Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review

The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.

Interventions to Improve Long-Term Adherence to Physical Rehabilitation: A Systematic Review

OBJECTIVE

To evaluate the impact of physical rehabilitation interventions, supplemented with one or more adherence-enhancing components, on outcomes among adults with hip or knee osteoarthritis or chronic lower back pain.

DESIGN

Primary literature search from inception of each database to July 27, 2021, guided by relevant search terms and keywords to search titles and abstracts. All articles meeting eligibility criteria were included for data abstraction.

DATA SOURCES

MEDLINE, CINAHL Complete, and Embase.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomized and nonrandomized trials evaluating adherence-focused intervention components conducted in addition to an index usual care or usual care-like physical rehabilitation program among adults with hip or knee osteoarthritis or chronic low back pain. Eligible studies included a comparator group of the same index physical rehabilitation intervention without the adjunctive adherence components. Included studies measured outcomes at least 3 months after the rehabilitation course.

RESULTS

Of the 10 studies meeting inclusion criteria, 6 interventions were delivered concurrent to an index rehabilitation program and 4 were delivered sequentially. Of the 3 studies that reported a positive effect on long-term adherence, only 1 was a low risk of bias study. There is very limited evidence of a beneficial treatment effect of adjunct adherence interventions on long-term physical function, self-efficacy, or adverse events.

CONCLUSION

We found inadequate evidence evaluating adherence-enhancing interventions for the specific promotion of long-term adherence to home rehabilitation programs. Future studies should consider testing interventions specifically built to target behavioral maintenance of home rehabilitation programs.

Effectiveness of strategies to improve adherence to physical therapy in patients with knee and hip osteoarthritis: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of current strategies oriented to increase adherence to physical therapy in subjects with knee and hip osteoarthritis (OA).

MATERIAL AND METHODS

A systematic review of electronic databases was conducted from inception until March 2023. Studies with experimental interventions using strategies to increase adherence to physical therapy programs in subjects with knee or hip OA were included. A meta-analysis compared the effects of such interventions with usual care for adherence-related measures (primary outcome), and functional and pain outcomes, using standardized mean differences (SMD) with a 95% confidence interval (CI). GRADE was used to determine the strength of the resultant evidence and the external validity of the findings.

RESULTS

Fifteen articles, assessing 1,818 participants, were included. The interventions included cognitive-behavior strategies, telephone calls, internet-based interventions, communication technologies, and booster sessions. A meta-analysis revealed that the experimental interventions increased adherence over usual care with a moderate effect size of SMD = 0.39 (95%CI = 0.08-0.71) and moderate certainty in this evidence.

CONCLUSION

Overall, this review supports that the strategies to promote adherence to physical therapy in individuals with knee and hip OA are effective. However, the positive impact on adherence rates does not always translate into improved clinical outcomes.

What are the unsupervised exercise adherence rates in clinical trials for knee osteoarthritis? A systematic review

BACKGROUND

Exercise is an effective intervention for knee osteoarthritis (OA), and unsupervised exercise programs should be a common adjunct to most treatments. However, it is unknown if current clinical trials are capturing information regarding adherence.

OBJECTIVE

To summarize the extent and quality of reporting of unsupervised exercise adherence in clinical trials for knee OA.

METHODS

Reviewers searched five databases (PubMed, CINAHL, Medline (OVID), EMBASE and Cochrane). Randomized controlled trials where participants with knee OA engaged in an unsupervised exercise program were included. The extent to which exercise adherence was monitored and reported was assessed and findings were subgrouped according to method for tracking adherence. The types of adherence measurement categories were synthesized. A quality assessment was completed using the Physiotherapy Evidence Database (PEDro) scores.

RESULTS

Of 3622 abstracts screened, 176 studies met criteria for inclusion. PEDro scores for study quality ranged from two to ten (mean=6.3). Exercise adherence data was reported in 72 (40.9%) studies. Twenty-six (14.8%) studies only mentioned collection of adherence. Adherence rates ranged from 3.7 to 100% in trials that reported adherence. For 18 studies (10.2%) that tracked acceptable adherence, there was no clear superiority in treatment effect based on adherence rates.

CONCLUSIONS

Clinical trials for knee OA do not consistently collect or report adherence with unsupervised exercise programs. Slightly more than half of the studies reported collecting adherence data while only 40.9% reported findings with substantial heterogeneity in tracking methodology. The clinical relevance of these programs cannot be properly contextualized without this information.

Development of a booster intervention for graded sensorimotor retraining (RESOLVE) in people with persistent low back pain: A nested, randomised, feasibility trial

INTRODUCTION

Low back pain contributes to an increasing global health burden exacerbated by unsustained improvements from current treatments. There is a need to develop, and test interventions to maintain initial improvements from low back pain treatments. One option is to implement a booster intervention. This study aimed to develop and test the feasibility of implementing a booster intervention delivered remotely to supplement the benefits from a complex intervention for chronic low back pain.

METHOD

This study was nested in the RESOLVE trial. The booster intervention was developed by an expert group, including a clinical psychologist, exercise physiologist and physiotherapists, and based on a motivational interviewing framework. We developed a conversational flow chart to support the clinician to guide participants towards achieving their pre-specified personal goals and future low back pain self-management. Participants with chronic low back pain who were aged over 18 years and fluent in English were recruited. The booster intervention was delivered in one session, remotely, by telephone. The intervention was considered feasible if: participants were able to be contacted or <3 contacts were necessary to arrange the booster session; there were sufficient willing participants (<15% of sample unwilling to participate); and participants and research clinicians reported a perceived benefit of >7/10.

