Projecting the direct cost burden of osteoarthritis in Canada using a microsimulation model

High health care use prior to elective surgery for osteoarthritis is associated with poor postoperative outcomes: A Canadian population-based cohort study

BACKGROUND

The characterization and influence of preoperative health care use on quality-of-care indicators (e.g., readmissions) has received limited attention in populations with musculoskeletal disorders. The purpose of this study was to characterize preoperative health care use and examine its effect on quality-of-care indicators among patients undergoing elective surgery for osteoarthritis.

METHODS

Data on health care use for 124,750 patients with elective surgery for osteoarthritis in Ontario, Canada, from April 1, 2015 to March 31, 2018 were linked across health administrative databases. Using total health care use one-year previous to surgery, patients were grouped from low to very high users. We used Poisson regression models to estimate rate ratios, while examining the relationship between preoperative health care use and quality-of-care indicators (e.g., extended length of stay, complications, and 90-day hospital readmissions). We controlled for covariates (age, sex, neighborhood income, rural/urban residence, comorbidities, and surgical anatomical site).

RESULTS

We found a statistically significant trend of increasing worse outcomes by health care use gradients that persisted after controlling for patient demographics and comorbidities. Findings were consistent across surgical anatomical sites. Moreover, very high users have relatively large numbers of visits to non-musculoskeletal specialists.

CONCLUSIONS

Our findings highlight that information on patients' preoperative health care use, together with other risk factors (such as comorbidities), could help decision-making when benchmarking or reimbursing hospitals caring for complex patients undergoing surgery for osteoarthritis.

Three-dimensional ultrasound to investigate synovitis in first carpometacarpal osteoarthritis: A feasibility study

BACKGROUND

Synovitis is one of the defining characteristics of osteoarthritis (OA) in the carpometacarpal (CMC1) joint of the thumb. Quantitative characterization of synovial volume is important for furthering our understanding of CMC1 OA disease progression, treatment response, and monitoring strategies. In previous studies, three-dimensional ultrasound (3-D US) has demonstrated the feasibility of being a point-of-care system for monitoring knee OA. However, 3-D US has not been tested on the smaller joints of the hand, which presents unique physiological and imaging challenges.

PURPOSE

To develop and validate a novel application of 3-D US to monitor soft-tissue characteristics of OA in a CMC1 OA patient population compared to the current gold standard, magnetic resonance imaging (MRI).

METHODS

A motorized submerged transducer moving assembly was designed for this device specifically for imaging the joints of the hands and wrist. The device used a linear 3-D scanning approach, where a 14L5 2-D transducer was translated over the region of interest. Two imaging phantoms were used to test the linear and volumetric measurement accuracy of the 3-D US device. To evaluate the accuracy of the reconstructed 3-D US geometry, a multilayer monofilament string-grid phantom (10 mm square grid) was scanned. To validate the volumetric measurement capabilities of the system, a simulated synovial tissue phantom with an embedded synovial effusion was fabricated and imaged. Ten CMC1 OA patients were imaged by our 3-D US and a 3.0 T MRI system to compare synovial volumes. The synovial volumes were manually segmented by two raters on the 2D slices of the 3D US reconstruction and MR images, to assess the accuracy and precision of the device for determining synovial tissue volumes. The Standard Error of Measurement and Minimal Detectable Change was used to assess the precision and sensitivity of the volume measurements. Paired sample t-tests were used to assess statistical significance. Additionally, rater reliability was assessed using Intra-Class Correlation (ICC) coefficients.

RESULTS

The largest percent difference observed between the known physical volume of synovial extrusion in the phantom and the volume measured by our 3D US was 1.1% (p-value = 0.03). The mean volume difference between the 3-D US and the gold standard MRI was 1.78% (p-value = 0.48). The 3-D US synovial tissue volume measurements had a Standard Error Measurement (SEm ) of 11.21 mm3 and a Minimal Detectible Change (MDC) of 31.06 mm3 , while the MRI synovial tissue volume measurements had an SEM of 16.82 mm3 and an MDC of 46.63 mm3 . Excellent inter- and intra-rater reliability (ICCs = 0.94-0.99) observed across all imaging modalities and raters.

CONCLUSION

Our results indicate the feasibility of applying 3-D US technology to provide accurate and precise CMC1 synovial tissue volume measurements, similar to MRI volume measurements. Lower MDC and SEm values for 3-D US volume measurements indicate that it is a precise measurement tool to assess synovial volume and that it is sensitive to variation between volume segmentations. The application of this imaging technique to monitor OA pathogenesis and treatment response over time at the patient's bedside should be thoroughly investigated in future studies.

Emerging roles of RNA binding proteins in intervertebral disc degeneration and osteoarthritis

The etiology of intervertebral disc degeneration (IDD) and osteoarthritis (OA) is complex and multifactorial. Both predisposing genes and environmental factors are involved in the pathogenesis of IDD and OA. Moreover, epigenetic modifications affect the development of IDD and OA. Dysregulated phenotypes of nucleus pulposus (NP) cells and OA chondrocytes, including apoptosis, extracellular matrix disruption, inflammation, and angiogenesis, are involved at all developmental stages of IDD and OA. RNA binding proteins (RBPs) have recently been recognized as essential post-transcriptional regulators of gene expression. RBPs are implicated in many cellular processes, such as proliferation, differentiation, and apoptosis. Recently, several RBPs have been reported to be associated with the pathogenesis of IDD and OA. This review briefly summarizes the current knowledge on the RNA-regulatory networks controlled by RBPs and their potential roles in the pathogenesis of IDD and OA. These initial findings support the idea that specific modulation of RBPs represents a promising approach for managing IDD and OA.

Tricompartment offloader knee brace reduces sagittal plane knee moments, quadriceps muscle activity, and pain during chair rise and lower in individuals with knee osteoarthritis

The Levitation tricompartment offloader (TCO) knee brace provides an assistive knee extension moment with the goal of unloading all three compartments of the knee and reducing pain for individuals with multicompartment knee osteoarthritis (OA). This study aimed to determine the effect of the TCO brace on sagittal plane knee moments, quadriceps muscle activity, and pain in individuals with multicompartment knee OA. Lower limb kinematics, kinetics, and electromyography data were collected during a chair rise and lower to determine differences between bracing conditions. TCO brace use significantly decreased the peak net knee external flexion moment in high power mode, providing extension assistance during chair rise [p<0.001; mean difference (MD) (98.75% CI) -0.8 (-1.0, -0.6)%BWxH] and bodyweight support during chair lower [p<0.001; -1.1 (-1.6, -0.7)%BWxH]. Quadriceps activation intensity was significantly reduced with brace use by up to 67% for the vastus medialis [Z = -2.55, p = 0.008] and up to 39% for the vastus lateralis [Z = -2.67, p = 0.004]. Participants reported significantly reduced knee pain with the TCO brace worn in high power mode compared to the no brace condition [p = 0.014; MD (97.5% CI) -18.8 (-32.22, -2.34) mm]. These results support the intended mechanism of joint unloading via extension assistance with the TCO brace. The observed biomechanical changes were accompanied by immediate reductions in user reported pain levels, and support the use of the TCO for conservative management to reduce knee pain in patients with multicompartment knee OA.

A novel Atlantic salmon (Salmo salar) bone collagen peptide delays osteoarthritis development by inhibiting cartilage matrix degradation and anti-inflammatory

Nowadays, the biological activity of collagen peptides has been revealed, but the effect of Atlantic salmon (Salmo salar) bone-derived collagen peptide (CPs) on osteoarthritis remains unclear. In this study, CPs was identified as a small molecular weight peptide rich in Gly-X-Y structure. Meanwhile, interleukin-1β (IL-1β)-induced hypertrophic chondrocytes and partial medial meniscectomy (pMMx) surgery model in rats were performed. In IL-1β stimulated chondrocytes, CPs significantly increased the type-II collagen content, reduced the type-X collagen abundance and chondrocytes apoptosis. Meanwhile, CPs reversed the increased expression of matrix metalloproteinase, metalloproteinase with thrombospondin motifs and RUNX family transcription factor 2 in chondrocytes induced by IL-1β. In vivo, CPs increased pain tolerance of rats and without organ toxicity at 1.6 g/kg.bw. CPs significantly decreased the levels of COMP and Helix-II in serum. Furthermore, a significant decrease of IL-1β in synovial fluid and cartilage tissue were observed by CPs intervention. From Micro-CT, CPs (0.8 g/kg.bw) significantly decreased Tb.sp and SMI value. Meanwhile, the expression of tumor necrosis factor and interleukin-6 were reduced by CPs administration both in vitro and in vivo. Together, CPs showed potential to be a novel and safe dietary supplement for helping anti-inflammatory and cartilage regeneration, ultimately hindering osteoarthritis development. However, the clear mechanism of CPs's positive effect on osteoarthritis needs to be further explored.

The impact of waiting time for orthopaedic consultation on pain levels in individuals with osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Time spent waiting for access to orthopaedic specialist health services has been suggested to result in increased pain in individuals with osteoarthritis (OA). We assessed whether time spent on an orthopaedic waiting list resulted in a detrimental effect on pain levels in patients with knee or hip OA.

