Variations among primary care physicians in exercise advice, imaging, and analgesics for musculoskeletal pain: results from a factorial experiment

Association of physical activity with loss of knee joint space width over two years: a compositional data analysis in the Osteoarthritis Initiative

OBJECTIVE

There is continued debate as to how engaging in physical activity (PA), including moderate-to-vigorous PA (MVPA), light PA (LPA), and sedentary time (SED), affects one's risk for knee osteoarthritis (OA). Traditional regression methods do not account for the codependence of these categories of PA, whereby when one category increases, the others must decrease. Thus, we used compositional data analysis (CoDA) to examine time spent in each category of PA, or PA composition, and its association with loss of knee joint space width (JSW), a common indicator of knee OA progression.

METHODS

We performed a secondary analysis of data from a subset of participants in the Osteoarthritis Initiative. These participants had minute-by-minute activity data collected over 7 days at baseline; we then categorized each minute as MVPA, LPA, or SED. Our exposure, PA composition, represented min/day spent in each category. Our outcome, medial JSW loss, was the difference in medial tibiofemoral JSW from baseline to 2 years later. We employed CoDA, using an isometric log-ratio transformation, to examine the association of PA composition with medial JSW loss over 2 years, adjusting for potential confounders.

RESULTS

We included 969 participants (age: 64.5 years, 56% female, body mass index [BMI]: 28.8 kg/m2). Mean PA composition was: MVPA 9.1 min/day, LPA 278 min/day, SED 690 min/day. Per adjusted regression models, higher MVPA was not associated with greater medial JSW loss (β = -0.0005, P = 0.97), nor was LPA (β = 0.06, P = 0.27) or SED (β = -0.06, P = 0.21).

CONCLUSION

Using CoDA, PA composition was not associated with medial JSW loss over 2 years.

Physical Activity Assessment and Promotion in Clinical Settings in the United States: A Scoping Review

OBJECTIVE

The purpose of this scoping review was to systematically examine interventions that focused on physical activity assessment and promotion in clinical settings in the United States.

DATA SOURCES

A literature search was performed in 6 major databases to extract published peer-reviewed studies from 2008 to 2019.

INCLUSION AND EXCLUSION CRITERIA

Interventions with practicing health professionals in the United States who performed physical activity assessment and promotion with adult patients 18 years of age and older. Studies were excluded if they were published in non-English, observational or case study designs, or gray literature.

DATA EXTRACTION

Studies were screened and coded based on the population, intervention, comparison, outcomes and study setting for scoping reviews (PRISMA-ScR) framework. Of 654 studies that were identified and screened for eligibility, 78 met eligibility criteria and were independently coded by two coders.

DATA SYNTHESIS

Data were synthesized using qualitative and descriptive methods.

RESULTS

Forty-three of the included studies were randomized controlled trials with a majority being delivered by physicians and nurses in primary care settings. Fifty-six studies reported statistically significant findings in outcome measures such as anthropometrics and chronic disease risk factors, with 17 demonstrating improvements in physical activity levels as a result of the interventions.

CONCLUSION

The assessment and promotion of physical activity in clinical settings appears to be effective but warrants continued research.

Evidence-based treatment recommendations for neck and low back pain across Europe: A systematic review of guidelines

BACKGROUND AND OBJECTIVE

This systematic review synthesized evidence from European neck and low back pain (NLBP) clinical practice guidelines (CPGs) to identify recommended treatment options for use across Europe.

DATABASES AND DATA TREATMENT

Comprehensive searches of thirteen databases were conducted, from 1st January 2013 to 4th May 2020 to identify up-to-date evidence-based European CPGs for primary care management of NLBP, issued by professional bodies/organizations. Data extracted included; aim and target population, methods for development and implementation and treatment recommendations. The AGREE II checklist was used to critically appraise guidelines. Criteria were devised to summarize and synthesize the direction and strength of recommendations across guidelines.

RESULTS

Seventeen CPGs (11 low back; 5 neck; 1 both) from eight European countries were identified, of which seven were high quality. For neck pain, there were consistent weak or moderate strength recommendations for: reassurance, advice and education, manual therapy, referral for exercise therapy/programme, oral analgesics and topical medications, plus psychological therapies or multidisciplinary treatment for specific subgroups. Notable recommendation differences between back and neck pain included, i) analgesics for neck pain (not for back pain); ii) options for back pain-specific subgroups-work-based interventions, return to work advice/programmes and surgical interventions (but not for neck pain) and iii) a greater strength of recommendations (generally moderate or strong) for back pain than those for neck pain.

