Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: a pragmatic randomized controlled trial

Efficacy of home-based exercise in the treatment of pain and disability at the hip and knee in patients with osteoarthritis: a systematic review and meta-analysis

BACKGROUND

An increasing body of evidence suggests that home-based exercise (HBE) therapy has significant therapeutic effects on knee osteoarthritis (KOA) and hip osteoarthritis (HipOA), and it has advantages such as cost savings, strong operability, and good compliance compared with hospitalization and exercise courses.

OBJECTIVE

To evaluate the efficacy of HBE in the treatment of KOA and HipOA.

METHODS

A systematic search was conducted in PubMed, Cochrane, Web of Science, and Embase to collect randomized controlled trials. The retrieval time was from database establishment until March 6, 2024. Stata 15.1 software was used for data analysis.

RESULTS

A total of 16 randomized controlled trials involving 3,015participants were included, with 1,519 participants in the intervention group and 1,496 in the control group. The meta-analysis showed that, compared to the control group, HBE can significantly improve pain [SMD=-0.38, 95% CI (-0.58, -0.18); P = 0.001], joint function      [SMD=-0.60, 95% CI (-1.01, -0.19); P = 0.004], balance ability [SMD=-0.67, 95% CI (-1.00, -0.34); P = 0.001], mobility (ADL) [SMD = 0.51, 95% CI (0.19, 0.82); P = 0.002] in patients with KOA and HipOA. There is no statistical difference in the improvement of joint stiffness [WMD = -0.80, 95% CI (-1.61, 0.01); P = 0.052]. In addition, subgroup analysis showed that HBE significantly improved pain, joint function, and balance ability in KOA patients compared with the control group. HipOA patients showed significant improvement in pain and joint function; However, HBE only improved activity ability in patients with comorbidities of KOA and HipOA.

CONCLUSION

HBE can effectively alleviate pain, improve joint function, and enhance physical function in patients with KOA and HipOA. However, more high-quality randomized controlled trials (RCTs) with large sample sizes and long-term interventions are needed to validate the efficacy of HBE due to limitations in the methodology and consistency of indicator outcomes in the included RCTs.

REGISTRATION NUMBER

We've registered with PROSPERO, and the number is CRD42023443085.

Effectiveness of an 11-week exercise intervention for patients with hip or knee osteoarthritis: results of a quasi-experimental pragmatic trial

OBJECTIVE

To assess the effectiveness of exercise and education in addition to standard care (SC) compared to SC alone in patients with hip or knee osteoarthritis (OA) during 24 months follow-up.

DESIGN

We conducted a quasi-experimental pragmatic clinical trial in care centers of a health insurance company. Overall, 1,030 subjects with hip and/or knee OA were included. The intervention group was recruited from clients participating in a hip/knee training (HKT, n = 515) in addition to SC. The control group (CO, n = 515) receiving SC only was recruited from the insurance database. HKT comprised 8 group sessions (1/week) of exercise and education, complemented by a 11-week structured home-exercise program (2/week). Primary endpoints were change of joint-related pain and function (WOMAC Index, score 0-10) after 3 months. Secondary endpoints related to follow-ups at 6, 12 and 24 months. All patient reported outcome measures were analyzed using linear mixed models (LMMs) investigating a time x treatment effect. A multivariable cox proportional hazards regression model was used to identify differences of joint replacement during follow-up between groups.

RESULTS

LMMs revealed statistically significant differences in favor of HKT for the primary outcomes WOMAC pain = 0.47 (CI 0.27-0.66; Effect Size (ES) = 0.22, p < 0.001) and WOMAC function = 0.27 (CI 0.11-0.44; ES = 0.13, p < 0.001). HKT was superior to CO for 6, 12, and 24 months as well (ES < 0.2, p ≤ 0.006). HKT was inferior regarding the first incidence of hip or knee AJR during follow-up in comparison to CO (adjusted hazard ratio, HR = 1.57; CI 1.08-2.30; p = 0.020).

CONCLUSIONS

This trial demonstrated short-, mid- and long-term superiority of exercise versus control. However, differences were smaller than those reported in previous efficacy trials, raising questions regarding clinical importance. Responder analysis will follow to identify possible predictors for patient responsiveness on an individual level. Further studies should investigate the frequency and reasons for joint replacement following exercise therapy.

TRIAL REGISTRATION

German Clinical Trial Register (DRKS00009251). Registered 10 September 2015.

Āsana for Back, Hips and Legs to Prevent Musculoskeletal Disorders among Dental Professionals: In-Office Yóga Protocol

Dental professionals are exposed to significant unavoidable physical stress, and theoretical ergonomic recommendations for a sitting workplace are inapplicable in many dental activities. Work-related musculoskeletal disorders (WMSDs) represent a serious health problem among dental professionals (prevalence: 64-93%), showing involvement of 34-60% for the low back and 15-25% for the hips. Muscle stress; prolonged sitting; forward bending and twisting of the torso and head; unbalanced working postures with asymmetrical weight on the hips and uneven shoulders; and others are inevitable for dental professionals. Therefore, the approach for the prevention and treatment of WMSDs must be therapeutic and compensatory. This project was conceived to provide a Yoga protocol for dental professionals to prevent or treat WMSDs from a preventive medicine perspective, and it would represent a Yoga-based guideline for the self-cure and prevention of musculoskeletal problems.

