Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial

HAP-FAST: a feasibility study incorporating qualitative, mechanistic and costing sub-studies alongside a randomised pilot trial comparing chest x-ray to low-dose CT scan and empirical antibiotics to antibiotics guided by the BIOFIRE® FILM ARRAY® pneumonia plus panel in adults with suspected non-ventilator-associated hospital-cquired pneumonia

INTRODUCTION

Non-ventilator-associated hospital-acquired pneumonia (nv-HAP) is the most common healthcare-associated infection (HCAI), is associated with high mortality and morbidity and places a major burden on healthcare systems. Diagnosis currently relies on chest x-rays to confirm pneumonia and sputum cultures to determine the microbiological cause. This approach leads to over-diagnosis of pneumonia, rarely identifies a causative pathogen and perpetuates unnecessary and imprecise antibiotic use. The HAP-FAST study aims to evaluate the feasibility of a randomised trial to evaluate the clinical impact of low-dose, non-contrast-enhanced thoracic CT scans and rapid molecular sputum analysis using the BIOFIRE® FILMARRAY® pneumonia plus panel (FAPP) for patients suspected with nv-HAP.

METHODS AND ANALYSIS

The HAP-FAST feasibility study consists of a pilot randomised trial, a qualitative study, a costing analysis and exploratory analyses of clinical samples to investigate the immune-pathophysiology of HAP. Participants are identified and recruited from four acute hospitals in the Northwest of the UK. Using a Research Without Prior Consent model, the pilot trial will recruit 220 adult participants, with or without mental capacity, and with suspected HAP. HAP-FAST is a non-blinded, sequential, multiple assignment, randomised trial with two possible stages of randomisation: first, chest x-ray (CXR) or CT; second, if treated as nv-HAP, FAPP or standard microbiological processing alone (no FAPP). Pathogen-specific antibiotic guidance will be provided for FAPP results. Randomisation uses a web-based platform and followed up for 90 days. The feasibility of a future trial will be determined by assessing trial processes, outcome measures and patient and staff experiences.

ETHICS AND DISSEMINATION

This study has undergone combined review by the UK NHS Research Ethics Committee and Health Research Authority. Results will be disseminated via peer-reviewed journals, via the funders' website and through a range of media to engage the public.

TRIAL REGISTRATION NUMBER

NCT05483309.

Budget impact of the Walk With Ease program for knee osteoarthritis

Objective

Walk With Ease (WWE) is an effective low-cost walking program. We estimated the budget impact of implementing WWE in persons with knee osteoarthritis (OA) as a measure of affordability that can inform payers' funding decisions.

Methods

We estimated changes in two-year healthcare costs with and without WWE. We used the Osteoarthritis Policy (OAPol) Model to estimate per-person medical expenditures. We estimated total and per-member-per-month (PMPM) costs of funding WWE for a hypothetical insurance plan with 75,000 members under two conditions: 1) all individuals aged 45+ with knee OA eligible for WWE, and 2) inactive and insufficiently active individuals aged 45+ with knee OA eligible. In sensitivity analyses, we varied WWE cost and efficacy and considered productivity costs.

Results

With eligibility unrestricted by activity level, implementing WWE results in an additional $1,002,408 to the insurance plan over two years ($0.56 PMPM). With eligibility restricted to inactive and insufficiently active individuals, funding WWE results in an additional $571,931 over two years ($0.32 PMPM). In sensitivity analyses, when per-person costs of $10 to $1000 were added with 10-50% decreases in failure rate (enhanced sustainability of WWE benefits), two-year budget impact varied from $242,684 to $6,985,674 with unrestricted eligibility and from -$43,194 (cost-saving) to $4,484,122 with restricted eligibility.

Conclusion

Along with the cost-effectiveness of WWE at widely accepted willingness-to-pay thresholds, these results can inform payers in deciding to fund WWE. In the absence of accepted thresholds to define affordability, these results can assist in comparing the affordability of WWE with other behavioral interventions.

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

Self-regulation training for people with knee osteoarthritis: a protocol for a feasibility randomised control trial (MiNT trial)

Introduction

Knee osteoarthritis (OA) is a chronic secondary musculoskeletal pain condition resulting in disability, reduced quality of life, and high societal costs. Pain associated with knee OA is linked to increased sensitivity in sensory, cognitive, and emotional areas of the brain. Self-regulation training targeting brain functioning related to pain experience could reduce pain and its associated disability. Self-regulatory treatments such as mindfulness meditation (MM) and electroencephalography neurofeedback (EEG-NF) training improve clinical outcomes in people with knee OA. A feasibility clinical trial can address factors that could inform the design of the full trial investigating the effectiveness of self-regulation training programmes in people with knee OA. This clinical trial will evaluate the feasibility, safety, acceptability, experience and perceptions of the self-regulatory training programmes.