CONCLUSIONS

This review of European CPGs identified a range of mainly non-pharmacological recommended treatment options for NLBP that have broad consensus for use across Europe.

SIGNIFICANCE

Consensus regarding evidence-based treatment recommendations for patients with neck and low back pain (NLBP) from recent European clinical practice guidelines identifies a wide range of predominantly non-pharmacological treatment options. This includes options potentially applicable to all patients with NLBP and those applicable to only specific patient subgroups. Future work within our Back-UP research team will transfer these evidence-based treatment options to an accessible clinician decision support tool for first contact clinicians.

Racial/Ethnic and Socioeconomic Disparities in Osteoarthritis Management

This article reviews the literature on racial and socioeconomic disparities in the management of osteoarthritis. Treatments investigated include arthritis education, dietary weight management, exercise/physical therapy, pharmacologic therapy with nonsteroidal antiinflammatory drugs and opioids, intra-articular steroid injections, and total joint replacement. The amount of evidence for each treatment modality varied, with the most evidence available for racial and socioeconomic disparities in total joint arthroplasty. Black patients, Hispanic patients, and patients with low socioeconomic status (SES) are less likely to undergo total joint replacement than white patients or patients with high SES, and generally have worse functional outcomes and more complications.

Physician Prescribing Patterns and Risk of Future Long-Term Opioid Use Among Patients With Rheumatoid Arthritis: A Prospective Observational Cohort Study

OBJECTIVE

To identify the extent to which opioid prescribing rates for patients with rheumatoid arthritis (RA) vary in the US and to determine the implications of baseline opioid prescribing rates on the probability of future long-term opioid use.

METHODS

We identified patients with RA from physicians who contributed ≥10 patients within the first 12 months of participation in the Corrona RA Registry. The baseline opioid prescribing rate was calculated by dividing the number of patients with RA reporting opioid use during the first 12 months by the number of patients with RA providing data that year. To estimate odds ratios (ORs) for long-term opioid use, we used generalized linear mixed models.

RESULTS

During the follow-up period, long-term opioid use was reported by 7.0% (163 of 2,322) of patients of physicians with a very low rate of opioid prescribing (referent) compared to 6.8% (153 of 2,254) of patients of physicians with a low prescribing rate, 12.5% (294 of 2,352) of patients of physicians with a moderate prescribing rate, and 12.7% (307 of 2,409) of patients of physicians with a high prescribing rate. The OR for long-term opioid use after the baseline period was 1.16 (95% confidence interval [95% CI] 0.79-1.70) for patients of low-intensity prescribing physicians, 1.89 (95% CI 1.27-2.82) for patients of moderate-intensity prescribing physicians, and 2.01 (95% CI 1.43-2.83) for patients of high-intensity prescribing physicians, compared to very low-intensity prescribing physicians.

CONCLUSION

Rates of opioid prescriptions vary widely. Our findings indicate that baseline opioid prescribing rates are a strong predictor of whether a patient will become a long-term opioid user in the future, after controlling for patient characteristics.

Racial/Ethnic Disparities in Physical Function Before and After Total Knee Arthroplasty Among Women in the United States

IMPORTANCE

Although racial/ethnic differences in functional outcomes after total knee arthroplasty (TKA) exist, whether such differences are associated with differences in presurgical physical function (PF) has not been thoroughly investigated.

OBJECTIVE

To examine trajectories of PF by race/ethnicity before and after TKA among older women.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among the prospective Women's Health Initiative with linked Medicare claims data. A total of 10 325 community-dwelling women throughout the United States with Medicare fee-for-service underwent primary TKA between October 1, 1993, and December 31, 2014, and were followed up through March 31, 2017.

EXPOSURES

Race/ethnicity comparisons between Hispanic or Latina women, non-Hispanic black or African American women, and non-Hispanic white women (hereafter referred to as Hispanic, black, and white women, respectively).

MAIN OUTCOMES AND MEASURES

Physical functioning scale scores and self-reported activity limitations with walking 1 block, walking several blocks, and climbing 1 flight of stairs were measured by the RAND 36-Item Health Survey during the decade before and after TKA, with a median of 9 PF measurements collected per participant over time.

