What Do People With Knee or Hip Osteoarthritis Need to Know? An International Consensus List of Essential Statements for Osteoarthritis

'I do hope more people can benefit from it.': The qualitative experience of individuals living with osteoarthritis who participated in the GLA:D™ program in Alberta, Canada

INTRODUCTION

The Good Life with osteoArthritis: Denmark (GLA:DTM) is an evidence-based program designed for individuals with symptomatic hip and knee osteoarthritis (OA). This program has reported improvement in pain, quality of life and self-efficacy, as well as delays in joint replacement surgery for adults with moderate to severe hip or knee OA. Evaluations of GLA:DTM implementation in several countries have focused on effectiveness, training, and feasibility of the program primarily from the provider perspective. Our objective was to examine how the GLA:DTM program was perceived and experienced by individuals with hip and knee OA to inform on-going program refinement and implementation.

METHODS

Thirty semi-structured telephone interviews were conducted with participants who completed the GLA:DTM program in Alberta. An interpretive description approach was used to frame the study and thematic analysis was used to code the data and identify emergent themes and sub-themes associated with participants' experience and perception of the GLA:DTM program.

RESULTS

Most participants had a positive experience of the GLA:DTM program and particularly enjoyed the group format, although some participants felt the group format prevented one-on-one support from providers. Three emergent themes related to acceptability were identified: accessible, adaptable, and supportive. Participants found the program to be accessible in terms of location, cost, and scheduling. They also felt the program was adaptable and allowed for individual attention and translatability into other settings. Finally, most participants found the group format to be motivating and fostered connections between participants.

CONCLUSION

The GLA:DTM program was perceived as acceptable by most participants, yet the group format may not be useful for all individuals living with OA. Recommended improvements included adapting screening to identify those suited for the group format, providing program access earlier in the disease progression trajectory, modifying educational content based on participants' knowledge of OA and finally, providing refresher sessions after program completion.

Reducing the burden of knee osteoarthritis through community pharmacy: Protocol for a randomised controlled trial of the Knee Care for Arthritis through Pharmacy Service

INTRODUCTION

Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio-economic wellbeing of those affected. Little community-based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Māori and non-Māori with knee OA in community pharmacy and providing co-ordinated, evidence- and community-based care may be a scalable, sustainable, equitable, effective and cost-effective approach to improve health and wellbeing.

AIM

Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee-related physical function and pain (co-primary outcomes). Secondary aims assess impacts on health-related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Māori.

METHODS AND ANALYSIS

A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12 months for Māori and non-Māori who have knee OA. Participants will be recruited in community pharmacies. Knee-related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee-related pain will be measured using an 11-point numeric pain rating scale. Primary outcome analyses will be conducted on an intention-to-treat basis using linear mixed models. Parallel within-trial health economic analysis and process evaluation will also be conducted.

ETHICS AND TRIAL DISSEMINATION

Ethical approval was obtained from the Central Health and Ethics Committee (2022-EXP-11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants.

Creaky knees: Is there a reason for concern? A qualitative study of the perspectives of people with knee crepitus

OBJECTIVE

Crepitus is a feature of osteoarthritis that may affect one's participation in exercise. An informed understanding is required of the perceptions that people have of their knee crepitus and how it affects their exercise behaviours. This study aims to investigate the role that crepitus may play in beliefs about exercise and knee health.

METHODS

Focus group and individual interviews were conducted online with participants who had knee crepitus. The transcripts were thematically analysed through an inductive approach.

RESULTS

Five main themes were identified from 24 participants: (1) individual variation of, (2) occurrence of, (3) meaning of knee crepitus, (4) attitudes and exercise behaviours regarding crepitus, and (5) knowledge deficits and needs concerning crepitus during exercise. The variety of crepitus sounds described occurred with a range of exercises or after inactivity. For those already with osteoarthritis or other symptoms, crepitus was of less concern than symptoms such as pain. Most participants had not ceased exercise but may have modified movement due to crepitus and associated symptoms; some had increased intentional strength training to try alleviating it. Participants agreed that more understanding about the processes causing crepitus and what exercise was safe for knee health would be beneficial.

CONCLUSION

Crepitus does not appear to be a major cause of concern for people who experience it. However, it is a factor that influences exercise behaviours as is pain. If health professionals could guide people with concerns about their crepitus, they may be more confident in exercising to benefit their joint health.

Effects of Hip Pain Diagnostic Labels and Their Explanations on Beliefs About Hip Pain and How to Manage It: An Online Randomized Controlled Trial

OBJECTIVES: To compare the effects of diagnostic labels and their explanations on people's beliefs about managing hip pain. DESIGN: Online randomized controlled trial involving 626 participants. METHODS: Participants aged ≥45 years with and without hip pain considered a hypothetical scenario (initial doctor consultation for hip pain). They were randomized to receive a diagnostic label and explanation of (1) hip osteoarthritis, (2) persistent hip pain, or (3) hip degeneration. Primary outcomes were the beliefs (1) exercise would damage the hip and (2) surgery is necessary at some stage (scales, 0 = definitely would not/unnecessary, 10 = definitely would/necessary). Secondary outcomes included beliefs about other treatments and care providers. RESULTS: Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain believed exercise was less damaging (mean difference -1.3 [95% CI: -1.9, -0.7] and -1.8 [-2.3, -1.2], respectively) and surgery less necessary (-1.5 [-2.1, -1.0] and -2.2 [-2.7, -1.6], respectively). Compared to hip osteoarthritis, participants who were allocated to persistent hip pain believed surgery was less necessary (-0.7 [-1.2, -0.1]), but not that exercise was less damaging (-0.5 [-1.1, 0.1]). Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain were less concerned about their hip and believed exercise and care from an exercise and sports physician, rheumatologist, or physiotherapist would be more helpful, and care from an orthopaedic surgeon less helpful. CONCLUSIONS: People who were allocated a diagnostic label and explanation of hip osteoarthritis or persistent hip pain believed exercise was less damaging and surgery less necessary for a hip problem than hip degeneration. J Orthop Sports Phys Ther 2023;53(11):673-684. Epub 5 October 2023. doi:10.2519/jospt.2023.11984.

Comprehensiveness, accuracy, quality, credibility and readability of online information about knee osteoarthritis

BACKGROUND

People are increasingly using the Internet to retrieve health information about chronic musculoskeletal conditions, yet content can be inaccurate and of variable quality.

OBJECTIVE

To summarise (i) comprehensiveness, (ii) accuracy and clarity, iii) quality of information about treatment choices, (iv) credibility and (v) readability of online information about knee osteoarthritis.

METHOD

Systematic appraisal of website content. Searches for "knee osteoarthritis" and "knee arthritis" were performed using Google and Bing (October 2020). The top 20 URLs of each search were screened for eligibility. Comprehensiveness, accuracy and clarity of content were matched against 14 pre-defined topic descriptors. DISCERN and HONcode were used to measure quality of information about treatment choices and website credibility, respectively. Flesch Reading Ease and Flesch-Kincaid Grade Level tests were used to assess readability.

