Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial

Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management

The mechanisms by which obesity affects osteoarthritis (OA) are of great concern to osteoarthritis researchers and clinicians who manage this disease. Inflammation and joint loads are pathways commonly believed to cause or to exacerbate the disease process. This article reviews the physiologic and mechanical consequences of obesity in older adults who have knee OA, the effects of long-term exercise and weight-loss interventions, the most effective nonpharmacologic treatments for obesity, and the usefulness and feasibility of translating these results to clinical practice.

Muscle and exercise in the prevention and management of knee osteoarthritis: an internal medicine specialist's guide

This article outlines the influence of muscle activity on knee-joint loading, describes the deficits in muscle function observed in people with knee osteoarthritis, and summarizes available evidence pertaining to the role of muscle in the development and progression of knee osteoarthritis. The article focuses on whether muscle deficits can be modified in knee osteoarthritis and whether improvements in muscle function lead to improved symptoms and joint structure. This article concludes with a discussion of exercise prescription for muscle rehabilitation in knee osteoarthritis.

The effectiveness of self-management educational interventions for osteoarthritis of the knee

BACKGROUND

Osteoarthritis (OA) is a common cause of pain and disability, and is the most common form of arthritis in the Western world. The most common joint to be affected is the knee. Pain and functional disability are common symptoms, which can lead to reduced quality of life and increase the risk of further morbidity.Current treatment aims to educate patients about the management of OA, reduce pain, improve function, decrease disability and reduce the progression of the disease. Education with clients has been described as a set of planned educational activities designed to improve patients' health behaviours and/or health status. The purpose of self-education is to maintain or improve health, or, in some cases, to slow deterioration by increasing participant's perception of self efficacy defined as an ability to control or manage various aspects of OA. To date, there is no systematic review of the literature undertaken to identify the effectiveness of self-management educational activities for osteoarthritis of the knee.

OBJECTIVE

The objective of this systematic review is to evaluate the effectiveness of self-management educational interventions on function and quality of life for adult subjects with OA of the knee.

SEARCH STRATEGY

A comprehensive search strategy was undertaken on databases available from University of South Australia from their inception to January 2007.

SELECTION CRITERIA

Randomised controlled trials or clinical controlled trials were sought which evaluated any self management interventions for osteoarthritis knee.Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments. Data extraction was via the Joanna Briggs Institute standard data extraction form for evidence of effectiveness, and Review Manager Software was used to calculate comparative statistics.

RESULTS

Thirteen trials were included in the review. Trials were clinically and methodologically heterogeneous. Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain (SMD -0.25, 95%CI -0.36 to -0.13, 11 trials 1379 participants). There was no effect on physical function (SMD 0.13, 95%CI -0.33 to -0.08, eight trials, 1156 subjects). No beneficial effects were found from self management interventions with improving quality of life. We also found the exercise component of self management (four trials) demonstrated a benefit with reducing pain, improving function and quality of life. Exercise also offered a benefit over no exercise. Overall methodological quality was moderate.

DISCUSSION

Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain and improving function. Significant heterogeneity was found between trials. This was controlled for in the analysis but may be explained by heterogeneity in both the intervention and control group. The exercise component of self management programmes appears to contribute a significant benefit.

CONCLUSION

There is encouraging evidence of a small benefit from exercise in self management programs. Clear guidelines can not be provided for practice regarding the exercise content due to heterogeneity but overall benefit suggests this component should be emphasized and implemented in primary care self management programmes.

The effect of tai chi on knee osteoarthritis pain in cognitively impaired elders: pilot study

This article reports a pilot study of the effect of tai chi (TC), a pharmacological adjunct and mild aerobic exercise, on osteoarthritic knee pain in elders with cognitive impairment (CI). The TC program included a warm-up, 12-form Sun-style TC, and a cool-down period, for a total of 20-40 minutes per session, twice a week for 15 weeks. The results showed no significant differences in knee pain after the TC intervention in 7 elders with CI. However, more minutes of TC attendance were related to improved pain scores (Spearman's rho=.78, P < .05). Greater accuracy in TC performance was also correlated with improvements in pain scores (Spearman's rho = .70, P=.08). Of 4 elders who participated in TC practice regularly (more than 20 sessions), 3 showed clinically important improvements, but 3 elders who participated in no sessions or only a few sessions showed no improvement.

Treating knee osteoarthritis with intra-articular hyaluronans

OBJECTIVE

Intra-articular hyaluronan (HA) or hylan is approved for the treatment of osteoarthritis (OA) knee pain. The authors review here published evidence of efficacy and safety of intra-articular HA for the treatment of knee pain. Since the systemic safety of nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase (COX-2) inhibitors for OA knee treatment are a current concern, the authors also offer recommendations for repositioning HA in the OA treatment paradigm.

