Exercise for osteoarthritis of the hip

A cycling and education programme for the treatment of hip osteoarthritis: a quality improvement study

Osteoarthritis of the hip is associated with pain, stiffness and limitations to activities of daily living. The aims of this quality improvement project were to introduce a service developed to promote the self-management of hip osteoarthritis through exercise and education and to assess the impact of the programme on pain, function and quality of life. The service was a six-week cycling and education programme and 119 participants took part. Statistically significant improvements were found for Oxford Hip Scores (Mean (SD) change 4.14, 95%, CI 3.02, 5.25, p < 0.001); Sit-to-stand scores (mean change 3.06, 95%, CI 2.33, 3.79, p < 0.001); EQ5D-5L Utility (mean change 0.06, 95%, CI 0.03, 0.09, p < 0.001); EQ5D VAS (mean change 7.05, 95%, CI 4.72, 9.39, p < 0.001); pain on weight-bearing (WB) (mean change 1.56, 95%, CI 0.77, 2.36, p < 0.001), HOOS function (median change (IQR) 7.35, 1.84 to 19.12, p < 0.001) and TUG test (median change 1.11, 0.31 to 2.43, p < 0.001). Participants reported improvements in pain and function; increased confidence in managing hip pain and an increase in motivation to exercise. These findings were supported by a patient and public involvement forum who suggested extending the programme to eight weeks. These results suggest that the service has potential in the management of hip osteoarthritis.

Leisure time physical activity and the risk of hip or knee replacement due to primary osteoarthritis: a population based cohort study (The HUNT Study)

BACKGROUND

The relationship between leisure time physical activity (LPA) and hip and knee OA and subsequent joint replacement has not yet been clearly defined. Some studies have found the risk of knee replacement (TKR) to increase with high levels of LPA, while others have found no overall relationship to either TKR or hip replacement (THR). The aim was to investigate the association between LPA and the risk of severe end-stage OA, defined as THR or TKR due to primary OA, in a large population-based cohort.

METHODS

Participants in the Nord-Trøndelag Health Study (HUNT) were followed prospectively to identify THR and TKR using the Norwegian Arthroplasty Register. Self-reported LPA was classified as inactive, low, moderate or high. The Cox proportional hazards model was used to calculate hazard ratios (HRs) according to levels of LPA with adjustments for confounding variables. Analyses were performed by age (<45, 45-59 and ≥60 years) and sex.

RESULTS

A total of 66 964 participants (mean age 46.8 years (SD 16.3) were included in the analyses. We identified 1636 THRs and 1016 TKRs due to primary OA during 17.0 years (median) of follow-up. High LPA was significantly associated with THR for women <45 years (HR 1.78, 95 % CI 1.08-2.94) and men between 45-59 years (HR 1.53, 95 % CI 1.10-2.13) at baseline. A significant trend was found only among women < 45 years at baseline (p = 0.02). We found that LPA was significantly associated with TKR for women only (HR 1.45, 95 % CI 1.03-2.04). No measures of LPA were associated with TKR for men.

CONCLUSION

In this population-based study, high level of LPA was associated with increased risk of THR where a significant trend of LPA was seen among women <45 years at baseline. For TKR, high LPA was associated with increased risk only in women. In contrast to previous studies, this study shows a possible association between high LPA and the risk of THR.

Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: a pragmatic randomized controlled trial

OBJECTIVE

To assess the effectiveness of exercise therapy added to general practitioner (GP) care compared with GP care alone, in patients with hip osteoarthritis (OA) during 12 months follow-up.

METHODS

We performed a multi-center parallel pragmatic randomized controlled trial in 120 general practices in the Netherlands. 203 patients, aged ≥45 years, with a new episode of hip complaints, complying with the ACR criteria for hip OA were randomized to the intervention group (n = 101; GP care with additional exercise therapy) or the control group (n = 102; GP care only). GP care was given by patient's own GP. The intervention group received, in addition, a maximum of 12 exercise therapy sessions in the first 3 months and hereafter three booster sessions. Blinding was not possible. Primary outcomes were hip pain and hip-related function measured with the HOOS questionnaire (score 0-100).