Methods

The proposed feasibility trial is based on a double-blind (outcome assessor and investigators), three-arm (MM usual care, EEG-NF + usual care and usual care control group) randomised controlled parallel clinical trial. Participants with knee OA will be recruited from the community and healthcare practices. A research assistant (RA) will administer both interventions (20-min sessions, four sessions each week, and 12 sessions over three successive weeks). Feasibility measures (participant recruitment rate, adherence to interventions, retention rate), safety, and acceptability of interventions will be recorded. An RA blinded to the group allocation will record secondary outcomes at baseline, immediately post-intervention (4th week), and 3 months post-intervention. The quantitative outcome measures will be descriptively summarised. The qualitative interviews will evaluate the participants' experiences and perceptions regarding various aspects of the trial, which includes identifying the barriers and facilitators in participating in the trial, evaluating their opinions on the research procedures, such as their preferences for the study site, and determining the level of acceptability of the interventions as potential clinical treatments for managing knee OA. Māori participant perceptions of how assessment and training practices could be acceptable to a Māori worldview will be explored. The interviews will be audio-recorded and analysed thematically.

Discussion

This trial will provide evidence on the feasibility, safety, and acceptability of the MM and EEG-NF training in people with knee OA, thus informing the design of a full randomised clinical control trial.

Walk with ease for knee osteoarthritis: A cost-effectiveness analysis

Objective

The Walk With Ease (WWE) program was developed by the Arthritis Foundation to help people with arthritis learn to exercise safely and improve arthritis symptoms. We sought to establish the value of the WWE program.

Methods

We used the Osteoarthritis Policy (OAPol) Model, a widely published and validated computer simulation of knee osteoarthritis (OA), to assess the cost-effectiveness of WWE in knee OA. We derived model inputs using data from a workplace wellness initiative in Montana that offered WWE to state employees. Our primary outcomes were quality-adjusted life years (QALYs) and costs over a 2-year period, which we used to calculate the incremental cost-effectiveness ratio (ICER). The base case analysis was restricted to subjects who were inactive or insufficiently active (<180 ​min/week of PA) at baseline. We performed scenario and probabilistic sensitivity analyses to determine the impact of uncertainty in model parameters on our results.

Results

In the base case analysis, adding WWE to usual care resulted in an ICER of $47,900/QALY. When the program was offered without preselection by baseline activity level, the ICER for WWE ​+ ​usual care was estimated at $83,400/QALY. Results of the probabilistic sensitivity analysis indicated that WWE offered to inactive or insufficiently active individuals has a 52% chance of having an ICER <$50,000/QALY.

Conclusion

The WWE program offers good value for inactive/insufficiently active individuals. Payers may consider including such a program to increase physical activity in individuals with knee OA.

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

BACKGROUND

A stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA).

OBJECTIVE

To evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective.

METHODS

An economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a 'high muscle strength subgroup', 'low muscle strength subgroup', and 'obesity subgroup' supplemented by a dietary intervention for the 'obesity subgroup' (experimental group), with usual ('non-stratified') exercise therapy (control group). Clinical outcomes included quality-adjusted life years - QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty.

RESULTS

During 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning.

CONCLUSIONS

We found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic.

Economic evaluation: a reader's guide to studies of cost-effectiveness

BACKGROUND

Understanding what an economic evaluation is, how to interpret it, and what it means for making choices in a health delivery context is necessary to contribute to decisions about healthcare resource allocation. The aim of this paper to demystify the working parts of a health economic evaluation, and explain to clinicians and clinical researchers how to read and interpret cost-effectiveness research.

MAIN BODY

This primer distils key content and constructs of economic evaluation studies, and explains health economic evaluation in plain language. We use the PICOT (participant, intervention, comparison, outcome, timeframe) clinical trial framework familiar to clinicians, clinical decision-makers, and clinical researchers, who may be unfamiliar with economics, as an aide to reading and interpreting cost-effectiveness research. We provide examples, primarily of physiotherapy interventions for osteoarthritis.

CONCLUSIONS

Economic evaluation studies are essential to improve decisions about allocating resources, whether those resources be your time, the capacity of your service, or the available funding across the entire healthcare system. The PICOT framework can be used to understand and interpret cost-effectiveness research.

The influence of manual therapy dosing on outcomes in patients with hip osteoarthritis: a systematic review

OBJECTIVE

To 1) Determine if specific dosing parameters of manual therapy are related to improved pain, disability, and quality of life outcomes in patients with hip osteoarthritis and 2) to provide recommendations for optimal manual therapy dosing based on our findings.

DESIGN

A systematic review of randomized controlled trials from the PubMed, CINAHL, and OVID databases that used manual therapy interventions to treat hip osteoarthritis was performed. Three reviewers assessed the risk of bias for included studies and extracted relevant outcome data based on predetermined criteria. Baseline and follow-up means and standard deviations for outcome measures were used to calculate effect sizes for within and between-group differences.

RESULTS

Ten studies were included in the final analyses totaling 768 participants, and half were graded as high risk of bias. Trends emerged: 1) large effect sizes were seen using long-axis distraction, mobilization and thrust manipulation, 2) mobilization with movement showed large effects for pain and range of motion, and (3) small effects were associated with graded mobilization. Durations of 10 to 30 minutes per session, and frequency 2-3 times per week for 2-6 weeks were the most common dosing parameters.