METHODS

Relevant HA literature was identified by searching MEDLINE and EMBASE from their inception to April 2008 using the search words hyaluronan, hyaluronic acid, sodium hyaluronate, and hylan G-F 20, with knee and OA. Data from randomized, placebo-controlled trials were reviewed and summarized in this article. While not a systematic review, this article reviews the best available evidence for the use of HA to treat knee OA.

RESULTS

For the most part, patients in the reviewed studies were adults over the age of 40 with mild to severe symptomatic OA of the knee. Reviewed studies demonstrated significant improvements in pain and physical function with HA or sodium hyaluronate and hylan G-F 20. HA or hylan products were most effective between 5 and 13 weeks after injection with improvements also observed at 14-26 weeks or sometimes longer, and were well tolerated with a low incidence of adverse events. HA also provides beneficial treatment effects when administered in conjunction with other therapies.

CONCLUSIONS

Intra-articular HA or hylan has proven to be an effective, safe, and tolerable treatment for symptomatic knee OA. In an effort to limit cardiovascular, gastrointestinal, and renal safety concerns with COX-2 selective and nonselective NSAIDs and maximize HA efficacy, the authors proposed using HA earlier in the treatment paradigm for knee OA and also as part of a comprehensive treatment strategy.

Physical activity: does long-term, high-intensity exercise in horses result in tendon degeneration?

This study explores the hypothesis that high-intensity exercise induces degenerative changes in the injury-prone equine superficial digital flexor tendon (SDFT), but not in the rarely injured common digital extensor tendon (CDET). The horse represents a large-animal model that is applicable to human tendon and ligament physiology and pathology. Twelve age-matched female horses undertook galloping exercise three times a week with trotting exercise on alternative days (high-intensity group, n = 6) or only walking exercise (low-intensity group, n = 6) for 18 mo. The SDFT, suspensory ligament, deep digital flexor tendon, and CDET were harvested from the forelimb. Tissue from the mid-metacarpal region of the right limb tendons was analyzed for water, DNA, sulfated glycosaminoglycan and collagen content, collagen type III-to-I ratios, collagen cross-links, and tissue fluorescence. Left limb tendons were mechanically tested to failure. The analyses showed matrix composition to have considerable diversity between the functionally different structures. In addition, the specific structures responded differently to the imposed exercise. High-intensity training resulted in a significant decrease in the GAG content in the SDFT, but no change in collagen content, despite a decrease in collagen fibril diameters. There were no signs of degeneration or change in mechanical properties of the SDFT. The CDET had a lower water content following high-intensity training and a higher elastic modulus. Long-term, high-intensity training in skeletally mature individuals results in changes that suggest accelerated aging in the injury-prone SDFT and adaptation in the CDET.

The epidemiology of sports-related fractures of the hand

OBJECTIVE

To describe the incidence and epidemiology of acute sports-related hand fractures in the adult general population.

DESIGN

Retrospective analysis of a prospectively collected database recording all inpatient and outpatient fractures in a well-defined population during 2000.

SETTING

Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, UK.

RESULTS

During 2000, 1430 hand fractures were recorded, 320 of which (22.4%) were sports injuries. Males were more commonly injured (86%). The overall incidence was 60/10(5)(104/10(5) among males and 17/10(5) among females). The average age was 24 years. There were 39 (12.2%) carpal, 108 (33.8%) metacarpal and 173 (54.1%) phalangeal fractures. Damage to the first and fifth rays was most common. Open fractures were uncommon (n=7; 2.2%). Eight sports were responsible for 87.8% of fractures, each sport displaying a characteristic pattern of injury within the hand. The majority of fractures (87.2%) were treated on an outpatient basis.

CONCLUSIONS

Sporting activity accounts for 22.4% of all hand fractures, with relatively few requiring operative intervention. Young males are most commonly affected. Certain sports are associated with distinct fracture patterns, allowing appropriate preventive measures to be taken.

Depression and osteoarthritis

Depression is significant among patients with arthritis and musculoskeletal illnesses. However, the impact of depression on osteoarthritis has not been extensively studied. This article highlights the close links between these 2 prevalent chronic conditions, and the associated individual and societal burden. Results from a large clinical trial of depressed older patients with arthritis showed that a focused, collaborative depression care intervention not only decreased depression but also improved arthritis-associated outcomes, such as pain severity and arthritis-related limitations in daily activities. Relative to patients given usual care, patients receiving intervention also reported better health status and higher quality of life. Analyses of the depression interventions uncovered a reciprocal interrelation between depression and pain. Higher severity of either depression or pain decreased the benefits of systematic depression treatment and was associated with worse pain and depression outcomes. Current approaches to management of depression and arthritis do not reflect readily-available evidence-based treatment. A pilot study using a combined approach to address both depression and pain problems among elderly patients with depression and osteoarthritis suggested that benefits for depression, pain, and functional outcomes are strengthened by providing both pain and depression care management. An integrated depression and pain program using evidenced-based pharmacologic and nonpharmacologic treatments is needed to achieve optimal depression and pain outcomes. Currently, a randomized trial is under way to evaluate effectiveness of a combined pain and depression intervention using pharmacologic and nonpharmacologic therapies. Key intervention components in these 2 innovative and integrated depression and pain programs can guide clinicians to treat both depression and pain with more focus and intensity.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study

OBJECTIVE

To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis.

