Response to Dr Forestier's eLetter on EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

Evaluating and Enhancing Large Language Models' Performance in Domain-specific Medicine: Explainable LLM with DocOA

BACKGROUND

Evaluating and Enhancing Large Language Models' Performance in Domain-specific Medicine: Explainable LLM with DocOA.

OBJECTIVE

This study focused on evaluating and enhancing the clinical capabilities and explainability of LLMs in specific domains, using osteoarthritis (OA) management as a case study.

METHODS

A domain specific benchmark framework was developed, which evaluate LLMs across a spectrum from domain-specific knowledge to clinical applications in real-world clinical scenarios. DocOA, a specialized LLM designed for OA management integrating retrieval-augmented generation (RAG) and instructional prompts, was developed. It can identify the clinical evidence upon which its answers are based through RAG, thereby demonstrating the explainability of those answers. The study compared the performance of GPT-3.5, GPT-4, and a specialized assistant, DocOA, using objective and human evaluations.

RESULTS

Results showed that general LLMs like GPT-3.5 and GPT-4 were less effective in the specialized domain of OA management, particularly in providing personalized treatment recommendations. However, DocOA showed significant improvements.

CONCLUSIONS

This study introduces a novel benchmark framework which assesses the domain-specific abilities of LLMs in multiple aspects, highlights the limitations of generalized LLMs in clinical contexts, and demonstrates the potential of tailored approaches for developing domain-specific medical LLMs.

CLINICALTRIAL

Exercise therapy for knee osteoarthritis pain: how does it work? A study protocol for a randomised controlled trial

INTRODUCTION

Muscle strengthening training (MST) and behavioural graded activity (BGA) show comparable effects on knee osteoarthritic (KOA) pain, but the mechanisms of action remain unclear. Both exercise-induced anti-inflammation and central sensitisation are promising pathways for pain relief in response to exercise therapy in patients with KOA: MST has the potential to decrease inflammation and BGA has the potential to decrease central sensitisation. Hence, this study aims to examine inflammation and central sensitisation as mediators for the effect of MST and/or BGA on pain in patients with KOA.

METHODS AND ANALYSIS

The Knee OsteoArthritis PAIN trial started on 10 January 2020 (anticipated end: April 2024). The three-arm clinical trial aims to recruit 90 KOA patients who will be randomly allocated to 12 weeks of (1) MST, (2) BGA or (3) care as usual. Assessments will be performed at baseline, 13 and 52 weeks after finishing the intervention. Outcomes, including pain (Knee injury and Osteoarthritis Outcome Score), were chosen in line with the OARSI recommendations for clinical trials of rehabilitation interventions for OA and the IMMPACT/OMERACT recommendations for the assessment of physical function in chronic pain clinical trials. Inflammation as well as features of central sensitisation (including conditioned pain modulation, offset analgesia, temporal summation of pain and event-related potentials following electrical stimulation), will be considered as treatment mediators. A multiple mediators model will be estimated with a path-analysis using structural equation models. In July 2023, all 90 KOA patients have been included and 42 participants already finished the study.

ETHICS AND DISSEMINATION

This study obtained ethics approval (B.U.N. 143201941843). Unravelling the mechanisms of action of exercise therapy in KOA will not only be extremely valuable for researchers, but also for exercise immunology and pain scientists and clinicians.

TRIAL REGISTRATION NUMBER

NCT04362618.

A new measure of exercise adherence: the ATEMPT (Adherence To Exercise for Musculoskeletal Pain Tool)

OBJECTIVES

This study aimed to (1) develop a new measure of adherence to exercise for musculoskeletal (MSK) pain (Adherence To Exercise for Musculoskeletal Pain Tool: ATEMPT) based on previously conceptualised domains of exercise adherence, (2) report the content and structural validity, internal consistency, test-retest reliability, and measurement error for the ATEMPT outcome measure in patients managed with exercise for MSK pain.

METHODS

ATEMPT was created using statements describing adherence generated by patients, physiotherapists and researchers, with content validity established. Baseline and retest questionnaires were distributed to patients recommended exercise for MSK pain in 11 National Health Service physiotherapy clinics. Items demonstrating low response variation were removed and the following measurement properties assessed: structural validity, internal consistency, test-retest reliability and measurement error.