RESULTS

Fifty participants with chronic non-specific low back pain were recruited to test the feasibility of implementing the booster intervention. Less than three contact attempts were necessary to arrange the booster session, only one participant declined to participate. Participants perceived the session to be beneficial; on a 0 to 10 scale of perceived benefit, the average score recorded was 8.3 (SD 2.0). Clinicians also reported a moderate perceived benefit to the participant; the average score recorded by clinicians was 6.3 (SD 1.6).

CONCLUSION

We developed a step by step, simple booster intervention that was perceived to be beneficial to participants with chronic low back pain. The booster can feasibly be delivered remotely following a complex intervention.

Pain neuroscience education, blended exercises and booster sessions as an effective therapy for pain, functional and psychological factors in patients with knee osteoarthritis: a study protocol for a single-blind randomised controlled trial with 22 factorial design during 6-month follow-up

INTRODUCTION

This study aims to investigate whether a pain neuroscience education (PNE) combined with a blended exercises programme including aerobic, resistance, neuromuscular, breathing, stretching and balance exercises and diet education provides greater pain relief and improvement in functional and psychological factors than PNE and blended exercises alone and whether 'exercise booster sessions (EBS)' approach may improve outcomes and increase adherence in patients with knee osteoarthritis (KOA) (by telerehabilitation (TR)).

METHODS AND ANALYSIS

In this single-blind randomised controlled trial, 129 patients (both genders; age >40) diagnosed with KOA will be randomly assigned to one of the 22 treatment combinations as: (1) blended exercises alone (36 sessions over 12 weeks), (2) PNE alone (three sessions over 2 weeks), (3) combination of PNE with blended exercises (exercise three times a week for 12 weeks combined with three sessions of PNE) and (4) a control group. Outcome assessors will be blinded towards group allocation. The primary outcome variables are the visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis index in knee osteoarthritis (WOMAC) score. Secondary outcomes include Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Stress Scale (DASS), Tampa Scale for Kinesiophobia (TSK), Short Falls Efficacy Scale International (FES-I), Pain Catastrophising Scale (PCS), Short Form Health Survey (SF-12) and Exercise Adherence Rating Scale (EARS), 30 s sit-to-stand test (30CST), Timed Up and Go (TUG), lower limbs' muscle strength and lower limb joints' active range of motion (AROM) will be performed at baseline, 3 and 6 months' postinterventions. The primary and secondary outcomes will assess at baseline, 3 months and 6 months postinterventions.The findings will be useful in establishing an effective treatment strategy covering multiple aspects behind KOA. The study protocol is conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the healthcare systems and self-care management. Results in comparison between groups will help to clarify the most effective of mixed-method TR (blended exercise, PNE, EBS with diet education) on more improvement in pain, functional and psychological factors in patients with KOA. This study will combine some of the most critical interventions, to be able to introduce a 'gold standard therapy' in the treatment of KOA.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committee for research involving human subjects of the Sport Sciences Research Institute of Iran (IR.SSRC.REC.1401.021). The study findings will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

IRCTID: IRCT20220510054814N1.

Researcher's Perspective on Musculoskeletal Conditions in Primary Care Physiotherapy Units through the International Classification of Functioning, Disability, and Health (ICF): A Scoping Review

(1) Background: Musculoskeletal disorders are the second cause of disability in the world. The International Classification of Functioning Disability and Health (ICF) is a tool for systematically describing functioning. Outcome measures for musculoskeletal disorders and functioning concepts embedded in them have not been described under the ICF paradigm. The objective of this scoping review was to identify ICF categories representing the researcher's perspective and to compare them with the ICF core set for post-acute musculoskeletal conditions. (2) Methods: This review was conducted as follows: (a) literature search using MEDLINE/PubMed, CINAHL, Web of Science, and Scopus databases; (b) study selection applying inclusion criteria (PICOS): musculoskeletal conditions in primary care, application of physiotherapy as a treatment, outcome measures related to functioning, and experimental or observational studies conducted in Western countries during the last 10 years; (c) extraction of relevant concepts; (d) linkage to the ICF; (e) frequency analysis; and (f) comparison with the ICF core set. (3) Results: From 540 studies identified, a total of 51 were included, and 108 outcome measures were extracted. In the ICF linking process, 147 ICF categories were identified. Analysis of data showed that 84.2% of the categories in the ICF core set for post-acute musculoskeletal conditions can be covered by the outcome measures analyzed. Sixty-eight relevant additional ICF categories were identified. (4) Conclusion: Outcome measures analyzed partially represent the ICF core set taken as a reference. The identification of additional categories calls into question the applicability of this core set in primary care physiotherapy units.

Patients' and clinicians' experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study

Background

We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups (‘high muscle strength subgroup’, ‘low muscle strength subgroup’, ‘obesity subgroup’), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the ‘obesity subgroup’). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements.

Methods

Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed.

Results

We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the ‘obesity subgroup’. In this ‘obesity subgroup’, physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the ‘high muscle strength subgroup’, the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these.

Conclusion

Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the ‘obesity subgroup’. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy.

Trial registration

The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05496-2.