RESULTS

In total, 9528 white women (mean [SD] age at surgery, 74.6 [5.5] years), 622 black women (mean [SD] age at surgery, 73.1 [5.3] years), and 175 Hispanic women (mean [SD] age at surgery, 73.1 [5.2] years) underwent TKA. During the decade prior to TKA, black women had lower PF scores than white women (mean difference, -5.8 [95% CI, -8.0 to -3.6]) and higher odds of experiencing difficulty walking a single block (5 years before TKA: odds ratio, 1.86 [95% CI, 1.57-2.21]), walking multiple blocks (odds ratio, 2.14 [95% CI, 1.83-2.50]), and climbing 1 flight of stairs (odds ratio, 1.81 [95% CI, 1.55-2.12]). After TKA, black women continued to have lower PF scores throughout the decade (mean difference 1 year after TKA, -7.8 [95% CI, -10.8 to -4.9]). After adjusting for preoperative PF scores, PF scores after TKA were attenuated (mean difference 1 year after TKA, -3.0 [95% CI, -5.3 to -0.7]), with no statistically significant differences in long-term follow-up. Hispanic women had similar PF scores to white women during the pre-TKA and post-TKA periods.

CONCLUSIONS AND RELEVANCE

This study suggests that black women had significantly poorer PF than white women during the decades before and after TKA. Poorer PF after surgery was associated with poorer preoperative PF. Reducing disparities in post-TKA functional outcomes should target maintenance of function preoperatively in the early stages of arthritic disease and/or reduction of delays to receiving TKA once need arises.

Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

BACKGROUND

Musculoskeletal (MSK) pain from the five most common presentations to primary care (back, neck, shoulder, knee or multi-site pain), where the majority of patients are managed, is a costly global health challenge. At present, first-line decision-making is based on clinical reasoning and stratified models of care have only been tested in patients with low back pain. We therefore, examined the feasibility of; a) a future definitive cluster randomised controlled trial (RCT), and b) General Practitioners (GPs) providing stratified care at the point-of-consultation for these five most common MSK pain presentations.

METHODS

The design was a pragmatic pilot, two parallel-arm (stratified versus non-stratified care), cluster RCT and the setting was 8 UK GP practices (4 intervention, 4 control) with randomisation (stratified by practice size) and blinding of trial statistician and outcome data-collectors. Participants were adult consulters with MSK pain without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records were tagged and individuals sent postal invitations using a GP point-of-consultation electronic medical record (EMR) template. The intervention was supported by the EMR template housing the Keele STarT MSK Tool (to stratify into low, medium and high-risk prognostic subgroups of persistent pain and disability) and recommended matched treatment options. Feasibility outcomes included exploration of recruitment and follow-up rates, selection bias, and GP intervention fidelity. To capture recommended outcomes including pain and function, participants completed an initial questionnaire, brief monthly questionnaire (postal or SMS), and 6-month follow-up questionnaire. An anonymised EMR audit described GP decision-making.

RESULTS

GPs screened 3063 patients (intervention = 1591, control = 1472), completed the EMR template with 1237 eligible patients (intervention = 513, control = 724) and 524 participants (42%) consented to data collection (intervention = 231, control = 293). Recruitment took 28 weeks (target 12 weeks) with > 90% follow-up retention (target > 75%). We detected no selection bias of concern and no harms identified. GP stratification tool fidelity failed to achieve a-priori success criteria, whilst fidelity to the matched treatments achieved "complete success".

CONCLUSIONS

A future definitive cluster RCT of stratified care for MSK pain is feasible and is underway, following key amendments including a clinician-completed version of the stratification tool and refinements to recommended matched treatments.

TRIAL REGISTRATION

Name of the registry: ISRCTN.

TRIAL REGISTRATION NUMBER

15366334. Date of registration: 06/04/2016.

Matching treatment options for risk sub-groups in musculoskeletal pain: a consensus groups study

BACKGROUND

Musculoskeletal (MSK) pain represents a considerable worldwide healthcare burden. This study aimed to gain consensus from practitioners who work with MSK pain patients, on the most appropriate primary care treatment options for subgroups of patients based on prognostic risk of persistent disabling pain. Agreement was sought on treatment options for the five most common MSK pain presentations: back, neck, knee, shoulder and multisite pain, across three risk subgroups: low, medium and high.