METHODS

We searched Ovid MEDLINE, EMBASE and EBSCOhost databases from inception until September 2021. Eligible articles included individuals with OA on an orthopaedic waitlist and not receiving active treatment, and reported pain measures at two or more time points. Random-effects meta-analysis was used to estimate the pooled effect of waiting time on pain levels. Meta-regression was used to determine predictors of effect size.

RESULTS

Thirty-three articles were included (n = 2,490 participants, 67 ± 3 years and 62% female). The range of waiting time was 2 weeks to 2 years (20.8 ± 18.8 weeks). There was no significant change in pain over time (effect size = 0.082, 95% CI = -0.009, 0.172), nor was the length of time associated with longitudinal changes in pain over time (β = 0.004, 95% CI = -0.005, 0.012). Body mass index was a significant predictor of pain (β = -0.043, 95% CI = -0.079, 0.006), whereas age and sex were not.

CONCLUSIONS

Pain remained stable for up to 1 year in patients with OA on an orthopaedic waitlist. Future research is required to understand whether pain increases in patients waiting longer than 1 year.

Balneotherapy and Health-related Quality of Life in Adults with Knee Osteoarthritis: a Prospective Observational Study Into a Real Clinical Practice Condition

Aim: To analyze the influence of balneotherapy applied in conditions of real clinical practice in Fitero’s Thermal Station (Spain) on HRQoL in adults with KOA. Materials and Methods: This was a prospective observational study conducted under conditions of real clinical practice with a 9-month follow-up. The individuals were beneficiaries of the Spanish social thermalism programme. A total of 10 sessions were prescribed, individually, considering the clinical situation and preferences of each participant. In all cases, 10 bath sessions were administered, along with other techniques. The clinical assessments were conducted before initiating the balneotherapy and 1, 3, 6 and 9 months after. The main variable was HRQoL (Euroqol 5D-5L; WOMAC). The statistical analysis was performed by intention to treat. Results: The study included 71 users. At 6 months, improvements were found in the following dimensions of the WOMAC questionnaire: pain (24.47%), stiffness (30.75%) and functional capacity (26.66%) (p<0.05). Pain and anxiety/depression showed statistically significant differences in the EQ 5D-5L throughout the study. Conclusions: HRQoL in KOA would improve with the Balneotherapy, prevailing the effects for up to 6 months. The absence of adverse effects and the ease of completing the treatment provided by the Spanish social thermalism system make this treatment feasible.

Future demand for primary hip and knee arthroplasty in Scotland

INTRODUCTION

The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand for arthroplasty services in the future. Understanding the scale of potential change is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm.

METHODS

We set out to provide projections of future primary knee and hip arthroplasty out to 2038 utilising historical trend data (2008-2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age group predictions were also performed.

RESULTS

The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 28% increase. The predicted rise of primary knee arthroplasty for all ages is from 164/100k/year in 2018 to 220/100k/year in 2038, a 34% increase. Based on a static 3-day length of stay average this would see 4280 and 7392 additional patient bed days required for primary hip and knee arthroplasty patients respectively per annum. The associated additional cost is anticipated to be approximately £26 million.

CONCLUSIONS

Anticipated future demand for arthroplasty will require significant additional resource and funding to prevent deterioration in quality of care and an increase in patient wait times, additional to that already required to clear the COVID-19 backlog. Understanding presented projections of changes to arthroplasty demand is key to future service delivery.

Exercise-induced modulation of myokine irisin in bone and cartilage tissue—Positive effects on osteoarthritis: A narrative review

Osteoarthritis is a chronic degenerative musculoskeletal disease characterized by pathological changes in joint structures along with the incidence of which increases with age. Exercise is recommended for all clinical treatment guidelines of osteoarthritis, but the exact molecular mechanisms are still unknown. Irisin is a newly discovered myokine released mainly by skeletal muscle in recent years—a biologically active protein capable of being released into the bloodstream as an endocrine factor, the synthesis and secretion of which is specifically induced by exercise-induced muscle contraction. Although the discovery of irisin is relatively recent, its role in affecting bone density and cartilage homeostasis has been reported. Here, we review the production and structural characteristics of irisin and discuss the effects of the different types of exercise involved in the current study on irisin and the role of irisin in anti-aging. In addition, the role of irisin in the regulation of bone mineral density, bone metabolism, and its role in chondrocyte homeostasis and metabolism is reviewed. A series of studies on irisin have provided new insights into the mechanisms of exercise training in improving bone density, resisting cartilage degeneration, and maintaining the overall environmental homeostasis of the joint. These studies further contribute to the understanding of the role of exercise in the fight against osteoarthritis and will provide an important reference and aid in the development of the field of osteoarthritis prevention and treatment.

Nutrition risk, physical activity and fibre intake are associated with body composition in OA: analysis of the Canadian Longitudinal Study on Aging

Objective

Sarcopenic obesity is a key feature in osteoarthritis (OA). While ideal OA treatment involves physical activity and diet, how diet influences OA pathophysiology is unclear. We explored the associations between diet, nutrition risk and physical activity with body composition in older adults with OA.

Methods

Baseline data from the Canadian Longitudinal Study on Aging data set were analysed. Participants with hip, knee, hand or multiple forms of OA were included in this cross-sectional analysis. Body composition measures (lean, fat and total masses (kg) and body fat percentage) were separate dependent variables. Regression analyses were conducted to explore associations between body composition with dietary intake (high calorie snack, fibre), nutrition risk (SCREEN II) and physical activity (Physical Activity Scale for the Elderly).

Results

1596 participants were 66.5 (9.0) years old with a body mass index of 28.2 (5.3) kg/m². Higher fibre cereal intake was associated with higher lean mass (unstandardised beta coefficient 0.5 (0.1, 0.9), p=0.02) and lower body fat percentage (-0.3 (-0.6, 0.0), p=0.046). Lower nutrition risk was associated with higher lean mass (0.1 (0.0, 0.1), p=0.03), lower fat mass (-0.05 (-0.1, 0.0), p=0.009) and lower body fat percentage (-0.1 (-0.1, 0.0), p<0.001). Higher physical activity was associated with higher lean mass (0.01 (0.01, 0.02), p<0.001), lower fat mass (-0.01 (0.0, 0.0), p=0.005) and lower body fat percentage (-0.01 (0.0, 0.0), p<0.001).

Conclusion

Greater physical activity and lower nutrition risk were associated with better body composition. While fibre intake was also associated body composition, the CIs were wide suggesting weak associations.

Assessment of the quality of life in patients with chronic degenerative osteoarticular diseases (gonarthrosis, coxarthrosis)

Quality of life is a multidimensional concept that refers to the individual perception of one's own life and that includes aspects of individual health (cultural, social or psychological). Arthrosis is a progressive condition that involves damage to cartilage, damage to the subchondral bone and changes in the synovial and periarticular structures. Material and method. The study aims to provide information on the impact of degenerative osteoarticular diseases (gonarthrosis and coxarthrosis) while assessing the health of the population in Suceava county (one of the most affected counties in Romania due to the COVID-19 pandemic) by studying a sample of the study population. Based on the results obtained, an analysis can be made and then general ideas about the entire population. Results and discussions. The application of the SF-36 questionnaire helps to identify ways to improve the quality of life of patients diagnosed with degenerative osteoarticular disorders, gonarthrosis and coxarthrosis, and to prevent the negative aspects. In the health field, quality of life is an indicator used to assess the physical, mental and social effects of illness and the applied medical treatments, as well as to analyze the needs of a patient during the illness. Conclusions. The suffering caused by this type of disease has an impact on the quality of life of patients, both physically and emotionally. A special role in assessing the quality of life in these patients is their emotional condition and the acceptance of their functional status, trying to improve it. The quality of life of patients with chronic degenerative osteoarticular diseases is a public health issue, by the duration of the disease, by family, social, economic and medical implications. Keywords: quality of life, degenerative osteoarticular diseases, general health conditions

Characteristics of Persons Seeking Care for Moderate to Severe Pain Due to Chronic Low Back Pain and Osteoarthritis: A Cross-Sectional Study

Purpose

To assess the associations between pain severity or physical (pQoL) and mental (mQoL) health-related quality of life and disability status or health-care utilization among persons living with moderate/severe pain due to chronic low back pain (CLBP) or osteoarthritis (OA), who received treatments in Quebec’s tertiary care pain centers.

Materials and Methods

This retrospective study was carried out using the Quebec Pain Registry (Canada) from 2008 to 2014 and contains data on persons referred to tertiary pain management clinics. Participants were selected if they were diagnosed with CLBP (N = 2663) or OA (N = 139) of more than 3 months duration and of pain intensity ≥5 on the Numeric Rating Scale (0–10) and completed baseline questionnaires.

Results

Less than 5% of persons were hospitalized in the 6 months before their first visit at the pain clinic, and 11.9% and 18.9% of persons with OA and CLBP, respectively, had a pain-related emergency room (ER) visit. Less than 1/5 and more than 1/4 of persons with OA and CLBP were receiving disability benefits, respectively. Persons with CLBP who had visited the ER, those on disability and those receiving disability benefits, reported higher levels of pain severity, interference, and lower levels of mQoL (and pQoL for those on disability or receiving benefits) compared to those who did not consult the ER, those not on disability or not receiving disability benefits, respectively (all p < 0.05). For OA, disability status was the only variable associated with pain interference and QoL (all p < 0.05).