METHODS

Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months.

RESULTS

Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests.

CONCLUSION

The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.

Exercise for osteoarthritis of the knee

BACKGROUND

Biomechanical factors, such as reduced muscle strength and joint malalignment, have an important role in the initiation and progression of knee osteoarthritis (OA). Currently, there is no known cure for OA; however, disease-related factors, such as impaired muscle function and reduced fitness, are potentially amenable to therapeutic exercise.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function.

SEARCH STRATEGY

Five electronic databases were searched, up until December 2007.

SELECTION CRITERIA

All randomized controlled trials randomising individuals and comparing some form of land-based therapeutic exercise (as opposed to exercises conducted in the water) with a non-exercise group.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed methodological quality. All analyses were conducted on continuous outcomes.

MAIN RESULTS

The 32 included studies provided data on 3616 participants for knee pain and 3719 participants for self-reported physical function. Meta-analysis revealed a beneficial treatment effect with a standardized mean difference (SMD) of 0.40 (95% confidence interval (CI) 0.30 to 0.50) for pain; and SMD 0.37 (95% CI 0.25 to 0.49) for physical function. There was marked variability across the included studies in participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. The results were sensitive to the number of direct supervision occasions provided and various aspects of study methodology. While the pooled beneficial effects of exercise programs providing less than 12 direct supervision occasions or studies utilising more rigorous methodologies remained significant and clinically relevant, between study heterogeneity remained marked and the magnitude of the treatment effect of these studies would be considered small.

AUTHORS' CONCLUSIONS

There is platinum level evidence that land-based therapeutic exercise has at least short term benefit in terms of reduced knee pain and improved physical function for people with knee OA. The magnitude of the treatment effect would be considered small, but comparable to estimates reported for non-steroidal anti-inflammatory drugs.

Physical therapists' use of therapeutic exercise for patients with clinical knee osteoarthritis in the United kingdom: in line with current recommendations?

BACKGROUND AND PURPOSE

Physical therapists have an important role in the management of clinical knee osteoarthritis (OA) through designing and supervising exercise programs. This study explored whether their current use of therapeutic exercise for patients with this condition is in line with recent recommendations.

SUBJECTS AND METHODS

A cross-sectional survey was conducted with a random sample of chartered (licensed) physical therapists (N=2,000) practicing in the United Kingdom. This survey included a vignette describing a patient with clinical knee OA as well as clinical management questions relating to the respondents' use of therapeutic exercise.

RESULTS

The questionnaire response rate was 58% (n=1,152), with 538 respondents stating they had treated a patient with clinical knee OA in the preceding 6 months. In line with recent recommendations, 99% of the physical therapists stated they would use therapeutic exercise for this patient population, although strengthening exercises were favored over aerobic exercises. Although nearly all physical therapists would monitor exercise adherence, only 12% would use an exercise diary. Seventy-six percent of physical therapists would provide up to 5 treatment sessions, and only 34% would offer physical therapy follow-up after discharge.

DISCUSSION AND CONCLUSION

The measure of physical therapists' current clinical practice was self-reported clinical behavior on the basis of a vignette. Although this is a valid measure of clinical behavior, in practice, physical therapists may use therapeutic exercise differently. There are disparities between physical therapists' current use of therapeutic exercise for clinical knee OA and recent recommendations. Identifying potential ways to overcome these disparities is an important step toward optimizing the outcome from therapeutic exercise for patients with clinical knee OA.

Short and medium-term effects of an education self-management program for individuals with osteoarthritis of the knee, designed and delivered by health professionals: a quality assurance study

BACKGROUND

Self-management (SM) programs are effective for some chronic conditions, however the evidence for arthritis SM is inconclusive. The aim of this case series project was to determine whether a newly developed specific self-management program for people with osteoarthritis of the knee (OAK), implemented by health professionals could achieve and maintain clinically meaningful improvements.

METHODS

PARTICIPANTS

79 participants enrolled; mean age 66, with established osteoarthritis of the knee. People with coexisting inflammatory joint disease or serious co-morbidities were excluded.

INTERVENTION

6-week disease (OA) and site (knee) specific self-management education program that included disease education, exercise advice, information on healthy lifestyle and relevant information within the constructs of self-management. This program was conducted in a community health care setting and was delivered by health professionals thereby utilising their knowledge and expertise.

MEASUREMENTS

Pain, physical function and mental health scales were assessed at baseline, 8 weeks, 6 and 12 months using WOMAC and SF-36 questionnaires. Changes in pain during the 8-week intervention phase were monitored with VAS.