The Effectiveness of Interventions and Intervention Components for Increasing Physical Activity and Reducing Sedentary Behaviour in People With Persistent Musculoskeletal Pain: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis investigated the effectiveness of physical activity (PA) and sedentary behavior (SB) interventions on PA and SB levels in people with persistent musculoskeletal pain. We explored the effectiveness of behavior change techniques (BCTs), the use of behavior change theory and non-PA/SB outcomes. Randomized controlled trials of PA or SB interventions for people with persistent musculoskeletal pain were eligible. Twenty-three studies were included. Quality of evidence was assessed using the GRADE approach. Meta-analysis demonstrated a small effect for PA post-intervention (Hedge's g = .321, CI .136-.507, P = .001, very low-quality evidence). There was no effect for longer-term follow-up PA (low quality evidence) or SB outcomes (very low-quality evidence). There was a small effect for studies with low risk-of-bias at longer-term follow-up PA. Self-report PA outcomes, PA and education interventions, non-self-selected PA, a combination of supervised and unsupervised PA and a combination of individual and group-based interventions had larger effects. Heterogeneity was moderate to considerable. Risk-of-bias, assessed using Cochrane risk-of-bias tool (version two), was generally low. Five promising BCTs were identified: "adding objects to the environment," "goal setting (outcome)," "action planning," "monitoring outcome(s) of behaviour by others without feedback" and "feedback on outcome(s) of behaviour." In conclusion, there is evidence for a modest benefit for PA interventions immediately post-intervention, however the quality of evidence is very low. There was no evidence for longer-term follow-up PA or SB. Higher quality studies of PA and SB interventions that use objective measures are needed. PROSPERO registration: CRD42020180260. PERSPECTIVE: This review investigated the effects of physical activity and sedentary behavior interventions on physical activity and sedentary behavior levels in people with persistent musculoskeletal pain. Current evidence shows a modest benefit for interventions on physical activity post-intervention but not at longer-term follow-up or on sedentary behavior at any time-point, however quality of evidence is low to very low.

Effects of booster sessions on self-management interventions for chronic musculoskeletal pain: a systematic review and meta-analysis of randomised controlled trials

ABSTRACT

Our objective was to investigate the effectiveness of booster sessions after self-management interventions as a means of maintaining self-management behaviours in the treatment of chronic musculoskeletal pain. We searched MEDLINE, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and PsychINFO. Two authors independently identified eligible trials and collected data. We calculated the odds ratio for the analyses of dichotomous data and standardised mean differences (SMDs) with 95% confidence interval (CI) for continuous variables. Our search identified 14 studies with a total of 1695 patients. All studies were at high risk of bias and provided very low quality evidence. For the primary outcomes, booster sessions had no evidence of an effect on improving patient-reported outcomes on physical function (SMD -0.13, 95% CI -0.32 to -0.06; P = 0.18), pain-related disability (SMD -0.16, 95% CI -0.36 to 0.03; P = 0.11), and pain self-efficacy (SMD 0.15, 95% CI -0.07 to 0.36; P = 0.18). For the secondary outcomes, booster sessions caused a significant reduction in patient-reported pain catastrophising (SMD -0.42, 95% CI -0.64 to -0.19; P = 0.0004) and no evidence of an effect on patient-reported pain intensity, depression, coping, or treatment adherence. There is currently little evidence that booster sessions are an effective way to prolong positive treatment effects or improve symptoms of long-term musculoskeletal conditions after self-management interventions. However, the studies were few with high heterogeneity, high risk of bias, and overall low quality of evidence. Our review argues against including booster sessions routinely to self-management interventions for the purpose of behaviour maintenance.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients

OBJECTIVE

To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA).

DESIGN

Prognosis systematic review.

LITERATURE SEARCH

We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019.

STUDY SELECTION CRITERIA

We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes.

DATA SYNTHESIS

For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis.

RESULTS

We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low.

CONCLUSION

Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.

Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain-A Scoping Review and Theoretical Models

(1) Background: Adherence to and the maintenance of treatment regimens are fundamental for pain self-management and sustainable behavioural changes. The first aim was to study older adults’ (>65 years) levels of adherence to and maintenance of musculoskeletal pain self-management programmes in randomized controlled trials. The second aim was to suggest theoretical models of adherence to and maintenance of a behaviour. (2) Methods: The study was conducted in accordance with the recommendations for a scoping review and the PRISMA-ScR checklist. Capability, motivation and opportunity were used to categorize the behavioural change components in the theoretical models. (3) Results: Among the four studies included, components targeting adherence were reported in one study, and maintenance was reported in two studies. Adherence was assessed by the treatment attendance rates, and maintenance was assessed by the follow-up data of outcome measures. For adherence, the capability components were mostly about education and the supervision, grading and mastery of exercise to increase self-efficacy. The motivation components included the readiness to change, self-monitoring and goal setting; and the opportunity components included booster sessions, feedback and social support. For maintenance, the capability components consisted of identifying high-risk situations for relapse and problem-solving skills. The motivation components included self-regulation and self-efficacy for problem solving, and the opportunity components included environmental triggers and problem solving by using social support. (4) Conclusion: There are several behavioural change components that should be used to increase older adults’ levels of adherence to and maintenance of a pain self-management behaviour.

Characteristics of effective home-based resistance training in patients with noncommunicable chronic diseases: a systematic scoping review of randomised controlled trials

Skeletal muscle atrophy, dysfunction, and weakness are consequences of noncommunicable diseases which result in exercise and functional limitations which contribute to poor quality of life and increased mortality. Home-based resistance training may promote skeletal muscle health. Electronic-based systematic searches were performed identifying randomised controlled trials utilising home-based resistance training in patients with noncommunicable diseases defined as cancer, cardiovascular disease, diabetes mellitus (type 1 and 2), chronic kidney disease (including dialysis), and chronic respiratory disease (asthma, chronic obstructive pulmonary disease, pulmonary hypertension). A comparator group was defined as one containing "non-exercise" or "usual care". Of the 239 studies identified (published between 1996 and 2020), 22 met the inclusion criteria. Sixteen studies contained an adjunct aerobic training component. Study designs and outcome measures showed large variation. Reporting of the principles of training applied within interventions was poor. Heterogeneity in study characteristics, and poor reporting of training characteristics, prevents formal recommendations for optimising home-based resistance training. However, home-based interventions are less resource-intensive than supervised programmes and appear to have the ability to improve or preserve pertinent outcomes such as strength, functional ability, and quality of life; potentially reducing the risk of mortality in patients with chronic disease.