METHODS

Three consensus group meetings were conducted with multi-disciplinary groups of practitioners (n = 20) using Nominal Group Technique, a systematic approach to building consensus using structured in-person meetings of stakeholders which follows a distinct set of stages.

RESULTS

For all five pain presentations, "education and advice" and "simple oral and topical pain medications" were agreed to be appropriate for all subgroups. For patients at low risk, across all five pain presentations "review by primary care practitioner if not improving after 6 weeks" also reached consensus. Treatment options for those at medium risk differed slightly across pain-presentations, but all included: "consider referral to physiotherapy" and "consider referral to MSK-interface-clinic". Treatment options for patients at high risk also varied by pain presentation. Some of the same options were included as for patients at medium risk, and additional options included: "opioids"; "consider referral to expert patient programme" (across all pain presentations); and "consider referral for surgical opinion" (back, knee, neck, shoulder). "Consider referral to rheumatology" was agreed for patients at medium and high risk who have multisite pain.

CONCLUSION

In addressing the current lack of robust evidence on the effectiveness of different treatment options for MSK pain, this study generated consensus from practitioners on the most appropriate primary care treatment options for MSK patients stratified according to prognostic risk. These findings can help inform future clinical decision-making and also influenced the matched treatment options in a trial of stratified primary care for MSK pain patients.

Why Aren't There More Female Pain Medicine Physicians?

Despite a growing awareness about the importance of gender equity and the rising number of women in medicine, women remain persistently underrepresented in pain medicine and anesthesiology. Pain medicine ranks among the bottom quartile of medical specialties in terms of female applicants, female trainees, and proportion of female practitioners. Female pain medicine physicians are also notably disadvantaged compared with their male colleagues in most objective metrics of gender equity, which include financial compensation, career advancement, public recognition, and leadership positions. Increased gender diversity among pain medicine physicians is vital to fostering excellence in pain research, education, and clinical care, as well as creating a high-quality work environment. Pain medicine stands at a crossroads as a specialty, and must examine reasons for its current gender gap and consider a call to action to address this important issue.

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

Background

Osteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.

Objectives

The overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.

Data sources

The North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.

Methods

Workstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.

Results

This programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.

Conclusions

Implementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.

Limitations

The key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.

Future work recommendations

(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.

Trial registration

Current Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Gaps in appropriate use of treatment strategies in osteoarthritis

Optimal management of osteoarthritis (OA) requires a combination of therapies, with behavioral (e.g., exercise and weight management) and rehabilitative components at the core, accompanied by pharmacological treatments and, in later stages, consideration of joint replacement surgery. Although multiple sets of OA treatment guidelines have been developed, there are gaps in the implementation of these recommendations. Key areas of concern include the underuse of exercise, weight management, and other behavioral and rehabilitation strategies as well as the overuse of opioid analgesics. In this review, we describe the major categories of treatment strategies for OA, including self-management, physical activity, weight management, physical therapy and other rehabilitative therapies, pharmacotherapies, and joint replacement surgery. For each category, we discuss the current evidence base to report on appropriate use, data regarding adherence to treatment recommendations, and potential approaches to optimize use.

Key Strategies for Physical Activity Interventions Among Older Women: Process Evaluation of a Clinical Trial

PURPOSE

To describe strategies salient to physical activity (PA) initiation and maintenance among older women who participated in a clinical trial that tested a PA intervention.

DESIGN

A descriptive phenomenological, qualitative design for a process evaluation of a successful clinical trial.

SETTING

Senior primary care clinics associated with a large medical center in a southern state.

PARTICIPANTS

A total of 20 older women at least 60 years without advanced frailty.

METHOD

Purposive sampling using maximum variation technique was used to select participants. A semi-structured interview guide facilitated individual, in-depth interviews lasting 45 to 90 minutes. Narratives were analyzed using content analysis with constant comparison technique to summarize the data.

RESULTS

Eight African American and 12 white older women with a mean age of 68 from control and intervention arms participated. Five central themes described salient strategies to promote and maintain PA: sensed benefits, motivation, and self-efficacy were central to success, while a reduction in barriers was essential before maintaining PA. The last theme, a life-changing awareness indicated that PA had become a shared value. An explanatory model describing interrelationships is presented.

CONCLUSIONS

This study suggests key strategies to include in PA interventions with older women. An unexpected finding was that PA became a shared value, an action promoted by the Culture of Health initiative to improve population health and well-being.