RESULTS

The overall estimates on hip pain and function during the 12-month follow-up showed no between-group difference (intention-to-treat). At 3-months follow-up there was a statistically significant between-group difference for HOOS pain -3.7 (95% CI: -7.3; -0.2), effect size -0.23 and HOOS function -5.3 (95% CI: -8.9; -1.6), effect size -0.31. No adverse events were reported.

CONCLUSIONS

No differences were found during 12-months follow-up on pain and function. At 3-months follow-up, pain and function scores differed in favor of patients allocated to the additional exercise therapy compared with GP care alone.

TRIAL REGISTRATION

The Netherlands Trial Registry NTR1462.

The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life.

METHODS

Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest.

RESULTS

Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life.

CONCLUSION

An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate.

More than just ticking a box…how patient and public involvement improved the research design and funding application for a project to evaluate a cycling intervention for hip osteoarthritis

PLAIN ENGLISH SUMMARY

Involving patients and the public in research helps to ensure that research remains relevant, and has an impact on the people it aims to benefit. Funding bodies now require patients and the public to be involved at all stages of research. Patients and members of the public were involved from the outset in research into a cycling and education programme for hip osteoarthritis. A group discussion took place with six participants from a trial of the programme. The group provided feedback on several areas including the relevance of the research, how the researchers proposed to recruit patients, the research design, the programme itself (including what they liked/didn't like about it), and how the researchers could publicise the research findings. The feedback received was invaluable, and helped shape the entire research project and funding application. The cycling and education programme has been extended in line with comments received from the group. They also helped identify the best way of gathering information from research participants and had suggestions for sharing the results, both of which were incorporated into the funding application. Often involving patients and the public in research can be seen as a 'tick box' exercise. However, this example shows how crucial involving patients and the public in research design is. It also shows how the funding application was made stronger as a result of patient input. Researchers should be encouraged to work closely with patients and the public to ensure their research is of the highest quality.

ABSTRACT

Background Involving patients and the public in research is an essential activity to ensure relevant, accessible, and appropriate research. There is increasing obligation from funding bodies on researchers to have well thought through plans for involving the public, and indeed it is often a condition for funding. Patient and public involvement activity in this project was conducted to inform a funding application to investigate the effectiveness of a cycling and education intervention in the treatment of hip osteoarthritis. Methods Six participants from a feasibility programme of the intervention attended a two-hour patient and public involvement consultation group to provide feedback on various aspects of the proposed research and intervention. During the consultation group, two independent facilitators followed a detailed plan formulated with the research team. Feedback was validated by the attendees via email following the consultation, and a report was issued to the research team. Further feedback on subsequent changes was sought via email and telephone with members of a Patient Advisory Group. Results The patient and public involvement consultation group provided invaluable feedback and suggestions which impacted on the design and quality of the research project and the intervention. Key changes to the intervention included extending the duration of the cycling programme from six to eight weeks, and inclusion of an exercise diary to promote adherence to the intervention. Key feedback regarding the design of the research and funding application included suggestions for methods of dissemination, and confirmation of the primary outcome measure. Conclusions Patient and public involvement was crucial to the design of the proposed research and intervention. It informed many aspects of the research design and made the funding application stronger as a result. Involving patients and the public in research is much more than an obligation, or 'tick box' exercise. It can change and improve research quality, which is crucial when answering questions that are meaningful and important to patients, and which leads to increased impact. Collaboration with patients and the public should be planned and reported from the conception of a research idea where the impact of such input can be considerable.

Effects of Adding an Internet-Based Pain Coping Skills Training Protocol to a Standardized Education and Exercise Program for People With Persistent Hip Pain (HOPE Trial): Randomized Controlled Trial Protocol

BACKGROUND

Persistent hip pain in older people is usually due to hip osteoarthritis (OA), a major cause of pain, disability, and psychological dysfunction.

OBJECTIVE

The purpose of this study is to evaluate whether adding an Internet-based pain coping skills training (PCST) protocol to a standardized intervention of education followed by physical therapist-instructed home exercise leads to greater reductions in pain and improvements in function.

DESIGN

An assessor-, therapist-, and participant-blinded randomized controlled trial will be conducted.

SETTING

The study will be conducted in a community setting.