Conclusion

Pain severity, pain interference and mQoL were associated with health-care utilization and disability status in persons with CLBP. These results were globally not found among persons with OA, which might be due to smaller sample size or unique characteristics of this population.

The burden of the most common rheumatic disease in Colombia

BACKGROUND

Estimating the burden of rheumatic diseases (RDs) requires proper evaluation of its lethal and nonlethal consequences. In Colombia, it is possible to find local data and Global Burden of Disease (GBD) reports that collect information from varied contexts and apply complex statistical models, but no on-site estimations are available.

METHODS

This was a descriptive study on the burden of RD based on occurrence and mortality data in the general population during 2015, including information and prevalence estimations from the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) study. Disability-adjusted life years (DALYs) were estimated by combining measures of years of life lost (YLL) and years lived with disability (YLDs). For disability weight estimations among cases, different COPCORD responses were mapped using flowcharts to show the severity distribution according to GBD. All model parameters and results were validated through an expert consensus panel.

RESULTS

Low back pain (LBP) was the RD with the greatest burden of disease, costing 606.05 (95% CI 502.76-716.58) DALYs per 100,000 inhabitants, followed by osteoarthritis (292.11; 95% CI 205.76-386.85) and rheumatoid arthritis (192.46, 95% CI 109.7-239.69).

CONCLUSIONS

The burden of RD is as high in Colombia as in other countries of the region. The results offer an interesting tool for optimizing healthcare system design as well as for planning the distribution of human and economic resources to achieve early diagnosis and adequate care of these diseases.

A comparison of three strategies to reduce the burden of osteoarthritis: A population-based microsimulation study

Objectives

The purpose of this study was to compare three strategies for reducing population health burden of osteoarthritis (OA): improved pharmacological treatment of OA-related pain, improved access to joint replacement surgery, and prevention of OA by reducing obesity and overweight.

Methods

We applied a validated computer microsimulation model of OA in Canada. The model simulated a Canadian-representative open population aged 20 years and older. Variables in the model included demographics, body mass index, OA diagnosis, OA treatment, mortality, and health-related quality of life. Model parameters were derived from analyses of national surveys, population-based administrative data, a hospital-based cohort study, and the literature. We compared 8 what-if intervention scenarios in terms of disability-adjusted life years (DALYs) relative to base-case, over a wide range of time horizons.

Results

Reductions in DALYs depended on the type of intervention, magnitude of the intervention, and the time horizon. Medical interventions (a targeted increase in the use of painkillers) tended to produce effects quickly and were, therefore, most effective over a short time horizon (a decade). Surgical interventions (increased access to joint replacement) were most effective over a medium time horizon (two decades or longer). Preventive interventions required a substantial change in BMI to generate a significant impact, but produced more reduction in DALYs than treatment strategies over a very long time horizon (several decades).

Conclusions

In this population-based modeling study we assessed the potential impact of three different burden reduction strategies in OA. Data generated by our model may help inform the implementation of strategies to reduce the burden of OA in Canada and elsewhere.

Intra-articular corticosteroid injection and genicular nerve block under ultrasound guidance in pain control of knee osteoarthritis

Background

Chronic knee osteoarthritis (OA) is a frequent disease among the elderly. Intra-articular corticosteroid injection (IACSI) was commonly adopted to alleviate knee OA-related pains. Recently, Genicular nerve block (GNB) has emerged as a new alternative technique. The current study aimed to investigate the efficacy of those two approaches when guided with ultrasound and to determine which one offers better results. This study included 40 patients with painful chronic knee OA (Nine males and 31 females, age ranged from 44 to 65 years) and were randomly assigned to two equal groups. Groups 1 was managed with ultrasound-guided IACSI and group 2 with ultrasound-guided GNB using a mixture of lidocaine and Triamcinolone Acetonide. The baseline mean visual analogue scale (VAS) and Oxford knee score (OKS) for the group 1 were 87.10 and 51.3, while for group 2 were 87.75 and 53.25 respectively. Follow up values were obtained at 2, 4 and 8 weeks using VAS and OKS.

Results

The VAS score and OKS score were significantly lower in the GNB group and IACSI group at 2, and 4 weeks after the procedure (p < 0.001 for all), then returned near baseline values at 8 weeks. When the two groups were compared according to changes in VAS and OKS from baseline at 2, 4, and 8 weeks, GNB group showed significant alleviation of pain (mean reduction of 58.5, 53.3, and 9.25 points at 2, 4, and 8 weeks versus 44.9, 39.4, and 5.6 points at the IACSI groups, p < 0.001 at 2 and 4 weeks, p < 0.006 at 8 weeks). Similarly at the OKS, the GNB group showed significantly better results (33.50, 28.60, and 8.5 at GNB and 26.45, 20.10, 5.25 at IACSI. p < 0.001 at all periods).

Conclusions

Both GNB and IACSI are effective methods to relieve chronic knee osteoarthritis-related pains. When compared to each other, GNB showed more significant pain relief and functional improvement than IACSI.

Automatic Assessment Of Hip Effusion From MRI

Joint effusion is a hallmark of osteoarthritis (OA) associated with stiffness, and may relate to pain, disability, and long-term outcomes. However, it is difficult to quantify accurately. We propose a new Deep Learning (DL) approach for automatic effusion assessment from Magnetic Resonance Imaging (MRI) using volumetric quantification measures (VQM). We developed a new multiplane ensemble convolutional neural network (CNN) approach for 1) localizing bony anatomy and 2) detecting effusion regions. CNNs were trained on femoral head and effusion regions manually segmented from 3856 images (63 patients). Upon validation on a non-overlapping set of 2040 images (34 patients) DL showed high agreement with ground-truth in terms of Dice score (0.85), sensitivity (0.86) and precision (0.83). Agreement of VQM per-patient was high for DL vs experts in term of Intraclass correlation coefficient (ICC)= 0.88[0.80,0.93]. We expect this technique to reduce inter-observer variability in effusion assessment, reducing expert time and potentially improving the quality of OA care.Clinical Relevance- Our technique for automatic assessment of hip MRI can be used for volumetric measurement of effusion. We expect this to reduce variability in OA biomarker assessment and provide more reliable indicators for disease progression.

Osteoarthritis and risk of hospitalization for ambulatory care-sensitive conditions: a general population-based cohort study

OBJECTIVE

To determine the association between OA and risk of hospitalization for ambulatory care-sensitive conditions (HACSCs).

METHODS

We included all individuals aged 40-85 years who resided in Skåne, Sweden on 31 December 2005 with at least one healthcare consultation during 1998-2005 (n = 515 256). We identified those with a main diagnosis of OA between 1 January 1998 and 31 December 2016. People were followed from 1 January 2006 until an HACSC, death, relocation outside Skåne, or 31 December 2016 (whichever occurred first). OA status was treated as a time-varying covariate (those diagnosed before 1 January 2006 considered as exposed for whole study period). We assessed relative [hazard ratios (HRs) using Cox proportional hazard model] and absolute (hazard difference using additive hazard model) effects of OA on HACSCs adjusted for potential confounders.

RESULTS

Crude incidence rates of HACSCs were 239 (95% CI: 235, 242) and 151 (150, 152) per 10 000 person-years among OA and non-OA persons, respectively. The OA persons had an increased risk of HACSCs [HR (95% CI) 1.11 (1.09, 1.13)] and its subcategories of medical conditions except chronic obstructive pulmonary disease [HR (95% CI) 0.86 (0.81, 0.90)]. There were 20 (95% CI: 16, 24) more HACSCs per 10 000 person-years in OA compared with non-OA persons. While HRs for knee and hip OA were generally comparable, only knee OA was associated with increased risk of hospitalization for diabetes.

CONCLUSION

OA is associated with an increased risk of HACSCs, highlighting the urgent need to improve outpatient care for OA patients.

Knee Ablation Approaches

Genicular nerve radiofrequency ablation has quickly become one of the most promising interventions for chronic knee pain secondary to osteoarthritis, with consistent improvements in pain and function. Although there are multiple techniques using slightly variable lesion locations, cannulas, lesion types, and imaging modalities, the clinical effectiveness targeting the anterior branches of the superior medial, superolateral, and inferior medial has reproducibly demonstrated clinically and statistically significant improvements up to 24 months after the procedure with minimal adverse events. This article summarizes the current knowledge of the sensory innervation of the knee joint, the principles of radiofrequency ablation, and the current literature on clinical outcomes.

Preliminary Evaluation of a New Orthotic for Patellofemoral and Multicompartment Knee Osteoarthritis

Purpose

Traditional knee osteoarthritis (OA) braces are usually indicated for a minority of patients with knee OA, as they are only suitable for those with unicompartmental disease affecting the tibiofemoral joint. A new assistive brace design is intended for use in a wider range of knee OA patients with heterogeneous symptoms characteristic of patellofemoral, tibiofemoral, or multicompartmental knee OA. The purpose of this case series was to explore whether the use of this novel “tricompartment offloader” (TCO) brace was associated with clinically relevant improvements in pain and function.