RESULTS

Thirty-five websites were included. Websites were generally comprehensive (median, range = 12, 0-14/14) with descriptors available for 67% (n = 330/490) of topics across all websites, but only 35% (n = 116/330) were accurate and clear. Quality of information about treatment choices was generally low (median DISCERN score, range = 40, 16-56/80). Credibility descriptors were present for 65% (n = 181/280) of items, with 81% (n = 146/181) of descriptors being clear. Median Flesch reading ease was 53 (range = 21-74), and Flesch-Kincaid grade level was 8 (range = 5-11).

CONCLUSION

Few websites provide accurate and clear content aligned to key research evidence. Quality of information about treatment choices was poor, with large variation in comprehensiveness, credibility and readability.

IMPLICATIONS

Careful consideration is required by clinicians to identify what online information people with knee osteoarthritis have accessed and to address misinformed beliefs.

Clinical reasoning in managing chronic hip pain: One in two Australian and New Zealand physiotherapists diagnosed a case vignette with clinical criteria for hip OA as hip OA. A cross-sectional survey

OBJECTIVES

Using a case vignette of an adult (George) presenting with hip pain consistent with hip OA, this study aimed to describe: (a) whether physiotherapists make diagnoses and identify bodily structures using either patient history and/or physical examination findings; (b) which diagnoses and bodily structures physiotherapists attribute to the hip pain; (c) how confident physiotherapists were in their clinical reasoning using patient history and physical examination findings; (d) what treatments physiotherapists would offer to George.

METHODS

We conducted a cross-sectional online survey of physiotherapists in Australia and New Zealand. We used descriptive statistics to analyse closed questions and content analysis for open-text responses.

RESULTS

Two hundred and twenty physiotherapists completed the survey (39% response-rate). After receiving the patient history, 64% diagnosed George's pain and 49% of these as hip OA; 95% attributed George's pain to a bodily structure(s). After receiving the physical examination, 81% diagnosed George's hip pain and 52% of these as hip OA; 96% attributed George's hip pain to a bodily structure(s). Ninety-six percent of respondents were at least somewhat confident in their diagnosis after the patient history, and 95% were similarly confident after the physical examination. Most respondents offered advice (98%) and exercise (99%), but fewer offered treatments for weight loss (31%), medication (11%), and psychosocial factors (<15%).

DISCUSSION

About half of the physiotherapists that diagnosed George's hip pain made a diagnosis of hip OA, despite the case vignette including clinical criteria for a diagnosis of OA. Physiotherapists offered exercise and education, but many physiotherapists did not offer other clinically indicated and recommended treatments, such as weight loss and sleep advice.

Knee osteoarthritis patient perspectives of their care in an australian private physiotherapy setting: a qualitative exploratory interview study

PURPOSE

This study aimed to understand perceptions that knee osteoarthritis patients have regarding their experiences of guideline-based recommendations within their care received from physiotherapists in private practice.

METHODS

A qualitative semi-structured interview study nested within a larger trial auditing care provided by physiotherapists. Recruited adults ≥ 45 years with knee osteoarthritis across nine primary care physiotherapy practices. Interview questions were anchored around the core elements recommended in guidelines for the management of knee osteoarthritis and patient perceptions of these were analysed using both content and thematic qualitative analysis approaches. Patient satisfaction with care received was asked at the time of interview.

RESULTS

Twenty-six patients volunteered for the study (mean 60 years, 58% female). Analysis identified that physiotherapists focused on treating symptoms through quadriceps strengthening exercises, which patients found to be effective, though focussed less on other aspects of evidenced-based care. Patient's perceived treatment to be effective in relieving pain and enabling them to stay active and they appreciated the positive role that their physiotherapist provided in alleviating their concerns. Overall, patients were satisfied with their physiotherapy care but would have liked more specific osteoarthritis education and longer-term management.

CONCLUSION

The description of the physiotherapy-related care received by people with knee osteoarthritis aligns with guideline recommendations, though mainly for strength-related exercise prescription. Despite some perceived shortfalls in care, patients do appear to be satisfied. However, improvements in patient outcomes may be possible if more elements of guideline-base care are regularly provided, including enhancing osteoarthritis education and fostering behaviour change.

TRIAL REGISTRATION

ACTRN12620000188932.

The osteoarthritis knowledge scale

OBJECTIVE

Accurate knowledge is central to effective self-care of osteoarthritis (OA). This study aimed to assess the measurement properties of the Osteoarthritis Knowledge Scale (OAKS) with versions for the hip and knee.

METHODS

Participants with hip OA (n = 144), knee OA (n = 327), and no OA (n = 735) were recruited. Rasch analysis was conducted to assess psychometric properties using data from all participants with hip OA and 144 randomly selected participants with either knee OA or no OA. Test-retest reliability and measurement error were estimated among those with hip (n = 51) and knee (n = 142) OA.

RESULTS

Four items from the draft scales were deleted following Rasch analysis. The final 11-item OAKS was unidimensional. Item functioning was not affected by gender, age, educational level, or scale version (hip or knee). Person separation index was 0.75. Test-retest intraclass correlation coefficient was 0.81 (95% CI 0.74, 0.86; hip version 0.66 [0.47, 0.79]; knee version 0.85 (0.79, 0.90)). Smallest detectable change was 9 points (scale range 11-55; hip OA version 11 points; knee OA version 8 points).

CONCLUSION

The OAKS is a psychometrically adequate, unidimensional measure of important OA knowledge that can be used in populations with and without hip and knee OA. Caution is needed when using with populations with only hip OA as test-retest reliability of the hip version did not surpass the acceptable range.

Effects of a Massive Open Online Course on osteoarthritis knowledge and pain self-efficacy in people with hip and/or knee osteoarthritis: protocol for the MOOC-OA randomised controlled trial

BACKGROUND

Osteoarthritis (OA) is a prevalent, chronic joint condition that commonly affects the knee and hip causing pain, impaired function, and reduced quality of life. As there is no cure, the main goal of treatment is to alleviate symptoms via ongoing self-management predominantly consisting of exercise and weight loss (if indicated). However, many people with OA do not feel adequately informed about their condition and management options to self-manage effectively. Patient education is recommended by all OA Clinical Practice Guidelines to support appropriate self-management, but little is known about the optimal delivery method and content. Massive Open Online Courses (MOOCs) are free, interactive, e-learning courses. They have been used to deliver patient education in other chronic health conditions but have not been used in OA.