RESULTS

Pain improved during the intervention phase: mean (95% CI) change 15 (8 to 22) mm. Improvements (0.3 to 0.5 standard deviation units) in indices of pain, mental health and physical functioning, assessed by SF-36 and WOMAC questionnaires were demonstrated from baseline to 12 months.

CONCLUSION

This disease and site-specific self-management education program improved health status of people with osteoarthritis of the knee in the short and medium term.

Does knee malalignment mediate the effects of quadriceps strengthening on knee adduction moment, pain, and function in medial knee osteoarthritis? A randomized controlled trial

OBJECTIVE

To examine whether the effects of 12 weeks of quadriceps strengthening on the knee adduction moment, pain, and function in people with medial knee osteoarthritis (OA) differ in those with and without varus malalignment.

METHODS

A single-blind, randomized controlled trial of 107 community volunteers with medial knee OA was conducted. Participants were stratified according to knee malalignment (more varus or more neutral) and then randomized into either a 12-week supervised home-based quadriceps strengthening group or a control group with no intervention. The primary outcome was the knee adduction moment, measured using 3-dimensional gait analysis. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index scores (measuring pain and physical function), step test score, stair climb test score, and maximum quadriceps isometric strength. Analyses of covariance were carried out based on intent-to-treat principles.

RESULTS

Quadriceps strengthening did not significantly alter the knee adduction moment in either the more malaligned or the more neutral group (unadjusted knee adduction moment 0.12 and 0.05% Nm/BWxHT, respectively). Function did not improve significantly following quadriceps strengthening in either alignment group, but there was a significant improvement in knee pain in the more neutrally aligned group (P < 0.001).

CONCLUSION

Quadriceps strengthening did not have any significant effect on the knee adduction moment in participants with either more varus or more neutral alignment. The benefits of quadriceps strengthening on pain were more evident in those with more neutral alignment. Knee alignment thus represents a local mechanical factor that can mediate symptomatic outcome from exercise interventions in knee OA.

Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management

The mechanisms by which obesity affects osteoarthritis (OA) are of great concern to osteoarthritis researchers and clinicians who manage this disease. Inflammation and joint loads are pathways commonly believed to cause or to exacerbate the disease process. This article reviews the physiologic and mechanical consequences of obesity in older adults who have knee OA, the effects of long-term exercise and weight-loss interventions, the most effective nonpharmacologic treatments for obesity, and the usefulness and feasibility of translating these results to clinical practice.

Molecular network of cartilage homeostasis and osteoarthritis

This review article presents the current understanding of the molecular basis of articular cartilaginous homeostasis, and outlines potential areas to focus on within the developing field of therapeutics for cartilage disorders. Articular cartilage, an integral component of joints in extremities and the vertebral column, is essential for locomotion. Disturbance of joint development or cartilage homeostasis causes congenital osteocartilaginous dysplasia or osteoarthritic diseases, respectively. Symptomatic treatments and surgical replacement of joints are effective but can also be problematic in terms of quality of life over time. Recently, new insights into the molecular biological basis of chondrocyte differentiation and cartilage homeostasis have been reported. While joint formation is regulated by several growth factors such as Wnts (wingless-related MMTV integration site) and Gdfs (growth and differentiation factors), the pathology of osteoarthritis is now interpreted as the disruption of balance between anabolic and catabolic signals. Current findings in molecular biology on joint development are reviewed concisely to aid in the understanding of the molecular network that governs articular cartilage development and homeostasis.

Nociception before and after exercise in rats bred for high and low aerobic capacity

Exercise and stress are known to influence pain perception. However, little is known about how level of fitness influences pain perception and the experience of pain. In the present study, pain perception before and after exercise to exhaustion was examined in 6 rats systematically bred to have a high aerobic capacity (HCR animals) and 6 rats systematically bred to have a low aerobic capacity (LCR animals). HCR animals had significantly higher pain thresholds compared to LCR animals before and after exercise (7.66 s compared to 6.01 s, t=-3.07, p<0.05; and 6.89 s versus 4.73 s, t=-3.73, p<0.01, respectively). In addition, both groups of animals displayed evidence of hyperalgesia following exercise compared to baseline. However, the pain thresholds of HCR animals returned to baseline levels faster than LCR animals following exercise. The findings support the hypothesis that level of fitness plays a role in the perception of pain. In addition, a higher level of fitness may serve as buffer against the effects of stress and help to reduce or prevent the experience of clinical pain. Further research is needed to examine the mechanisms that underlie this phenomenon.

A proposal for a new screening paradigm and tool called Exercise Assessment and Screening for You (EASY)

The Exercise Assessment and Screening for You (EASY) is a tool developed to help older individuals, their health care providers, and exercise professionals identify different types of exercise and physical activity regimens that can be tailored to meet the existing health conditions, illnesses, or disabilities of older adults. The EASY tool includes 6 screening questions that were developed based on an expert roundtable and follow-up panel activities. The philosophy behind the EASY is that screening should be a dynamic process in which participants learn to appreciate the importance of engaging in regular exercise, attending to health changes, recognizing a full range of signs and symptoms that might indicate potentially harmful events, and becoming familiar with simple safety tips for initiating and progressively increasing physical activity patterns. Representing a paradigm shift from traditional screening approaches that focus on potential risks of exercising, this tool emphasizes the benefits of exercise and physical activity for all individuals.