Materials and Methods

A retrospective analysis of individuals with knee OA (n = 40) was conducted to assess pain, function, physical activity, and use of medication and other treatments before and after brace use. Validated outcome measures including the Visual Analog Scale (VAS) and Lower Extremity Functional Scale (LEFS) were used to assess pain and physical function (primary outcome measures). Exploratory measures were used to quantify physical activity levels and use of medication and other treatments (secondary outcome measures).

Results

Average total pain (VAS) scores decreased by 36.6 mm and physical function (LEFS) scores increased by 16.0 points following the use of the TCO brace. Overall, 70% of the participants indicated increased weekly physical activity and 60% reported a decrease in their use of at least one other treatment.

Conclusions

Results from this case series suggest that the TCO brace shows strong potential to fill a conservative treatment gap for patients with heterogeneous symptoms of knee OA that are characteristic of patellofemoral or multicompartment disease. Further investigation is warranted.

An individualized decision aid for physicians and patients for total knee replacement in osteoarthritis (Value-based TKR study): study protocol for a multi-center, stepped wedge, cluster randomized controlled trial

Background

Total knee replacement (TKR) is one of the most commonly performed routine procedures in the world. Prognostic studies indicate that the number of TKR will further increase constituting growing burden on healthcare systems. There is also substantial regional heterogeneity in TKR rates within and between countries. Despite the known therapeutic effects, a subset of patients undergoing TKR does not benefit from the procedure as intended. To improve the appropriateness of TKR indication, the EKIT initiative (“evidence and consensus based indication critera for total arthroplasty”) developed a clinical guideline for Germany on the indication of TKR. This guideline is the basis for a digital medical decision aid (EKIT tool) to facilitate shared decision making (SDM) in order to improve decision quality for elective surgery. The aim of this cluster randomized trial is to investigate the effectiveness of the EKIT tool on decision quality.

Methods

The Value-based TKR study is a prospective pragmatic multi-center, stepped wedge, cluster randomized controlled trial (SW-RCT). The EKIT tool provides (1) a systematic presentation of individual patient and disease-specific information (symptoms, expectations), (2) the fulfillment of the indication criteria and (3) health information about safety and effectiveness of TKR. All study sites will follow routine care as control clusters until the start of the intervention. In total, there will be 10 clusters (study sites) and 6 sequential steps over 16 month, with clusters receiving the intervention with a minimum 2 months of standard routine care. The primary outcome is patients’ decision quality measured with the Decision Quality Instrument (DQI)-Knee Osteoarthritis questionnaire. Furthermore, we will collect information on global patient satisfaction, patient reported outcome measures and the fulfilment of the individual expectations 12 months after SDM. The power calculation yielded an estimated power of 89% using robust Poisson regression under the following assumptions: 10 study sites with a total of N=1,080 patients (including a dropout rate of 11%), a 10% increase in decision quality due to the use of the EKIT tool, and a significance level of 5%.

Discussion

There is a high potential for transferring the intervention into routine practice if the evaluation is positive.

Trial registration

ClinicalTrials.gov: NCT04837053. Registered on 08/04/2021.

SNHG5 protects chondrocytes in interleukin-1β-stimulated osteoarthritis via regulating miR-181a-5p/TGFBR3 axis

Long noncoding RNAs (lncRNAs) have been considered as important modulators in the development of osteoarthritis. The present study investigates whether there is a link between lncRNA small nucleolar RNA host gene 5 (SNHG5) and osteoarthritis pathogenesis, and the underlying molecular mechanism. To establish an in vitro model of osteoarthritis, interleukin 1β (IL-1β) was used to treat chondrocytes (C20/A4 cells) for mimicking the inflammatory condition in osteoarthritis pathogenesis. SNHG5 and miR-181a-5p expression levels were then detected in cartilage tissues of osteoarthritis patients and C20/A4 cells by quantitative polymerase chain reaction (qPCR). Cell counting kit-8 and 5-ethynyl-2'-deoxyuridine assays were applied for detecting the viability of chondrocytes, and the apoptosis of chondrocytes was examined through caspase-3 activity assay and flow cytometry analysis. Western blot and qPCR were employed for determining the expression levels of TGFBR3, ADAMTS5, and MMP-13. The regulatory relationships among SNHG5, miR-181a-5p, and TGFBR3 were verified by RNA immunoprecipitation and dual-luciferase reporter assays. The expression levels of SNHG5 and TGFBR3 were markedly decreased, and miR-181a-5p expression was enhanced in osteoarthritis tissues and chondrocytes treated with IL-1β. SNHG5 knockdown inhibited the viability of chondrocytes, induced apoptosis, and promoted the expression levels of ADAMTS5 and MMP-13. Conversely, SNHG5 overexpression could counteract the effects of IL-1β, increase the viability of chondrocytes and suppress apoptosis. Mechanically, SNHG5 positively regulated TGFBR3 expression via sponging miR-181a-5p. Moreover, miR-181a-5p overexpression and TGFBR3 knockdown counteracted the effects of SNHG5 on chondrocytes. SNHG5 can probably protect chondrocytes from the inflammatory response and reduce the degradation of the extracellular matrix via modulating the miR-181a-5p/TGFBR3 axis.

Does weight loss reduce the incidence of total knee and hip replacement for osteoarthritis?-A prospective cohort study among middle-aged and older adults with overweight or obesity

Objective

This study aims to investigate the association between weight change and total knee or hip replacement (TKR or THR) for OA among middle-aged and older adults with overweight or obesity.

Method

Weight data were collected in 2006–2009 and in 2010 from the 45 and Up Study—a population-based cohort aged ≥45 years in New South Wales, Australia. Participants were included if they had a baseline body mass index (BMI) ≥ 25 kg/m² and no history of TKR or THR. Weight change was categorised into four groups: >7.5% loss; >5–7.5% loss; stable (≤5% change) and >5% gain. Hospital admission data were linked to identify TKR and THR for OA, and multivariable Cox regression was used to assess risk of TKR and THR.

Results

Of 23,916 participants, 2139 lost >7.5% weight, 1655 lost 5–7.5% weight, and 4430 gained >5% weight. Over 5.2 years, 1009 (4.2%) underwent TKR and 483 (2.0%) THR. Compared to weight-stable, weight loss of >7.5% was associated with reduced risk of TKR after adjusting for age, sex, BMI, socioeconomic and lifestyle factors (hazard ratio 0.69, 95%CI 0.54–0.87), but had no association with THR. Weight loss of 5–7.5% was not associated with altered risk of either TKR or THR. Weight gain was associated with increased risk of THR after adjusting for confounders, but not TKR.

Conclusion

This study suggests that a weight loss target >7.5% is required to reduce the risk of TKR in adults with overweight or obesity. Weight gain should be avoided as it increases the risk of THR.

The cholinergic system in joint health and osteoarthritis: a narrative-review

Osteoarthritis (OA) poses a major health and economic burden worldwide due to an increasing number of patients and the unavailability of disease-modifying drugs. In this review, the latest understanding of the involvement of the cholinergic system in joint homeostasis and OA will be outlined. First of all, the current evidence on the presence of the cholinergic system in the normal and OA joint will be described. Cholinergic innervation as well as the non-neuronal cholinergic system are detected. In a variety of inflammatory diseases, the classic cholinergic anti-inflammatory pathway lately received a lot of attention as via this pathway cholinergic agonists can reduce inflammation. The role of this cholinergic anti-inflammatory pathway in the context of OA will be discussed. Activation of this pathway improved the progression of the disease. Secondly, chondrocyte hypertrophy plays a pivotal role in osteophyte formation and OA development; the impact of the cholinergic system on hypertrophic chondroblasts and endochondral ossification will be evaluated. Cholinergic stimulation increased chondrocyte proliferation, delayed chondrocyte differentiation and caused early mineralisation. Moreover, acetylcholinesterase and butyrylcholinesterase affect the endochondral ossification via an acetylcholine-independent pathway. Thirdly, subchondral bone is critical for cartilage homeostasis and metabolism; the cholinergic system in subchondral bone homeostasis and disorders will be explored. An increase in osteoblast proliferation and osteoclast apoptosis is observed. Lastly, current therapeutic strategies for OA are limited to symptom relief; here the impact of smoking on disease progression and the potential of acetylcholinesterase inhibitors as candidate disease-modifying drug for OA will be discussed.

Effect of a prebiotic supplement on knee joint function, gut microbiota, and inflammation in adults with co-morbid obesity and knee osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Osteoarthritis (OA) is a chronic and painful condition where the articular cartilage surfaces progressively degenerate, resulting in loss of function and progressive disability. Obesity is a primary risk factor for the development and progression of knee OA, defined as the "metabolic OA" phenotype. Metabolic OA is associated with increased fat deposits that release inflammatory cytokines/adipokines, thereby resulting in systemic inflammation which can contribute to cartilage degeneration. There is currently no cure for OA. Prebiotics are a type of dietary fiber that can positively influence gut microbiota thereby reducing systemic inflammation and offering protection of joint integrity in rodents. However, no human clinical trials have tested the effects of prebiotics in adults with obesity suffering from knee OA. Therefore, the purpose of this double-blind, placebo-controlled, randomized trial is to determine if prebiotic supplementation can, through positive changes in the gut microbiota, improve knee function and physical performance in adults with obesity and knee OA.