CONCLUSIONS

There were varied effect sizes associated with pain, function, and quality of life for both thrust and non-thrust mobilizations, and mobilization with movement into hip flexion and internal rotation. Due to the heterogeneity of MT dosage, it is difficult to recommend a specific manual therapy dosage for those with hip osteoarthritis.

Cost-effectiveness of Physical Therapy vs Intra-articular Glucocorticoid Injection for Knee Osteoarthritis: A Secondary Analysis From a Randomized Clinical Trial

IMPORTANCE

Physical therapy and glucocorticoid injections are initial treatment options for knee osteoarthritis, but available data indicate that most patients receive one or the other, suggesting they may be competing interventions. The initial cost difference for treatment can be substantial, with physical therapy often being more expensive at the outset, and cost-effectiveness analysis can aid patients and clinicians in making decisions.

OBJECTIVE

To investigate the incremental cost-effectiveness between physical therapy and intra-articular glucocorticoid injection as initial treatment strategies for knee osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation is a secondary analysis of a randomized clinical trial performed from October 1, 2012, to May 4, 2017. Health economists were blinded to study outcomes and treatment allocation. A randomized sample of patients seen in primary care and physical therapy clinics with a radiographically confirmed diagnosis of knee osteoarthritis were evaluated from the clinical trial with 96.2% follow-up at 1 year.

INTERVENTIONS

Physical therapy or glucocorticoid injection.

MAIN OUTCOMES AND MEASURES

The main outcome was incremental cost-effectiveness between 2 alternative treatments. Acceptability curves of bootstrapped incremental cost-effectiveness ratios (ICERs) were used to identify the proportion of ICERs under the specific willingness-to-pay level ($50 000-$100 000). Health care system costs (total and knee related) and health-related quality-of-life based on quality-adjusted life-years (QALYs) were obtained.

RESULTS

A total of 156 participants (mean [SD] age, 56.1 [8.7] years; 81 [51.9%] male) were randomized 1:1 and followed up for 1 year. Mean (SD) 1-year knee-related medical costs were $2113 ($4224) in the glucocorticoid injection group and $2131 ($1015) in the physical therapy group. The mean difference in QALY significantly favored physical therapy at 1 year (0.076; 95% CI, 0.02-0.126; P = .003). Physical therapy was the more cost-effective intervention, with an ICER of $8103 for knee-related medical costs, with a 99.2% probability that results fall below the willingness-to-pay threshold of $100 000.

CONCLUSIONS AND RELEVANCE

A course of physical therapy was cost-effective compared with a course of glucocorticoid injections for patients with knee osteoarthritis. These results suggest that, although the initial cost of delivering physical therapy may be higher than an initial course of glucocorticoid injections, 1-year total knee-related costs are equivalent, and greater improvement in QALYs may justify the initial higher costs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01427153.

Costing Methodology and Key Drivers of Health Care Costs Within Economic Analyses in Musculoskeletal Community and Primary Care Services: A Systematic Review of the Literature

Background: Identifying variation in musculoskeletal service costs requires the use of specific standardized metrics. There has been a large focus on costing, efficiency, and standardized metrics within the acute musculoskeletal setting, but far less attention in primary care and community settings. Objectives: To (a) assess the quality of costing methods used within musculoskeletal economic analyses based primarily in primary and community settings and (b) identify which cost variables are the key drivers of musculoskeletal health care costs within these settings. Methods: Medline, AMED, EMBASE, CINAHL, HMIC, BNI, and HBE electronic databases were searched for eligible studies. Two reviewers independently extracted data and assessed quality of costing methods using an established checklist. Results: Twenty-two studies met the review inclusion criteria. The majority of studies demonstrated moderate- to high-quality costing methods. Costing issues included studies failing to fully justify the economic perspective, and not distinguishing between short- and long-run costs. Highest unit costs were hospital admissions, outpatient visits, and imaging. Highest mean utilization were the following: general practitioner (GP) visits, outpatient visits, and physiotherapy visits. Highest mean costs per patient were GP visits, outpatient visits, and physiotherapy visits. Conclusion: This review identified a number of key resource use variables that are driving musculoskeletal health care costs in the community/primary care setting. High utilization of these resources (rather than high unit cost) appears to be the predominant factor increasing mean health care costs. There is, however, need for greater detail with capturing these key cost drivers, to further improve the accuracy of costing information.

Are education, exercise and diet interventions a cost-effective treatment to manage hip and knee osteoarthritis? A systematic review

OBJECTIVE

To identify research gaps and inform implementation we systematically reviewed the literature evaluating cost-effectiveness of recommended treatments (education, exercise and diet) for the management of hip and/or knee OA.