Dose-Response Effects of Tai Chi and Physical Therapy Exercise Interventions in Symptomatic Knee Osteoarthritis

BACKGROUND

Therapeutic exercise is a currently recommended nonpharmacological treatment for knee osteoarthritis (KOA). The optimal treatment dose (frequency or duration) has not been determined.

OBJECTIVE

To examine dose-response relationships, minimal effective dose, and baseline factors associated with the timing of response from 2 exercise interventions in KOA.

DESIGN

Secondary analysis of a single-blind, randomized trial comparing 12-week Tai Chi and physical therapy exercise programs (Trial Registry #NCT01258985).

SETTING

Urban tertiary care academic hospital PARTICIPANTS: A total of 182 participants with symptomatic KOA (mean age 61 years; BMI 32 kg/m², 70% female; 55% white).

METHODS

We defined dose as cumulative attendance-weeks of intervention, and treatment response as ≥20% and ≥50% improvement in pain and function. Using log-rank tests, we compared time-to-response between interventions, and used Cox regression to examine baseline factors associated with timing of response, including physical and psychosocial health, physical performance, outcome expectations, self-efficacy, and biomechanical factors.

MAIN OUTCOME MEASURES

Weekly Western Ontario and McMasters Osteoarthritis Index (WOMAC) pain (0-500) and function (0-1700) scores.

RESULTS

Both interventions had an approximately linear dose-response effect resulting in a 9- to 11-point reduction in WOMAC pain and a 32- to 41-point improvement in function per attendance-week. There was no significant difference in overall time-to-response for pain and function between treatment groups. Median time-to-response for ≥20% improvement in pain and function was 2 attendance-weeks and for ≥50% improvement was 4-5 attendance-weeks. On multivariable models, outcome expectations were independently associated with incident function response (hazard ratio = 1.47, 95% confidence interval 1.004-2.14).

CONCLUSIONS

Both interventions have approximately linear dose-dependent effects on pain and function; their minimum effective doses range from 2-5 weeks; and patient perceived benefits of exercise influence the timing of response in KOA. These results may help clinicians to optimize patient-centered exercise treatments and better manage patient expectations.

LEVEL OF EVIDENCE

II.

Health Care Provider Counseling for Physical Activity or Exercise Among Adults with Arthritis - United States, 2002 and 2014

Arthritis affects an estimated 54 million U.S. adults and, as a common comorbidity, can contribute arthritis-specific limitations or barriers to physical activity or exercise for persons with diabetes, heart disease, and obesity (1). The American College of Rheumatology's osteoarthritis management guidelines recommend exercise as a first-line, nonpharmacologic strategy to manage arthritis symptoms (2), and a Healthy People 2020 objective is to increase health care provider counseling for physical activity or exercise among adults with arthritis.* To determine the prevalence and percentage change from 2002 to 2014 in receipt of health care provider counseling for physical activity or exercise (counseling for exercise) among adults with arthritis, CDC analyzed 2002 and 2014 National Health Interview Survey (NHIS) data. From 2002 to 2014, the age-adjusted prevalence of reporting health care provider counseling for exercise among adults with arthritis increased 17.6%, from 51.9% (95% confidence interval [CI] = 49.9%-53.8%) to 61.0% (CI = 58.6%-63.4%) (p<0.001). The age-adjusted prevalence of reporting health care provider counseling for exercise among persons with arthritis who described themselves as inactive increased 20.1%, from 47.2% (CI = 44.0%-50.4%) in 2002 to 56.7% (CI = 52.3%-61.0%) in 2014 (p = 0.001). Prevalence of counseling for exercise has increased significantly since 2002; however, approximately 40% of adults with arthritis are still not receiving counseling for exercise. Improving health care provider training and expertise in exercise counseling and incorporating prompts into electronic medical records are potential strategies to facilitate counseling for exercise that can help adults manage their arthritis and comorbid conditions.

Effects of Treadmill Exercise on Advanced Osteoarthritis Pain in Rats

OBJECTIVE

Exercise is commonly recommended for patients with osteoarthritis (OA) pain. However, whether exercise is beneficial in ameliorating ongoing pain that is persistent, resistant to nonsteroidal antiinflammatory drugs (NSAIDs), and associated with advanced OA is unknown.