METHODS

A two-arm parallel-design, assessor- and participant-blinded superiority randomised controlled trial. People with persistent knee/hip pain consistent with a clinical diagnosis of knee/hip OA (n = 120) are being recruited from the Australia-wide community. Participants are randomly allocated into one of two groups i) electronic information pamphlet (control group) or ii) MOOC (experimental group). Those allocated to the control group receive access to an electronic pamphlet about OA and its recommended management, currently available from a reputable consumer organisation. Those allocated to the MOOC receive access to a 4-week 4-module interactive consumer-facing e-Learning course about OA and its recommended management. Course design was informed by behaviour theory and learning science, and consumer preferences. The two primary outcomes are OA knowledge and pain self-efficacy with a primary endpoint of 5 weeks and a secondary endpoint of 13 weeks. Secondary outcomes include measures of fear of movement, exercise self-efficacy, illness perceptions, OA management and health professional care seeking intentions, physical activity levels, and actual use of physical activity/exercise and weight loss, pain medication, and health professional care seeking to manage joint symptoms. Clinical outcomes and process measures are also collected.

DISCUSSION

Findings will determine whether a comprehensive consumer-facing MOOC improves OA knowledge and confidence to self-manage joint pain compared to a currently available electronic OA information pamphlet.

TRIAL REGISTRATION

Prospectively registered (Australian New Zealand Clinical Trials Registry ID: ACTRN12622001490763).

Knee osteoarthritis and the knowledgeable, trustworthy pharmacist: Patient and pharmacist perceptions of community pharmacy-based education and support

BACKGROUND

Osteoarthritis (OA) clinical guidelines recommend self-management education, but education is often not included in primary care consultations.

OBJECTIVE

To explore pharmacists' and patients' perceptions of a pharmacist-led model of service delivery for knee OA that was integrated within pharmacies' day-to-day workflow.

METHODS

Cross-sectional qualitative design using Thematic Analysis. Community pharmacies were recruited in New Zealand and Australia. Pharmacy patients were screened for knee OA and offered tailored explanations, self-management information and referral for further support. Pharmacist focus groups and patient 1:1 interviews explored perceptions of the service delivery model.

RESULTS

Nineteen pharmacists and 12 patients with knee OA participated. Pharmacist and patient data were analysed separately, with themes compared and contrasted to derive three meta-themes. Meta-theme 1: 'Welcome Engagement' included two pharmacist themes ('putting my broad skill set to use' and 'we're here and happy to help') and two patient themes ('information delivered well' and 'a welcome offer of help'). Meta-theme 2: 'The Knowledgeable and Trustworthy Pharmacist' included two pharmacist themes ('professional knowledge to help all sorts of patients' and 'managing time to help my patients') and one patient theme ('the accessible professional who I know and trust'). Meta-theme 3: 'The Opportunity for More Support' included one pharmacist theme ('this is not the end of the story') and one patient theme ('more help is available').

CONCLUSION

Community pharmacists are well-positioned to provide information and support to people with knee OA. Pharmacists appreciate the opportunity to better use their skills and accessibility for OA care, and patients welcome this engagement.

Stevioside targets the NF-κB and MAPK pathways for inhibiting inflammation and apoptosis of chondrocytes and ameliorates osteoarthritis in vivo

Osteoarthritis (OA) is a joint disease that is characterized by articular cartilage degeneration and destruction. Stevioside (SVS) is a diterpenoid glycoside extracted from Stevia rebaudiana Bertoni with some specific effects against inflammatory and apoptotic, whereas it is still unclear what function SVS has in osteoarthritis. This study focuses on the anti-inflammatory and anti-apoptosis functions of SVS on chondrocytes induced by interleukin (IL)-1beta, and the role of SVS in an osteoarthritis model for mice. We can detect the production of inflammatory factors such as nitric oxide (NO) and prostaglandin E2 (PGE2) using real-time quantitative polymerase chain reaction (RT-qPCR), the Griess reaction, and enzyme linked immunosorbent assay (ELISA). On the basis of Western blot, we have observed the protein expressions of cartilage matrix metabolism, inflammatory factors, and apoptosis of chondrocytes. Simultaneously, the pharmacological effects of SVS in mice were evaluated by hematoxylin and eosin (HE), toluidine blue, Safranin O, and immunohistochemical staining. The results show that SVS slows extracellular matrix degradation and chondrocyte apoptosis. In addition, SVS mediates its cellular effect by inhibiting the activation of mitogen-activated protein kinase (MAPK) and nuclear factor kappa B (NF-κB) signaling pathways. Meanwhile, molecular docking studies revealed that SVS has excellent binding capabilities to p65, extracellular signal-regulated kinase (ERK), p38, and c-Jun N-terminal kinase (JNK). The study suggests that SVS can be developed as a potential osteoarthritis treatment.

Falls prevention and osteoarthritis: time for awareness and action

Osteoarthritis (OA) and falls both commonly affect older people. While high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management. OA care and falls prevention have for too long been considered as separate clinical constructs. In the context of ageing populations and growing numbers of people with OA, the time to raise awareness and enact appropriate action is now. This Perspectives on Rehabilitation article draws on the findings from a comprehensive mixed-methods falls and OA research program (which uniquely spanned population, clinician, and consumer perspectives) to better understand existing evidence-practice gaps and identify key opportunities for improvements in clinical care.IMPLICATIONS FOR REHABILITATIONWhile high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management and this represents a concerning knowledge-to-practice gap.Given ageing populations and growth in the number of people with OA, it is time for falls prevention to be incorporated within routine OA care for older people.To achieve this, we need to re-shape current messaging around falls prevention and develop targeted resources to optimise clinician knowledge and skills in this area.

Exercise physiologists use of pain neuroscience education for treating knee osteoarthritis: A qualitative interview study

OBJECTIVES

To explore how Australian exercise physiologists (EPs) utilise pain neuroscience education (PNE) in their management of patients with knee osteoarthritis.

METHODS

A semi-structured interview concerning a knee osteoarthritis vignette was designed to understand each participant's beliefs about physical activity, pain, injury and coping strategies and quantify their use of pain neuroscience concepts. Themes were derived from pre-determined pain target concepts as well as others that emerged from thematic analysis.

RESULTS

Thirty EPs (57% male, mean clinical experience 7 years (SD 7.1) participated in the semi-structured interviews. 13 themes emerged. EPs primarily focussed on: (1) active treatment strategies are better than passive, (2) pain and tissue damage rarely relate, and (3) learning about pain can help individuals and society. Other themes included the use of biomedical-based education, pain during exercise and delivery of PNE. Underutilised themes included the role of the brain in pain, validation that pain is real and personal, the concept of danger sensors as opposed to pain sensors, and pain depends on the balance between safety and danger.

CONCLUSION

EPs primarily advised on active treatment approaches (e.g. exercise and self-management). Quality of care is likely to improve through increasing focus on the systemic benefits of exercise in overcoming psychological barriers (e.g. fear avoidance and pain catastrophising) that may prevent exercise treatment engagement. Broadening PNE to reconceptualise knee osteoarthritis pain as a sign of an overprotective nervous system, rather than structural damage, may facilitate greater patient engagement in exercise therapies, thus improving patient outcomes.