Effect of home exercise of quadriceps on knee osteoarthritis compared with nonsteroidal antiinflammatory drugs: a randomized controlled trial

OBJECTIVES

To examine the effect of home-based exercise on knee osteoarthritis among Japanese in comparison with that of nonsteroidal antiinflammatory drugs (NSAIDs).

DESIGN

An open-labeled, randomized, controlled, multiclinic trial compared home-based quadriceps exercise with NSAIDs. Treatments were basically evaluated after 8 wks and compared with the baseline scores. Outcomes were evaluated with a set of psychometric measurements including the Western Ontario and McMaster Universities Arthritis Index (WOMAC), 36-Item Short-Form Health Survey (SF-36), Japanese Knee Osteoarthritis Measure (JKOM), and pain with the visual analog scale.

RESULTS

A total of 142 patients entered this trial to provide the baseline data. After 21 cases withdrew, the final number analyzed was 121 cases: 63 for the exercise group and 58 for the NSAIDs group. Between these two groups, there was no significant difference in gender, age, body height and weight, body mass index, or each score at baseline. The subjects in both groups showed improvements in all scores at the end of intervention. The difference in improvement rate of each score between the two groups was not statistically significant, though the mean rank score measured with JKOM in the exercise was slightly better than that of the NSAIDs.

CONCLUSIONS

Home-based exercise using quadriceps strengthening improves knee osteoarthritis no less than NSAIDs.

OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines

PURPOSE

To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world.

METHODS

Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale.

RESULTS

Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided.

CONCLUSION

Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.

If You Want Patients with Knee Osteoarthritis (OA) to Exercise: Tell them about NSAIDS

PURPOSE: Exercise is an important adjunctive treatment for knee OA; however it is underutilized, in part because of the known difficulties related to initiating and adhering to exercise programs. Although there are ample data documenting the latter, patient preferences for exercise in comparison to other options have not been examined. METHODS: Participants were recruited as part of an intervention trial to improve decision-making in knee OA. Patients with knee pain on most days of the preceding month completed an Adaptive Conjoint Analysis interactive computer survey designed to elicit patient preferences for a cream (capsaicin), oral medications, [acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)], intra-articular (IA) injections (up to four times per year) and exercise (low impact aerobic exercise and/or strength training three times per week). Preferences were determined based on individual respondent's trade-offs between: route of administration, probability of having less pain, probability of improved strength and endurance, risk of dyspepsia, and risk of ulcer. Preferences were calculated as "shares" which sum to 100. RESULTS: 90 subjects completed the computer tool; mean age ± SD = 68 ± 9 (range = 53-87). Patients preferred exercise over other treatment options whether IA injections and NSAIDs were described as being 20% or 50% more effective at decreasing symptoms compared to other options. The relative importance assigned to treatment benefits and risks were 29% and 41% respectively. Patient demographic characteristics were not related to preferences; however, patients with more self reported knee pain were less likely to prefer exercise compared to their counterparts (r = -0.3, p=0.004). CONCLUSIONS: In this study, patients preferred exercise over pharmacologic options for treatment of knee OA. Preferences were driven by patients' unwillingness to accept the risk of adverse effects. Our findings also suggest that subjects with greater knee pain may be more reluctant to exercise compared to their counterparts. Presentation of exercise in the context of other available therapies might increase patient willingness to try exercising by making the trade-offs between exercise and medications more apparent.

Long-term impact of Fit and Strong! on older adults with osteoarthritis

PURPOSE

We present final outcomes from the multiple-component Fit and Strong! intervention for older adults with lower extremity osteoarthritis.

DESIGN AND METHODS

A randomized controlled trial compared the effects of this exercise and behavior-change program followed by home-based reinforcement (n=115) with a wait list control (n=100) at 2, 6, and 12 months. Fit and Strong! combined flexibility, aerobic walking, and resistance training with education and group problem solving to enhance self-efficacy for exercise and maintenance of physical activity. All participants developed individualized plans for long-term maintenance.

RESULTS

Relative to controls, treatment participants experienced statistically significant improvements in self-efficacy for exercise (p=.001), minutes of exercise per week (p=.000), and lower extremity stiffness (p=.018) at 2 months. These benefits were maintained at 6 months and were accompanied by increased self-efficacy for adherence to exercise over time (p=.001), reduced pain (p=.040), and a marginally significant increase in self-efficacy for arthritis pain management (p=.052). Despite a substantially smaller sample size at 12 months, significant treatment-group effects were maintained on self-efficacy for exercise (p=.006) and minutes of exercise per week (p=.001), accompanied by marginally significant reductions in lower extremity stiffness (p=.056) and pain (p=.066). No adverse health effects were seen. Effect sizes for self-efficacy for exercise and for maintenance of physical activity were 0.798 and 0.713, and 0.905 and 0.669, respectively, in the treatment group at 6 and 12 months.