METHODS

Rats treated with intraarticular (IA) monosodium iodoacetate (MIA) or saline underwent treadmill exercise or remained sedentary starting 10 days postinjection. Tactile sensory thresholds and weight bearing were assessed, followed by radiography at weekly intervals. After 4 weeks of exercise, ongoing pain was assessed using conditioned place preference (CPP) to IA or rostral ventromedial medulla (RVM)-administered lidocaine. The possible role of endogenous opioids in exercise-induced pain relief was examined by systemic administration of naloxone. Knee joints were collected for micro-computed tomography (micro-CT) analysis to examine pathologic changes to subchondral bone and metaphysis of the tibia.

RESULTS

Treadmill exercise for 4 weeks reversed MIA-induced tactile hypersensitivity and weight asymmetry. Both IA and RVM lidocaine D35, administered post-MIA, induced CPP in sedentary but not exercised MIA-treated rats, indicating that exercise blocks MIA-induced ongoing pain. Naloxone reestablished weight asymmetry in MIA-treated rats undergoing exercise and induced conditioned place aversion, indicating that exercise-induced pain relief is dependent on endogenous opioids. Exercise did not alter radiographic evidence of OA. However, micro-CT analysis indicated that exercise did not block lateral subchondral bone loss or trabecular bone loss in the metaphysis, but did block MIA-induced medial bone loss.

CONCLUSION

These findings support the conclusion that exercise induces pain relief in advanced, NSAID-resistant OA, likely through increased endogenous opioid signaling. In addition, treadmill exercise blocked MIA-induced bone loss in this model, indicating a potential bone-stabilizing effect of exercise on the OA joint.

Physician assessments of drug seeking behavior: A mixed methods study

Background

Pain complaints are common, but clinicians are increasingly concerned about overuse of opioid pain medications. This may lead patients with actual pain to be stigmatized as “drug-seeking,” or attempting to obtain medications they do not require medically. We assessed whether patient requests for specific opioid pain medication would lead physicians to classify them as drug-seeking and change management decisions.

Methods and findings

Mixed-methods analysis of interviews with 192 office-based primary care physicians after viewing video vignettes depicting patients presenting with back pain. For each presentation physicians were randomly assigned to see either an active request for a specific medication or a more general request for help with pain. The main outcome was assignment by the physician of “drug-seeking” as a potential diagnosis among patients presenting with back pain. Additional outcomes included other actions the physician would take and whether the physician would prescribe the medication requested.

A potential diagnosis of drug-seeking behavior was included by 21% of physicians seeing a specific request for oxycodone vs. 3% for a general request for help with back pain(p<0.001). In multivariable models an active request was most strongly associated with a physician-assigned diagnosis of drug-seeking behavior(OR 8.10; 95% CI 2.11–31.15;p = 0.002); other major patient and physician characteristics, including gender and race, did not have strong associations with drug-seeking diagnosis. Physicians described short courses of opioid medications as a strategy for managing patients with pain while avoiding opioid overuse.

Conclusions

When patients make a specific request for opioid pain medication, physicians are far more likely to suspect that they are drug-seeking. Physician suspicion of drug-seeking behavior did not vary by patient characteristics, including gender and race. The strategies used to assess patients further varied widely. These findings indicate a need for the development of better clinical tools to support the evaluation and management of patients presenting with pain.

GPs' attitudes, beliefs and behaviours regarding exercise for chronic knee pain: a questionnaire survey

OBJECTIVES

The aim of this study was to investigate general practitioners' (GPs) attitudes, beliefs and behaviours regarding the use of exercise for patients with chronic knee pain (CKP) attributable to osteoarthritis.

SETTING

Primary care GPs in the UK.

PARTICIPANTS

5000 GPs, randomly selected from Binley's database, were mailed a cross-sectional questionnaire survey.

OUTCOME MEASURES

GPs' attitudes and beliefs were investigated using attitude statements, and reported behaviours were identified using vignette-based questions. GPs were invited to report barriers experienced when initiating exercise with patients with CKP RESULTS: 835 (17%) GPs responded. Overall, GPs were positive about general exercise for CKP. 729 (87%) reported using exercise, of which, 538 (74%) reported that they would use both general and local (lower limb) exercises. However, only 92 (11% of all responding) GPs reported initiating exercise in ways aligning with best-evidence recommendations. 815 (98%) GPs reported barriers in using exercise for patients with CKP, most commonly, insufficient time in consultations (n=419; 51%) and insufficient expertise (n=337; 41%).