RESULTS

Baseline and retest data were collected from 382 and 112 patients with MSK pain, respectively. Confirmatory factor analysis established that a single factor solution was the best fit according to Bayesian Information Criterion. The 6-item version of the measure (scored 6-30) demonstrated optimal internal consistency (Cronbach's Alpha 0.86, 95% CI 0.83 to 0.88) with acceptable levels of test-retest reliability (intraclass correlation coefficient 0.84, 95% CI 0.78 to 0.88) and measurement error (smallest detectable change 3.77, 95% CI 3.27 to 4.42) (SE of measurement 2.67, 95% CI 2.31 to 3.16).

CONCLUSION

The 6-item ATEMPT was developed from the six domains of exercise adherence. It has adequate content and structural validity, internal consistency, test-retest reliability and measurement error in patients with MSK pain, but should undergo additional testing to establish the construct validity and responsiveness.

Development of a Digital Health Intervention to Support Patients on a Waitlist for Orthopedic Specialist Care: Co-Design Study

BACKGROUND

The demand for orthopedic specialist consultations for patients with osteoarthritis in public hospitals is high and continues to grow. Lengthy waiting times are increasingly affecting patients from low socioeconomic and culturally and linguistically diverse backgrounds who are more likely to rely on public health care.

OBJECTIVE

This study aimed to co-design a digital health intervention for patients with OA who are waiting for an orthopedic specialist consultation at a public health service, which is located in local government areas (LGAs) of identified social and economic disadvantage.

METHODS

The stakeholders involved in the co-design process included the research team; end users (patients); clinicians; academic experts; senior hospital staff; and a research, design, and development agency. The iterative co-design process comprised several key phases, including the collation and refinement of evidence-based information by the research team, with assistance from academic experts. Structured interviews with 16 clinicians (female: n=10, 63%; male: n=6, 38%) and 11 end users (age: mean 64.3, SD 7.2 y; female: n=7, 64%; male: n=4, 36%) of 1-hour duration were completed to understand the requirements for the intervention. Weekly workshops were held with key stakeholders throughout development. A different cohort of 15 end users (age: mean 61.5, SD 9.7 y; female: n=12, 80%; male: n=3, 20%) examined the feasibility of the study during a 2-week testing period. The System Usability Scale was used as the primary measure of intervention feasibility.

RESULTS

Overall, 7 content modules were developed and refined over several iterations. Key themes highlighted in the clinician and end user interviews were the diverse characteristics of patients, the hierarchical structure with which patients view health practitioners, the importance of delivering information in multiple formats (written, audio, and visual), and access to patient-centered information as early as possible in the health care journey. All content was translated into Vietnamese, the most widely spoken language following English in the local government areas included in this study. Patients with hip and knee osteoarthritis from culturally and linguistically diverse backgrounds tested the feasibility of the intervention. A mean System Usability Scale score of 82.7 (SD 16) was recorded for the intervention, placing its usability in the excellent category.

CONCLUSIONS

Through the co-design process, we developed an evidence-based, holistic, and patient-centered digital health intervention. The intervention was specifically designed to be used by patients from diverse backgrounds, including those with low health, digital, and written literacy levels. The effectiveness of the intervention in improving the physical and mental health of patients will be determined by a high-quality randomized controlled trial.

Flat flexible school shoes for adolescents with patellofemoral pain: a randomised, assessor-blinded, parallel-group feasibility trial

Objectives

To determine the feasibility of conducting a large-scale randomised controlled trial on the efficacy of flat, flexible school footwear versus traditional school footwear in adolescents (aged 12-18 years) with patellofemoral pain (PFP).

Methods

Adolescents with PFP were recruited for this study. Participants were randomised to wear either a (1) flat, flexible school shoe or (2) a traditional school shoe. Participants wore the shoes as per school requirements for 12 weeks. Feasibility was assessed by (1) adherence to allocated shoe wear of ≥75% of total weekly school shoe wear time (recorded through weekly log sheets), (2) a recruitment rate of one participant per fortnight and (3) a dropout rate of ≤ 20%. Descriptive statistics were used for feasibility outcomes.