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider

OBJECTIVE

To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

METHODS

An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

RESULTS

After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

CONCLUSIONS

The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.

The effect of an integrated multidisciplinary rehabilitation programme for patients with chronic low back pain: Long-term follow up of a randomised controlled trial

Objective:

To compare the long-term effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme, in terms of back-specific disability, in patients with chronic low back pain.

Design:

A single-centre, pragmatic, two-arm parallel, randomised controlled trial.

Setting:

A rheumatology rehabilitation centre in Denmark.

Subjects:

A total of 165 adults (aged ⩾ 18 years) with chronic low back pain.

Interventions:

An integrated programme (a pre-admission day, two weeks at home, two weeks inpatient followed by home-based activities, plus two 2-day inpatient booster sessions, and six-month follow-up visit) was compared with an existing programme (four-week inpatient, and six-month follow-up visit).

Main measure:

The primary outcome was disability measured using the Oswestry Disability Index after one year. Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). Analysis was by intention-to-treat, using linear mixed models.

Results:

303 patients were assessed for eligibility of whom 165 patients (mean age 50 years (SD 13) with a mean Oswestry Disability Index score of 42 (SD 11)) were randomly allocated (1:1 ratio) to the integrated programme (n = 82) or the existing programme (n = 83). The mean difference (integrated programme minus existing programme) in disability was –0.53 (95% CI –4.08 to 3.02); p = 0.770). No statistically significant differences were found in the secondary outcomes.

Conclusion:

The integrated programme was not more effective in reducing long-term disability in patients with chronic low back pain than the existing programme.

The effect of an integrated multidisciplinary rehabilitation programme alternating inpatient interventions with home-based activities for patients with chronic low back pain: a randomized controlled trial

Objective:

To compare the effectiveness of an integrated rehabilitation programme with an existing rehabilitation programme in patients with chronic low back pain.

Design:

A single-centre, pragmatic, two-arm parallel, randomized controlled trial (1:1 ratio).

Setting:

A rheumatology inpatient rehabilitation centre in Denmark.

Subjects:

A total of 165 adults (aged ⩾ 18 years) with chronic low back pain.

Interventions:

An integrated rehabilitation programme comprising an alternation of three weeks of inpatient stay and 12 weeks of home-based activities was compared with an existing rehabilitation programme of four weeks of inpatient stay.

Main measures:

Patient-reported outcomes were collected at baseline and at the 26-week follow-up. The primary outcome was back-specific disability (Oswestry Disability Index). Secondary outcomes included pain intensity (Numerical Rating Scale), pain self-efficacy (Pain Self-Efficacy Questionnaire), health-related quality of life (EuroQol-5 Domain 5-level (EQ-5D)), and depression (Major Depression Inventory). A complete case analysis was performed.

Results:

A total of 303 patients were assessed for eligibility of whom 165 (mean age: 50 years (SD 13) and mean Oswestry Disability Index score 42 (SD 11)) were randomized (83 to existing rehabilitation programme and 82 to integrated rehabilitation programme). Overall, 139 patients provided the 26-week follow-up data. Baseline demographic and clinical characteristics were comparable between programmes. The between-group difference in the Oswestry Disability Index score when adjusting for the corresponding baseline score was −0.28 (95% confidence interval (CI): −4.02, 3.45) which was neither statistically nor clinically significant. No significant differences were found in the secondary outcomes.

Conclusion:

An integrated rehabilitation programme was no more effective than an existing rehabilitation programme at the 26-week follow-up.

Therapeutic alliance facilitates adherence to physiotherapy-led exercise and physical activity for older adults with knee pain: a longitudinal qualitative study

QUESTIONS

What are people's experiences and perceived impact of physiotherapist-led exercise interventions for knee pain attributable to osteoarthritis? What barriers and facilitators to change in exercise and physical activity behaviour exist over time?

DESIGN

A longitudinal qualitative study was undertaken; it involved face-to-face, semi-structured and longitudinal interviews.

PARTICIPANTS

Interviews were undertaken with older adults with knee pain and who had been randomised to one of three physiotherapist-led exercise intervention arms in the Benefits of Effective Exercise for knee Pain (BEEP) trial. Thirty participants were enrolled in this qualitative study, with interviews scheduled at the end of the trial intervention period and 12 months later.

DATA ANALYSIS

A 'layered approach' to thematic analysis was used, including open coding (using constant comparison), deductive coding and within-case and cross-case longitudinal analysis of change.

RESULTS

Different levels of exercise supervision, progression and individualisation emerged, matching the content of the intervention protocols. Barriers to exercise and general physical activity were similar across intervention arms (lack of motivation, time, physical environment, lack of supervision and/or monitoring). Despite individualising exercise programs and specifically targeting exercise, some barriers to adherence remained at 12 months. Factors facilitating longer-term exercise adherence included change in or retained knowledge about the role of exercise for knee pain and the presence and quality of a therapeutic alliance, which was also reflective of the participants' experience of the intervention, regardless of the trial arm.

CONCLUSION

Despite a focus on individualisation and exercise adherence, barriers remained in the longer term. Strong therapeutic alliance during treatment appeared to facilitate adherence to exercise and general physical activity. The findings highlight ongoing physiotherapy support and therapeutic alliance as targets for future adherence-enhancing interventions for exercise in older adults with knee pain.

Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review

Background

Lower limb osteoarthritis (OA) causes high levels of individual pain and disability and is an increasing socio-economic burden to global healthcare systems. Physical Activity interventions are commonly provided by physiotherapists to help patients with lower limb OA manage their clinical symptoms.

Objective

To identify and evaluate the effectiveness of behavioural change techniques (BCTs) within physiotherapy interventions to increase physical activity (PA) adherence in patients with lower limb OA.

Design

A systematic review was conducted, following Cochrane guidelines according to a published and registered protocol (CRD42016039932). Two independent researchers conducted searches, determined eligibility, assessed risk of bias (Cochrane tool), intervention fidelity (NIHBCC checklist), and coded randomised controlled trials (RCTs) for BCTs (V1 taxonomy). BCT effectiveness ratios were calculated and RCT risk of bias and intervention fidelity were summarised narratively.

Data sources

A highly sensitive search strategy was conducted on Medline, Embase, PsycINFO, CENTRAL, CINAHL and PEDro and grey literature databases from inception to January 2^nd, 2018. Reference lists of included RCTs and relevant articles were reviewed, and a citation search was conducted using Web of Science.

Eligibility criteria for selecting studies

RCTs that evaluated the effectiveness of a physiotherapy intervention that incorporated ≥1 BCT that promoted home or community-based PA adherence in patients with lower limb osteoarthritis.

Results

Twenty-four RCTs (n = 2366 participants) of variable risk of bias (RoB) (5 low; 7 moderate; 12 high) and poor intervention reporting from 10 countries were included. Heterogeneity of intervention BCTs and PA adherence outcome measures precluded meta-analysis. Thirty-one distinct BCTs were identified in 31 interventions across RCTs. In general, BCTs demonstrated higher effectiveness ratios for short-term and long-term PA adherence compared with medium-term outcomes. The BCTs ‘behavioural contract’, ‘non-specific reward’, ‘patient-led goal setting’ (behaviour), ‘self-monitoring of behaviour’, and ‘social support (unspecified) demonstrated the highest effectiveness ratios across time points to promote PA adherence.

Conclusions

BCTs demonstrate higher short and long-term than medium-term effectiveness ratios. Further research involving low RoB RCTs incorporating transparently reported interventions with pre-specified BCTs aimed at optimising lower limb OA patient PA adherence is required.

Incremental clinical effectiveness and cost effectiveness of providing supervised physiotherapy in addition to usual medical care in patients with osteoarthritis of the hip or knee: 2-year results of the MOA randomised controlled trial

OBJECTIVE

To investigate the clinical- and cost-effectiveness at 2-year follow-up of providing individual, supervised exercise physiotherapy and/or manual physiotherapy in addition to usual medical care.

METHOD

People with hip or knee osteoarthritis meeting the American College of Rheumatology clinical diagnostic criteria were randomised (1:1, concealed, assessor-blinded) to four groups: usual medical care; supervised exercise physiotherapy; manual physiotherapy; or combined exercise and manual physiotherapy. Physiotherapy group participants were provided 10 50-min treatment sessions including booster sessions at 4 and 13 months, in addition to usual care. The primary outcome at 2-year follow-up was incremental cost-utility ratio (ICUR) of each physiotherapy intervention in addition to usual care, compared with usual care alone, from the health system and societal perspectives. To allow interpretation of negative ICURs, we report incremental net benefit (INB). The primary clinical outcome was the Western Ontario and McMaster Osteoarthritis Index (WOMAC).

RESULTS

Of 206 patients, 186 (90·3%) were retained at 2-year follow-up. Exercise physiotherapy and manual physiotherapy dominated usual care, demonstrating cost savings; combined therapy did not. Exercise therapy had the highest incremental net benefits (INBs), statistically significant at all willingness-to-pay (base-case: societal New Zealand (NZ)$6,312, 95%CI 334 to 12,279; health system NZ$8,065, 95%CI 136 to 15,994). Clinical improvements were superior to usual care only in the exercise physiotherapy group (-28.2 WOMAC points, 95%CI -49.2 to -7.1). No serious adverse events were recorded.

CONCLUSION

Individually supervised exercise therapy is cost-effective and clinically effective in addition to usual medical care at 2-year follow-up, and leads to cost savings for the health system and society.

TRIAL REGISTRATION

Prospectively registered with the Australian NZ Clinical Trials Registry, reference ACTRN12608000130369.

Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis

Synopsis Osteoarthritis (OA) of the hip and knee is among the leading causes of global disability, highlighting the need for early, targeted, and effective treatment. The benefits of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first-line treatment in clinical practice. Furthermore, unlike other treatments for OA, such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Helping people with OA become more physically active, along with structured exercise therapy targeting symptoms and impairments, is crucial, considering that the majority of people with hip and knee OA do not meet physical activity recommendations. Osteoarthritis is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels, and comorbidities. J Orthop Sports Phys Ther 2018;48(6):439-447. Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877.

