supervised exercise therapy and patient education in patients with knee or hip osteoarthritis (OA).

METHODS

We recruited 16 499 of 25 933 eligible patients (64%; mean age 64.9; SD 9.6; 73% women) from the Good Life with osteoArthritis in Denmark (GLA:D) registry. Change in proportions of analgesic users (categorised according to analgesic risk profile; opioids > non-steroidal anti-inflammatory drugs > paracetamol) was assessed from before to after an 8-week supervised exercise therapy and patient education programme targeting knee or hip OA pain and functional limitations.

RESULTS

Patients reported 13.2 mm (95% CI 12.8 to 13.6) less pain (visual analogue scale 0-100 mm) at follow-up compared with baseline. The proportion of analgesic users reduced from 62.2% (95% CI 61.5 to 63.0) at baseline to 44.1% (95% CI 43.3 to 44.9) at follow-up (absolute change: 18.1% (95% CI 17.3 to 19.0)). Among patients using analgesics at baseline, 52% changed to a lower risk analgesic or discontinued analgesic use. The proportion of opioid users after the exercise therapy was 2.5% (95% CI 2.1 to 2.9) lower than baseline; this represents a relative reduction of 36%.

CONCLUSION

Among patients with knee or hip OA using analgesics, more than half either discontinued analgesic use or shifted to lower risk analgesics following an 8-week structured exercise therapy and patient education programme (GLA:D). These data encourage randomised controlled trial evaluation of whether supervised exercise therapy, combined with patient education, can reduce analgesic use, including opioids, among patients with knee and hip OA pain.

The Applicability of a High-Intensity Functional Exercise Program Among Older People With Dementia Living in Nursing Homes

Exercise programs for people with dementia need to be optimized. We therefore evaluated the applicability of a high-intensity functional exercise program among people with dementia in nursing homes with regard to attendance, achieved exercise intensity, adverse events, a focus on dementia type, and whether symptoms of dementia or other medical conditions common in this population were associated with program applicability.

Factors Associated With the Outcome of a First-Line Intervention for Patients With Hip or Knee Osteoarthritis or Both: Data From the BOA Register

OBJECTIVE

This study explored the association of patients' demographics, health status, symptom severity, previous osteoarthritis (OA) care, and psychological status with the change in pain severity following a first-line intervention including education and exercise for OA provided nationwide in Swedish primary care.

METHODS

This register-based cohort study included 23,309 people with knee or hip OA from the Better Management of Patients with OA register. Linear regression models were used to assess the association of independent variables with the change in pain from baseline to 3 and 12 months. All the analyses were stratified based on the affected joint (hip vs knee).

RESULTS

In people with hip and people with knee OA, high levels of baseline pain were associated with decreased pain at both follow-ups (3 months: knee B = -.67; hip B = -.64; 12 months: knee B = -.70; hip B = -.66), whereas being older, overweight, or female had a weak or no association. Finally, at both follow-ups, bilateral OA was associated with increased pain only in people with knee OA, whereas comorbidities and the willingness to undergo surgery were associated with increased pain regardless of the affected joint.

CONCLUSIONS

Baseline pain showed the strongest association among the analyzed variables, whereas sex, age, and body mass index appear to be weakly associated with the pain change after a first-line intervention. Comorbidities and willingness to undergo surgery showed a potentially important association and may have a negative impact on the pain change following a first-line intervention.

IMPACT

In people with hip or knee OA, age, sex, body mass index, and previous surgery are only weakly associated with the change in pain after a first-line intervention supporting the evidence recommending exercise and education as a foundation for all OA therapy. Having comorbidities and being willing to undergo surgery is associated with a worse outcome from a first-line intervention, including exercise and education. Individualized treatments addressing the disease perception and the specific comorbidity profile may improve the outcomes.