METHODS

Adults (n = 60) with co-morbid obesity (BMI > 30 kg/m2) and knee OA (Kellgren-Lawrence grade II-III) will be recruited from the Alberta Hip and Knee Clinic and the Rocky Mountain Health Clinic and surrounding community of Calgary, Canada, and randomized (stratified by sex, BMI, and age) to prebiotic (oligofructose-enriched inulin; 16 g/day) or a calorie-matched placebo (maltodextrin) for 6 months. Anthropometrics, performance-based tests, knee pain, serum inflammatory markers and metabolomics, quality of life, and gut microbiota will be assessed at baseline, 3 months, 6 months (end of prebiotic supplementation), and 3 months following the end of the prebiotic supplementation.

CLINICAL SIGNIFICANCE

There is growing pressure on health care systems for aggressive OA treatment such as total joint replacement. Less aggressive, yet effective, conservative treatment options have the potential to address the growing prevalence of co-morbid obesity and knee OA by delaying the need for joint replacement or ideally preventing its need altogether. The results of this clinical trial will provide the first evidence regarding the efficacy of prebiotic supplementation on knee joint function and pain in adults with obesity and knee OA. If successful, the results may provide a simple, safe, and easy to adhere to intervention to reduce knee joint pain and improve the quality of life of adults with co-morbid knee OA and obesity.

TRIAL REGISTRATION

Clinical Trials.gov NCT04172688 . Registered on 21 November 2019.

Determining the feasibility of a trial to evaluate the effectiveness of phototherapy versus placebo at reducing pain during physical activity for people with knee osteoarthritis: a pilot randomized controlled trial

BACKGROUND

Although practice guidelines recommend physical activity and exercise for the management of knee osteoarthritis, pain is a common barrier to participation. Phototherapy has been shown to reduce pain intensity for people with knee osteoarthritis, but it is unclear if it reduces pain during physical activity or contributes to improved rehabilitation outcomes.

OBJECTIVE

The aim of this study is to assess the feasibility of performing a fully powered randomized controlled trial (RCT) comparing an active phototherapy intervention versus placebo on pain during physical activity for people with knee osteoarthritis.

METHODS

A pilot RCT was conducted to test the feasibility of a trial comparing 8-sessions (4 weeks) of active phototherapy versus placebo. People were able to participate if they (1) were an English speaking adult (> 18 years of age), (2) had received a diagnosis of knee osteoarthritis from a physician, and (3) self-reported experiencing pain and disability related to their knee osteoarthritis for > 3 months. Primary outcomes were the feasibility of participant recruitment, retention, assessment procedures, and maintaining high treatment fidelity. Secondary outcomes piloted for a full trial included pain during physical activity (primary outcome of full trial); self-reported pain severity, physical function, stiffness, adherence to prescribed exercise, global rating of change, patient satisfaction, and adverse events; 6-min walk test; and pressure pain threshold.

RESULTS

Twenty participants (4 men; 16 women) with knee osteoarthritis and a mean age of 63.95 (SD: 9.27) years were recruited over a 3-week period (6.7 participants per week). Fifteen out of 20 (75%) of participants completed the primary outcome assessment at 4 weeks and 19/20 (95%) of participants were retained and completed the final 16-week assessment. Overall, 89% of all assessment items were completed by participants across all time-points. Fifteen out of 20 participants (75%) completed all 8 treatment sessions. Treatment fidelity was 100% for all completed treatment sessions. No adverse events were reported by participants in either group.

CONCLUSIONS

Results suggest that the trial methodology and intervention are feasible for implementation in a fully powered randomized controlled trial to determine the effectiveness of phototherapy at reducing pain during physical activity for people with knee osteoarthritis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04234685 , January 21, 2020-Retrospectively registered.

Why Do People Undergo THR and What Do They Expect to Gain-A Comparison of the Views of Patients and Health Care Professionals

Little concerted effort has been made to understand why individuals undergo total hip replacement (THR) surgery and their rehabilitation goals. Similarly, insight of views and perspective of health care professionals’ (HCPs) regarding surgery and what objective measures help them with decision-making is lacking. This patient and public involvement report aimed to explore both patients’ and HCPs’ perspectives of THR surgery. Twenty patients, 10 pre-THR, 10 post-THR, 9 physiotherapists, and 6 surgeons took part. Results suggest a consensus among patients and HCPs on pain reduction being the main reason for undergoing THR. The inability to carry out simple daily activities such as dog walking and sleep deprivation had a significant effect on patients’ mental and physical well-being. This article is the first to explore the views of THR patients and HCPs on reasons behind THR surgery amalgamated into a single report. As walking is important, wearable activity monitors are suggested as a possible motivator to enhance patient compliance to self-care rehabilitation and increase quality of life. A future research project on the use of such wearable activity monitors in enhancing mobility post-THR is therefore planned.

Effect of sweet fennel seed extract capsule on knee pain in women with knee osteoarthritis

BACKGROUND AND OBJECTIVES

Knee osteoarthritis is one of the most common types of arthritis. The disease not only has a high disease burden but also reduces the quality of life of patients. The purpose of this research was to study the effect of Foeniculum vulgare Mill. (commonly known as Fennel) seed extract on knee pain in women patients with knee osteoarthritis.

METHODS

In this randomized, double-blind trial, a total of 66 patients were assigned randomly via the blocking method in two groups, fennel and placebo. All patients received four capsules daily of either powdered fennel extract (each capsule contained 200 mg dried fennel extract from 7 g of fennel seeds) or placebo twice a day for two weeks. The patients completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and Visual Analog Scale (VAS) for pain intensity measurement before and after the study completion. Data were then analyzed via intention to treat method using the SPSS statistical software package.

RESULTS

Two weeks after the trial, a significant decrease was noted between the two groups in terms of pain, disability, total WOMAC score, and VAS variables. After comparing the pre- and post-intervention, the variables mentioned above revealed a significant decline in both groups. The stiffness variable indicated a significant reduction in the fennel group (between baseline and study completion) after two weeks, but this decline was not significant in the placebo group, and was not significant either between the two groups. At the end of the trial, the percentage change was higher in the fennel group than in the placebo group. Also, the effect size was greater in the fennel group especially in pain variable based on WOMAC and VAS than in the placebo group.

CONCLUSION

The results indicated that fennel may be an appropriate alternative for complementary treatment in patients with knee osteoarthritis. This study is the first clinical trial using oral fennel on knee pain in these patients, and the outcomes should be confirmed through additional studies.

MicroRNA-410-3p modulates chondrocyte apoptosis and inflammation by targeting high mobility group box 1 (HMGB1) in an osteoarthritis mouse model

Background

Osteoarthritis (OA) is the most prevalent type of arthritis, which commonly involves inflammation in the articular cartilage in OA pathogenesis. MicroRNAs (miRNAs) play essential roles in the regulation and pathophysiology of various diseases including OA. MiR-410-3p has been demonstrated to mediate inflammatory pathways, however, the regulatory functions of miR-410-3p in OA remain largely unknown.

Methods

The regulations of miR-410-3p were investigated in OA. Mouse primary chondrocytes and mouse in vivo models were used. The expression levels of miR-410-3p and HMGB1 were measured by qPCR. The transcription activity of NF-κB was assessed by luciferase reporter assay. MTT assay was performed to assess cellular proliferation. Cell apoptosis was evaluated with the Fluorescein Isothiocyanate (FITC) Annexin V assay. Expression levels of proteins were determined by Western blot.

Results

The results demonstrated that miR-410-3p was markedly downregulated in articular cartilage tissues as well as in lipopolysaccharide (LPS)-treated chondrocytes in OA mice. In addition, upregulation of miR-410-3p markedly inhibited LPS-induced apoptosis of chondrocytes. The results also demonstrated that the high mobility group box 1 (HMGB1) was a target of miR-410-3p. LPS-induced upregulated expression of HMGB1 significantly suppressed expression of miR-410-3p. Furthermore, upregulation of miR-410-3p markedly inhibited HMGB1 expression, the nuclear factor (NF)-kB activity and pro-inflammatory cytokines production. Taken together, the results suggested that miR-410-3p targeted HMGB1 and modulated chondrocytes apoptosis and inflammation through the NF-κB signaling pathway.

Conclusions

These findings provide insights into the potential of miR-410-3p/ HMGB1 as therapeutic targets for OA treatment.