METHODS

Specific Yoga positions (āsana, such as Virāsana, Virabhadrāsana, Garudāsana, Utkatāsana, Trikonāsana, Anuvittāsana, Chakrāsana, Uttanāsana, Pashimottanāsana) have been selected, elaborated on and adapted to be practiced in a dental office using a dental stool or the dental office walls or a dental unit chair. The protocol is specifically devised for dental professionals (dentists, dental hygienists and dental assistants) and targeted for the low back, hips and legs (including knees and ankles). The protocol includes Visranta Karaka Sthiti (supported positions) in sitting (Upavistha Sthiti) and standing (Utthistha Sthiti) positions, twisting/torsions (Parivrtta), flexions/forward bend positions (Pashima) and extensions/arching (Purva) for musculo-articular system decompression and mobilization.

RESULTS

Over 60 Yogāsana-specifically ideated for back detensioning and mobilization, lumbar lordosis restoration, trunk side elongation, hip release and leg stretches and decontraction-are shown and described. The paper provides a meticulous description for each position, including the detailed movement, recommendations and mistakes to avoid, and the breathing pattern (breath control) in all the breath-driven movements (āsana in vinyāsa). An exhaustive analysis of posture-related disorders affecting the lower body among dental professionals is reported, including low-back pain, hip pain and disorders, piriformis syndrome and quadratus femoris dysfunction (gluteal pain), iliopsoas syndrome, multifidus disorders, femoroacetabular and ischiofemoral impingement, spinopelvic mobility, lumbopelvic rhythm, impairment syndromes, lower crossed syndrome, leg pain, knee pain and ankle disorders.

CONCLUSIONS

A detailed guideline of āsana for low-back decompression, hip joint destress, piriformis and gluteal muscle release, lumbar lordosis recovery and a spinopelvic mobility increase has been elaborated on. The designed Yogāsana protocol represents a powerful tool for dental professionals to provide relief to retracted stiff muscles and unbalanced musculoskeletal structures in the lower body.

'I saw it as a marriage-You can't have one without the other': A qualitative study of patient and physiotherapist experiences with a therapeutic combined strength and aerobic physical activity exercise programme for hip osteoarthritis

INTRODUCTION

To explore physiotherapist and patient experiences with, and acceptability of, a 12-week physiotherapist-guided combined strength and aerobic physical activity exercise programme for hip osteoarthritis (OA).

METHODS

A qualitative study using semi-structured interviews with 13 people with hip OA and four physiotherapists. Patients underwent a 12-week home exercise programme customised by weekly visits with one of the four physiotherapists. The programme aimed for patients to participate in 150 min of moderate-intensity aerobic physical activity, and 20-30 min of strengthening exercise 2-3 times per week in concordance with American College of Sports Medicine (ACSM) dosage guidelines. Following the programme, patients and physiotherapists participated in individual semi-structured interviews to explore the acceptability of the exercise programme and barriers and facilitators to participation. Data were audio-recorded, transcribed and analysed using a thematic approach.

RESULTS

Five over-arching themes (supporting subthemes) were identified from both patient and physiotherapist interviews: (i) positive outcomes (functional improvements, pain relief, empowerment through experience, commitment to continue); (ii) combined benefits of aerobic and strength exercises (complimentary effects, strengthening exercises key); (iii) valuing support from the physiotherapist (personalised care, skill performance feedback, coach effect, accountability); (iv) motivation and opportunity for exercise (positive symptom loop, integration into daily routine, prior exercise experience, Fitbit motivation); and (v) time-consuming commitment (physiotherapy visit frequency, travel inconvenience, time for exercise).

CONCLUSIONS

Experiences of participants in this study indicate that, although time-consuming, a combined aerobic physical activity and strengthening programme prescribed at ACSM dosage guidelines is acceptable and confers positive outcomes in individuals with hip OA.

Primary care-based models of care for osteoarthritis; a scoping review

OBJECTIVE

To identify and describe the extent, nature, characteristics, and impact of primary care-based models of care (MoCs) for osteoarthritis (OA) that have been developed and/or evaluated.

DESIGN

Six electronic databases were searched from 2010 to May 2022. Relevant data were extracted and collated for narrative synthesis.

RESULTS

Sixty-three studies pertaining to 37 discrete MoCs from 13 countries were included, of which 23 (62%) could be classified as OA management programmes (OAMPs) comprising a self-management intervention to be delivered as a discrete package. Four models (11%) focussed on enhancing the initial consultation between a patient presenting with OA at the first point of contact into a local health system and the clinician. Emphasis was placed on educational training for general practitioners (GPs) and allied healthcare professionals delivering this initial consultation. The remaining 10 MoCs (27%) detailed integrated care pathways of onward referral to specialist secondary orthopaedic and rheumatology care within local healthcare systems. The majority (35/37; 95%) were developed in high-income countries and 32/37 (87%) targeted hip/and or knee OA. Frequently identified model components included GP-led care, referral to primary care services and multidisciplinary care. The models were predominantly 'one-size fits all' and lacked individualised care approaches. A minority of MoCs, 5/37 (14%) were developed using underlying frameworks, three (8%) of which incorporated behaviour change theories, while 13/37 (35%) incorporated provider training. Thirty-four of the 37 models (92%) were evaluated. Outcome domains most frequently reported included clinical outcomes, followed by system- and provider-level outcomes. While there was evidence of improved quality of OA care associated with the models, effects on clinical outcomes were mixed.