People With Knee Osteoarthritis Attending Physical Therapy Have Broad Education Needs and Prioritize Information About Surgery and Exercise: A Concept Mapping Study

OBJECTIVES

To (1) identify the education priorities of people with knee osteoarthritis, including perceived importance and confidence that a health care professional can address each, and (2) match priorities to education-specific content recommendations in knee osteoarthritis management guidelines.

DESIGN

Concept mapping methodology.

METHODS

Participants generated, sorted (based on themes), and rated (5-point Likert scales: importance and confidence) education priorities. Multidimensional scaling and hierarchical cluster analysis of sorting data produced a cluster map with overarching domains. Priorities were matched against education-specific content recommendations in knee osteoarthritis guidelines.

RESULTS

Participants (brainstorming, n = 43; sorting and rating, n = 24) generated 76 priorities. A 4-domain, 11-cluster map was the most useful representation of sorting data: (i) understanding treatment options (relationship of education and exercise with surgery, adjunct options, treatment decision making); (ii) exercise therapy (how to exercise, why exercise); (iii) understanding and managing the condition (symptom management, understanding symptoms, understanding the condition); and (4) surgical, medical, and dietary management (surgery, medications, diet and supplements). The "relationship of education and exercise with surgery" (3.88/5), "surgery" (3.86/5), and "how to exercise" (3.78/5) clusters were rated highest for importance. Few priorities identified by participants were clearly recommended as education-specific content recommendations in the American College of Rheumatology (3%, n = 2/76), European Alliance of Associations for Rheumatology (12%, n = 9/76), National Institute for Health and Care Excellence (16%, n = 12/76), and Osteoarthritis Research Society International (1%, n = 1/76) guidelines.

CONCLUSION

People with knee osteoarthritis presenting to physical therapists have broad education needs and prioritize information about surgery and exercise. J Orthop Sports Phys Ther 2022;52(9):595-606. Epub: 17 June 2022. doi:10.2519/jospt.2022.11089.

Physical Therapists Prioritize Providing Education About Exercise Therapy and to Dispel Misconceptions About Radiology for People With Knee Osteoarthritis: A Concept Mapping Study

OBJECTIVE

To (1) identify the education priorities that physical therapists have for people with knee osteoarthritis, including perceived importance and capability to provide, and (2) match priorities to education-specific content recommendations in knee osteoarthritis guidelines.

DESIGN

Concept mapping methodology.

METHODS

Physical therapists generated, sorted (based on themes), and rated (5-point Likert scales: importance and capability) patient education priorities. Priorities were matched against education-specific content recommendations in knee osteoarthritis guidelines. Additional education-specific content recommendations were added from guidelines and expert opinion if necessary. Multidimensional scaling and hierarchical cluster analysis produced a cluster map with overarching domains.

RESULTS

Physical therapists (brainstorming, n = 41; sorting, n = 20; rating, n = 22) generated 56 priorities, with 13 added (n = 2 from guidelines, n = 11 from expert opinion). Few priorities were clearly included as education-specific content recommendations in guidelines (ACR [2%, n = 1/56], EULAR [14%, 8/56], NICE [11%, 6/56], and OARSI [0%, 0/56]). An 8-cluster map emerged with 3 overarching domains: (i) first-line care (exercise therapy, lifestyle modification and general health, and weight management), (ii) knowledge formation and countering misconceptions (radiology misconceptions, understanding and managing pain and disability, and general beliefs and understanding about osteoarthritis), and (iii) decision making for medical management (surgery and medications). The exercise therapy cluster was rated the highest for both importance (3.84/5) and capability (4.00). The medications and weight management clusters were rated the lowest for importance (2.54) and capability (2.82), respectively.

CONCLUSION

Physical therapists prioritize a range of education topics for people with knee osteoarthritis, focusing on exercise therapy. Physical therapists feel least capable of providing weight management education. J Orthop Sports Phys Ther 2022;52(9):607-619. Epub: 17 June 2022. doi:10.2519/jospt.2022.11090.

Primary care physicians' perceptions of the utility of novel education materials for patients with knee osteoarthritis

PURPOSE

To support primary care physicians (PCPs) and their patients with knee osteoarthritis (OA), we created a series of evidence-based whiteboard educational videos for patients with knee OA. In a previous study we piloted these videos with patients to understand their acceptability and impact. The purpose of this study was to explore PCPs' perspectives to understand the utility of novel patient education videos to support management.

MATERIALS AND METHOD

We conducted a qualitative descriptive study using semi-structured interviews of newly practicing and resident PCPs after watching a series of patient education videos. A thematic analysis approach was used combining both inductive and research question driven coding, category formation, and theme identification.

RESULTS

Ten participants were included. Barriers to optimal management were identified including the challenge of patient adherence and access to non-operative treatments. PCPs indicated that the videos would support their management of patients with knee OA by (1) supporting credibility and building trust with their patient, (2) reinforcing patient understanding, and (3) enhancing their own management of patients.

CONCLUSION

Future implementation of these resources with attention to barriers that may limit uptake is necessary and may optimize management of knee OA in primary care.IMPLICATIONS FOR REHABILITATIONThe provision of patient educational materials may support patient buy-in regarding appropriate management, enhance patient understanding, and improve physicians' future practice.Viewing these videos could potentially improve physicians' future resource use, recommendation of non-operative treatments, and the quality of their total knee replacement referrals, which has benefits to both the patient and the healthcare system.Perceived barriers to implementing evidence-based recommendations may pose a challenge for patients and clinicians and should be considered to help facilitate the uptake of educational interventions.

Knee Osteoarthritis Education Interventions in Published Trials Are Typically Unclear, Not Comprehensive Enough, and Lack Robust Development: Ancillary Analysis of a Systematic Review

OBJECTIVE

To summarize the content, development, and delivery of education interventions in clinical trials for people with knee osteoarthritis (OA).

DESIGN

Ancillary analysis of a systematic review.

LITERATURE SEARCH

MEDLINE, EMBASE, SPORTDiscus, CINAHL, and Web of Science were searched from inception to April 2020.

STUDY SELECTION CRITERIA

Randomized controlled trials involving patient education for people with knee OA.

DATA SYNTHESIS

Content of education interventions was matched against a predefined topic list (n = 14) and categorized as accurate and clear, partially accurate/lacks clarity, or not reported. We examined whether education interventions included skill development or stated learning objectives and if they were developed based on theory, previous research, or codesign principles. Delivery methods and mode(s) were also identified. Data were summarized descriptively.