PARTICIPANTS

The participants will be 142 people over 50 years of age with self-reported hip pain consistent with hip OA.

INTERVENTION

Participants will be randomly allocated to: (1) a control group receiving a 24-week standardized intervention comprising an 8-week Internet-based education package followed by 5 individual physical therapy exercise sessions plus home exercises (3 times weekly) or (2) a PCST group receiving an 8-week Internet-based PCST protocol in addition to the control intervention.

MEASUREMENTS

Outcomes will be measured at baseline and 8, 24, and 52 weeks, with the primary time point at 24 weeks. Primary outcomes are hip pain on walking and self-reported physical function. Secondary outcomes include health-related quality-of-life, participant-perceived treatment response, self-efficacy for pain management and function, pain coping attempts, pain catastrophizing, and physical activity. Measurements of adherence, adverse events, use of health services, and process measures will be collected at 24 and 52 weeks. Cost-effectiveness will be assessed at 52 weeks.

LIMITATIONS

A self-reported diagnosis of persistent hip pain will be used.

CONCLUSIONS

The findings will help determine whether adding an Internet-based PCST protocol to standardized education and physical therapist-instructed home exercise is more effective than education and exercise alone for persistent hip pain. This study has the potential to guide clinical practice toward innovative modes of psychosocial health care provision.

Hip osteoarthritis: patients with complex comorbidities can make exceptional improvements following intensive exercise and education

A 71-year-old man presenting with hip osteoarthritis, with a complex range of comorbidities was referred by his general practitioner to CHAIN (Cycling against Hip PAIN), a 6 week programme developed to aid self-management of hip osteoarthritis through exercise, education and advice, as defined by the National Institute for Health and Care Excellence (NICE) guidelines. Significant improvements were seen in Oxford hip score, the Hip disability and Osteoarthritis Outcome Score (HOOS) - function score, sit-to-stand test, timed up and go test, pain scores and hip flexion. There was also a weight loss of 2.1 kg. The man reported 'an amazing difference' in his affected hip and leg, and improved fitness. Many clinicians would have questioned the man's suitability for the programme due to his coexisting medical conditions. This case study shows that patients may be much more able than we think to achieve significant improvement with exercise.

Exercise therapy in hip osteoarthritis--a randomized controlled trial

BACKGROUND

Roughly one in ten persons in the industrialized world suffers from hip osteoarthritis, a disease for which there is no cure. The goal of conservative therapy is to relieve symptoms, preferably with methods that let patients assume responsibility for their own treatment, e.g., physical training.

METHOD

In a randomized controlled trial, we studied the effectiveness of twelve weeks of exercise therapy in patients with hip osteoarthritis (THüKo), compared to no treatment (control group) and placebo ultrasound treatment of the hip (placebo ultrasound group). The primary endpoint was a comparison of the pain scores of the intervention versus control groups on the generic SF-36 health questionnaire. Secondary endpoints included comparisons across all three study groups of scores on the 7 other scales of the SF-36 and on the pain, physical function, and stiffness scales of the osteoarthritis-specific WOMAC Index. The statistical analysis was performed with ANCOVA, with baseline values as a covariate. Between-group effects were subsequently tested pairwise (two-tailed t-tests, alpha = 0.05).

RESULTS

As for the primary endpoint, pain reduction was significantly greater in the intervention than in the control group (mean difference 5.7 points, 95% confidence interval [CI] 0.4-11.1 points, p = 0.034). The comparisons across all three study groups (i.e., secondary endpoints, with 71 subjects in the intervention group, 68 in the control group, and 70 in the placebo group) revealed no significant between-group effects with respect to the SF-36. On the WOMAC Index, however, statistically significant differences were found for pain reduction between the intervention and control group (mean difference 7.4 points, 95% CI 3.0-11.8, p = 0.001) and between the intervention and placebo group (mean difference 5.1 points, 95% CI 0.7-9.4, p = 0.024). Comparable mean differences were also found for functional improvement.

CONCLUSION

Twelve weeks of exercise therapy in hip osteoarthritis patients of normal vitality reduced pain and improved physical function. No significant improvement was found in these patients' general health-related quality of life.