IMPLICATIONS

This consistent pattern of benefits indicates that this low-cost intervention is efficacious for older adults with lower extremity osteoarthritis.

Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain

OBJECTIVE

To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program.

METHODS

Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness.

RESULTS

Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost 224 pounds (95% confidence interval [95% CI] 184 pounds, 262 pounds) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay 1,900 pounds for improvements in functioning. Indiv-rehab cost 314 pounds/person and Grp-rehab 125 pounds/person. Indiv-rehab cost 189 pounds (95% CI 168 pounds, 208 pounds) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP 5,500 pounds. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome.

CONCLUSION

Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.

Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial

OBJECTIVE

Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.

METHODS

We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age >/=50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation.

RESULTS

A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (-3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] -5.88, -0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (-3.53; 95% CI -6.52, -0.55) or group rehabilitation (-3.16; 95% CI -6.55, -0.12).

CONCLUSION

ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.

Facteurs dont il faut tenir compte dans la création d’un guide d’activité physique pour les Canadiens qui ont un handicap physiqueCet article est tiré d’un supplément intitulé Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines (Favoriser les lignes directrices et la mesure de l’activité physique au Canada: examen scientifique et justification selon les données probantes pour l’avenir des lignes directrices de l’activité physique canadienne) publié par Physiologie appliquée, nutrition et métabolisme et la Revue canadienne de santé publique. On peut aussi mentionner Appl. Physiol. Nutr. Metab. 32 (Suppl. 2F) ou Can. J. Public Health 98 (Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.

Considerations for the development of a physical activity guide for Canadians with physical disabilitiesThis article is part of a supplement entitled Advancing physical activity measurement and guidelines in Canada: a scientific review and evidence-based foundation for the future of Canadian physical activity guidelines co-published by Applied Physiology, Nutrition, and Metabolism and the Canadian Journal of Public Health. It may be cited as Appl. Physiol. Nutr. Metab. 32(Suppl. 2E) or as Can. J. Public Health 98(Suppl. 2)

This paper provides a brief overview of the epidemiological data regarding Canadians with physical disabilities, with a particular emphasis on health status. A literature review is then presented, focusing on activity levels and the physiological and health-related quality of life benefits of activity for people with four different physical disabilities (arthritis, fibromyalgia, spinal cord injury, and multiple sclerosis). The unique physical activity barriers faced by people with physical disabilities are discussed. The paper concludes with recommendations for the development of a physical activity guide for Canadians with physical disabilities.

Supervised or unsupervised exercise for the treatment of hip and knee osteoarthritis. Clinical practice recommendations

OBJECTIVES

To develop clinical practice guidelines concerning supervised or unsupervised kinesiotherapy for treating lower-limb osteoarthritis (OA).

METHOD

The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used to develop guidelines. RESULTS-CONCLUSION: Physical exercise is a part of the treatment of lower-limb OA. An educational pre-program is recommended to inform the patient about the ease and effectiveness of the physical exercise. Use of the SOFMER methodology led to recommending a program of initial physical exercise supervised by a physiotherapist, then an unsupervised program at home with compliance. The type, intensity, and frequency of the exercises must be adapted to each patient. Complementary randomized controlled studies are necessary to characterize the best exercises and their intensity and frequency. The OA location and gravity, functional need, and characteristics of patients will be useful in future studies.

The value of individual or collective group exercise programs for knee or hip osteoarthritis. Clinical practice recommendations

OBJECTIVE

To develop clinical practice guidelines concerning individual and group exercise therapy for knee and/or hip osteoarthritis (OA).

METHOD

We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, to develop the guidelines.

RESULTS

Physical exercises are proposed for knee and hip OA. The benefit of individual exercises is low to moderate for pain, strength and ability to walk. The effectiveness is not maintained over time if the individual exercise program is not continued. The benefit of group exercise is also low to moderate for pain, strength, balance and ability to walk. There is no evidence of the superiority of one modality over the other (individual or group).

CONCLUSION

More randomised controlled trials with good methodology are needed to compare the effectiveness of individual versus group exercise therapy for knee and hip OA.

Community-based treatment of late life depression an expert panel-informed literature review

OBJECTIVES

To present findings from an expert panel-informed literature review on community-based treatment of late-life depression.

METHODS

A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions.

RESULTS

A total of 3,543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions.