RESULTS

Thirty-eight education interventions (30 trials) were included. Interventions lacked comprehensiveness (median topics per intervention = 3/14, range = 0-11). Few topics were accurately and clearly described (10%, 13/136). Sixty-one percent (n = 23/38) of interventions targeted skill development, and 34% (n = 13/38) identified learning objectives. Forty-two percent (n = 16/38) were based on theory; 45% (n = 17/38) were based on research for chronic conditions, including 32% (n = 12/38) based on OA. Eleven percent of interventions (n = 4/38) were codesigned. Education was typically facilitated through face-to-face sessions (median = 9, range = 0-55), supplemented with telephone calls and/or written materials.

CONCLUSION

Education interventions for people with knee OA lacked comprehensiveness plus accurate and clear descriptions of topics covered. Most interventions failed to identify learning objectives and were not based on theory, previous research, or codesign principles. J Orthop Sports Phys Ther 2022;52(5):276-286. Epub 14 Dec 2021. doi:10.2519/jospt.2022.10771.

Reported practices related to, and capability to provide, first-line knee osteoarthritis treatments: a survey of 1064 Australian physical therapists

BACKGROUND

Physical therapists play a key role in providing first-line knee osteoarthritis treatments, including patient education and exercise therapy.

OBJECTIVES

Describe Australian physical therapists' awareness of guidelines; reported practices; and beliefs about capability, opportunity, motivation, and evidence.

METHODS

An online cross-sectional survey was completed by physical therapists prior to attending the Good Living with osteoArthritis from Denmark (GLA:D®) Australia training courses (March 2017 to December 2019). The survey instrument was developed by an expert panel and was informed by the Theoretical Domains Framework.

RESULTS

1064 physical therapists from all Australian states and territories participated. 11% (n = 121) could name an accepted guideline, 98% agreed it was their job to deliver patient education and exercise therapy, and 92% agreed this would optimise outcomes. Most reported providing strength exercise (99%), written exercise instructions (95%), treatment goal discussion (88%), and physical activity advice (83%) all or most of the time. Fewer provided aerobic exercise (66%), neuromuscular exercise (54%), and weight management discussion (56%) all or most of the time. Approximately one quarter (23-24%) believed they did not have the skills, knowledge, or confidence to provide education and exercise therapy recommended by guidelines, and just 48% agreed they had been trained to do so.

CONCLUSION

Australian physical therapists treating knee osteoarthritis typically provide strength-based home exercise with written instructions, alongside goal setting and physical activity advice. Just one in nine could name a guideline. Education and training activities are needed to support physical therapists to access, read and implement guidelines, especially for aerobic and neuromuscular exercise, and weight management.

The efficacy of balneotherapy, mud therapy and spa therapy in patients with osteoarthritis: an overview of reviews

Osteoarthritis is a degenerative disease considered a leading cause of functional disability. Its treatment is based on a combination of pharmacological and non-pharmacological interventions, but the role of these latter is still debated. This overview of systematic reviews aimed at evaluating the short-term efficacy of different thermal modalities in patients with osteoarthritis. We searched PubMed, Scopus, CINHAL, Web of Science, ProQuest and the Cochrane Database of Systematic Reviews from inception until October 2020, with no language restrictions. We selected the following outcomes a priori: pain, stiffness and quality of life. Seventeen systematic reviews containing 27 unique relevant studies were included. The quality of the reviews ranged from low to critically low. Substantial variations in terms of interventions studied, comparison groups, population, outcomes and follow-up between the included SRs were found. From a re-analysis of primary data, emerged that balneotherapy was effective in reducing pain and improving stiffness and quality of life, mud therapy significantly reduced pain and stiffness, and spa therapy showed pain relief. However, the evidence supporting the efficacy of different thermal modalities could be seriously flawed due to methodological quality and sample size, to the presence of important treatment variations, and to the high level of heterogeneity and the absence of a double-blind design. There is some encouraging evidence that deserves clinicians' consideration, suggesting that thermal modalities are effective on a short-term basis for treating patients with AO.

Exercise and education for community-dwelling older participants with knee osteoarthritis: a video-linked programme protocol based on a randomised controlled trial

Background

Neuromuscular and quadriceps exercises have been shown to be effective approaches to relieve pain and to improve function for patients with knee osteoarthritis. In this study, we aim to provide an informative feasible model in which therapeutic exercise and education will be undertaken with physiotherapy supervision and instruction via video link. We also aim to explore the relationship between program-induced pain alleviation/functional improvements and reduction in irritability, which might be mediated through program-induced psychosocial benefits.

Methods

In this proposed two-parallel group (neuromuscular exercise versus quadriceps exercise), single-blinded, randomised controlled trial, participants aged ≥50 years with osteoarthritic knee pain will undergo a 12-week intervention, comprising video-linked education, supervised exercises, and a 12-week follow-up. Seven measurements will be taken to collect longitudinal data. A generalised estimating equation will be used to establish the adjusted difference in effectiveness on pain, function, irritability, and psychosocial outcomes between participants undertaking neuromuscular exercises and those undertaking quadriceps exercises. The primary outcomes are overall average pain in the knee joint during walking, as assessed through the 11-point Numerical Pain Rating Scale, and the Western Ontario and McMaster Universities osteoarthritis index physical function subscale. Furthermore, pressure pain threshold and changes in self-report pain scores pre-, during, and post-exercise were also measured as an indication of irritability. In addition, both the 6-min walk test and a timed up & go test were used to assess walking function performance. Finally, patients’ emotions (e.g., fear and catastrophising), self-trust, needs in terms of disease knowledge, mental resilience, social support and health-related quality of life were investigated. Two four-wave cross-lagged models will be used to investigate directional relationships, aiming to investigate the complex mechanisms concerning the effects of exercise programmes.

Discussion

Through summarising the study’s strengths and limitations, this study may provide promising insights in terms of exercise therapy optimisation for people with knee osteoarthritis and/or other chronic pain within a psychosocial framework.

Trial registration

ChiCTR2100041978 (chictr.org.cn), January 10, 2021.

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

Knee osteoarthritis: key treatments and implications for physical therapy

BACKGROUND

Knee osteoarthritis (OA) is a chronic progressive disease that imparts a substantial socioeconomic burden to society and healthcare systems. The prevalence of knee OA has dramatically risen in recent decades due to consistent increases in life expectancy and obesity worldwide. Patient education, physical exercise, and weight loss (for overweight or obese individuals) constitute the first-line knee OA treatment approach. However, less than 40% of patients with knee OA receive this kind of intervention. There is an unmet need for healthcare professionals treating individuals with knee OA to understand the current recommended treatment strategies to provide effective rehabilitation.

OBJECTIVE

To guide physical therapists in their clinical decision making by summarizing the safest and most efficacious treatment options currently available, and by delineating the most traditional outcome measures used in clinical research for knee OA.

CONCLUSION

There is a need for healthcare providers to abandon low-quality and ineffective treatments and educate themselves and their patients about the current best evidence-based practices for knee OA.