METHODS

We searched Medline, Embase, Cochrane Central Register of Controlled Trials, National Health Services Economic Evaluation Database, and EconLit from inception to November 2019 for trial-based economic evaluations investigating hip and/or knee OA core treatments. Two investigators screened relevant publications, extracted data and synthesized results. Risk of bias was assessed using the Consensus on Health Economic Criteria list.

RESULTS

Two cost-minimization, five cost-effectiveness and 16 cost-utility analyses evaluated core treatments in six health systems. Exercise therapy with and without education or diet was cost-effective or cost-saving compared to education or physician-delivered usual care at conventional willingness to pay (WTP) thresholds in 15 out of 16 publications. Exercise interventions were cost-effective compared to physiotherapist-delivered usual care in three studies at conventional WTP thresholds. Education interventions were not cost-effective compared to usual care or placebo at conventional WTP thresholds in three out of four publications.

CONCLUSIONS

Structured core treatment programs were clinically effective and cost-effective, compared to physician-delivered usual care, in five health care systems. Providing education about core treatments was not consistently cost-effective. Implementing structured core treatment programs into funded clinical pathways would likely be an efficient use of health system resources and enhance physician-delivered usual primary care.

Health Economic Evaluations of Hip and Knee Interventions in Orthopaedic Sports Medicine: A Systematic Review and Quality Assessment

BACKGROUND

The economic burden of musculoskeletal diseases is substantial and growing. Economic evaluations compare costs and health benefits of interventions simultaneously to help inform value-based care; thus, it is crucial to ensure that studies are using appropriate methodology to provide valid evidence on the cost-effectiveness of interventions. This is particularly the case in orthopaedic sports medicine, where several interventions of varying costs are available to treat common hip and knee conditions.

PURPOSE

To summarize and evaluate the quality of economic evaluations in orthopaedic sports medicine for knee and hip interventions and identify areas for quality improvement.

STUDY DESIGN

Systematic review; Level of evidence, 3.

METHODS

The Medline, AMED, OVID Health Star, and EMBASE databases were searched from inception to March 1, 2020, to identify economic evaluations that compared ≥2 interventions for hip and/or knee conditions in orthopaedic sports medicine. We assessed the quality of full economic evaluations using the Quality of Health Economic Studies (QHES) tool, which consists of 16 questions for a total score of 100. We classified studies into quartiles based on QHES score (extremely poor quality to high quality) and we evaluated the frequency of studies that addressed each of the 16 QHES questions.

RESULTS

A total of 93 studies were included in the systematic review. There were 41 (44%) cost analyses, of which 21 (51%) inappropriately concluded interventions were cost-effective. Only 52 (56%) of the included studies were full economic evaluations, although 40 of these (77%) fell in the high-quality quartile. The mean QHES score was 83.2 ± 19. Authors consistently addressed 12 of the QHES questions; questions that were missed or unclear were related to statistical uncertainty, appropriateness of costing methodology, and discussion of potential biases. The most frequently missed question was whether the cost perspective of the analysis was stated and justified.

CONCLUSION

The number of studies in orthopaedic sports medicine is small, despite their overall good quality. Yet, there are still many highly cited studies based on low-quality or partial economic evaluations that are being used to influence clinical decision-making. Investigators should follow international health economic guidelines for study design and critical appraisal of studies to further improve quality.

Cost-effectiveness of 12 weeks of supervised treatment compared to written advice in patients with knee osteoarthritis: a secondary analysis of the 2-year outcome from a randomized trial

OBJECTIVE

To assess the 24-month cost-effectiveness of supervised treatment compared to written advice in knee osteoarthritis (OA).

DESIGN

100 adults with moderate-severe OA not eligible for total knee replacement (TKR) randomized to a 12-week individualized, supervised treatment (exercise, education, diet, insoles and pain medication) or written advice. Effectiveness was measured as change in quality-adjusted life years (QALYs) from baseline to 24 months, including data from baseline, 3, 6, 12 and 24 months, while healthcare costs and transfer payments were derived from national registries after final follow-up. Incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. A sensitivity analysis resampling existing data was conducted and the probability of cost-effectiveness was estimated using a 22,665 Euros/QALY threshold. In a sensitivity analysis, cost-effectiveness was calculated for different costs of the supervised treatment (actual cost in study; cost in private practice; and in-between cost).

RESULTS

Average costs were similar between groups (6,758 Euros vs 6,880 Euros), while the supervised treatment were close to being more effective (incremental effect (95% CI) of 0.075 (-0.005 to 0.156). In the primary analysis excluding deaths, this led the supervised treatment to be cost-effective, compared to written advice. The sensitivity analysis demonstrated that the results were sensitive to changes in the cost of treatment, but in all scenarios the supervised treatment was cost-effective (ICERs of 6,229 to 20,688 Euros/QALY).

CONCLUSIONS

From a 24-month perspective, a 12-week individualized, supervised treatment program is cost-effective compared to written advice in patients with moderate-severe knee OA not eligible for TKR.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01535001.