Irisin Recovers Osteoarthritic Chondrocytes In Vitro

Physical exercise favors weight loss and ameliorates articular pain and function in patients suffering from osteoarthritis. Irisin, a myokine released upon muscle contraction, has demonstrated to yield anabolic effects on different cell types. This study aimed to investigate the effect of irisin on human osteoarthritic chondrocytes (hOAC) in vitro. Our hypothesis was that irisin would improve hOAC metabolism and proliferation. Cells were cultured in growing media and then exposed to either phosphate-buffered saline (control group) or human recombinant irisin (experimental group). Cell proliferation, glycosaminoglycan content, type II/X collagen gene expression and protein quantification as well as p38/extracellular signal-regulated kinase (ERK) mitogen-activated protein kinase (MAPK), protein kinase B (Akt), c-Jun N-terminal kinase (JNK), and nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB) involvement were evaluated. Furthermore, gene expression of interleukin (IL)-1 and -6, matrix metalloproteinase (MMP)-1 and -13, inducible nitric oxide synthase (iNOS), and tissue inhibitor of matrix metalloproteinases (TIMP)-1 and -3 were investigated following irisin exposure. Irisin increased hOAC cell content and both type II collagen gene expression and protein levels, while decreased type X collagen gene expression and protein levels. Moreover, irisin decreased IL-1, IL-6, MMP-1, MMP-13 and iNOS gene expression, while increased TIMP-1 and TIMP-3 levels. These effects seemed to be mediated by inhibition of p38, Akt, JNK and NFκB signaling pathways. The present study suggested that irisin may stimulate hOAC proliferation and anabolism inhibiting catabolism through p38, Akt, JNK, and NFκB inactivation in vitro, demonstrating the existence of a cross-talk between muscle and cartilage.

Patient and care partner views on exercise and structured physical activity for people with Progressive Supranuclear Palsy

INTRODUCTION

Progressive Supranuclear Palsy (PSP) is a debilitating form of atypical Parkinsonism. People living with PSP experience movement disorders affecting walking, balance and eye movements. The role of exercise in optimising movement remains unclear.

AIMS

To identify beliefs about exercise and structured physical activity through the experience of people with PSP.

METHODS

Using a phenomenological theoretical framework, qualitative methods were employed to obtain the views of people living with PSP, and their care partners, by in-depth interviews. Questions derived from a systematic review and expert opinions guided the interviews which were audio-recorded, transcribed and de-identified. Two researchers independently conducted thematic analysis and reached consensus on emerging themes.

RESULTS

There were 16 participants. Four themes were identified: (i) there are beliefs and preferences about exercise and physical activity that can impact on engagement; (ii) difficulty coping with disease progression impacts activities; (iii) facilitators to exercise include individual preferences, access to facilities and expert advice; and (iv) perceived barriers include beliefs about limited exercise options, falls risk, cost, transport and access to credible information.

DISCUSSION

People living with PSP want early guidance about the condition and the role of exercise. It is important to quickly enable people to have access to evidence and resources supporting exercise and structured physical activities. Consideration of individual preferences and access to expert advice facilitate engagement. Individual barriers need to be identified and solutions found.

CONCLUSION

People living with PSP are amenable to exercise, especially early in the disease process. Clear guidelines are warranted to document which exercises, and physical activities are most beneficial.

The association between comorbidity and physical activity levels in people with osteoarthritis: Secondary analysis from two randomised controlled trials

Objective

To determine whether comorbidity presence, frequency or type is associated with Physical Activity (PA) levels in people with Osteoarthritis (OA).

Design

Secondary data analysis of adults aged ≥45, with OA related pain recruited to the BEEP trial (knee pain, n = 514) (ISRCTN93634563) and the MOSAICS trial (peripheral joint pain, n = 525) (ISRCTN06984617). Comorbidities considered were respiratory, cardiovascular diseases (CVD), depression, type 2 diabetes and obesity. Self-report PA was measured using the Physical Activity Scale for the Elderly (PASE). Linear regression models were used to estimate the mean change (β) in PA with comorbidity presence, frequency and type adjusting for potential confounding covariates.

Results

In the BEEP trial comorbidity presence was associated with a decrease in PASE score (β = -32.25 [95% confidence interval (95% CI) −48.57, −15.93]). Each additional comorbidity was associated with an incrementally lower PASE score, one comorbidity (β = −24.42 [-42.45, −6.38]), two comorbidities β = −34.76 [-56.05, −13.48]), and three or more comorbidities β = −73.71 [-106.84, −40.58]) compared to those with no comorbidity. This pattern was similar in MOSAICS, but with a plateau in association from two comorbidities onward. In BEEP and MOSAICS, respiratory (β = −40.60 [-60.50, −20.35]; β = −11.82 [-34.95, 11.31]) and CVD (β = −27.15 [-53.25, −1.05]; β = −30.84 [-51.89, −9.80]) comorbidities were associated with the largest reduction in PASE scores respectively.