CONCLUSION

There are emerging efforts internationally to develop evidence-based models focused on non-surgical primary care OA management. Notwithstanding variations in healthcare systems and resources, future research should focus on model development alignment with implementation science frameworks and theories, key stakeholder involvement including patient and public representation, provision of training and education for providers, treatment individualisation, integration and coordination of services across the care continuum and incorporation of behaviour change strategies to foster long-term adherence and self-management.

Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis

BACKGROUND

Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both.

METHODS

We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049).

FINDINGS

Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0-100 scale (with 100 corresponding to worst pain), with a difference of -6·36 points (95% CI -8·45 to -4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, -3·77 points (-5·97 to -1·57, BoS 30·0%, τ2 14·4) in the medium term, and -3·43 points (-5·18 to -1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0-100 scale (with 100 corresponding to worst physical function), with a difference of -4·46 points in the short term (95% CI -5·95 to -2·98, BoS 10·5%, τ2 10·1), -2·71 points in the medium term (-4·63 to -0·78, BoS 33·6%, τ2 11·9), and -3·39 points in the long term (-4·97 to -1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks).

INTERPRETATION

There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.

FUNDING

Chartered Society of Physiotherapy Charitable Trust and the National Institute for Health and Care Research.

Do imaging findings modify the effect of non-surgical treatment in patients with knee and hip osteoarthritis? A systematic literature review

OBJECTIVES

To review the available evidence on diagnostic imaging findings in knee and hip osteoarthritis (OA) as treatment effect modifiers in non-surgical OA interventions.

METHODS

MEDLINE, Embase and The Cochrane Central Register of Controlled Trials were searched from the earliest records published to 22 March 2022. Studies in knee and hip OA reporting subgroup analyses in randomised controlled trials with imaging findings as potential treatment effect modifiers were included. Studies were critically appraised using the Cochrane risk of bias tool and a subgroup analysis quality assessment.

RESULTS

Of 10 014 titles and abstracts screened, eight studies met the inclusion criteria, six on knee OA and two on hip OA. The studies investigated effect modifiers in exercise therapy, intra-articular injections and unloading shoes. Imaging findings assessed as potential treatment effect modifiers were radiographic OA severity, hip effusion (ultrasound), bone marrow lesions and meniscal pathology (MRI). Two studies fulfilled the methodological quality criteria for assessing effect modification. One reported that radiographic knee OA severity modified the effect of unloading shoes on walking pain. Those with more severe radiographic knee OA had a greater response to shoe inserts. One reported no interaction between radiographic OA severity or joint effusion and the effect of intraarticular injections of corticosteroid or hyaluronic acid in hip OA, indicating no difference in response in people with greater hip joint effusion or radiographic OA severity compared with those with less severe joint disease.

CONCLUSION

Overall, methodological limitations and very few studies do not permit conclusions on diagnostic imaging findings as effect modifiers in non-surgical interventions in knee and hip OA.Radiographic severity of knee OA potentially modifies the effect of unloading shoes.

PROSPERO REGISTRATION NUMBER

CRD42020181934.

Effect of exercise therapy in patients with hip osteoarthritis: A systematic review and cumulative meta-analysis

Objective

To evaluate the existing evidence on the effect of exercise therapy in patients with hip osteoarthritis (OA) compared to no treatment and explore whether a further trial will change the current evidence.

Design

Systematic review and cumulative meta-analysis using randomized controlled trials (RCT) to determine the effect on pain and function post-treatment, and at 6-9 months after treatment. Standardized mean difference (SMD) ​≤ ​-0.37 was considered clinically worthwhile. Extended funnel plots were used to simulate the impact of a new trial on the pooled effect size of pain and function.

Results

18 RCTs were included. Post-treatment we found a beneficial effect of exercise therapy on pain (SMD -0.38, 95% Confidence Interval (CI): 0.55 to -0.22) and function (SMD -0.31, 95% CI -0.49 to -0.11). A beneficial effect of exercise therapy on pain (SMD -0.23, 95% CI: 0.41 to -0.05) and function (SMD -0.29, 95% CI: 0.45 to -0.12) was found 6-9 months after treatment. Most effect estimates were small, and it is unclear whether these are clinically meaningful. Extended funnel plots and a simulation of a new trial showed that only a new trial with a larger effect than the current pooled effect or a trial including 74,843 participants would change the pooled effect estimate from an unclear to a clearly clinically worthwhile effect.

Conclusions

We found a beneficial effect of exercise therapy on pain and function in hip OA. It is unlikely a new trial added to current evidence will change the conclusion.

Long-Term Clinical Outcomes of a Remote Digital Musculoskeletal Program: An Ad Hoc Analysis from a Longitudinal Study with a Non-Participant Comparison Group

Digital solutions have emerged as an alternative to conventional physiotherapy, particularly for chronic musculoskeletal pain (CMP) management; however, its long-term effects remain largely unexplored. This study focuses on patients reporting CMP, assessing 1-year clinical outcomes after a multimodal digital care program (DCP) versus non-participants, who enrolled in the program but never engaged in a single exercise session or partook of the educational content made available to them. In this longitudinal study ad-hoc analysis, pain and functionality outcomes at 1-year reassessment were studied, focusing on the odds of reaching minimal clinically important difference (MCID) and, overall average reduction in both outcomes. Healthcare utilization was additionally studied within the same period. From 867 individuals allocated to the study, 460 completed the 1-year reassessment (intervention group: 310; comparison group: 150). The intervention group presented sustained and greater pain reduction until 1-year reassessment than the comparison group, reflecting greater odds ratio of achieving the MCID both in pain and functionality (1.90 95% CI: 1.27-2.86, p = 0.002 and 2.02 95% CI: 1.31-3.12, p = 0.001, respectively). A lower healthcare utilization during the 1-year follow-up was observed in the intervention group than in the comparison group. This study suggests that a digital CMP program may have a lasting impact on improved pain and functionality in patients with CMP.