The effectiveness of web-based patient education and action and coping plans as an adjunct to patient treatment in physiotherapy: A randomized controlled trial

Objective: The study investigated: (1) the effect of combining web-based patient education (WBPE) with action and coping plans on patients' adherence to physiotherapy and their subsequent functional outcomes; and (2) the participants' satisfaction with the WBPE program. Methods: One hundred and eight participants enrolled in this 8-week two group randomized controlled trial. They were allocated to either the WBPE planning group or the attention-control group. The WBPE group made action and coping plans and were familiarized with their web-based program. The attention control group was given access to a web-based neutral information program about shoulder injuries and physiotherapy rehabilitation. Throughout the 8-week study physiotherapists measured the participants' clinic-based adherence and participants recorded their home-based adherence using a self-report diary. Functional outcomes for all participants were measured at the beginning and end of the study. Participants provided feedback about their respective websites. Results: The intervention group had a significantly higher clinic based adherence than the control group (p < 0.04). Both groups had a significant improvement in shoulder function but there was no significant difference between them. Participants in the intervention group were highly satisfied with the WBPE program. The preferred delivery of physiotherapy by 87% of the intervention group was a combination of face-to-face appointments and WBPE. Control participants indicated that they would have appreciated information about shoulder exercises and the shoulder complex in their program. Discussion: The WBPE program was an effective adjunct to physiotherapy in terms of patient satisfaction and clinic-based treatment adherence.

The Influence of Exercise Dosing on Outcomes in Patients With Knee Disorders: A Systematic Review

Study Design Systematic review. Background Therapeutic exercise is commonly used to treat individuals with knee disorders, but dosing parameters for optimal outcomes are unclear. Large variations exist in exercise prescription, and research related to specific dosing variables for knee osteoarthritis, patellar tendinopathy, and patellofemoral pain is sparse. Objectives To identify specific doses of exercise related to improved outcomes of pain and function in individuals with common knee disorders, categorized by effect size. Methods Five electronic databases were searched for studies related to exercise and the 3 diagnoses. Means and standard deviations were used to calculate effect sizes for the exercise groups. The overall quality of evidence was assessed using the Physiotherapy Evidence Database scale. Results Five hundred eighty-three studies were found after the initial search, and 45 were included for analysis after screening. Physiotherapy Evidence Database scale scores were "fair" quality and ranged from 3 to 8. For knee osteoarthritis, 24 total therapeutic exercise sessions and 8- and 12-week durations of exercise were parameters most often associated with large effects. An exercise frequency of once per week was associated with no effect. No trends were seen with exercise dosing for patellar tendinopathy and patellofemoral pain. Conclusion This review suggests that there are clinically relevant exercise dosing variables that result in improved pain and function for patients with knee osteoarthritis, but optimal dosing is still unclear for patellar tendinopathy and patellofemoral pain. Prospective studies investigating dosing parameters are needed to confirm the results from this systematic review. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2018;48(3):146-161. Epub 10 Jan 2018. doi:10.2519/jospt.2018.7637.

Change in physical activity level and clinical outcomes in older adults with knee pain: a secondary analysis from a randomised controlled trial

Background

Exercise interventions improve clinical outcomes of pain and function in adults with knee pain due to osteoarthritis and higher levels of physical activity are associated with lower severity of pain and higher levels of physical functioning in older adults with knee osteoarthritis in cross-sectional studies. However, to date no studies have investigated if change in physical activity level during exercise interventions can explain clinical outcomes of pain and function. This study aimed to investigate if change in physical activity during exercise interventions is associated with future pain and physical function in older adults with knee pain.

Methods

Secondary longitudinal data analyses of a three armed exercise intervention randomised controlled trial. Participants were adults with knee pain attributed to osteoarthritis, over the age of 45 years old (n = 514) from Primary Care Services in the Midlands and Northwest regions of England.

Crude and adjusted associations between absolute change in physical activity from baseline to 3 months (measured by the self-report Physical Activity Scale for the Elderly (PASE)) and i) pain ii) physical function (Western Ontario and McMaster Universities Osteoarthritis Index) and iii) treatment response (OMERACT-OARSI responder criteria) at 3 and 6 months follow-up were investigated using linear and logistic regression.

Results

Change in physical activity level was not associated with future pain, function or treatment response outcomes in crude or adjusted models at 3 or 6 months (P > 0.05). A 10 point increase in PASE was not associated with pain β = − 0.01 (− 0.05, 0.02), physical function β = − 0.09 (− 0.19, 0.02) or likelihood (odds ratio) of treatment response 1.02 (0.99, 1.04) at 3 months adjusting for sociodemographics, clinical covariates and the trial intervention arm. Findings were similar for 6 month outcome models.

Conclusions

Change in physical activity did not explain future clinical outcomes of pain and function in this study. Other factors may be responsible for clinical improvements following exercise interventions. However, the PASE may not be sufficiently responsive to measure change in physical activity level. We also recommend further investigation into the responsiveness of commonly used physical activity measures.

Trial registration

(ISRCTN93634563). Registered 29th September 2011.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-1968-z) contains supplementary material, which is available to authorized users.

Exercise, Manual Therapy, and Booster Sessions in Knee Osteoarthritis: Cost-Effectiveness Analysis From a Multicenter Randomized Controlled Trial

BACKGROUND

Limited information exists regarding the cost-effectiveness of rehabilitation strategies for individuals with knee osteoarthritis (OA).

OBJECTIVE

The study objective was to compare the cost-effectiveness of 4 different combinations of exercise, manual therapy, and booster sessions for individuals with knee OA.

DESIGN

This economic evaluation involved a cost-effectiveness analysis performed alongside a multicenter randomized controlled trial.

SETTING

The study took place in Pittsburgh, Pennsylvania; Salt Lake City, Utah; and San Antonio, Texas.

PARTICIPANTS

The study participants were 300 individuals taking part in a randomized controlled trial investigating various physical therapy strategies for knee OA.

INTERVENTION

Participants were randomized into 4 treatment groups: exercise only (EX), exercise plus booster sessions (EX+B), exercise plus manual therapy (EX+MT), and exercise plus manual therapy and booster sessions (EX+MT+B).

MEASUREMENTS

For the 2-year base case scenario, a Markov model was constructed using the United States societal perspective and a 3% discount rate for costs and quality-adjusted life years (QALYs). Incremental cost-effectiveness ratios were calculated to compare differences in cost per QALY gained among the 4 treatment strategies.