Conclusion

Comorbidity presence and frequency is associated with lower PA levels and respiratory and CVD comorbidities have the greatest impact. Future exploratory work needs to be done to understand how and why comorbidity is associated with PA levels in people with OA.

Low adherence to exercise may have influenced the proportion of OMERACT-OARSI responders in an integrated osteoarthritis care model: secondary analyses from a cluster-randomised stepped-wedge trial

BACKGROUND

To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model.

METHODS

The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8-12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0-10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group.

RESULTS

Two hundred eighty-four intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (OR_adjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders.

CONCLUSIONS

The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02333656. Registered 7. January 2015.

Improving osteoarthritis care by digital means - Effects of a digital self-management program after 24- or 48-weeks of treatment

Background

Osteoarthritis (OA) is highly prevalent in older adults and a growing cause of disability. Easily accessible first-line treatment of OA is increasingly important. Digital self-management programs have in recent years become available. Evidence of short-term effects of such programs are abundant, yet reports on long-term benefits and adherence to treatment are scarce. The current study’s objective was to investigate the long-term pain and function outcomes of people with hip or knee OA participating in a digital self-management programme.

Methods and findings

In this longitudinal cohort study, individuals with hip and knee OA, from the register of a digital self-management program and with 0-24-week (n = 499) or 0-48-week adherence (n = 138), were included. The treatment effect in terms of monthly pain (NRS, 0–10 worst to best) and physical function (30-second chair stand test (30CST), number of repetitions) change were investigated using a mixed model, controlling for the effect of age, body mass index (BMI), gender and index joint. For the 24-week sub-sample, pain NRS decreased monthly by -0.43 units (95% CI -0.51, -0.35, mean knee pain from 5.6 to 3.1, and hip pain from 5.9 to 3.8) and 30CST repetitions increased monthly by 0.76 repetitions (95% CI 0.64, 0.89 mean for knee from 10.0 to 14.3, and for hip from 10.9 to 14.8). For the 48-week sub-sample, pain decreased monthly by -0.39 units (95% CI -0.43, -0.36, mean knee pain from 5.7 to 3.2, and hip pain from 5.8 to 3.8), and repetitions increased by 0.72 repetitions (95% CI 0.65, 0.79, mean repetitions for knee from 10.3 to 14.4, and for hip from 11.1 to 14.9). There were no clinically relevant effects on the improvement of pain or function by any covariate (age, sex, index joint). The lack of a control group and randomization limit our ability to explain the mechanisms of the observed results.

Conclusions

Continuously participating in a digital OA treatment program for 6 or 12 months was associated with a clinically important decrease in joint pain and increased physical function, in hip and knee OA. Future research should follow OA-related outcomes in participants that end their treatment to explore when and why that decision was made.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Exercise therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer

BACKGROUND

Survival for stage I to III, hormone receptor-positive, breast cancer has substantially improved over time due to advances in screening, surgery and adjuvant therapy. However many adjuvant therapies have significant treatment-related toxicities, which worsen quality of life for breast cancer survivors. Postmenopausal women with hormone receptor-positive breast cancer are now prescribed aromatase inhibitors (AI) as standard, with longer durations of therapy, up to 10 years, being considered for certain women. AI treatment is associated with a high incidence of AI-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS reduces compliance with AI therapy in up to one half of women undergoing adjuvant AI therapy, potentially compromising breast cancer outcomes. Exercise has been investigated for the prevention and treatment of AIMSS but the effect of this intervention remains unclear.

OBJECTIVES

To assess the effects of exercise therapies on the prevention or management of aromatase inhibitor-induced musculoskeletal symptoms (AIMSS) in women with stage I to III hormone receptor-positive breast cancer.

SEARCH METHODS

We searched Cochrane Breast Cancer's Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases up to 13 December 2018. We also searched two conference proceedings portals and two clinical trials registries for ongoing studies or unpublished trials, or both, in August 2019. We also reviewed reference lists of the included studies.

SELECTION CRITERIA

We included randomised controlled trials that compared exercise versus a comparator arm. We did not impose any restriction on the comparator arm, which could include an alternative type of exercise, no exercise or a waiting list control. Both published and non-peer-reviewed studies were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed risk of bias and certainty of the evidence using the GRADE approach. The outcomes investigated were pain, joint stiffness, grip strength, health-related quality of life, cancer-specific quality of life, adherence to AI therapy, adverse events, incidence of AIMSS, breast cancer-specific survival and overall survival. For continuous outcomes that were assessed with the same instrument, we used the mean difference (MD); for those outcomes that used different instruments, we used the standardised mean difference (SMD) for the analysis. For dichotomous outcomes, we reported outcomes as an odds ratio (OR).