Does tension applied in kinesio taping affect pain or function in older women with knee osteoarthritis? A randomised controlled trial

OBJECTIVE

To analyse the short-term effects of kinesio taping (KT) with tension (KTT) or without tension (KTNT) in older women with knee osteoarthritis (KOA), and compare them to controls who did not receive KT.

DESIGN

Randomised controlled trial.

SETTING

University physiotherapy school clinic.

PARTICIPANTS

Forty-five older women (fifteen participants per group) with 66.8 (±5.6) years and clinical diagnosis of KOA were assessed pre, post and 3 days after intervention.

INTERVENTIONS

Participants were randomly allocated to KTT, who received two simultaneous applications of KT with tension on the knee and rectus femoris; KTNT, who received the same application as the KTT group, but without tension and a control group that attended a class on KOA.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was pain intensity and secondary outcomes were knee-related health status, functional capacity, muscle strength and global rating of change.

RESULTS

No between-group differences were observed in pain after the first intervention (KTT vs KTNT: mean difference (MD), -1.8 points; 95% CI -4.2 to 0.5; KTT vs control: MD, -1.2 points; 95% CI -3.6 to 1.2; KTNT vs control: MD, 0.66 points; 95% CI -1.7 to 3.0) or 3 days later (KTT vs KTNT: MD, -1.3 points; 95% CI -3.7 to 1.0; KTT vs control: MD, 0.13 points; 95% CI -2.2 to 2.5; KTNT vs control: MD, 1.4 points; 95% CI -0.9 to 3.8). The lack of between-group differences was also found for secondary outcomes.

CONCLUSION

The short-term use of KT with or without tension in older woman with KOA had no beneficial effects on pain and function. These findings call into question the clinical use of KT as a non-pharmacological therapy for this population.

TRIAL REGISTRATION NUMBER

NCT03624075.

Exercise and education for knee osteoarthritis-What are accredited exercise physiologists providing?

OBJECTIVES

Clinical guidelines for the non-surgical management of knee osteoarthritis (OA) recommend exercise and education. This study aimed to evaluate the extent to which accredited exercise physiologists (AEPs) deliver exercise and education for knee OA and how it aligns with clinical practice guidelines.

DESIGN

Cross-sectional survey.

METHOD

An online survey targeted to AEPs across Australia to understand the exercise and education content of their interventions for knee OA. Likert scale and multiple-choice questions were used to measure responses relating to exercise prescription. Thematic analysis was used to evaluate the nature of education being delivered by AEPs. The revised neurophysiology of pain questionnaire (r-NPQ) was used to quantify pain neuroscience knowledge.

RESULTS

A total of 161 AEPs completed the survey (63 men, 98 women; mean experience 5.8 ± 4.7 years). Exercises commonly prescribed included: strength (99% of respondents), weight bearing (90%) and aerobic (83%), with 98% of AEPs prescribing exercise for the affected and unaffected limb. Only 32% of respondents frequently considered prescribing 'exercise into pain'. The four main education themes were exercise (86%), self-management (61%), weight loss (56%) and pain management (51%). Specific pain neuroscience education (PNE) was provided by only 21% of respondents.

CONCLUSIONS

Exercise prescription mostly aligned with evidence-based recommendations. The education component of AEP interventions for knee OA focused on the benefits of exercise. However, other education guideline recommendations about the disease, appropriate treatments and self-management were underutilised. The PNE knowledge of AEPs was comparable with other secondary care providers, although only a minority of AEPs provide PNE.

Mitochondria: Potential Targets for Osteoarthritis

Osteoarthritis (OA) is a common and disabling joint disorder that is mainly characterized by cartilage degeneration and narrow joint spaces. The role of mitochondrial dysfunction in promoting the development of OA has gained much attention. Targeting endogenous molecules to improve mitochondrial function is a potential treatment for OA. Moreover, research on exogenous drugs to improve mitochondrial function in OA based on endogenous molecular targets has been accomplished. In addition, stem cells and exosomes have been deeply researched in the context of cartilage regeneration, and these factors both reverse mitochondrial dysfunctions. Thus, we hypothesize that biomedical approaches will be applied to the treatment of OA. Furthermore, we have summarized the global status of mitochondria and osteoarthritis research in the past two decades, which will contribute to the research field and the development of novel treatment strategies for OA.

A Review of Non-Surgical Pain Management in Osteoarthritis

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

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Most Important Frequently Asked Questions From Patients With Hip or Knee Osteoarthritis: A Best-Worst Scaling Exercise

OBJECTIVE

To collect and prioritize the frequently asked questions (FAQs) that patients with hip or knee osteoarthritis (OA) and health care professionals consider to be the most important; to identify informational needs that go beyond guideline recommendations.

METHODS

FAQs were collected among health care professionals and from the arthritis helpline of the Dutch Arthritis Foundation. After deleting overlapping FAQs, the remaining FAQs were prioritized by patients and health care professionals using a maximum difference scaling method. A hierarchical Bayesian method was used to calculate relative importance scores. Differences between health care professionals and patients were analyzed using independent t-tests.

RESULTS

A total of 28 health care professionals and the arthritis helpline provided 192 FAQs. After deleting overlapping FAQs, 60 FAQs were prioritized by 94 patients (57 [60.6%] women, mean age 67.3 years) and 122 health care professionals (67 [54.9%] women, mean age 45.7 years). The FAQ "What can I do myself to decrease symptoms and to prevent the OA from getting worse?" was prioritized as the most important by both patients and professionals. FAQs that were highly prioritized by patients but significantly different from professionals were more directed toward treatment options offered by health care professionals, whereas highly prioritized FAQs of professionals were more often focused on treatment options involving self-management.

CONCLUSION

The health care professionals' perspective on informational needs differs from that of OA patients. These differences are important to address in order to achieve more active involvement of patients in their own treatment process.

Osteoarthritis

Osteoarthritis is a leading cause of disability and source of societal cost in older adults. With an ageing and increasingly obese population, this syndrome is becoming even more prevalent than in previous decades. In recent years, we have gained important insights into the cause and pathogenesis of pain in osteoarthritis. The diagnosis of osteoarthritis is clinically based despite the widespread overuse of imaging methods. Management should be tailored to the presenting individual and focus on core treatments, including self-management and education, exercise, and weight loss as relevant. Surgery should be reserved for those that have not responded appropriately to less invasive methods. Prevention and disease modification are areas being targeted by various research endeavours, which have indicated great potential thus far. This narrative Seminar provides an update on the pathogenesis, diagnosis, management, and future research on osteoarthritis for a clinical audience.

Patients' perceived needs for allied health, and complementary and alternative medicines for low back pain: A systematic scoping review

OBJECTIVES

Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP.

METHODS

A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated.

RESULTS

Forty-four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed-methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short-term duration of these therapies.

CONCLUSIONS

Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient-centred guidelines and service models for LBP. Understanding patients' concerns regarding active-based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health-care system.