[Prescription frequency of physical therapy and analgesics before total hip and knee arthroplasy : An epidemiological analysis of routine health care data from Germany]

BACKGROUND

Osteoarthritis of the hip or knee joint is a widespread disease with a strong influence on the quality of life. At present, the extent of conservative treatment with physical therapies and analgesics before the use of a total joint arthroplasty (TJA) of the hip or knee is largely unclear in Germany.

OBJECTIVES

The aim was to analyze the prescription frequency according to regional and socio-demographic factors.

MATERIALS AND METHODS

Based on routine health care data from BARMER insurance, patients who received a TJA of the hip or knee from 2011 to 2013 were analyzed. Included were consistently insured patients with the main discharge diagnosis of osteoarthritis who did not receive any further TJA for eight quarters before and after replacement. The prescription frequency of physical therapies and analgesics, stratified according to age groups, gender, number of comorbidities and federal state was analyzed.

RESULTS

40,242 persons with hip TJA and 35,652 persons with knee TJA were included. In the year prior to surgery, 49.4% of patients (hip TJA: 49.9%; knee TJA: 48.9%) received at least one physical therapy and 81.0% were prescribed analgesics. Regionally, the prescription frequency of physical therapies for hip TJA varied between 35.7% (Bremen) and 70.6% (Saxony) and for knee TJA between 37.6% (Saarland) and 66.9% (Saxony).

CONCLUSION

The prescription frequency of physical therapy does not fully correspond to current treatment recommendations. The prescription of physical therapies in the year before the TEP shows regional differences, with fundamentally lower prescription frequencies in the former states of West Germany.

A systematic review of economic evaluations of conservative treatments for chronic lower extremity musculoskeletal complaints

Objective

The aim was to appraise and synthesize studies evaluating the clinical and cost effectiveness of conservative interventions for chronic lower extremity musculoskeletal (MSK) conditions and describe their characteristics, including the type of economic evaluation, primary outcomes and which conditions.

Methods

The search strategy related to economic evaluations of lower limb MSK conditions that used conservative therapies. Eight electronic databases were searched (CENTRAL, MEDLINE, PubMed, EMBASE, CINAHL, PEDro, NHSEED and Proquest), as were the reference lists from included articles. The quality of articles was appraised using a modified version of the economic evaluations’ reporting checklist (economic) and The Cochrane Collaboration’s tool for assessing risk of bias (clinical).

Results

Twenty-six studies were eligible and included in the review. Economic evaluations of conservative interventions for OA or pain affecting the knee/hip (n = 25; 93%) were most common. The main approaches adopted were cost–utility analysis (n = 17; 68%) or cost–effectiveness analysis (n = 5; 19%). Two studies involved interventions including footwear/foot orthoses; for heel pain (n = 1; 4%) and overuse injuries (n = 1; 4%). Fifty per cent of economic evaluations adopted the EQ-5D-3L as the primary outcome measure for quality of life and quality-adjusted life year calculations.

Conclusion

Economic evaluations have been conducted largely for exercise-based interventions for MSK conditions of the hip and knee. Few economic evaluations have been conducted for other clinically important lower limb MSK conditions. A matrix presentation of costs mapped with outcomes indicated increasing costs with either no difference or improvements in clinical effectiveness. The majority of economic evaluations were of good reporting quality, as were the accompanying clinical studies.

Can cost-effectiveness results be combined into a coherent league table? Case study from one high-income country

BACKGROUND

Doubts exist around the value of compiling league tables for cost-effectiveness results for health interventions, primarily due to methods differences. We aimed to determine if a reasonably coherent league table could be compiled using published studies for one high-income country: New Zealand (NZ).

METHODS

Literature searches were conducted to identify NZ-relevant studies published in the peer-reviewed journal literature between 1 January 2010 and 8 October 2017. Only studies with the following metrics were included: cost per quality-adjusted life-year or disability-adjusted life-year or life-year (QALY/DALY/LY). Key study features were abstracted and a summary league table produced which classified the studies in terms of cost-effectiveness.

RESULTS

A total of 21 cost-effectiveness studies which met the inclusion criteria were identified. There were some large methodological differences between the studies, particularly in the time horizon (1 year to lifetime) but also discount rates (range 0 to 10%). Nevertheless, we were able to group the incremental cost-effectiveness ratios (ICERs) into general categories of being reported as cost-saving (19%), cost-effective (71%), and not cost-effective (10%). The median ICER (adjusted to 2017 NZ$) was ~ $5000 per QALY/DALY/LY (~US$3500). However, for some interventions, there is high uncertainty around the intervention effectiveness and declining adherence over time.

CONCLUSIONS

It seemed possible to produce a reasonably coherent league table for the ICER values from different studies (within broad groupings) in this high-income country. Most interventions were cost-effective and a fifth were cost-saving. Nevertheless, study methodologies did vary widely and researchers need to pay more attention to using standardised methods that allow their results to be included in future league tables.