RESULTS

In the 2-year analysis, booster strategies (EX+MT+B and EX+B) dominated no-booster strategies, with both lower health care costs and greater effectiveness. EX+MT+B had the lowest total health care costs. EX+B cost[Formula: see text]1061 more and gained 0.082 more QALYs than EX+MT+B, for an incremental cost-effectiveness ratio of[Formula: see text]12,900/QALY gained.

LIMITATIONS

The small number of total knee arthroplasty surgeries received by individuals in this study made the assessment of whether any particular strategy was more successful at delaying or preventing surgery in individuals with knee OA difficult.

CONCLUSIONS

Spacing exercise-based physical therapy sessions over 12 months using periodic booster sessions was less costly and more effective over 2 years than strategies not containing booster sessions for individuals with knee OA.

Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To evaluate whether interventions aimed at increasing adherence to therapeutic exercise increase adherence greater than a contextually equivalent control among older adults with chronic low back pain and/or hip/knee osteoarthritis.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

Five databases (MEDLINE (PubMed), CINAHL, SportDISCUS (EBSCO), Embase (Ovid) and Cochrane Library) were searched until 1 August 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials that isolated the effects of interventions aiming to improve adherence to therapeutic exercise among adults ≥45 years of age with chronic low back pain and/or hip/knee osteoarthritis were included.

RESULTS

Of 3899 studies identified, nine studies (1045 participants) were eligible. Four studies, evaluating strategies that aimed to increase motivation or using behavioural graded exercise, reported significantly better exercise adherence (d=0.26-1.23). In contrast, behavioural counselling, action coping plans and/or audio/video exercise cues did not improve adherence significantly. Meta-analysis using a random effects model with the two studies evaluating booster sessions with a physiotherapist for people with osteoarthritis revealed a small to medium significant pooled effect in favour of booster sessions (standardised mean difference (SMD) 0.39, 95% CI 0.05 to 0.72, z=2.26, p=0.02, I²=35%).

CONCLUSIONS

Meta-analysis provides moderate-quality evidence that booster sessions with a physiotherapist assisted people with hip/knee osteoarthritis to better adhere to therapeutic exercise. Individual high-quality trials supported the use of motivational strategies in people with chronic low back pain and behavioural graded exercise in people with osteoarthritis to improve adherence to exercise.

Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis: Synthesis of the Literature Using Behavior Change Theory

Exercise is recommended for hip and knee osteoarthritis (OA). Patient initiation of, and adherence to, exercise is key to the success of managing symptoms. This study aimed to (1) identify modifiable barriers and facilitators to participation in intentional exercise in hip and/or knee OA, and (2) synthesize findings using behavior change theory. A scoping review with systematic searches was conducted through March 2015. Two reviewers screened studies for eligibility. Barriers and facilitators were extracted and synthesized according to the Theoretical Domains Framework (TDF) by two independent reviewers. Twenty-three studies (total of 4633 participants) were included. The greatest number of unique barriers and facilitators mapped to the Environmental Context and Resources domain. Many barriers were related to Beliefs about Consequences and Beliefs about Capabilities, whereas many facilitators were related to Reinforcement. Clinicians should take a proactive role in facilitating exercise uptake and adherence, rather than trusting patients to independently overcome barriers to exercise. Strategies that may be useful include a personalized approach to exercise prescription, considering environmental context and available resources, personalized education about beneficial consequences of exercise and reassurance about exercise capability, and use of reinforcement strategies. Future research should investigate the effectiveness of behavior change interventions that specifically target these factors.

Exercise, manual therapy, and use of booster sessions in physical therapy for knee osteoarthritis: a multi-center, factorial randomized clinical trial

OBJECTIVE

(1) Do treatment effects differ between participants receiving manual therapy (MT) with exercise compared to subjects who don't, (2) are treatment effects sustained better when participants receive booster sessions compared to those who don't over a one year period in subjects with knee osteoarthritis (KOA)?

DESIGN

Multi-center, 2 × 2 factorial randomized clinical trial. 300 participants with knee OA were randomized to four groups: exercise-no boosters (Ex), exercise-with boosters (Ex+B), manual therapy+exercise-no boosters (MT+Ex), manual therapy+exercise-with boosters (MT+Ex+B). The primary outcome was the Western Ontario and McMaster osteoarthritis index (WOMAC) at 1 year. Secondary outcomes included knee pain, physical performance tests, and proportions of participants meeting treatment responder criteria.

RESULTS

There were no differences between groups on the WOMAC at 1 year or on any performance-based measures. Secondary analyses indicated a) better scores on the WOMAC and greater odds of being a treatment responder at 9 weeks for participants receiving MT, b) greater odds of being a treatment responder at 1 year for participants receiving boosters. Exploratory interaction analysis suggested knee pain decreases for participants receiving boosters and increases for participants not receiving boosters from 9 weeks to 1 year.

CONCLUSIONS

MT or use of boosters with exercise did not result in additive improvement in the primary outcome at 1 year. Secondary outcomes suggest MT may have some short term benefit, and booster sessions may improve responder status and knee pain at 1 year. However, the role of booster sessions remains unclear in sustaining treatment effects and warrants further study.

CLINICAL TRIALS

gov (NCT01314183).

Wearable technologies in osteoarthritis: a qualitative study of clinicians' preferences

OBJECTIVE

This study investigates clinicians' views of health-related wearable technologies in the context of supporting osteoarthritis (OA) long-term management. Clinicians' preferences are critical in identifying realistic implementation strategies for such technologies.