CONCLUSIONS

While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

Total joint arthroplasties: current concepts of patient outcomes after surgery

Total hip and knee arthroplasties are effective surgical interventions for relieving hip pain and improving physical function caused by arthritis. Although the majority of patients substantially improve, not all report gains or are satisfied after receiving total joint arthroplasty. This article reviews the literature on patient outcomes after total hip and knee arthroplasties for osteoarthritis, and the evidence pertaining to factors that affect these patient-centered outcomes. Mounting evidence suggests that no single patient-related or perioperative factor clearly predicts the amount of pain relief or functional improvement that will occur following total hip or knee arthroplasty.

Arthritis Burden and Impact are Greater among U.S. Women than Men: Intervention Opportunities

OBJECTIVES

To summarize arthritis burden and impact among women compared with men, using updated surveillance and impact measures; to describe public health approaches to arthritis; and to review effective, evidence-based arthritis self-management interventions.

RESULTS

Arthritis continues to burden the U.S. population as the leading cause of physical disability and affects women disproportionately: women with arthritis report greater prevalence of activity and work limitations, psychological distress, and severe joint pain than their male counterparts. Three main public health interventions can reduce arthritis impact: self-management education, physical activity, and weight management. Self-management education programs are proven to reduce pain and depression, delay disability, improve self-efficacy, physical function, and quality of life, and reduce healthcare costs. Appropriate physical activity decreases pain, improves function, and delays disability. The American College of Rheumatology recommends maintaining a healthy weight to benefit patients with hip or knee osteoarthritis. Women appear more receptive to certain information delivery methods (i.e., physician counseling) than men, suggesting gender-specific targeting of interventions may be of use.

CONCLUSIONS

Effective interventions remain underused. The Centers for Disease Control and Prevention Arthritis Program and its partners, including state arthritis programs, continue their efforts to build the arthritis public health science base, monitor burden and impact, evaluate and disseminate evidence-based interventions, and work to decrease and delay disability, and increase quality of life among those with arthritis. As new approaches are developed, women and other disproportionately impacted groups merit particular consideration in tailoring and delivering programs to reduce arthritis burden.

Deconditioned Knee: The Effectiveness of a Rehabilitation Program that Restores Normal Knee Motion to Improve Symptoms and Function

BACKGROUND

Knee pain can cause a deconditioned knee. Deconditioned is defined as causing one to lose physical fitness. Therefore, a deconditioned knee is defined as a painful syndrome caused by anatomical or functional abnormalities that result in a knee flexion contracture (functional loss of knee extension), decreased strength, and decreased function. To date, no published studies exist examining treatment for a deconditioned knee.

OBJECTIVE

To determine the effectiveness of a rehabilitation program focused on increasing range of motion for patients with a deconditioned knee.

METHODS

Fifty patients (mean age 53.2 years) enrolled in the study. Objective evaluation included radiographs, knee range of motion, and isokinetic strength testing. The International Knee Documentation Committee (IKDC) subjective questionnaire was used to measure symptoms and function. Patients were given a rehabilitation program to increase knee extension (including hyperextension) and flexion equal to the normal knee, after which patients were instructed in leg strengthening exercises.

RESULTS

Knee extension significantly improved from a mean deficit of 10° to 3° and knee flexion significantly improved from a mean deficit of 19° to 9°. The IKDC survey scores significantly improved from a mean of 34.5 points to 70.5 points 1 year after beginning treatment. The IKDC subjective pain frequency and severity scores were significantly improved.

CONCLUSIONS

A rehabilitation program that improves knee range of motion can relieve pain and improve function for patients with a deconditioned knee.

Group and home-based tai chi in elderly subjects with knee osteoarthritis: a randomized controlled trial

OBJECTIVE

To evaluate the effects of tai chi consisting of group and home-based sessions in elderly subjects with knee osteoarthritis.

DESIGN

A randomized, controlled, single-blinded 12-week trial with stratification by age and sex, and six weeks of follow-up.

SETTING

General community.

PARTICIPANTS

Forty-one adults (70 +/- 9.2 years) with knee osteoarthritis.

INTERVENTIONS

The tai chi programme featured six weeks of group tai chi sessions, 40 min/session, three times a week, followed by another six weeks (weeks 7 -12) of home-based tai chi training. Subjects were requested to discontinue tai chi training during a six-week follow-up detraining period (weeks 13-18). Subjects in the attention control group attended six weeks of health lectures following the same schedule as the group-based tai chi intervention (weeks 0 -6), followed by 12 weeks of no activity (weeks 7-18).

MAIN OUTCOME MEASURES

Knee pain measured by visual analogue scale, knee range of motion and physical function measured by Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were recorded at baseline and every three weeks throughout the 18-week study period. Data were analysed using a mixed model ANOVA.

RESULTS

The six weeks of group tai chi followed by another six weeks of home tai chi training showed significant improvements in mean overall knee pain (P = 0.0078), maximum knee pain (P = 0.0035) and the WOMAC subscales of physical function (P = 0.0075) and stiffness (P = 0.0206) compared to the baseline. No significant change of any outcome measure was noted in the attention control group throughout the study. The tai chi group reported lower overall pain and better WOMAC physical function than the attention control group at weeks 9 and 12. All improvements disappeared after detraining.