MAIN RESULTS

We included seven studies with 400 randomised participants; one study assessed exercise for preventing AIMSS and six studies assessed treating AIMSS. For preventing AIMSS, the single study reported no difference in pain scores, grip strength or compliance to taking AI medication between groups. Data values were not provided in the study and no other outcomes were reported. For managing AIMSS, we found that the evidence for the effect of exercise therapies on overall change in worst pain scores was very uncertain (SMD -0.23, 95% confidence interval (CI) -0.78 to 0.32; 4 studies, 284 women; very low-certainty evidence). The evidence suggested that exercise therapies result in little to no difference in overall change in stiffness scores (Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) stiffness score MD -0.76, 95% CI -1.67 to 0.15 and Visual Analogues Scale (VAS) stiffness score MD -0.42, 95% CI -2.10 to 1.26; 1 study, 53 women; low-certainty evidence). The evidence was very uncertain for the outcomes of overall change in grip strength (MD 0.30, 95% CI -0.55 to 1.15; 1 study, 83 women; very low-certainty evidence); overall change in health-related quality of life (subscales of SF-36 tool ranged from least benefit of MD 1.88, 95% CI -2.69 to 6.45 to most benefit of MD 9.70, 95% CI 1.67 to 17.73; 2 studies, 123 women, very low-certainty evidence); overall change in cancer-specific quality of life (MD 4.58, 95% CI -0.61 to 9.78; 2 studies, 136 women; very low-certainty evidence); and adherence to aromatase inhibitors (OR 2.43, 95% CI 0.41 to 14.63; 2 studies, 224 women; very low-certainty evidence). There were no adverse events identified across four studies in either arm (0 events reported; 4 studies; 331 participants; low-certainty evidence). There were no data reported on incidence of AIMSS, breast cancer-specific survival or overall survival.

AUTHORS' CONCLUSIONS

Given the wide-ranging benefits of exercise for people affected by cancer, it was surprising that this review provided no clear evidence of benefit for exercise therapies in women with early breast cancer with AIMSS. This review only yielded seven eligible studies with 400 participants, which is likely to have underpowered the findings. The meta-analysis was challenging due to the considerable heterogeneity amongst the trials, with a wide range of exercise regimens and follow-up periods. Despite these inconclusive findings, exercise needs to be part of routine care for women with breast cancer due to its wide-ranging benefits. Future research in this area would be enhanced with further understanding of the mechanism of AIMSS, a single clear definition of the condition, and phase III randomised controlled trials that are adequately powered to test targeted exercise interventions on the key clinical outcomes in this condition.

'My hip is damaged': a qualitative investigation of people seeking care for persistent hip pain

OBJECTIVES

Clinicians who use the biopsychosocial approach to manage musculoskeletal pain disorders aim to understand how patients make sense of their symptoms. Treatment includes targeting the negative beliefs and coping responses that can lead to progressive pain and disability. We aimed to explore how people seeking care for persistent hip pain and disability make sense of their symptoms.

METHODS

Cross-sectional qualitative study. People were eligible if they were aged ≥18 years, were consulting an orthopaedic surgeon for persistent hip pain and offered a non-surgical intervention. Data were collected through interviews that explored patients' beliefs about the identity (diagnosis), causes, consequences, timeline and controllability of their symptoms, their strategies to cope with pain and their experiences in seeking healthcare. Transcribed interview data were analysed thematically using a framework approach.

RESULTS

Sixteen people (median age=51, range=33-73 years; median duration hip pain=3 years, range=3 months-20 years) participated. Most participants (10/16) believed their pain was caused by an exercise-related injury. Because of the results of imaging and interactions with healthcare professionals, all participants believed they had damaged hip structures. All described ineffective strategies to manage their pain and multiple failed treatments. For many (7/16), a lack of control over symptoms threatened their physical and mental health.

CONCLUSIONS

The way participants with persistent hip pain and disability made sense of their symptoms contributed to them avoiding physical activity, and it impaired their sleep, emotional well-being and physical health.