The quality of life - an indicator for assessing the recovery program in patients diagnosed with degenerative disorders

Introduction. Osteoarthritis is a chronic joint disease, a progressive non-inflammatory arthropathy-type. Globally, around 1.7 billion people are affected by musculoskeletal and rheumatic diseases, which indicates an increase in the last 20 years of around 45%. Material and method. The objectives of the treatment of patients diagnosed with osteoarthritis were: decreasing the pain, increasing joint mobility, muscle strength, trophic and muscle tone, increasing the quality of life and reintegration into the social and family environment. Demographic data and the functional status were assessed using the VAS scale, the WOMAC scale, the QOL scale. Results and discussions. The pain, the most important symptom in osteoarthritis, was diminished in the patients from the group, the evaluation on the VAS scale, but also on the WOMAC scale has showed the value reduction and the statistical significance of this decrease. The quality of life in the group patients after the application of the complex recovery treatment, especially of the kinetotherapy program. Conclusions. The application of the individualized recovery treatment and adapted to the age group has allowed the improvement of the values of the parameters of pain, rigidity, functional capacity. The recovery of patients aged 55-65 is important to ensure the percentage of professionally active persons, to reduce medical costs, as well as those generated by absenteeism, and the socio-professional reintegration of these patients.

Procedural Treatments for Knee Osteoarthritis: A Review of Current Injectable Therapies

Knee osteoarthritis is a common painful degenerative condition affecting the aging Canadian population. In addition to pain and disability, osteoarthritis is associated with depression, comorbid conditions such as diabetes, and increased caregiver burden. It is predicted to cost the Canadian healthcare system $7.6 billion dollars by 2031. Despite its high cost and prevalence, controversy persists in the medical community regarding optimal therapies to treat knee osteoarthritis. A variety of medications like nonsteroidal anti-inflammatories and opioids can cause severe side effects with limited benefits. Total knee arthroplasty, although a definitive management, comes with risk such as postoperative infections, revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications because of a safer side effect profile and are much less invasive than a joint replacement. Platelet-rich plasma is beginning to replace the more common injectable therapies of intra-articular corticosteroids and hyaluronic acid, but larger trials are needed to confirm this effect. Small studies have examined prolotherapy and stem cell therapy and demonstrate some benefits. Trials involving genicular nerve block procedures have been successful. As treatments evolve, injectable therapies may offer a safe and effective pathway for patients suffering from knee osteoarthritis.

The comparison of efficacy of single intraarticular steroid injection versus the combination of genicular nerve block and intraarticular steroid injection in patients with knee osteoarthritis: a randomised study

OBJECTIVES

The aim of this study is to evaluate the efficacy of genicular nerve block (GNB) and intraarticular corticosteroid injection (IACSI) in patients with knee osteoarthritis (OA).

METHODS

Forty patients with Kellgren-Lawrence grade 2-4 knee OA were included for the study. Patients were divided into two groups randomly as IACS and IACS + GNB groups. All patients were evaluated with ultrasound for cartilage thickness, patellar tendon thickness, quadriceps tendon thickness and quadriceps muscle cross-sectional area (QMA). Pain intensity of the patients was evaluated with visual analogue scale and the Leeds Assessment of Neuropathic Symptoms and Signs pain scale. Functional status of the patients was evaluated with Western Ontario and Mc Master Universities Osteoarthritis Index. Quality of life of the patients was assessed with Nottingham Health Profile (NHP). All assessments were measured and compared at baseline, 1st month and 3rd month after treatment.

RESULTS

All evaluation parameters were significantly improved in IACSI and IACSI + GNB groups. However, the improvement was better in IACSI + GNB group compared to those in IACSI group in terms of all evaluation parameters except QMA (0.10 ± 0.18 and 0.11 ± 0.22, respectively) and NHP scores in 1st month evaluation (- 3.11 ± 6.99 and - 3.54 ± 1.74, respectively).

CONCLUSIONS

When combined with IACSI, GNB yields better analgesic effect and improves function in patients with knee OA compared to only IACSI.

Efficacy and potential determinants of exercise therapy in knee and hip osteoarthritis: A systematic review and meta-analysis

BACKGROUND

Exercise is an effective treatment for osteoarthritis. However, the effect may vary from one patient (or study) to another.

OBJECTIVE

To evaluate the efficacy of exercise and its potential determinants for pain, function, performance, and quality of life (QoL) in knee and hip osteoarthritis (OA).

METHODS

We searched 9 electronic databases (AMED, CENTRAL, CINAHL, EMBASE, MEDLINE Ovid, PEDro, PubMed, SPORTDiscus and Google Scholar) for reports of randomised controlled trials (RCTs) comparing exercise-only interventions with usual care. The search was performed from inception up to December 2017 with no language restriction. The effect size (ES), with its 95% confidence interval (CI), was calculated on the basis of between-group standardised mean differences. The primary endpoint was at or nearest to 8 weeks. Other outcome time points were grouped into intervals, from<1 month to≥18 months, for time-dependent effects analysis. Potential determinants were explored by subgroup analyses. Level of significance was set at P≤0.10.

RESULTS

Data from 77 RCTs (6472 participants) confirmed statistically significant exercise benefits for pain (ES 0.56, 95% CI 0.44-0.68), function (0.50, 0.38-0.63), performance (0.46, 0.35-0.57), and QoL (0.21, 0.11-0.31) at or nearest to 8 weeks. Across all outcomes, the effects appeared to peak around 2 months and then gradually decreased and became no better than usual care after 9 months. Better pain relief was reported by trials investigating participants who were younger (mean age<60 years), had knee OA, and were not awaiting joint replacement surgery.

CONCLUSIONS

Exercise significantly reduces pain and improves function, performance and QoL in people with knee and hip OA as compared with usual care at 8 weeks. The effects are maximal around 2 months and thereafter slowly diminish, being no better than usual care at 9 to 18 months. Participants with younger age, knee OA and not awaiting joint replacement may benefit more from exercise therapy. These potential determinants, identified by study-level analyses, may have implied ecological bias and need to be confirmed with individual patient data.

Impact of comorbidities and functional impairment on 5-year loss of health utility in patients with lower-limb osteoarthritis in the KHOALA cohort

PURPOSE

To examine the respective and combined impact of "hypothetical" functional impairment (FI) and burden of comorbidities accrual on a 5-year risk of health utility (HU) loss in osteoarthritis (OA).

METHODS

Participants of the Knee and Hip Osteoarthritis Long-term Assessment (KHOALA) study with a 5-year follow-up were included. FI, number of comorbidities and HU were measured annually by the WOMAC, Functional Comorbidity Index and Short-Form 6D, respectively. We estimated the population risk of HU loss (PRD: population risk difference, PRR: population risk ratio) under hypothetical FI and comorbidities using the parametric G-formula. Then, mediation analysis investigated the causal mechanism of comorbidities on HU through FI by estimating total, direct and indirect effects.

RESULTS

We examined data from 767 patients (68.8% women; 61.6 years). The estimated 5-year risk of HU loss was 47.5% [41.9; 52.2] under natural course and 24.9% [15.5; 34.2] when imposing "Patient acceptable function and No comorbidity" corresponding to a PRD = - 22.6 [- 26.5; - 21.2] and a PRR = 0.5 [0.4; 0.6]. The estimated total risk of HU loss comparing "Two comorbidities" versus "No comorbidity" was significant without mediation effect of FI: Total = 10.1% [6.8; 12.9]; direct = 8.0% [2.7; 13.1]; indirect = 2.1% [- 2.0; 5.2].

CONCLUSIONS

FI and comorbidities are important and independent determinants of HU loss in patient with OA. Half of cases (50%) of HU loss during 5 years could be avoided by preventing comorbidities (30%) and limiting FI under patient acceptable function (20%). Caregivers should additionally pay close attention to the prevention and the treatment of comorbidities in routine management of OA.

Association between osteoarthritis and increased risk of dementia: A systemic review and meta-analysis

OBJECTIVE

To investigate the possible association between osteoarthritis (OA) and the risk of dementia.

METHODS

Cohort, case-control, and cross-sectional studies were obtained from wide literature search up to 20 April 2018 from following electronic databases: PubMed, Embase, Cochrane, using the MeSH terms: "osteoarthritis" AND "dementia". The literature search was then expanded to congress abstracts. After screening and selection of relevant studies by two investigators, data was extracted. Estimates were then calculated using a random-effect size model. Sensitivity-analysis was conducted for gender and age adjusted studies and pooled for studies with STROBE quality assessment score ≥75%. Publication bias was assessed by Funnel plot. Analyses were performed using Data Analysis and Statistical Software Version 14.2.

RESULTS

Nearly 1549 publication references were initially retrieved. Twenty-six publications were checked with full-text. Six observational studies with 388,252 individuals were included. OA was associated with a significantly increased risk for dementia (OR = 1.20; 95% confidence interval (CI), 1.03-1.39, I = 95.6%, P < .05). After pooling the studies with adjustment of age and gender, the risk increased (OR 1.36; 95% CI, 1.22-1.51, I = 75.6%, P < .0001). After pooling the study with a STROBE Quality score ≥75% the risk for dementia was slightly increased (OR 1.33; 95% CI, 1.17-1.5, I = 93.5%, p < 0.0001).

CONCLUSIONS

There is an association between osteoarthritis and the risk of dementia. This meta-analysis does not provide causality. Further prospective cohort studies are needed to clarify, if knee-, hip-, or hand-OA are independent risk factors for Alzheimer's disease and vascular dementia.