Cross cultural aspects of rehabilitation in rheumatic diseases

PURPOSE OF REVIEW

The aim of this article is to describe progress in the understanding of the relationship between culture, race, ethnicity and similar factors as they pertain to rehabilitation and the rheumatic diseases. This review highlights important current issues and indicates areas for future study.

RECENT FINDINGS

There is very little published research in this area of rehabilitation medicine. Recent findings and observations indicate that there are many important cultural aspects of rehabilitation in the rheumatic diseases with several societal as well as individual implications. This is a rapidly growing area of work as it is being increasingly recognized that an understanding of these cross cultural issues is essential in order to be able to ensure the delivery of clinically and cost effective rehabilitation services which are client centred and consequently culturally appropriate. Although the interrelationship of culture, race, genetics, ethnicity, language, religion, history, geography, socioeconomic status and educational level is complex, studies are beginning to reveal the contributions of these factors to ensuring minimization of disability and high quality rehabilitation strategies.

SUMMARY

Although much neglected, the importance of cultural aspects of rehabilitation in rheumatic diseases is being increasingly recognized and understood. Issues that have been identified include the rehabilitation needs assessment of different ethnic groups, the development of culturally valid outcome measures and the implementation and evaluation of culturally competent multidisciplinary rehabilitation programs.

Anterior knee pain and thigh muscle strength after intramedullary nailing of a tibial shaft fracture: an 8-year follow-up of 28 consecutive cases

OBJECTIVES

Chronic anterior knee pain is a common complication after intramedullary nailing of a tibial shaft fracture. The source of pain is often not known, although it correlates with a simultaneous decrease in thigh muscle strength. No long-term follow-up study has assessed whether weakness of the thigh muscles is associated with anterior knee pain after the procedure in question.

DESIGN

Prospective study.

SETTING

University Hospital of Tampere, University of Tampere.

PATIENTS

The muscular performance of 40 consecutive patients with a nailed tibial shaft fracture was tested isokinetically in a follow-up examination an average of 3.2 +/- 0.4 (SD) years after the initial surgery. An 8-year follow-up was possible in 28 of these cases.

MAIN OUTCOME MEASUREMENTS

Isokinetic muscle strength measurements were made in 28 patients at an average 8.1 +/- 0.3 (SD) years after nail insertion and an average 6.6 +/- 0.3 (SD) years after nail extraction. All nails were extracted at an average 1.6 +/- 0.2 years after the nailing.

RESULTS

: Seven patients were painless initially and still were at final follow-up (never pain, or NP). In 13 patients, the previous symptom of anterior knee pain was no longer present at final follow-up [pain, no pain (PNP)], and the remaining 8 had anterior knee pain initially and at final follow-up [always pain group (AP)]. With reference to the hamstring muscles, the mean peak torque difference between the injured and uninjured limb was -2.2% +/- 12% in the NP group, 1.6% +/- 15% in the PNP group, and 10.3% +/- 30% in the AP group at a speed of 60 degrees/second (Kruskal-Wallis test; chi(2) = 1.0; P = 0.593). At a speed of 180 degrees/second, the corresponding differences were -2.9% +/- 23% and 7.0% +/- 19% and 4.4% +/- 16% (Kruskal-Wallis test; chi = 1.7; P = 0.429). With reference to the quadriceps muscles, the mean peak torque difference was -2.8% +/- 9% in the NP group, 5.9% +/- 15% in the PNP group, and -13.0% +/- 16% in the AP group at a speed of 60 degrees/second (Kruskal-Wallis test; chi(2) = 7.9; P = 0.019). At 180 degrees/second, the corresponding differences were -9.4% +/- 13% and 4.9% +/- 16% and -1.9% +/- 9%, respectively (Kruskal-Wallis test; chi(2) = 4.8; P = 0.092).

CONCLUSION

Based on this prospective long-term follow-up study, it appears that the anterior knee pain symptoms that are present after intramedullary nailing of a tibial shaft fracture disappear in a number of patients 3 to 8 years after surgery. Quadriceps, but not hamstring weakness, and lower functional knee scores are associated with anterior knee pain at 8 years.

Nutritional considerations in joint health

Osteoarthritis, a debilitating joint disorder, is the most common form of arthritis in the United States, where it affects an estimated 21 million people. In 2004, the direct and indirect health care costs associated with all forms of arthritis were approximately 86 billion dollars. Joint discomfort from osteoarthritis and other joint disorders may reduce physical activity in individuals experiencing this condition, resulting in energy imbalance and weight gain. Increased weight can exacerbate existing problems, as additional stress on joints stimulates risk of additional joint disorders. Dietitians play a role in preventing or reversing the problem of joint disorders by promoting nutrient-rich diets that support joint health through improvement in cartilage metabolism. In addition, counseling individuals on weight management and active lifestyles are key strategies for the management of joint health.