Synergistic effects of hip/knee osteoarthritis and comorbidities on mobility and self-care limitations among older adults: Cross-sectional analysis of the Oxford pain, Activity and Lifestyle study

OBJECTIVE

To estimate synergistic effects of hip/knee osteoarthritis (OA) and comorbidities on mobility or self-care limitations among older adults.

METHODS

We used baseline, cross-sectional data from the Oxford Pain, Activity and Lifestyle (OPAL) study. Participants were community-dwelling adults aged 65 years or older who completed a postal questionnaire. Participants reported demographic information, hip/knee OA, comorbidities and mobility and self-care limitations. We used modified Poisson regression models to estimate the independent and combined relative risks (RR) of mobility or self-care limitations, the relative excess risk due to interaction (RERI) between hip/knee OA and comorbidities, attributable proportion of the risk due to the interaction and the ratio of the combined effect and the sum of the individual effects, known as the synergy index.

RESULTS

Of the 4,972 participants included, 1,532 (30.8%) had hip/knee OA, and of them 42.9% reported mobility limitations and 8.4% reported self-care limitations. Synergistic effects impacting self-care limitations were observed between hip/knee OA and anxiety (RR: 3.09, 95% Confidence Interval (CI): 2.00 to 4.78; RERI: 0.93, 95% CI: 0.01 to 1.90), and between hip/knee OA and depressive symptoms (RR: 2.71, 95% CI: 1.75 to 4.20; RERI: 0.58, 95% CI: 0.03 to 1.48). The portion of the total RR attributable to this synergism was 30% and 22% respectively.

CONCLUSIONS

This study demonstrates that synergism between hip/knee OA and anxiety or depressive symptoms contribute to self-care limitations. These findings highlight the importance of assessing and addressing anxiety or depressive symptoms when managing older adults with hip/knee OA to minimize self-care limitations.

Effects of Physical Activity in Knee and Hip Osteoarthritis: A Systematic Umbrella Review

INTRODUCTION

We conducted a systematic umbrella review to evaluate the literature relating to effects of physical activity on pain, physical function, health-related quality of life, comorbid conditions and osteoarthritis (OA) structural disease progression in individuals with lower-extremity OA.

METHODS

Our primary search encompassed 2011 to February 2018 for existing systematic reviews (SR), meta-analyses (MA) and pooled analyses dealing with physical activity including exercise (not mixed with any other intervention and compared to a no-activity control group). A supplementary search encompassed 2006 to February 2018 for original research related to physical activity (including exercise) and lower limb OA progression. Study characteristics were abstracted, and risk of bias was assessed.

RESULTS

Physical activity decreased pain and improved physical function (strong evidence) and improved health-related quality of life (moderate evidence) among people with hip or knee OA relative to less active adults with OA. There was no evidence to suggest accelerated OA progression for physical activity below 10,000 steps per day. Both physical activity equivalent to the 2008 Physical Activity Guidelines for Americans (150 min·wk of moderate-intensity exercise in bouts ≥10 min) and lower levels of physical activity (at least 45 total minutes per week of moderate-intensity) were associated with improved or sustained high function. No SR/MA addressing comorbid conditions in OA were found. Measurable benefits of physical activity appeared to persist for periods of up to 6 months following cessation of a defined program.

CONCLUSIONS

People with lower-extremity OA should be encouraged to engage in achievable amounts of physical activity, of even modest intensities. They can choose to accrue minutes of physical activity throughout the entire day, irrespective of bout duration, and be confident in gaining some health and arthritis-related benefits.

Diabetes Is Associated with Musculoskeletal Pain, Osteoarthritis, Osteoporosis, and Rheumatoid Arthritis

AIM

To investigate the associations between diabetes and musculoskeletal pain, osteoarthritis, osteoporosis, and rheumatoid arthritis.

METHODS

Self-reported data were provided by the nationwide Danish National Health Survey 2013. Inclusion criteria were age ≥ 40 years and known diabetes status. The exposure variable was diabetes, and the outcome variables included musculoskeletal pain during the last 14 days in three body sites (back/lower back, limbs, and shoulder/neck), osteoarthritis, osteoporosis, and rheumatoid arthritis. Logistic regression analyses adjusted for age, gender, BMI, education, marital status, and physical activity were performed.