Progressive resistance training compared to neuromuscular exercise in patients with hip osteoarthritis and the additive effect of exercise booster sessions: protocol for a multicentre cluster randomised controlled trial (The Hip Booster Trial)

INTRODUCTION

The primary aim of this randomised controlled trial is to investigate the effectiveness of 3 months of progressive resistance training (PRT) compared to neuromuscular exercise (NEMEX) on functional performance in patients with hip osteoarthritis (OA). Secondary aims are to investigate the effectiveness of exercise booster sessions (EBS) in prolonging the effects of the initial exercise interventions as well as to investigate the cost-effectiveness of PRT, NEMEX and EBS at 12-month follow-up.

METHODS AND ANALYSIS

This multicentre cluster randomised controlled trial will be conducted at hospitals and physiotherapy clinics across Denmark. A total of 160 participants with clinically diagnosed hip OA will be recruited. Participants will be cluster randomised to a 3-month intervention of either PRT or NEMEX and to receive EBS or not, resulting in four treatment arms.The primary outcome is change in functional performance, measured by the 30 s chair stand test at 3 months for the primary comparison and at 12 months for the EBS comparisons. Secondary outcomes include changes in 40 m fast-paced walk test, 9-step timed stair climb test, leg extensor muscle power and maximal strength, Hip disability and Osteoarthritis Outcome Score subscales, EuroQol Group 5-dimension, global perceived effect, physical activity and pain. Outcomes are measured at baseline, after the initial 3 months of intervention, and at 6-month, 9-month and 12-month follow-up. An intention-to-treat approach will be used for analysing changes in the primary and secondary outcome measures.

ETHICS AND DISSEMINATION

The trial has been approved by the Central Denmark Region Committee on Biomedical Research Ethics (Journal No 1-10-72-267-20) and registered at the Danish Data Protection Agency (Journal No 1-16-02-11-21). Results will be published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04714047.

Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study

Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.

Multimodal Interventions Including Rehabilitation Exercise for Older Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-analyses of Randomized Controlled Trials

BACKGROUND AND PURPOSE

Musculoskeletal disorders (MSKDs) are the most common causes of disabilities for older adults. The aim of this systematic review and meta-analysis is to assess the effectiveness of multimodal interventions including exercise rehabilitation for older adults with chronic MSKDs.

METHODS

A literature search was conducted up to February 2019 in 5 bibliographical databases to identify randomized controlled trials (RCTs) that compared multimodal interventions including exercise rehabilitation with usual medical care or no intervention. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed and pooled mean differences (MDs) or standardized mean differences (SMDs) were calculated.

RESULTS

Sixteen RCTs (n = 2322 participants) were included. One RCT was considered at low risk of bias, 8 had some concerns of bias, and 7 had a high risk of bias. Participants suffered from hip or knee osteoarthritis (OA) (n = 12 RCTs), low back pain (LBP) (n = 2 RCTs) and generalized chronic pain (GCP) (n = 2 RCTs). Multimodal interventions were significantly more effective than usual care to decrease pain (visual analog scale, out of 10 points) in the short term, MD: -0.71 (95% confidence interval [CI] -1.08 to -0.34, n = 900), and in the long term: MD: -0.52 (95% CI -0.98 to -0.05, n = 575), but these differences are not considered clinically important. In terms of disabilities, multimodal interventions were also significantly more effective than usual care. The SMDs were -0.47 (95% CI -0.61 to -0.34, n = 903) and -0.29 (95% CI -0.46 to -0.13, n = 568) for OA trials in the short and long terms, respectively, and -0.47 (95% CI -0.81 to -0.12, n = 211) for LBP and GCP trials in the short term. The magnitude of these effects may be considered as small to moderate.

CONCLUSION

Multimodal intervention including exercise rehabilitation combined with usual medical care is an efficacious therapeutic option to reduce disabilities in older adults with chronic MSKDs. A significant but not clinically important effect was observed for pain. The most beneficial component of the multimodal interventions in terms of education, exercises, or medication remains to be determined.