Osteoarthritis phenotypes and novel therapeutic targets

The success of disease-modifying osteoarthritis drug (DMOAD) development is still elusive. While there have been successes in preclinical and early clinical studies, phase 3 clinical trials have failed so far and there is still no approved, widely available DMOAD on the market. The latest research suggests that, among other causes, poor trial outcomes might be explained by the fact that osteoarthritis (OA) is a heterogeneous disease with distinct phenotypes. OA trials might be more successful if they would address and target a specific phenotype. The increasing availability of advanced techniques to detect particular OA characteristics expands the possibilities to distinguish between such potential OA phenotypes. Magnetic resonance imaging is among the key imaging techniques to stratify and monitor patients with changes in bone, cartilage and inflammation. Biochemical markers have mainly used as secondary parameters and could further delineate phenotypes. Moreover, post-hoc analyses of trial data have suggested the existence of distinct pain phenotypes and their relevance in the design of clinical trials. Although ongoing work in the field supports the concept of OA heterogeneity, this has not yet resulted in more effective treatment options. This paper reviews the current knowledge about potential OA phenotypes and suggests that combining patient clinical data, quantitative imaging, biochemical markers and utilizing data-driven approaches in patient selection and efficacy assessment will allow for more successful development of effective DMOADs.

The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030

Background

Comprehensive national joint replacement registries with well-validated data offer unique opportunities for examining the potential future burden of hip and knee osteoarthritis (OA) at a population level. This study aimed to forecast the burden of primary total knee (TKR) and hip replacements (THR) performed for OA in Australia to the year 2030, and to model the impact of contrasting obesity scenarios on TKR burden.

Methods

De-identified TKR and THR data for 2003–2013 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population projections and obesity trends were obtained from the Australian Bureau of Statistics, with public and private hospital costs sourced from the National Hospital Cost Data Collection. Procedure rates were projected according to two scenarios: (1) constant rate of surgery from 2013 onwards; and (2) continued growth in surgery rates based on 2003–2013 growth. Sensitivity analyses were used to estimate future TKR burden if: (1) obesity rates continued to increase linearly; or (2) 1–5% of the overweight or obese population attained a normal body mass index.

Results

Based on recent growth, the incidence of TKR and THR for OA is estimated to rise by 276% and 208%, respectively, by 2030. The total cost to the healthcare system would be $AUD5.32 billion, of which $AUD3.54 billion relates to the private sector. Projected growth in obesity rates would result in 24,707 additional TKRs totalling $AUD521 million. A population-level reduction in obesity could result in up to 8062 fewer procedures and cost savings of up to $AUD170 million.

Conclusions

If surgery trends for OA continue, Australia faces an unsustainable joint replacement burden by 2030, with significant healthcare budget and health workforce implications. Strategies to reduce national obesity could produce important TKR savings.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2411-9) contains supplementary material, which is available to authorized users.

Can obesity and physical activity predict outcomes of elective knee or hip surgery due to osteoarthritis? A meta-analysis of cohort studies

OBJECTIVE

The aim of this study was to systematically review the literature to identify whether obesity or the regular practice of physical activity are predictors of clinical outcomes in patients undergoing elective hip and knee arthroplasty due to osteoarthritis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE AND ELIGIBILITY CRITERIA

A systematic search was performed on the Medline, CINAHL, EMBASE and Web of Science electronic databases. Longitudinal cohort studies were included in the review. To be included, studies needed to have assessed the association between obesity or physical activity participation measured at baseline and clinical outcomes (ie, pain, disability and adverse events) following hip or knee arthroplasty.

DATA EXTRACTION

Two independent reviewers extracted data on pain, disability, quality of life, obesity, physical activity and any postsurgical complications.

RESULTS

62 full papers were included in this systematic review. From these, 31 were included in the meta-analyses. Our meta-analysis showed that compared to obese participants, non-obese participants report less pain at both short term (standardised mean difference (SMD) -0.43; 95% CI -0.67 to -0.19; P<0.001) and long term post-surgery (SMD -0.36; 95% CI -0.47 to -0.24; P<0.001), as well as less disability at long term post-surgery (SMD -0.32; 95% CI -0.36 to -0.28; P<0.001). They also report fewer postsurgical complications at short term (OR 0.48; 95% CI 0.25 to 0.91; P<0.001) and long term (OR 0.55; 95% CI 0.41 to 0.74; P<0.001) along with less postsurgical infections after hip arthroplasty (OR 0.33; 95% CI 0.18 to 0.59; P<0.001), and knee arthroplasty (OR 0.42; 95% CI 0.23 to 0.78; P=0.006).

CONCLUSIONS

Presurgical obesity is associated with worse clinical outcomes of hip or knee arthroplasty in terms of pain, disability and complications in patients with osteoarthritis. No impact of physical activity participation has been observed.

PROSPERO REGISTRATION NUMBER

CRD42016032711.

Serum microRNA array analysis identifies miR-140-3p, miR-33b-3p and miR-671-3p as potential osteoarthritis biomarkers involved in metabolic processes

Background

MicroRNAs (miRNAs) in circulation have emerged as promising biomarkers. In this study, we aimed to identify a circulating miRNA signature for osteoarthritis (OA) patients and in combination with bioinformatics analysis to evaluate the utility of selected differentially expressed miRNAs in the serum as potential OA biomarkers.

Methods

Serum samples were collected from 12 primary OA patients, and 12 healthy individuals were screened using the Agilent Human miRNA Microarray platform interrogating 2549 miRNAs. Receiver Operating Characteristic (ROC) curves were constructed to evaluate the diagnostic performance of the deregulated miRNAs. Expression levels of selected miRNAs were validated by quantitative real-time PCR (qRT-PCR) in all serum and in articular cartilage samples from OA patients (n = 12) and healthy individuals (n = 7). Bioinformatics analysis was used to investigate the involved pathways and target genes for the above miRNAs.

Results

We identified 279 differentially expressed miRNAs in the serum of OA patients compared to controls. Two hundred and five miRNAs (73.5%) were upregulated and 74 (26.5%) downregulated. ROC analysis revealed that 77 miRNAs had area under the curve (AUC) > 0.8 and p < 0.05. Bioinformatics analysis in the 77 miRNAs revealed that their target genes were involved in multiple signaling pathways associated with OA, among which FoxO, mTOR, Wnt, pI3K/akt, TGF-β signaling pathways, ECM-receptor interaction, and fatty acid biosynthesis. qRT-PCR validation in seven selected out of the 77 miRNAs revealed 3 significantly downregulated miRNAs (hsa-miR-33b-3p, hsa-miR-671-3p, and hsa-miR-140-3p) in the serum of OA patients, which were in silico predicted to be enriched in pathways involved in metabolic processes. Target-gene analysis of hsa-miR-140-3p, hsa-miR-33b-3p, and hsa-miR-671-3p revealed that InsR and IGFR1 were common targets of all three miRNAs, highlighting their involvement in regulation of metabolic processes that contribute to OA pathology. Hsa-miR-140-3p and hsa-miR-671-3p expression levels were consistently downregulated in articular cartilage of OA patients compared to healthy individuals.

Conclusions

A serum miRNA signature was established for the first time using high density resolution miR-arrays in OA patients. We identified a three-miRNA signature, hsa-miR-140-3p, hsa-miR-671-3p, and hsa-miR-33b-3p, in the serum of OA patients, predicted to regulate metabolic processes, which could serve as a potential biomarker for the evaluation of OA risk and progression.

Electronic supplementary material

The online version of this article (10.1186/s13148-017-0428-1) contains supplementary material, which is available to authorized users.

Using Microsimulation to Estimate the Future Health and Economic Costs of Salmonellosis under Climate Change in Central Queensland, Australia

BACKGROUND

The incidence of salmonellosis, a costly foodborne disease, is rising in Australia. Salmonellosis increases during high temperatures and rainfall, and future incidence is likely to rise under climate change. Allocating funding to preventative strategies would be best informed by accurate estimates of salmonellosis costs under climate change and by knowing which population subgroups will be most affected.

OBJECTIVE

We used microsimulation models to estimate the health and economic costs of salmonellosis in Central Queensland under climate change between 2016 and 2036 to inform preventative strategies.

METHODS

We projected the entire population of Central Queensland to 2036 by simulating births, deaths, and migration, and salmonellosis and two resultant conditions, reactive arthritis and postinfectious irritable bowel syndrome. We estimated salmonellosis risks and costs under baseline conditions and under projected climate conditions for Queensland under the A1FI emissions scenario using composite projections from 6 global climate models (warm with reduced rainfall). We estimated the resulting costs based on direct medical expenditures combined with the value of lost quality-adjusted life years (QALYs) based on willingness-to-pay.

RESULTS

Estimated costs of salmonellosis between 2016 and 2036 increased from 456.0 QALYs (95% CI: 440.3, 473.1) and AUD29,900,000 million (95% CI: AUD28,900,000, AUD31,600,000), assuming no climate change, to 485.9 QALYs (95% CI: 469.6, 503.5) and AUD31,900,000 (95% CI: AUD30,800,000, AUD33,000,000) under the climate change scenario.

CONCLUSION

We applied a microsimulation approach to estimate the costs of salmonellosis and its sequelae in Queensland during 2016-2036 under baseline conditions and according to climate change projections. This novel application of microsimulation models demonstrates the models' potential utility to researchers for examining complex interactions between weather and disease to estimate future costs. https://doi.org/10.1289/EHP1370.