Patients' perceived needs of osteoarthritis health information: A systematic scoping review

BACKGROUND

Optimal management of osteoarthritis requires active patient participation. Understanding patients' perceived health information needs is important in order to optimize health service delivery and health outcomes in osteoarthritis. We aimed to review the existing literature regarding patients' perceived health information needs for OA.

METHODS

A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoarthritis health information were categorized.

RESULTS

30 studies from 2876 were included: 16 qualitative, 11 quantitative and 3 mixed-methods studies. Three areas of perceived need emerged: (1) Need for clear communication: terms used were misunderstood or had unintended connotations. Patients wanted clear explanations. (2) Need for information from various sources: patients wanted accessible health professionals with specialist knowledge of arthritis. The Internet, whilst a source of information, was acknowledged to have dubious reliability. Print media, television, support groups, family and friends were utilised to fulfil diverse information needs. (3) Needs of information content: patients desired more information about diagnosis, prognosis, management and prevention.

CONCLUSIONS

Patients desire more information regarding the diagnosis of osteoarthritis, its impact on daily life and its long-term prognosis. They want more information not only about pharmacological management options, but also non-pharmacological options to help them manage their symptoms. Also, patients wanted this information to be delivered in a clear manner from multiple sources of health information. To address these gaps, more effective communication strategies are required. The use of a variety of sources and modes of delivery may enable the provision of complementary material to provide information more successfully, resulting in better patient adherence to guidelines and improved health outcomes.

Determinants of pain, disability, health-related quality of life and physical performance in patients with knee osteoarthritis awaiting total joint arthroplasty

PURPOSE

In patients suffering from knee osteoarthritis awaiting knee arthroplasty, to measure associations between several selected determinants and pain, disability, health-related quality of life and physical performance.

MATERIAL AND METHODS

Validated self-reported measures were collected: (1) Western Ontario and McMaster Universities Osteoarthritis Index, (2) Lower Extremity Functional Scale (LEFS) and (3) Short-Form 36 (SF-36). Physical performance was also assessed with four validated performance tests. Demographic, socioeconomic, psychosocial and clinical characteristics of the participants were also measured. Multivariate regression analyses were used to evaluate potential associations.

RESULTS

Higher fear-avoidance beliefs, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse pain, function or HRQOL (p < 0.05) and explained 12%-35% of the variances of the self-reported measure scores. Pretest pain and change in pain during posttest, greater comorbidities, psychological distress and use of a walking aid were significantly associated with worse performance on the physical tests (p < 0.05) and explained 41%-59% of the variances of the different physical tests results.

CONCLUSIONS

Several determinants were significantly associated with worse pain, disability, health-related quality of life or physical performance. Several of these associations may be considered clinically important, including psychosocial determinants in relation to self-reported measures, but to physical performance as well. Implications for rehabilitation Knee osteoarthritis is a highly prevalent and disabling condition incurring important socioeconomic costs. Several modifiable determinants have been shown to contribute to pain and disability in individuals suffering from knee OA awaiting TKA. Recent studies demonstrated the efficacy of education and rehabilitation (prehabilitation) in individuals awaiting TKA.

Supporting the Evaluation and Implementation of Musculoskeletal Models of Care: A Globally Informed Framework for Judging Readiness and Success

OBJECTIVE

To develop a globally informed framework to evaluate readiness for implementation and success after implementation of musculoskeletal models of care (MOCs).

METHODS

Three phases were undertaken: 1) a qualitative study with 27 Australian subject matter experts (SMEs) to develop a draft framework; 2) an eDelphi study with an international panel of 93 SMEs across 30 nations to evaluate face validity, and refine and establish consensus on the framework components; and 3) translation of the framework into a user-focused resource and evaluation of its acceptability with the eDelphi panel.

RESULTS

A comprehensive evaluation framework was developed for judging the readiness and success of musculoskeletal MOCs. The framework consists of 9 domains, with each domain containing a number of themes underpinned by detailed elements. In the first Delphi round, scores of "partly agree" or "completely agree" with the draft framework ranged 96.7%-100%. In the second round, "essential" scores ranged 58.6%-98.9%, resulting in 14 of 34 themes being classified as essential. SMEs strongly agreed or agreed that the final framework was useful (98.8%), usable (95.1%), credible (100%) and appealing (93.9%). Overall, 96.3% strongly supported or supported the final structure of the framework as it was presented, while 100%, 96.3%, and 100% strongly supported or supported the content within the readiness, initiating implementation, and success streams, respectively.

CONCLUSION

An empirically derived framework to evaluate the readiness and success of musculoskeletal MOCs was strongly supported by an international panel of SMEs. The framework provides an important internationally applicable benchmark for the development, implementation, and evaluation of musculoskeletal MOCs.

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.

Hip and Knee Osteoarthritis Affects Younger People, Too

Synopsis Although osteoarthritis (OA) has traditionally been considered a disease of older age, hip and knee OA can and does affect younger adults, with a profound impact on psychosocial well-being and work capacity. Obesity and a history of traumatic knee injury (eg, anterior cruciate ligament rupture and/or meniscal tear) are key risk factors for the accelerated development of knee OA, while structural hip deformities (including those contributing to femoroacetabular impingement syndrome) are strong predictors of early-onset hip OA. In view of these associations, rising rates of obesity and sports injuries are concerning, and may signal a future surge in OA incidence among younger people. Assessment of hip and knee OA in younger people should focus on a patient-centered history, comprehensive physical examination, performance-based measures, and patient-reported outcome measures to enable monitoring of symptoms and function over time. Referral for imaging should be reserved for people presenting with atypical signs or symptoms that may indicate diagnoses other than OA. Nonpharmacological approaches are core strategies for the management of hip and knee OA in younger people, and these include appropriate disease-related education, activity modification (including for work-related tasks), physical therapist- prescribed exercise programs to address identified physical impairments, and weight control or weight loss. High-quality evidence has shown no benefit of arthroscopy for knee OA, and there are no published clinical trials to support the use of hip arthroscopy for OA. Referral for joint-conserving or joint replacement surgery should be considered when nonpharmacological and pharmacological management strategies are no longer effective. J Orthop Sports Phys Ther 2017;47(2):67-79. doi:10.2519/jospt.2017.7286.

Qualitative Development of a Discrete Choice Experiment for Physical Activity Interventions to Improve Knee Osteoarthritis

OBJECTIVE

To describe the qualitative process used to develop attributes and attribute levels for inclusion in a discrete choice experiments (DCE) for older adult physical activity interventions.

DESIGN

Five focus groups (n=41) were conducted, grounded in the Health Action Process Approach framework. Discussion emphasized identification and prioritization attributes for a DCE on physical activity. Semi-structured interviews (n=6) investigated attribute levels and lay-language for the DCE. A focus group with physical activity researchers and health care providers was the final stakeholder group used to establish a comprehensive approach for the generation of attributes and levels. A DCE pilot test (n=8) was then conducted with individuals of the target patient population. All transcripts were analyzed using a constant comparative approach.