Secondary Analysis of a Study on Exercise Therapy in Hip Osteoarthritis: Follow-Up Data on Pain and Physical Functioning

We evaluated the short- and longer-term effects of exercise therapy in hip osteoarthritis patients (OA) at baseline, three, six, and 12 months in a randomized setting, followed by a non-randomized setting. The primary randomized intervention (E = exercise, P = placebo–ultrasound, C = control) was followed by a voluntary three-month exercise therapy for P and C (renamed P-E, C-E). Participants randomized to E were not offered treatment again (E-C). Effect sizes (ES; 95% CI) were calculated for within-group effects across time for bodily pain (SF-36) and WOMAC pain, function, and stiffness. ANCOVAs of post-treatment scores were used for group comparison after the group-specific exercise intervention phase. Exercise adherence was assessed and related to post-treatment scores of clinical outcomes. Data of 115 participants of the RCT eligible for follow-up and completing exercise therapy were included into our analyses. Small to medium beneficial long-term effects of cumulative interventional effects, including exercise training, persisted in all groups. Group E-C (n = 49) showed significant 12 months vs. baseline within-group ES in all outcomes (ES 0.39–0.59) except stiffness. Findings were less prominent for exercise therapy in a non-randomized setting (C-E, P-E, both n = 33). Differences are partially explained by adherence rates, highlighting the relevance of therapy compliance strategies. Short-term between-group differences (ANCOVAs) only showed statistically significant differences for WOMAC function between P-E and E-C in favor of E-C (6.4 (95% CI 1.6–11.2; score range 0–100)).

Exercise as Medicine During the Course of Hip Osteoarthritis

Exercise is now considered medicine in numerous chronic conditions and is essentially without side effects. We hypothesize that exercise is primary, secondary, and tertiary prevention at different stages of hip osteoarthritis (preclinical, mild-moderate, and severe hip osteoarthritis) and after total hip arthroplasty.

Designing Trials with Purpose: Pragmatic Clinical Trials of Nonpharmacological Approaches for Pain Management

OBJECTIVE

Pain is one of the most significant causes of morbidity and disability worldwide. The efficacy of several nonpharmacological approaches for pain management has been established, but significant gaps exist between this evidence and their limited availability and use in routine clinical practice. Questions remain about their effectiveness and how best to integrate them in usual care to optimize patient-centered outcomes. Pragmatic clinical trials (PCTs) may help address this gap. Informed by the Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2), we sought to describe the key features of optimized PCTs of nonpharmacological approaches for the management of pain and common co-occurring conditions.

METHODS

To accomplish this objective, we searched the published literature on PCTs of nonpharmacological pain management approaches from 2010-2019 and applied the PRECIS-2 criteria. We discuss key PRECIS-2 domains of interest for designing and performing PCTs and cite specific examples from the published literature as potential models for future PCTs.

RESULTS

We found 13 nonpharmacological PCTs. They were heterogeneous in size, recruitment, follow-up time, and location. The lessons learned from these studies led us to explicate key features of trials on the explanatory-pragmatic continuum across the PRECIS-2 domains that can be used by future investigators when designing their clinical trials of nonpharmacological approaches to pain management.

CONCLUSIONS

We encourage the increased application of PCTs to produce timely and valuable results and products that will inform the development of safe and effective integrated pain care plans that optimize important patient-centered outcomes.

Weight Control in Postmenopausal Korean Patients with Osteo-arthritis

Background:

Weight control is crucial for osteoarthritis management. This study investigated weight control methods in postmenopausal Korean osteoarthritis patients and examined their correlation with subjective health status and figure recognition, obesity, quality of life (QoL), and hemodynamic variables.

Methods:

One thousand six hundred and seventy-eight female postmenopausal osteoarthritis patients participated in the 2018 Korea National Health and Nutrition Examination Survey. A frequency analysis was conducted for weight control methods, and phi coefficients for crossover analyses or Cramer’s V coefficient were calculated to identify the relationships between weight-control-related variables and subjective health status and QoL. Using independent t-tests, we examined the relationships of weight control methods with hemodynamic variables.

Results:

Postmenopausal osteoarthritis patients’ preferred weight control methods were exercise, meal volume reduction, functional diet consumption, and the skipping of meals. Osteoarthritis patients who performed exercise demonstrated improved subjective figure recognition and health status, body weight, and recent 2-week discomfort, QoL, and hemodynamic variables (systolic blood pressure and fasting glucose, hemoglobin A1C, total cholesterol, high-density lipoprotein cholesterol, and high-sensitivity C-reactive protein [hs-CRP] levels). However, patients who attempted weight control by food volume reduction made relatively harder efforts to lose weight but were more likely to view themselves as obese, and demonstrated higher pain levels, anxiety/depression, and recent 2-week discomfort. Further, they exhibited lower triglyceride levels, as did patients who skipped meals.

Conclusion:

Overall, Korean postmenopausal osteoarthritis patients’ preferred weight control methods were exercise and reduced food intake. Although reduced food intake was effective for weight control, exercise improved mental health and hemodynamics, particularly inflammation (hs-CRP) levels.

Responders to Exercise Therapy in Patients with Osteoarthritis of the Hip: A Systematic Review and Meta-Analysis

The Outcome Measures in Rheumatology workgroup (OMERACT), together with the Osteoarthritis Research Society International (OARSI) developed the OMERACT-OARSI responder criteria. These criteria are used to determine if a patient with osteoarthritis (OA) ‘responds’ to therapy, meaning experiences a clinically relevant effect of therapy. Recently, more clinical OA trials report on this outcome and most OA trials have data to calculate the number of responders according to these criteria. A systematic review and meta-analysis were performed on the response to exercise therapy, compared to no or minimal intervention in patients with hip OA using the OMERACT-OARSI responder criteria. The literature was searched for relevant randomized trials. If a trial fit the inclusion criteria, but number of responders was not reported, the first author was contacted. This way the numbers of responders of 14 trials were collected and a meta-analysis on short term (directly after treatment, 12 trials n = 1178) and long term (6–8 months after treatment, six trials n = 519) outcomes was performed. At short term, the risk difference (RD) was 0.14 (95% confidence interval (CI) 0.06–0.22) and number needed to treat (NNT) 7.1 (95% CI 4.5–17); at long term RD was 0.14 (95% CI 0.07–0.20) and NNT 7.1 (95% CI 5.0–14.3). Quality of evidence was moderate for the short term and high for the long term. In conclusion, 14% more hip OA patients responded to exercise therapy than to no therapy.