RESULTS

9,238 participants with diabetes were 65.6 ± 11.0 (mean ± SD) years old; 55.6% were males. 99,980 participants without diabetes were 59.2 ± 11.8 years old; 46.7% were males. Diabetes was associated with back/lower back pain (OR 1.2 (CI 95% 1.1-1.2), p < 0.001), pain in the limbs (1.4 (1.3-1.4), p < 0.001), shoulder/neck pain (1.2 (1.1-1.3), p < 0.001), osteoarthritis (1.3 (1.2-1.4), p < 0.001), osteoporosis (1.2 (1.1-1.4), p = 0.010), and rheumatoid arthritis (1.6 (1.4-1.7), p < 0.001). In participants with diabetes, physical activity was associated with reduced pain (e.g., back/lower back pain (0.7 (0.6-0.7), p < 0.001)).

CONCLUSION

Diabetes was associated with elevated odds of having musculoskeletal pain. Diabetes was also associated with elevated odds of having osteoarthritis, osteoporosis, and rheumatoid arthritis. The most frequent disease in individuals with diabetes was osteoarthritis. The reported pain may have negative impacts on the level of physical activity. Health-care professionals should remember to inform patients with diabetes that musculoskeletal pain, osteoarthritis, osteoporosis, and rheumatoid arthritis are not contraindications to exercise training.

Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area

The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where SIJ is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, when the SIJ might be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the SIJ(s)-a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this Perspective article argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models with contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.

Barriers and facilitators to recommended physical activity in lower-limb osteoarthritis: protocol for a qualitative study exploring patients and physiotherapist perspectives using the theoretical domains framework and behaviour change taxonomy

INTRODUCTION

Osteoarthritis (OA) is the leading cause of disability and pain in older adults. Although increasing physical activity (PA) can help reduce symptoms, patients with lower-limb OA are less active than the general public. Although physiotherapists commonly deliver PA programmes, they lack knowledge of key barriers and facilitators to adherence to prescribed PA that patients with lower-limb OA experience while attending physiotherapy appointments (treatment period) and after discharge (post-treatment period). This study aims to explore the perspectives of patients with lower-limb OA of barriers and facilitators to adherence to physiotherapy prescribed PA in the treatment and post-treatment time periods to inform the development of intervention underpinned by behaviour change theory.

METHODS AND ANALYSIS

A qualitative study, based on phenomenology, will purposively recruit patients with lower-limb OA who have had physiotherapy. In-depth semi-structured interviews will be undertaken following discharge from physiotherapy at a single time point. Participants' perspectives of physiotherapy interventions, including barriers and facilitators to prescribed PA and techniques that they felt optimised adherence to physiotherapist PA prescription will be explored (phase I). The acceptability and feasibility of delivering a physiotherapy intervention incorporating the techniques identified in the semi-structured interviews will then be explored through focus groups conducted with physiotherapists (phase II). Data will be coded following thematic analysis, with barriers and facilitators mapped to the constructs on the theoretical domains framework, and behaviour change techniques identified following definitions from Michie's V1 taxonomy.

ETHICS AND DISSEMINATION

Findings from this study will inform development of a physiotherapy intervention underpinned by behaviour change theory aiming to optimise adherence to PA prescription in patients with lower-limb OA during the treatment and post-treatment time periods. This study has ethical approval (IRAS 247904) and results will be disseminated through publications in peer-reviewed journals and presentations at conferences and to study participants.

Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis

Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective than the best-established pharmacological interventions. In this article, we describe the presentation of OA pain and give an overview of its peripheral and central mechanisms. We then provide a state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise, weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising directions for clinical practice, including novel education strategies to target unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions, and innovative, brain-directed treatments. Finally, we discuss potential future research in areas, such as treatment adherence and personalized rehabilitation for OA pain.

Modifiable Determinants of Exercise Use in a Diverse Ethnic Population With Osteoarthritis

OBJECTIVE

To determine the extent of ethnic differences in the use of exercise for therapy and identify relevant modifiable determinants of exercise use among patients with knee/hip osteoarthritis (OA).

METHODS

Knee/hip OA study participants were identified. Surveys were administered to collect patient sociodemographic and clinical information, and beliefs and attitudes about providers and treatments. Final multivariable logistic regression models were created using a fully conditional method.