CONCLUSIONS

While GPs' attitudes and beliefs regarding exercise for CKP were generally positive, initiation of exercise was often poorly aligned with current recommendations, and barriers and uncertainties were reported. GPs' use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise, and/or by other professionals taking on this role.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background

Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings.

Objectives

Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community.

Review methods

We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion.

Results

We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed.

Conclusions

In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control.

Limitations

We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers.

Future work

There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

It Is Time to Invite Patients to the Physical Activity Party…

Physical activity is associated with a myriad of health benefits relevant to adults who commonly receive rehabilitation. Unfortunately, the prescription for exercise and overall activity still continues to be overlooked, which is a missed opportunity because those receiving rehabilitation are most likely to benefit from the effects of physical activity. The purpose of this supplement is to fill this knowledge gap by featuring articles that examine the efficacy of physical activity, and describe mechanisms underlying changes in physical activity and how physical activity in rehabilitation populations fits within broader medical and public health frameworks.

Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial

BACKGROUND

Efficient approaches are needed for delivering nonpharmacological interventions for management of knee osteoarthritis (OA).

OBJECTIVE

This trial compared group-based versus individual physical therapy interventions for management of knee OA.

DESIGN AND METHODS

Three hundred twenty patients with knee OA at the VA Medical Center in Durham, North Carolina, (mean age=60 years, 88% male, 58% nonwhite) were randomly assigned to receive either the group intervention (group physical therapy; six 1-hour sessions, typically 8 participants per group) or the individual intervention (individual physical therapy; two 1-hour sessions). Both programs included instruction in home exercise, joint protection techniques, and individual physical therapist evaluation. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range=0-96, higher scores indicate worse symptoms), measured at baseline, 12 weeks, and 24 weeks. The secondary outcome measure was the Short Physical Performance Battery (SPPB; range=0-12, higher scores indicate better performance), measured at baseline and 12 weeks. Linear mixed models assessed the difference in WOMAC scores between arms.

RESULTS

At 12 weeks, WOMAC scores were 2.7 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% confidence interval [CI]=-5.9, 0.5; P=.10), indicating no between-group difference. At 24 weeks, WOMAC scores were 1.3 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-4.6, 2.0; P=.44), indicating no significant between-group difference. At 12 weeks, SPPB scores were 0.1 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-0.5, 0.2; P=.53), indicating no difference between groups.

LIMITATIONS

This study was conducted in one VA medical center. Outcome assessors were blinded, but participants and physical therapists were not blinded.

CONCLUSIONS

Group physical therapy was not more effective than individual physical therapy for primary and secondary study outcomes. Either group physical therapy or individual physical therapy may be a reasonable delivery model for health care systems to consider.

Long term use of analgesics and risk of osteoarthritis progressions and knee replacement: propensity score matched cohort analysis of data from the Osteoarthritis Initiative

OBJECTIVES

To determine the association between the long-term use of analgesics and progression of osteoarthritis (OA) as evidenced by up to 3-years follow-up worsening of radiographic Kellgren-Lawrence (KL) grade and incidence of knee replacement (KR).

DESIGN

Using nearest neighbor matching of the propensity scores with caliper in the Osteoarthritis Initiative (OAI) cohort, 173 index (Analgesic +) and 173 referent (Analgesic -) subjects were included. Analgesic + and - subjects had analgesics in all and none of their visits, respectively. Analgesic + and - subjects were balanced in their demographics, baseline, first, second and third year body mass index (BMI), Western Ontario and McMaster (WOMAC) total score, Physical and Mental health summary scales (SF-12), Physical Activity Scale for the Elderly (PASE) and Charleston Comorbidity Scale. Analgesic + and - subjects were also matched for baseline radiographic KL grade. Interval increase in the KL grade and incidence of KR were defined as the outcome.

RESULTS

Included subjects had average 6.5 years of follow-up. By the third year, 44 subjects had an interval increase in the KL grade; 29 in Analgesic + and 15 among Analgesic - subjects (P = 0.024). By the eighth-year, 41 subjects had their first KR; 29 in Analgesic + and 12 among Analgesic - subjects (P = 0.005). Hazard Ratio (HR) of OA progression and KR for Analgesic + subjects was 1.91 (1.02-3.57) and 2.57 (1.31-5.04), respectively.

CONCLUSIONS

Long-term use of analgesics may be associated with radiographic progression of knee OA and increased risk of future KR.