Impact of Jiggling Exercise as Conservative Treatment for Hip Osteoarthritis: A Report of Two Cases

Total hip arthroplasty has been recognized as a feasible treatment for hip osteoarthritis, especially in advanced and terminal stages, but whether it is the best treatment for patients who are younger, have comorbidities, and/or are likely to have low compliance to medical treatment is unknown. Jiggling exercise, which involves the continuous shaking of the foot and leg in small steps, has been reported to be the easiest and a less invasive exercise for patients with hip osteoarthritis. We herein report two patients who performed jiggling exercise as conservative treatment and had successful outcomes. The first case was a 28-year-old woman with advanced-stage hip osteoarthritis that could not be treated with hip preservation surgery; furthermore, the patient refused to undergo total hip arthroplasty because of her young age. The second case was a 74-year-old woman with terminal-stage hip osteoarthritis in whom total hip arthroplasty was deemed not feasible because of possible low compliance due to mental disorder. One year after the initiation of the jiggling exercise, both patients had remarkable clinical improvement. Three years later, remarkable joint remodelling was also revealed in plain radiographs. Jiggling exercise might be a feasible conservative treatment option for joint preservation.

Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis

Background

Guidelines recommend exercise as a core treatment for osteoarthritis (OA). However, it is unclear which type of exercise is most effective, leading to inconsistency between different recommendations.

Objectives

The aim of this systematic review and network meta-analysis was to investigate the relative efficacy of different exercises (aerobic, mind–body, strengthening, flexibility/skill, or mixed) for improving pain, function, performance and quality of life (QoL) for knee and hip OA at, or nearest to, 8 weeks.

Methods

We searched nine electronic databases up until December 2017 for randomised controlled trials that compared exercise with usual care or with another exercise type. Bayesian network meta-analysis was used to estimate the relative effect size (ES) and corresponding 95% credibility interval (CrI) (PROSPERO registration: CRD42016033865).

Findings

We identified and analysed 103 trials (9134 participants). Aerobic exercise was most beneficial for pain (ES 1.11; 95% CrI 0.69, 1.54) and performance (1.05; 0.63, 1.48). Mind–body exercise, which had pain benefit equivalent to that of aerobic exercise (1.11; 0.63, 1.59), was the best for function (0.81; 0.27, 1.36). Strengthening and flexibility/skill exercises improved multiple outcomes at a moderate level. Mixed exercise was the least effective for all outcomes and had significantly less pain relief than aerobic and mind–body exercises. The trend was significant for pain (p = 0.01), but not for function (p = 0.07), performance (p = 0.06) or QoL (p = 0.65).

Conclusion

The effect of exercise varies according to the type of exercise and target outcome. Aerobic or mind–body exercise may be the best for pain and function improvements. Strengthening and flexibility/skill exercises may be used for multiple outcomes. Mixed exercise is the least effective and the reason for this merits further investigation.

Electronic supplementary material

The online version of this article (10.1007/s40279-019-01082-0) contains supplementary material, which is available to authorized users.

Exercise prescription for weight management in obese adults at risk for osteoarthritis: synthesis from a systematic review

BACKGROUND

The aim of this systematic review was to identify principles of exercise interventions associated with improved physical function, weight management or musculoskeletal pain relief among young and middle-aged adults with obesity and propose an evidence-based exercise prescription that could assist in secondary prevention of osteoarthritis.

METHODS

A structured electronic review was conducted using MEDLINE, PubMed, and SPORTDiscus. The search string included 1) "obes*" AND "exercise" AND "interven*" AND "musculoskeletal pain OR knee pain OR hip pain". Studies 1) were randomized controlled trials of humans, with a non-exercise control, 2) included participants aged 18-50 years, and 3) had outcomes that included physical function, musculoskeletal pain, and/or body composition. Studies were excluded if participants had peri-menopausal status, cancer, or obesity-related co-morbidities. A recommended exercise prescription was developed based on common principles used in the included exercise interventions with greatest change in function or pain.

RESULTS

Seven studies were included. Similarities in exercise intensity (40-80% VO_2max), frequency (three times per week), duration (30-60 min), and exercise mode (treadmill, cross-trainer, stationary bike, aquatic exercise) were observed in exercise interventions that resulted in improved physical function and/or pain, compared to non-exercise control groups.

CONCLUSION

Common principles in exercise prescription for improvements in weight management, physical function and pain relief among otherwise healthy people with obesity. Exercise prescription including moderate intensity exercise for 30-60 min, three times per week can be considered an effective treatment for weight management and obesity-related musculoskeletal symptoms. Exercise should be recommended to at-risk individuals as part of secondary prevention of osteoarthritis.

A Pilot Randomized Controlled Trial for Aerobic and Strengthening Exercises on Physical Function and Pain for Hip Osteoarthritis

BACKGROUND

Hip osteoarthritis (OA) limits lower extremity physical function. Exercise therapy may improve physical function and reduce pain in patients with hip OA.