SETTING

General community and university-based research setting.

PARTICIPANTS

Volunteers (N=55) aged >45 years with knee pain, aches, or stiffness for at least 1 month over the previous 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interview guides, attributes, attribute levels, and discrete choice experiment.

RESULTS

The most influential identified attributes for physical activity were time, effort, cost, convenience, enjoyment, and health benefits. Each attribute had 3 levels that were understandable in the pilot test of the DCE.

CONCLUSIONS

The identification of 6 physical activity attributes that are most salient to adults with knee osteoarthritis resulted from a systematic qualitative process, including attribute-ranking exercises. A DCE will provide insight into the relative importance of these attributes for participating in physical activity, which can guide intervention development.

Establishing cross-discipline consensus on contraception, pregnancy and breast feeding-related educational messages and clinical practices to support women with rheumatoid arthritis: an Australian Delphi study

OBJECTIVE

Recognising the need for a best-practice and consistent approach in providing care to women with rheumatoid arthritis (RA) in relation to (1) general health, (2) contraception, (3) conception and pregnancy, (4) breast feeding and (5) early parenting, we sought to achieve cross-discipline, clinical consensus on key messages and clinical practice behaviours in these 5 areas.

DESIGN

3-round eDelphi study. In round 1, panellists provided free-text responses to open-ended questions about care for women with RA across the 5 areas. Subsequently, panellists refined and scored the synthesised responses, presented as metathemes, themes and detailed elements. Where ≥5% of panellists did not support a theme in a given round, it was removed.

SETTING

Panel of practicing Australian rheumatologists (n=22), obstetricians/obstetric medicine physicians (n=9) and pharmacists (n=5).

RESULTS

34 (94.4%) panellists participated in all 3 rounds. The panel supported 18 themes across the 5 areas (support/strongly support: 88.2-100%) underpinned by 5 metathemes. Metathemes focused on coordination in information delivery, the mode and timing of information delivery, evidence underpinning information, engagement of the right health professionals at the right time and a non-judgemental approach to infant feeding. Themes included practices for primary prevention of chronic disease and their sequelae, the importance of contraception and planning pregnancy and breast feeding, close monitoring of medications, supporting mental well-being, managing disease activity and providing practical support for early parenting.

CONCLUSIONS

A cross-disciplinary clinical panel highly supported key information and clinical practices in the care for women with RA across the continuum of contraception to early parenting within a whole-person, chronic disease management approach.

Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS)

BACKGROUND

The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system.

METHODS

The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory.

RESULTS

The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback.

CONCLUSIONS

The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.

Pain trajectory and exercise-induced pain flares during 8 weeks of neuromuscular exercise in individuals with knee and hip pain

OBJECTIVE

Patients considering or engaged in exercise as treatment may expect or experience transient increases in joint pain, causing fear of exercise and influencing compliance. This study investigated the pain trajectory during an 8-week neuromuscular exercise (NEMEX) program together with acute exercise-induced pain flares in persons with knee or hip pain.

DESIGN

Individuals above 35 years self-reporting persistent knee or hip pain for the past 3 months were offered 8 weeks of supervised NEMEX, performed in groups twice weekly. The program consisted of 11 exercises focusing on joint stability and neuromuscular control. Participants self-reported joint pain on a 0-10 numerical rating scale (NRS) at baseline and 8-weeks follow-up. NRS pain ratings were also collected before and immediately after every attended exercise session.

RESULTS

Joint pain was reduced from baseline (NRS 3.6; 95% CI 3.2-4.1) to 8-weeks follow-up (2.6; 95% CI 2.1-3.1), (P < 0.01). Pain decreased 0.04 NRS (95% CI 0.02-0.05, P < 0.01) on average per exercise session and pre- to post-exercise pain decreased 0.04 NRS (95% CI 0.03-0.05, P < 0.01) on average per session, approaching no acute exercise-induced pain in the last weeks.

CONCLUSION

This study found a clear decrease in size of acute exercise-induced pain flares with increasing number of exercise sessions. In parallel, pain ratings decreased over the 8 weeks exercise period. Our findings provide helpful information for clinicians, which can be used to educate and balance patient expectation when starting supervised neuromuscular exercise.

Patient information and emotional needs across the hip osteoarthritis continuum: a qualitative study

Background

Osteoarthritis (OA) is the most common form of arthritis worldwide, affecting a growing number of people in the ageing populations. Currently, it affects about 50 % of all people over 65 years of age. There are no disease-modifying treatments for OA; hence preference-sensitive treatment options include symptom reduction, self-management and surgical joint replacement for suitable individuals. People have both ethical and legal rights to be informed about treatment choices and to actively participate in decision-making. Individuals have different needs; they differ in their ability to understand and make use of the provided information and to sustain behaviour change-dependent treatments over time.

Methods

As a part of a larger research project that aims to develop and test a web-based support tool for patients with hip OA, this paper is a qualitative in-depth study to investigate patients’ need for information and their personal emotional needs. We invited 13 patients to participate in individual interviews, which were audiotaped. The audio-tapes were transcribed verbatim and analysed using an inductive thematic analysis approach.

Results

The thematic analysis revealed a pattern of patients’ information and emotional needs, captured in several key questions relevant to the different stages of the disease experience. Based on these results and research literature, we developed a model illustrating the patients' disease experience and treatment continuum. Six phases with accompanying key questions were identified, displaying how patients information and emotional needs arise and change in line with the progression of the disease experience, the clinical encounters and the decision-making process. We also identified and included in the model an alternative route that bypasses the surgical treatment option.

Conclusion

Patients with hip OA are in great need of information both at the time of diagnosis and further throughout the disease development and care continuum. Lack of information may result in unnecessary and dysfunctional misconceptions, underuse of potentially helpful treatment options and uninformed decisions. Patients need continuous support from health professionals and their families in order to find and consider effective treatment strategies.

Multiple Criteria Decision Analysis for Health Care Decision Making--Emerging Good Practices: Report 2 of the ISPOR MCDA Emerging Good Practices Task Force

Health care decisions are complex and involve confronting trade-offs between multiple, often conflicting objectives. Using structured, explicit approaches to decisions involving multiple criteria can improve the quality of decision making. A set of techniques, known under the collective heading, multiple criteria decision analysis (MCDA), are useful for this purpose. In 2014, ISPOR established an Emerging Good Practices Task Force. The task force's first report defined MCDA, provided examples of its use in health care, described the key steps, and provided an overview of the principal methods of MCDA. This second task force report provides emerging good-practice guidance on the implementation of MCDA to support health care decisions. The report includes: a checklist to support the design, implementation and review of an MCDA; guidance to support the implementation of the checklist; the order in which the steps should be implemented; illustrates how to incorporate budget constraints into an MCDA; provides an overview of the skills and resources, including available software, required to implement MCDA; and future research directions.