OARSI Clinical Trials Recommendations: Design and conduct of implementation trials of interventions for osteoarthritis

Rigorous implementation research is important for testing strategies to improve the delivery of effective osteoarthritis (OA) interventions. The objective of this manuscript is to describe principles of implementation research, including conceptual frameworks, study designs and methodology, with specific recommendations for randomized clinical trials of OA treatment and management. This manuscript includes a comprehensive review of prior research and recommendations for implementation trials. The review of literature included identification of seminal articles on implementation research methods, as well as examples of previous exemplar studies using these methods. In addition to a comprehensive summary of this literature, this manuscript provides key recommendations for OA implementation trials. This review concluded that to date there have been relatively few implementation trials of OA interventions, but this is an emerging area of research. Future OA clinical trials should routinely consider incorporation of implementation aims to enhance translation of findings.

Commentary on recent therapeutic guidelines for osteoarthritis

BACKGROUND

Despite availability of international evidence-based guidelines for osteoarthritis (OA) management, agreement on the different treatment modalities is lacking.

METHOD

A symposium of European and US OA experts was held within the framework of the Annual European Congress of Rheumatology to discuss and compare guidelines and recommendations for the treatment of knee OA and to reach a consensus for management, particularly for areas in which there is no clear consensus: non-pharmacological therapy; efficacy and safety of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs); intra-articular (i.a.) hyaluronates (HA); and the role of chondroitin sulfate (CS) and/or glucosamine sulfate (GS).

RESULTS

All guidelines reviewed agree that knee OA is a progressive disease of the joint whose management requires non-pharmacological and pharmacological approaches. Discrepancies between guidelines are few and mostly reflect heterogeneity of expert panels involved, geographical differences in the availability of pharmacotherapies, and heterogeneity of the studies included. Panels chosen for guideline development should include experts with real clinical experience in drug use and patient management. Implementation of agreed guidelines can be thwarted by drug availability and reimbursement plans, resulting in optimal OA treatment being jeopardized, HA and symptomatic slow-acting drugs for osteoarthritis (SySADOAs) being clear examples of drugs whose availability and prescription can greatly vary geographically. In addition, primary care providers, often responsible for OA management (at least in early disease), may not adhere to clinical care guidelines, particularly for non-pharmacological OA treatment.

CONCLUSION

Harmonization of the recommendations for knee OA treatment is challenging but feasible, as shown by the step-by-step therapeutic algorithm developed by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). More easily disseminated and implemented guidance for OA treatment in the primary care setting is key to improved management of OA.

Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management

Background

The Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics.

Methods

Baseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants’ Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants’ Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation.

Results

Study clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from “rural” to “small city”), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%).

Conclusions

Although PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation.

Trial registration

Clinical Trial Registration Number: NCT 01435109

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-413) contains supplementary material, which is available to authorized users.

Daily walking and the risk of incident functional limitation in knee osteoarthritis: an observational study

OBJECTIVE

Physical activity is recommended to mitigate functional limitations associated with knee osteoarthritis (OA). However, it is unclear whether walking on its own protects against the development of functional limitation.

METHODS

Walking over 7 days was objectively measured as steps/day within a cohort of people with or at risk of knee OA from the Multicenter Osteoarthritis Study. Incident functional limitation over 2 years was defined by performance-based (gait speed <1.0 meter/second) and self-report (Western Ontario and McMaster Universities Osteoarthritis Index physical function score >28 of 68) measures. We evaluated the association of steps/day at baseline with developing functional limitation 2 years later by calculating risk ratios adjusted for potential confounders. The number of steps/day that best distinguished risk for developing functional limitation was estimated from the maximum distance from chance on receiver operating characteristic curves.

RESULTS

Among 1,788 participants (mean age 67 years, mean body mass index 31 kg/m(2) , 60% women), each additional 1,000 steps/day was associated with a 16% and 18% reduction in incident functional limitation by performance-based and self-report measures, respectively. Walking <6,000 and <5,900 steps/day were the best thresholds to distinguish incident functional limitation by performance-based (sensitivity 67.3%, specificity 71.8%) and self-report (sensitivity 58.7%, specificity 68.9%) measures, respectively.

CONCLUSION

More walking was associated with less risk of functional limitation over 2 years. Walking >6,000 steps/day provides a preliminary estimate of the level of walking activity to protect against developing functional limitation in people with or at risk of knee OA.