Implementation of a 'Joint Clinic' to resolve unmet need for orthopaedic services in patients with hip and knee osteoarthritis: a program evaluation

Background

Osteoarthritis is the most common form of arthritis, principally affecting the older population. Highly prevalent, disabling diseases such as osteoarthritis strain the capacity of health systems, and can result in unmet need for services. The Joint Clinic was initiated to provide secondary care consultations and access to outpatient services for people with advanced hip or knee osteoarthritis, who were referred by their general practitioner for orthopaedic consultation but not offered an orthopaedic specialist appointment.

Methods

This longitudinal programme evaluation comprised four components: a proof-of-concept evaluation; an implementation evaluation; a process evaluation; and an outcomes evaluation. Interviews and surveys of general practitioners, staff, and patients were conducted pre- and post-implementation. Interviews were transcribed, and thematic analysis was completed. In addition, Joint Clinic patient visits and outcomes were reviewed.

Results

One hundred and eleven primary care physicians (GPs) and 66 patients were surveyed, and 28 semi-structured interviews of hospital staff and GPs were conducted. Proof of concept was satisfied. Interim and final implementation evaluations indicated adherence to the concept model, high levels of acceptance of and confidence in the programme and its staff, and timely completion within budget. Process evaluation revealed positive impacts of the programme and positive stakeholder perceptions, with some weaknesses in communication to the outer context of primary care. The Joint Clinic saw a total of 637 patient visits during 2 years of operation. Unmet need was reduced by 90%. Patient and referring physician satisfaction was high. Hospital management confirmed that the programme will continue.

Conclusions

This evaluation indicates that the Joint Clinic concept model is fit for purpose, functioned well within the organisation, and achieved its primary objective of reducing unmet need of secondary care consultation for those suffering advanced hip or knee osteoarthritis.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2702-1) contains supplementary material, which is available to authorized users.

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.

Cost-utility analysis of interventions to improve effectiveness of exercise therapy for adults with knee osteoarthritis: the BEEP trial

Objectives

Evidence regarding the cost-effectiveness of enhancing physical therapy exercise programmes in order to improve outcomes for patients with knee OA remains unclear. This study investigates the cost-effectiveness of two enhanced physical therapy interventions compared with usual physical therapy care (UC) for adults with knee OA.

Methods

A trial-based cost–utility analysis of individually tailored exercise (ITE) or targeted exercise adherence (TEA) compared with UC was undertaken over a period of 18 months. Patient-level costs were obtained, and effectiveness was measured in terms of quality-adjusted life years (QALYs), allowing the calculation of cost per QALY gained from a base-case UK health-care perspective.

Results

The UC group was associated with lower National Health Service (NHS) costs [ITE-UC: £273.30, 95% CI: £−62.10 to £562.60; TEA-UC: £141.80, 95% CI: £−135.60 to £408.10)] and slightly higher QALY gains (ITE-UC: −0.015, 95% CI: −0.057 to 0.026; TEA-UC: −0.003, 95% CI: −0.045 to 0.038). In the base case, UC was the most likely cost-effective option (probability <40% of ITE or TEA cost-effective at £20 000/QALY). Differences in total costs were attributable to intervention costs, number of visits to NHS consultants and knee surgery, which were higher in both ITE and TEA groups.

Conclusion

This is the first economic evaluation comparing usual physical therapy care vs enhanced exercise interventions for knee OA that involves greater exercise individualization, supervision and progression or that focuses on exercise and physical activity adherence over the longer term. Our findings show that UC is likely to be the most cost-effective option.

Trial registration

Current Controlled Trials ISRCTN 93634563.

Trial protocol

Full details of the trial protocol can be found in the Supplementary Appendix, available with the full text of this article at http://www.biomedcentral.com/1471-2474/15/254 doi: 10.1186/1471-2474-15-254

Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).

DATA SOURCES

Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.

STUDY SELECTION

Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.

DATA EXTRACTION

Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.

RESULTS

Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).

CONCLUSIONS

This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

REVIEW REGISTRATION

PROSPERO 2016:CRD42016032799.

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.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

Cost-Effectiveness of Physical Therapy Only and of Usual Care for Various Health Conditions: Systematic Review

BACKGROUND

Given continually rising health care costs, interventions of health care providers should be cost-effective.

PURPOSE

This review aimed to summarize current cost-effectiveness of physical therapy. Specific aims were: (1) to analyze cost-effectiveness of physical therapy only compared with usual care only, (2) to analyze cost-effectiveness of physical therapy added to usual care compared with usual care only, and (3) to specify in which health conditions physical therapy only or physical therapy added to usual care was cost-effective.

DATA SOURCES

Topic-related systematic reviews were searched in MEDLINE, CINAHL, PEDro, and Cochrane Library and manually.

STUDY SELECTION

Studies published between 1998 and 2014 that investigated the cost-effectiveness of interventions carried out by physical therapists were reviewed. The methodological quality was assessed with the Cochrane risk of bias assessment for intervention studies and with the Quality of Health Economic Analyses Scale.

DATA EXTRACTION

Effectiveness and cost data for calculating incremental cost-effectiveness ratios (ICERs) and the original authors' conclusions were extracted.