OBJECTIVE

To evaluate the feasibility of a randomized controlled trial (RCT) to measure the effect of a structured hip-specific resistance and aerobic exercise program on physical function and self-reported pain in adults with hip OA.

DESIGN

Pilot RCT.

SETTING

Academic medical center.

PARTICIPANTS

Thirty one adults with radiographic hip OA.

INTERVENTIONS

Participants were randomly allocated in a 2:1 ratio to a 3-month structured exercise intervention (n = 21) or a 3-month waitlist control (n = 10).

MAIN OUTCOME MEASURES

The 6-minute walk test was the primary outcome measure. Self-reported physical function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale and pain visual analog scale (VAS). Measures of feasibility were assessed as secondary outcomes.

RESULTS

From baseline to 3 months, the median change from baseline in distance covered during the 6-minute walk test in the intervention group (49 m) was double that of the control group (22 m), but the difference was not statistically significant (P = .13). Likewise, the WOMAC physical function subscale score median changes in the intervention group (5 points) were double that of the controls (2 points), although the difference was not statistically significant (P = .06). Median change in pain scores was slightly reduced in each group but not significantly different between groups (P = .53).

CONCLUSION

Although no statistically significant between-group differences were found in this pilot RCT, improvements were seen in measures of physical function compared to controls. A larger RCT of this structured exercise program may be warranted.

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

Background

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

Objective

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

Design

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

Data sources

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

Eligibility criteria for selecting studies

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

Results

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

Conclusions

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

Comparison of effectiveness of the home exercise program and the home exercise program taught by physiotherapist in knee osteoarthritis

BACKGROUND

Home-based exercise therapy is effective in reducing pain and improving function in adults with osteoarthritis of the knee.

OBJECTIVE

To investigate and compare the effectiveness of the home exercise program and the home exercise program taught by a physiotherapist in knee osteoarthritis.

METHODS

The study was conducted with 80 patients with knee osteoarthritis. The patients were randomized into two groups. The first group was given the home exercise brochure by the orthopedist, while the second group did home exercises under the guidance of the physiotherapist. The goniometer for the range of motion (ROM) of the knee, Myometer for evaluation of the quadriceps and hamstring muscles strength, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form Health Survey (SF-36) were used for evaluation.

RESULTS

Statistically significant improvements were found in the post-treatment ROM, VAS, quadriceps and hamstring muscles strength, WOMAC and SF-36 values in both groups (p< 0.05). When the change values were compared, the evaluation results of group II were better than group I statistically (p< 0.05).

CONCLUSIONS

This study proved that home exercises taught by a physiotherapist were more useful for patients with knee osteoarthritis. When the home exercise program is implemented, a new role is created for a physiotherapist.

Behaviour change techniques applied in interventions to enhance physical activity adherence in patients with chronic musculoskeletal conditions: A systematic review and meta-analysis

OBJECTIVE

To identify Behaviour Change Techniques (BCTs) applied in interventions to enhance physical activity (PA) adherence in patients with chronic musculoskeletal conditions and to investigate the effectiveness of these interventions in increasing PA adherence.

METHODS

A systematic search of seven databases was conducted. We included (cluster/quasi-) randomised controlled trials comparing behaviour change interventions to no/placebo/minimal interventions or usual care and involving at least a three-month post-intervention follow-up. Methodological quality was assessed, study characteristics and BCTs were narratively summarised and a meta-analysis was conducted.

RESULTS

Across 22 included studies, we coded 8-18 BCTs (mean = 11.2) in intervention and 0-12 (mean = 3.5) in control groups. Common BCTs were "graded tasks", "goal setting", "self-monitoring", "problem solving" and "feedback". Meta-analyses of 17 studies revealed a small medium-term effect (3-6 months post-intervention, standardised mean difference (SMD) = 0.20, 95% CI 0.08-0.33) and no long-term effect (7-12 months post-intervention, SMD = 0.13, 95% CI -0.02 to 0.28). Subgroup analysis yielded a higher effect (SMD = 0.29, 95% CI 0.19-0.40) for interventions using a greater number of BCTs.

CONCLUSION

There is moderate quality evidence that interventions using BCTs are effective to enhance medium-term physical activity adherence.

PRACTICE IMPLICATION

While superiority of single BCTs was not shown, it is likely that using more BCTs results in better adherence.

Daily Pain Measurements and Retrospective Pain Measurements in Hip Osteoarthritis Patients With Intermittent Pain

OBJECTIVE

To examine the value of daily pain measurements in patients with hip osteoarthritis (OA), and whether the reliability of retrospective measurements was lower in patients with intermittent pain than in patients with more constant pain.

METHODS

We used data from a randomized controlled trial that investigated the effectiveness of general practitioner care plus exercise therapy in 203 patients with hip OA. During the first 6 weeks, patients scored their pain each day. These daily measurements were available for 185 patients. At 6-week follow-up, patients filled in a questionnaire rating their pain during the previous week. We examined whether the daily measurements provided results for pain other than those provided by retrospective measurements, using a linear mixed-effects model. We also explored differences between subgroups, based on the frequency and severity of intermittent pain, during the pain course and reliability between retrospective measurements and daily measurements.