RESULTS

Hispanic participants (n = 130), compared to non-Hispanic participants (n = 232), were less likely to have private medical insurance (9.2% versus 31.0%) or to report having excellent/very good health (40.7% versus 52.6%). They were also less likely to report using exercise for OA treatment in the last 6 months (56% versus 73%; P = 0.003). When adjusted for age and disease severity, the difference in exercise use among ethnicities remained significant (odds ratio [OR] 0.59 [95% confidence interval (95% CI) 0.36-0.99]). In a multivariable logistic regression model designed to determine the most important determinants of exercise use for OA treatment, in the last 6 months the following were all associated with exercise use: having knee instead of hip OA (OR 2.83 [95% CI 1.51-5.29]), having family/friends who exercise (OR 3.20 [95% CI 1.76-5.84]), having a good understanding of what happens after exercise (OR 2.19 [95 CI 1.15-4.19]), and higher perceived benefit of exercise (OR 2.24 [95% CI 1.64-3.04]).

CONCLUSION

Among patients with knee/hip OA, Hispanics were less likely to exercise for OA treatment. Increased knowledge about the benefits of exercise for treatment and improved familiarity with exercise as treatment for OA may increase exercise use.

Adverse events of exercise therapy in randomised controlled trials: a systematic review and meta-analysis

OBJECTIVE

To evaluate the relative risk (RR) of serious and non-serious adverse events in patients treated with exercise therapy compared with those in a non-exercising control group.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Primary studies were identified based on The Cochrane Database of Systematic Reviews investigating the effect of exercise therapy.

ELIGIBILITY CRITERIA

At least two of the authors independently evaluated all identified reviews and primary studies. Randomised controlled trials were included if they compared any exercise therapy intervention with a non-exercising control. Two authors independently extracted data. The RR of serious and non-serious adverse events was estimated separately.

RESULTS

180 Cochrane reviews were included and from these, 773 primary studies were identified. Of these, 378 studies (n=38 368 participants) reported serious adverse events and 375 studies (n=38 517 participants) reported non-serious adverse events. We found no increase in risk of serious adverse events (RR=0.96 (95%CI 0.90 to 1.02, I²: 0.0%) due to exercise therapy. There was, however, an increase in non-serious adverse events (RR=1.19 (95%CI 1.09 to 1.30, I²: 0.0%). The number needed to treat for an additional harmful outcome for non-serious adverse events was 6 [95%CI 4 to 11).

CONCLUSION

Participating in an exercise intervention increased the relative risk of non-serious adverse events, but not of serious adverse events. Exercise therapy may therefore be recommended as a relatively safe intervention.PROSPERO registration numberCRD42014014819.

The Better Management of Patients with Osteoarthritis Program: Outcomes after evidence-based education and exercise delivered nationwide in Sweden

We evaluated a structured education- and exercise-based self-management program for patients with knee or hip osteoarthritis (OA), using a registry-based study of data from 44,634 patients taken from the Swedish “Better Management of Patients with Osteoarthritis” registry. Outcome measures included a numeric rating scale (NRS), EuroQol five dimension scale (EQ-5D), Arthritis self-efficacy scale (ASES-pain and ASES-other symptoms), pain frequency, any use of OA medication, desire for surgery, fear–avoidance behavior, physical activity, and sick leave were reported at baseline, 3 and 12 month. Changes in scale variables were analyzed using general linear models for repeated measures and changes in binary variables by McNamara’s test. All analyses were stratified by joint. At the 3-month follow-up, patients with knee (n = 30686) and hip (n = 13948) OA reported significant improvements in the NRS-pain, the EQ-5D index, the ASES-other symptoms, and ASES-pain scores with standardized effect size (ES) ranges for patients with knee OA of 0.25–0.57 and hip OA of 0.15–0.39. Significantly fewer patients reported pain more than once weekly, took OA medication, desired surgery, showed fear–avoidance behavior, and were physically inactive. At the 12-month follow-up, patients with knee (n = 21647) and hip (n = 8898) OA reported significant improvements in NRS-pain, EQ-5D index, and a decrease in ASES-other symptoms and ASES-pain scores with an ES for patients with knee OA of –0.04 to 0.43 and hip OA of –0.18 to 0.22. Significantly fewer patients reported daily pain, desired surgery (for hip OA), reported fear–avoidance behavior, and reported sick leave. Following these interventions, patients with knee and hip OA experienced significant reductions in symptoms and decreased willingness to undergo surgery, while using less OA medication and taking less sick leave. The results indicate that offering this program as the first-line treatment for OA patients may reduce the burden of this disease.