DATA SYNTHESIS

The 18 included studies presented low risk of bias and contained 8 comparisons of physical therapy only with usual care only and 11 comparisons of physical therapy added to usual care with usual care only. Based on ICERs, physical therapy only or added to usual care was cost-effective in 9 out of the 19 comparisons and in 10 comparisons according to the original authors' conclusions.

CONCLUSION

Physical therapy only or added to usual care implies improved health in almost all studies. The cost-effectiveness of such interventions was demonstrated in half of the studies. This result might have been influenced by the fact that different definitions of the notion of "cost-effectiveness" exist.

Effectiveness and efficiency of an 11-week exercise intervention for patients with hip or knee osteoarthritis: a protocol for a controlled study in the context of health services research

BACKGROUND

Osteoarthritis is the most common reason for pain in older adults, and the individual and economic burden of this disease is immense. The chronic character of osteoarthritis requires a long-term therapeutic treatment. In this regard life-style interventions such as physical exercises that can be carried out by the patient himself are recommended as first line treatment. There is evidence for the short-term benefit of exercise therapy in terms of pain reduction and physical functioning. Nonetheless research agendas highlight the need for multifaceted interventions that incorporate exercise strategies into patient care. Studies should be conducted with appropriate sample sizes and should allow statements on long-term effects as well as cost-utility and safety. These open questions are under the scope of this study.

METHODS/DESIGN

This is a controlled study in the context of health services research. The study population consists of n = 1400 subjects with hip or knee osteoarthritis. The intervention group will be recruited from participants of a country-wide health insurance offer for people with hip or knee osteoarthritis. Potential participants for the control group (ratio 10:1 (control vs. intervention) will be filtered out from the insurance data base according to pre-defined matching criteria and asked by letter for their participation. The final statistical twins from the responders (1:1) will be determined via propensity score matching. The progressive training intervention comprises 8 supervised group sessions, supplemented by home exercises (2/week over 11 weeks). Exercises include mobilization, strengthening and training of postural control. Primary outcomes are pain and function measured with the WOMAC Index immediately after the intervention period. Among other things, health related quality of life, self-efficacy, cost utility and safety will be evaluated as secondary outcomes. Participants will be followed up 6, 12 and 24 month after baseline.

DISCUSSION

Results of this trial will document the effects of clinical as well as economic outcomes in a regular health care setting on the basis of a large sample size. As such, results of this trial might have great impact on future implementations of group- and home-based exercises in hip or knee osteoarthritis.

TRAIL REGISTRATION

German Clinical Trial Register DRKS00009251 . Registered 10 September 2015.

Cost-utility of exercise therapy in patients with hip osteoarthritis in primary care

OBJECTIVE

To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care.

METHOD

This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data.

RESULTS

A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group (€ 1233) compared to the control group (€ 1331). The average annual societal costs per patient were lower in the intervention group (€ 2634 vs € 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02).

CONCLUSION

Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects.

TRIAL REGISTRATION NUMBER

NTR1462.

Economic evaluation alongside factorial trials: a systematic review of empirical studies

Although economic evaluations have been performed alongside factorial trials, there seems to be limited guidance/consensus on appropriate methods of analysis. Following Centre for Review and Dissemination guidance, a systematic review of published literature for all years was performed to explore how economic evaluation alongside factorial trials have been conducted and only full economic evaluations conducted alongside factorial trials were included. A total of 16 relevant studies were identified, and an assessment of these indicated that two methods: within-the-table and at-the-margins approaches were used for the analysis. With the exception of one study, all others did not consider interactions in costs and outcomes or give a detailed explanation of why a particular approach was adopted. The authors recommend that additional guidance is needed, and further research is required to evaluate the impact of alternative methods on policy recommendations and establish good practice methods for the economic analysis of factorial trials.

Effects of proprioceptive circuit exercise on knee joint pain and muscle function in patients with knee osteoarthritis

[Purpose] This study applied proprioceptive circuit exercise to patients with degenerative knee osteoarthritis and examined its effects on knee joint muscle function and the level of pain. [Subjects] In this study, 14 patients with knee osteoarthritis in two groups, a proprioceptive circuit exercise group (n = 7) and control group (n = 7), were examined. [Methods] IsoMed 2000 (D&R Ferstl GmbH, Hemau, Germany) was used to assess knee joint muscle function, and a Visual Analog Scale was used to measure pain level. [Results] In the proprioceptive circuit exercise group, knee joint muscle function and pain levels improved significantly, whereas in the control group, no significant improvement was observed. [Conclusion] A proprioceptive circuit exercise may be an effective way to strengthen knee joint muscle function and reduce pain in patients with knee osteoarthritis.

Orthopaedic manual physical therapy for shoulder pain and impaired movement in a patient with glenohumeral joint osteoarthritis: a case report

STUDY DESIGN

Case report.