DESIGN

Qualitative study incorporating an inductive thematic analysis applied to identify key themes from clinicians' responses.

PARTICIPANTS

Clinicians, including 4 general practitioners, 4 physiotherapists and 5 orthopaedic surgeons were interviewed.

SETTING

The study was conducted in a University setting.

RESULTS

Participants all agreed wearable technologies could positively complement their role and enhance their relationship with patients. Perceived benefits of wearable technologies included monitoring patients' progress, treatment evaluation, monitoring compliance and informing clinical decision-making. The device should be designed to provide objective data of patients' locomotion capability in an easy and timely fashion via a simple interface. Data should be available to both clinicians and patients to provide them with the motivation to achieve clinical goals and allow them to take ownership of their treatment. The use of technology was also seen as a way to more effectively plan treatment and manage patients' contact time saving time and cost.

CONCLUSIONS

Findings support the use of wearable technologies to enhance current OA management and suggest clinical uses. Adoption of technologies could have implications on the effectiveness of treatment provided overcoming current barriers, in particular compliance with treatment.

Osteoarthritis year in review 2015: clinical

The purpose of this review is to highlight clinical research in osteoarthritis (OA). A literature search was conducted using PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) with the search terms "osteoarthritis [All Fields] AND treatment [All Fields]" and the following limits activated: humans, English language, all adult 19+ years, published between April 1, 2014 and April 1, 2015. A second literature search was then conducted with the search terms "osteoarthritis [All Fields] AND epidemiology [All Fields]", with the same limits. Reports of surgical outcome, case series, surgical technique, tissue sample or culture studies, trial protocols, and pilot studies were excluded. Of 1523, 150 were considered relevant. Among epidemiologic and observational clinical studies, themes included physical activity, early knee OA, and confidence/instability/falls. Symptom outcomes of pharmacologic treatments were reported for methotrexate, adalimumab, anti-nerve growth factor monoclonal antibodies, strontium ranelate, bisphosphonates, glucosamine, and chondroitin sulfate, and structural outcomes of pharmacologic treatments for strontium ranelate, recombinant human fibroblast growth factor 18, and glucosamine and chondroitin sulfate. Symptom outcomes of non-pharmacologic interventions were reported for: neuromuscular exercise, quadriceps strengthening, weight reduction and maintenance, TENS, therapeutic ultrasound, stepped care strategies, cognitive behavior therapy for sleep disturbance, acupuncture, gait modification, booster physical therapy, a web-based therapeutic exercise resource center for knee OA; hip physical therapy for hip OA; and joint protection and hand exercises for hand OA. Structure outcomes of non-pharmacologic interventions were reported for patellofemoral bracing.

Osteoarthritis year in review 2015: rehabilitation and outcomes

OBJECTIVE

The purpose of this narrative review was to highlight recent research in the rehabilitation of people with osteoarthritis (OA) by summarizing findings from selected key systematic reviews and randomized controlled trials (RCTs).

METHODS

A systematic search was conducted using the PubMed, Physiotherapy Evidence Database (PEDro) and Cochrane databases from April 1st 2014 to March 31st 2015. A selection of these is discussed based on study quality, relevance, contribution to new knowledge or controversial findings. Methodological quality of RCTs was assessed using guidelines from PEDro.

RESULTS

From 274 articles, 74 were deemed to meet the eligibility criteria including 24 systematic reviews and 50 studies reporting on findings from RCTs. Overall the methodological quality of the RCTs was moderate. The studies were grouped into several themes covering; evidence of rehabilitation outcomes in less studied joints including the hand and hip; new insights into exercise in knee OA; effects of biomechanical treatments on symptoms and structure in knee OA; and effects of acupuncture.

CONCLUSIONS

Exercise was the most common treatment evaluated. Although little evidence supported benefit of exercise for hand OA, exercise has positive effects for hip and knee OA symptoms and these benefits may depend upon patient phenotypes. The first evidence that a brace can influence knee joint structure emerged. The latest evidence suggests that acupuncture has, at best, small treatment effects on knee OA pain of unlikely clinical relevance.

The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial

STUDY DESIGN

A factorial randomized controlled trial.

OBJECTIVES

To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether "booster sessions" compared to consecutive sessions may improve outcomes.

BACKGROUND

The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established.

METHODS

All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures were the numeric pain-rating scale and physical performance tests.

RESULTS

Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P = .009) and manual therapy (P = .023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone.

CONCLUSION

Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808).

Pilot Enhancement of the Arthritis Foundation Exercise Program with a Healthy Aging Program

Older adults with arthritis or joint pain were targeted for a pilot program enhancing the Arthritis Foundation Exercise Program with the 10 Keys™ to Healthy Aging Program. Using a one-group, pre-post design, feasibility was examined and improvements in preventive behaviors, arthritis outcomes, and cardiometabolic outcomes were explored. A 10-week program was developed, instructors were recruited and trained, and four sites and 51 participants were recruited. Measures included attendance, adherence, satisfaction, preventive behaviors, Western Ontario and McMaster Universities Osteoarthritis Index (pain and stiffness), glucose, and cholesterol. Three fourths of participants attended >50% of the sessions. At 6 and 12 months, more than one half performed the exercises 1 to 2 days per week, whereas 28% and 14% exercised 3 to 7 days per week, respectively. Participants (92%) rated the program as excellent/very good. Nonsignificant changes were observed in expected directions. Effect sizes were small for arthritis and cardiometabolic outcomes. This program engaged community partners, demonstrated feasibility, and showed improvements in some preventive behaviors and health risk profiles. [Res Gerontol Nurs. 2016; 9(3):123-132.].