Effectiveness and efficiency of different weight machine-based strength training programmes for patients with hip or knee osteoarthritis: a protocol for a quasi-experimental controlled study in the context of health services research

INTRODUCTION

Osteoarthritis is a chronic musculoskeletal disease with a major impact on the individual and the healthcare system. As there is no cure, therapy aims for symptom release and reduction of disease progression. Physical exercises have been defined as a core treatment for osteoarthritis. However, research questions related to dose response, sustainability of effects, economic efficiency and safety are still open and will be evaluated in this trial, investigating a progressive weight machine-based strength training.

METHODS AND ANALYSIS

This is a quasi-experimental controlled trial in the context of health services research. The intervention group (n=300) is recruited from participants of an offer for insurants of a health insurance company suffering from hip or knee osteoarthritis. Potential participants of the control group are selected and written to from the insurance database according to predefined matching criteria. The final statistical twins from the control responders will be determined via propensity score matching (n=300). The training intervention comprises 24 supervised mandatory sessions (2/week) and another 12 facultative sessions (1/week). Exercises include resistance training for the lower extremity and core muscles by use of weight machines and small training devices. The training offer is available at two sites. They differ with respect to the weight machines in use resulting in different dosage parameters. Primary outcomes are self-reported pain and function immediately after the 12-week intervention period. Health-related quality of life, self-efficacy, cost utility and safety will be evaluated as secondary outcomes. Secondary analysis will be undertaken with two strata related to study site. Participants will be followed up 6, 12 and 24 months after baseline.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register DRKS00009257. Pre-results.

Distribution and Drivers of Average Direct Cost of Osteoarthritis in Canada From 2003 to 2010

OBJECTIVE

To estimate the distribution and drivers of the average direct cost of osteoarthritis (OA) in Canada using a population-based health microsimulation model of OA from 2003 to 2010.

METHODS

We used a previously published microsimulation model to estimate the distribution of average cost of OA across different cost components and OA stages. OA stages were defined according to the patient flow within the health care system. Cost components associated with pharmacologic and nonpharmacologic treatments, physician visits, and hospitalization were included. Scenario analysis was performed to evaluate average cost drivers from 2003 to 2010.

RESULTS

During the study period, the OA population size grew from 2.9 to 3.6 million, while the average cost increased from $577 to $811 (Canadian) per patient per year. The highest increase in share of cost components was for total joint replacement (TJR) surgery (24% to 32%). The highest average cost was incurred by patients in stage 4 (during and after revision surgery), while around 80% of OA patients were in stage 1 (OA diagnosed but has not visited an orthopedic surgeon). Increase in the proportion of OA patients receiving TJR surgeries (34%) and price inflation (29%) were the most significant drivers of average cost.

CONCLUSION

The average cost of OA has been increasing during the study period mostly due to an increase in the proportion of patients receiving TJR surgeries and price inflation. The distribution of average cost of OA across disease stages needs to be considered when designing policies targeting specific aspects of OA care.

A Practical ANOVA Approach for Uncertainty Analysis in Population-Based Disease Microsimulation Models

OBJECTIVES

To provide a practical approach for calculating uncertainty intervals and variance components associated with initial-condition and dynamic-equation parameters in computationally expensive population-based disease microsimulation models.

METHODS

In the proposed uncertainty analysis approach, we calculated the required computational time and the number of runs given a user-defined error bound on the variance of the grand mean. The equations for optimal sample sizes were derived by minimizing the variance of the grand mean using initial estimates for variance components. Finally, analysis of variance estimators were used to calculate unbiased variance estimates.

RESULTS

To illustrate the proposed approach, we performed uncertainty analysis to estimate the uncertainty associated with total direct cost of osteoarthritis in Canada from 2010 to 2031 according to a previously published population health microsimulation model of osteoarthritis. We first calculated crude estimates for initial-population sampling and dynamic-equation parameters uncertainty by performing a small number of runs. We then calculated the optimal sample sizes and finally derived 95% uncertainty intervals of the total cost and unbiased estimates for variance components. According to our results, the contribution of dynamic-equation parameter uncertainty to the overall variance was higher than that of initial parameter sampling uncertainty throughout the study period.

CONCLUSIONS

The proposed analysis of variance approach provides the uncertainty intervals for the mean outcome in addition to unbiased estimates for each source of uncertainty. The contributions of each source of uncertainty can then be compared with each other for validation purposes so as to improve the model accuracy.

Productivity costs of work loss associated with osteoarthritis in Canada from 2010 to 2031

OBJECTIVE

To estimate and project the productivity costs of work loss (PCWL) associated with osteoarthritis (OA) in Canada using the Population Health Model (POHEM).

DESIGN

We integrated an employment module based on 2006 Canadian Census into the previously developed microsimulation model of OA. The Canadian Community Health Survey (CCHS) Cycle 2.1 with an OA sample aged 25-64 (n = 7067) was used to calibrate the results of the employment module and to estimate the fraction of non-employment associated with OA. Probabilities of non-employment together with attributable fractions were then implemented in POHEM to estimate PCWL associated with OA from 2010 to 2031.

RESULTS

Among the OA population, 44.4% and 59.4% of non-employment due to illness was associated with OA for those not working full-year and part-year, respectively. According to POHEM projections, the size of the working age population with OA increased from 1.5 million in 2010 to 1.7 million in 2031. The PCWL associated with OA increased from $12 billion to $17.5 billion in constant 2008 Canadian dollars. Around 38% of this increase was due to the increase in OA prevalence and changes in demographics, while the rest was due to increase in real wage growth. Male and female OA patients between 55 and 64 years of age had the highest total projected PCWL, respectively.

CONCLUSIONS

The total PCWL associated with OA in Canada is estimated to be substantial and increasing in future years. Results of this study could be used to inform policies aiming to increase employment sustainability among individuals with OA.

Economic and Humanistic Burden of Osteoarthritis: A Systematic Review of Large Sample Studies

BACKGROUND

Osteoarthritis (OA) consumes a significant amount of healthcare resources, and impairs the health-related quality of life (HRQoL) of patients. Previous reviews have consistently found substantial variations in the costs of OA across studies and countries. The comparability between studies was poor and limited the detection of the true differences between these studies.

OBJECTIVE

To review large sample studies on measuring the economic and/or humanistic burden of OA published since May 2006.

METHODS

We searched MEDLINE and EMBASE databases using comprehensive search strategies to identify studies reporting economic burden and HRQoL of OA. We included large sample studies if they had a sample size ≥1000 and measured the cost and/or HRQoL of OA. Reviewers worked independently and in duplicate, performing a cross-check between groups to verify agreement. Within- and between-group consolidation was performed to resolve discrepancies, with outstanding discrepancies being resolved by an arbitrator. The Kappa statistic was reported to assess the agreement between the reviewers. All costs were adjusted in their original currency to year 2015 using published inflation rates for the country where the study was conducted, and then converted to 2015 US dollars.

RESULTS

A total of 651 articles were screened by title and abstract, 94 were reviewed in full text, and 28 were included in the final review. The Kappa value was 0.794. Twenty studies reported direct costs and nine reported indirect costs. The total annual average direct costs varied from US$1442 to US$21,335, both in USA. The annual average indirect costs ranged from US$238 to US$29,935. Twelve studies measured HRQoL using various instruments. The Short Form 12 version 2 scores ranged from 35.0 to 51.3 for the physical component, and from 43.5 to 55.0 for the mental component. Health utilities varied from 0.30 for severe OA to 0.77 for mild OA.

CONCLUSION

Per-patient OA costs are considerable and a patient's quality of life remains poor. Variations in costing methods are a barrier to understanding the true differences in the costs of OA between studies. Standardizing healthcare resource items, the definition of OA-relevant costs, and productivity loss measures would facilitate the comparison.

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.

Interprofessional education as part of becoming a doctor or physiotherapist in a competency-based curriculum

INTRODUCTION

Interprofessional learning is a critical pre-requisite for future interprofessional work. Structural adaptations in education offer possibilities to introduce new concepts. Rheumatic and musculoskeletal diseases (RMD) are both prevented and treated by physicians and physiotherapists but the development of interprofessional roles is seldom part of curricula.

PROJECT DESCRIPTION

A complex, longitudinal interprofessional educational approach for future doctors and physiotherapists was designed and implanted at various stages (anatomy, physical examination, pathology, therapy). Most segments of the RMD curriculum are now based on interprofessional classes. Student satisfaction with learning is continually and comparatively evaluated. Learning success is assessed with practical and written exams.

RESULTS

Interprofessional teaching was first introduced in 2013 for 420 first-year and 360 fourth-year medical students, along with 40 first- and third-year physiotherapy majors. The satisfaction with teaching and learning is high and distinctly above average for all teaching areas (satisfaction RMD rated as 2.4; average for all is 3.3). The percentage of those who pass the final exam is 94%. 100% of the students surveyed support the continuation of this interprofessional unit.

CONCLUSION

Interprofessional teaching of RMD can be successfully implemented for future physicians and physiotherapists at different learning levels.