Results

24 adolescents (15 men, 9 women, mean (SD) age 14.3 (1.7) years) participated in this study. Two participants (8%) were lost to follow-up. The recruitment rate was 1.7 participants per fortnight. 11 of 12 participants (91%) in the flat flexible shoe group and 9 of 10 participants (90%) in the traditional shoe group met the minimum adherence for shoe wear. Mean weekly shoe wear was 20 (7.6) and 21 (4.5) hours per week in the flat, flexible, and traditional shoe groups, respectively.

Conclusion

Our results indicate that progression to a full-scale randomised controlled trial is feasible based on the current protocol. A full-scale randomised controlled trial powered to detect estimates of treatment efficacy using flat, flexible school shoes versus traditional school shoes is warranted and will guide evidence-based management of adolescent PFP.

Ajugol's upregulation of TFEB-mediated autophagy alleviates endoplasmic reticulum stress in chondrocytes and retards osteoarthritis progression in a mouse model

BACKGROUND

Osteoarthritis (OA), a degenerative disease with a high global prevalence, is characterized by the degradation of the extracellular matrix (ECM) and the apoptosis of chondrocytes. Ajugol, a extract derived from the herb Rehmannia glutinosa, has not yet been investigated for its potential in modulating the development of OA.

METHODS

We employed techniques such as western blotting, immunofluorescence, immunohistochemistry, X-ray imaging, HE staining, and SO staining to provide biological evidence supporting the role of Ajugol as a potential therapeutic agent for modulating OA. Furthermore, in an in vivo experiment, intra-peritoneal injection of 50 mg/kg Ajugol effectively mitigated the progression of OA following destabilization of the medial meniscus (DMM) surgery.

RESULTS

Our findings revealed that treatment with 50 μM Ajugol activated TFEB-mediated autophagy, alleviating ER stress-induced chondrocyte apoptosis and ECM degradation caused by TBHP. Furthermore, in an in vivo experiment, intra-peritoneal injection of 50 mg/kg Ajugol effectively mitigated the progression of OA following destabilization of the medial meniscus (DMM) surgery.

CONCLUSION

These results provide compelling biological evidence supporting the role of Ajugol as a potential therapeutic agent for modulating OA by activating autophagy and attenuating ER stress-induced cell death and ECM degradation. The promising in vivo results further suggest the potential of Ajugol as a treatment strategy for OA progression.

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

The role of the therapeutic physical exercise and the complex recovery treatment for the patients with chronic degenerative diseases during the COVID-19 pandemic

Abstract: Background: Osteoarthritis is one of the most common causes of pain and musculoskeletal disability and mainly affects the middle-aged and the elderly. The condition is chronic and disabling, it diminishes the patients' quality of life. Purpose. The study had the purpose of pointing out a possible connection between physical ac-tivity and the reduction of pain accompanied by the increased functional capacity in patients with chronic degenerative diseases during the COVID-19 pandemic. Material and method: The study was conducted on an outpatient basis for a period of 6 months on a number of 40 patients diagnosed with osteoarthritis. The evaluation of the pa-tients was made at the beginning of the treatment and at its end (after 4 weeks), as well as at the control after 12 weeks. Results: The study included a number of 40 patients over 45 years old, divided into 2 study groups: in group L1-knee osteoarthritis and in group L2 -hip osteoarthritis. The therapeutic physical exercise reduced pain and stiff-ness, and it also improved the functional capacity. Conclusions: Therapeutic physical exercise has an important role in the reduction of pain and disability, as well as in the increase in the quality of life, if it is done properly. Keywords: osteoarthritis, therapeutic physical exercise, pain, pandemic COVID-19

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.

mHealth Apps for Musculoskeletal Rehabilitation: State of the Practice Review (Preprint)

Background

The number of mobile health (mHealth) apps released for musculoskeletal (MSK) injury treatment and self-management with home exercise programs (HEPs) has risen rapidly in recent years as digital health interventions are explored and researched in more detail. As this number grows, it is becoming increasingly difficult for users to navigate the market and select the most appropriate app for their use case. It is also unclear what features the developers of these apps are harnessing to support patient self-management and how they fit into clinical care pathways.

Objective

The objective of this study was to scope the current market of mHealth apps for MSK rehabilitation and to report on their features, claims, evidence base, and functionalities.

Methods

A cross-sectional study of apps for MSK rehabilitation was performed across the iTunes App Store and Google Play Store. Four search terms were used, namely, physiotherapy rehabilitation, physical therapy rehabilitation, rehabilitation exercise, and therapeutic exercise to identify apps, which were then cross-referenced against set selection criteria by 4 reviewers. Each reviewer, where possible, downloaded the app and accessed supplementary literature available on the product to assist in data extraction.

Results

A total of 1322 apps were identified. After applying the inclusion and exclusion criteria and removing duplicates, 144 apps were included in the study. Over half (n=81, 56.3%) of the included apps had been released within the past 3 years. Three quarters (n=107, 74.3%) of the apps made no reference to evidence supporting the design or efficacy of the app, with only 11.1% (n=16) providing direct citations to research. Most of the apps did utilize exercise pictures (n=138, 95.8%) or videos (n=97, 67.4%); however, comparatively few harnessed additional features to encourage engagement and support self-management, such as an adherence log (n=66, 45.8%), communication portal (n=32, 22.2%), patient-reported outcome capture (n=36, 25%), or direct feedback (n=57, 39.6%). Of note and concern, many of these apps prescribed generic exercises (n=93, 64.6%) in the absence of individualized input to the user, with few providing specific patient education (n=43, 34%) and safety advice or disclaimers (n=38, 26.4%).

Conclusions

The cohort of apps included in this study contained a large heterogeneity of features, so it is difficult for users to identify the most appropriate or effective app. Many apps are missing the opportunity to offer key features that could promote exercise adherence and encourage self-management in MSK rehabilitation. Furthermore, very few developers currently offering products on the market are providing evidence to support the design and efficacy of their technologies.

Exercise therapy in hip osteoarthritis--a randomized controlled trial

BACKGROUND

Roughly one in ten persons in the industrialized world suffers from hip osteoarthritis, a disease for which there is no cure. The goal of conservative therapy is to relieve symptoms, preferably with methods that let patients assume responsibility for their own treatment, e.g., physical training.

METHOD

In a randomized controlled trial, we studied the effectiveness of twelve weeks of exercise therapy in patients with hip osteoarthritis (THüKo), compared to no treatment (control group) and placebo ultrasound treatment of the hip (placebo ultrasound group). The primary endpoint was a comparison of the pain scores of the intervention versus control groups on the generic SF-36 health questionnaire. Secondary endpoints included comparisons across all three study groups of scores on the 7 other scales of the SF-36 and on the pain, physical function, and stiffness scales of the osteoarthritis-specific WOMAC Index. The statistical analysis was performed with ANCOVA, with baseline values as a covariate. Between-group effects were subsequently tested pairwise (two-tailed t-tests, alpha = 0.05).

RESULTS

As for the primary endpoint, pain reduction was significantly greater in the intervention than in the control group (mean difference 5.7 points, 95% confidence interval [CI] 0.4-11.1 points, p = 0.034). The comparisons across all three study groups (i.e., secondary endpoints, with 71 subjects in the intervention group, 68 in the control group, and 70 in the placebo group) revealed no significant between-group effects with respect to the SF-36. On the WOMAC Index, however, statistically significant differences were found for pain reduction between the intervention and control group (mean difference 7.4 points, 95% CI 3.0-11.8, p = 0.001) and between the intervention and placebo group (mean difference 5.1 points, 95% CI 0.7-9.4, p = 0.024). Comparable mean differences were also found for functional improvement.

CONCLUSION

Twelve weeks of exercise therapy in hip osteoarthritis patients of normal vitality reduced pain and improved physical function. No significant improvement was found in these patients' general health-related quality of life.