BACKGROUND

Comprehensive treatment strategies are needed for individuals with glenohumeral joint osteoarthritis (OA), especially when they are young and active. Prior dislocation, with or without subsequent shoulder stabilization surgery, complicates the clinical presentation and increases the risk of OA progression. The purpose of this case report was to describe an orthopaedic manual physical therapy approach used in a patient with glenohumeral joint OA who presented with shoulder pain and impaired movement. CASE DESCRIPTION A 38-year-old male military officer presented with left-shoulder pain of 2 months in duration that was unrelieved with a subacromial injection. He reported a history of anterior-inferior dislocation with subsequent stabilization surgery 15 years prior and arthroscopic subacromial decompression 2 years prior. Physical examination demonstrated painful limitations in shoulder elevation and internal/external rotation movements, stiffness with testing using accessory glides, and rotator cuff and scapular musculature weakness associated with pain.

OUTCOMES

Treatment consisted of 5 sessions provided over 4 weeks. The plan of care included manual physical therapy, exercises, and progressive functional activities specifically tailored to the patient's clinical presentation. Shoulder Pain and Disability Index scores decreased from 43% to 17%, and the Patient-Specific Functional Scale average score improved from 3.0 to 7.3 out of 10. After 4 additional weeks of a home exercise program, the Shoulder Pain and Disability Index score was 4% and Patient-Specific Functional Scale average score was 9.0. Improvements in self-reported function were maintained at 6 months. Four "booster" treatment sessions were administered at 9 months, contributing to sustained outcomes through 1 year.

DISCUSSION

In a young, active patient with glenohumeral joint OA, clinically meaningful short-term improvements in self-reported function and pain, maintained at 1 year, were observed with manual physical therapy and exercise.

LEVEL OF EVIDENCE

Therapy, level 4.

Defining the principles of musculoskeletal disability and rehabilitation

Disability is strongly associated with musculoskeletal conditions such as arthritis, low back pain and other soft tissue and joint disorders. The burden of these conditions may become exponentially high in the absence of rehabilitation. To understand disability, the ICF (International Classification of Functioning, Disability and Health) provides the framework to disentangle the different domains that comprise disability. Disability in ICF term is defined as an impairment of the body functions and body structure and limited activity and restricted participation and can be influenced by environmental and personal factors. The ICF can provide the domains of disability pertinent to individuals with musculoskeletal conditions by using ICF Core Sets. Musculoskeletal-related disability is amenable to rehabilitation and there is evidence to suggest the effectiveness of multidisciplinary forms of rehabilitation programs. Community-based programs as an extension of rehabilitation also have evidence to improve clinical and quality of life outcomes in people with musculoskeletal conditions.

Subacromial impingement syndrome and pain: protocol for a randomised controlled trial of exercise and corticosteroid injection (the SUPPORT trial)

BACKGROUND

Subacromial impingement syndrome is the most frequent cause of shoulder problems which themselves affect 1 in 3 adults. Management commonly includes exercise and corticosteroid injection. However, the few existing trials of exercise or corticosteroid injection for subacromial impingement syndrome are mostly small, of poor quality, and focus only on short-term results. Exercise packages tend to be standardised rather than individualised and progressed. There has been much recent interest in improving outcome from corticosteroid injections by using musculoskeletal ultrasound to guide injections. However, there are no high-quality trials comparing ultrasound-guided and blind corticosteroid injection in subacromial impingement syndrome. This trial will investigate how to optimise the outcome of subacromial impingement syndrome from exercise (standardised advice and information leaflet versus physiotherapist-led exercise) and from subacromial corticosteroid injection (blind versus ultrasound-guided), and provide long-term follow-up data on clinical and cost-effectiveness.

METHODS/DESIGN

The study design is a 2x2 factorial randomised controlled trial. 252 adults with subacromial impingement syndrome will be recruited from two musculoskeletal Clinical Assessment and Treatment Services at the primary-secondary care interface in Staffordshire, UK. Participants will be randomised on a 1:1:1:1 basis to one of four treatment groups: (1) ultrasound-guided subacromial corticosteroid injection and a physiotherapist-led exercise programme, (2) ultrasound-guided subacromial corticosteroid injection and an advice and exercise leaflet, (3) blind subacromial corticosteroid injection and a physiotherapist-led exercise programme, or (4) blind subacromial corticosteroid injection and an advice and exercise leaflet. The primary intention-to-treat analysis will be the mean differences in Shoulder Pain and Disability Index (SPADI) scores at 6 weeks for the comparison between injection interventions and at 6 months for the comparison between exercise interventions. Although independence of treatment effects is assumed, the magnitude of any interaction effect will be examined (but is not intended for the main analyses). Secondary outcomes will include comparison of long-term outcomes (12 months) and cost-effectiveness. A secondary per protocol analysis will also be performed.

DISCUSSION

This protocol paper presents detail of the rationale, design, methods and operational aspects of the SUPPORT trial.

TRIAL REGISTRATION

Current controlled trials ISRCTN42399123.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness

OBJECTIVE

To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee.

DESIGN

In this 2 × 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation.

RESULTS

Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group.

CONCLUSIONS

Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12608000130369.