RESULTS

Daily measurements showed no different effect of exercise therapy on pain compared with retrospective measurements. We found statistical differences (by analysis of variance) during the course of pain between the subgroups based on the intensity of intermittent pain. Reliability between retrospective and daily measurements was lower in the subgroup with severe intermittent pain (Cronbach's α = 0.642) than in other subgroups (Cronbach's α >0.843).

CONCLUSION

In this specific trial, daily measurements did not yield more precise or additional information compared with retrospective measurements at the 6-week follow-up. However, reliability of retrospective measurements may be lower in patients with a higher intensity of intermittent pain.

Exercise Therapy Interventions in Patients With Hip Osteoarthritis: Comparison of the Effects of DVD and Website-Based Interventions

Background

Prevalence of developmental hip dysplasia is high in Japan. Exercise therapy has been proven effective to treat certain aspects of hip osteoarthritis. Moreover, therapy provided via digital video discs (DVDs) and websites allows patients to exercise in the comfort of their own homes. However, no studies have evaluated the effectiveness of visual instructions in patients with hip disorders.

Objective

This study aimed to compare the effectiveness of exercise therapy administered via DVD and that administered via a website.

Methods

We developed a six-step progressive exercise therapy program for patients with hip osteoarthritis, which included three kinds each of open kinetic chain and closed kinetic chain exercises. Once the program was developed, exercise DVDs were produced. In addition to the six-step exercise program, our website was enabled to count the number of exercises performed by each patient and was accessible via the Internet at any time. Patients with hip osteoarthritis for whom surgery was not advised were enrolled by one university hospital in the Kansai area in Japan. Clinical symptoms and hip function were quantified using the Japanese Orthopedic Association Hip Disease Evaluation Questionnaire (JHEQ) and the Oxford Hip Score (OHS). Quality of life was measured using the SF-8 Health Survey, and self-efficacy for continued exercise was measured using the General Self-Efficacy Scale (GSES). Questionnaires were completed preintervention and after 6 months.

Results

At 6-month follow-up, 10 DVD users (1 male, 9 female; mean age 51.3, SD 16.1 years) and 18 website users (2 male, 16 female; mean age 52.4, SD 10.4 years) were reachable. The change in each parameter could not be confirmed a significant improvement. However, most items tended to reflect overall improvement during the 6 months of intervention (P=.05-.94; paired t test). Regarding effect size, we considered a small effect to be greater than 0.2. Little effect was observed for JHEQ pain, SF-8 physical component summary (PCS), and SF-8 mental component summary in the DVD group, as well as OHS, SF-8 (PCS), and GSES in the website group.

Conclusions

When comparing the effectiveness of exercise therapy between our DVD and website, we found that although both groups tended to improve in physical function, only the website group showed tendency of enhanced self-efficacy.

The importance of dose in land-based supervised exercise for people with hip osteoarthritis. A systematic review and meta-analysis

PURPOSE

To compare effects of land-based exercise programmes with high vs low or uncertain compliance with dose recommendations among people with hip osteoarthritis (OA).

DESIGN

A systematic review with meta-analyses of supervised exercise programmes in people with symptomatic hip OA was conducted. Dose of the exercise interventions was evaluated according to the American College of Sports Medicine's (ACSM) recommendations for developing and maintaining cardiorespiratory fitness, muscular strength and flexibility in healthy adults. Compliance ratios with the recommendations were calculated. Standardized Mean Differences (SMDs) were calculated in meta-analyses for the outcomes pain and self-reported physical function. Outcome effects were compared between the sub-groups of studies with interventions with "high" vs "uncertain" compliance with the ACSM recommendations.

RESULTS

Twelve studies including 1202 participants were included. Seven were categorized with "high" and five with "uncertain" compliance with the ACSM recommendations. Ten studies had an overall low risk of bias. Comparing exercise with no exercise, the pooled SMD for pain was -0.42 (95% CI -0.58, -0.26) in the high compliance group, favouring exercise. In the uncertain compliance group the pooled SMD was 0.04 (95% CI -0.24, 0.31). For physical function the SMD was -0.41 (95% CI -0.58, -0.24) in the high compliance group and -0.23 (95% CI -0.52, 0.06) in the uncertain compliance group.

CONCLUSIONS

The results show that land-based supervised exercise interventions with high compliance to the ACSM recommendations result in significantly larger improvements in pain and non-significantly larger improvement in self-reported physical function compared with land-based supervised exercise interventions with uncertain compliance.

Clinical results of arthroscopic surgery in patients over 50 years of age-what viability does it have as a joint preservative surgery?

BACKGROUND

To identify whether hip arthroscopy is a suitable option for treating hip pain in elderly patients and investigate the clinical outcomes of hip arthroscopic surgery for labrum tear and/or osteoarthritis in patients over 50 years of age.

METHODS

Between August 2009 and May 2014, a series of 23 patients (6 men and 17 women) with a mean age of 59 years underwent arthroscopy. We retrospectively examined the clinical records, radiographs, and outcome questionnaires from all patients. The mean follow-up period was 28 months.

RESULTS

The mean Japan Orthopedic Association hip score after surgery improved by a statistically significant amount. Eight patients (34.8%) were noted to have a progression of osteoarthritis (OA) diagnosed by radiograph, and one underwent THA after 13 months following arthroscopic surgery. The patients in which OA progression was noted were identified as having radiographical OA preoperatively and acetabular cartilage damage in the arthroscopic findings.

CONCLUSIONS

Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings.