Behavioural physical activity interventions in participants with lower-limb osteoarthritis: a systematic review with meta-analysis

Follow-up of individualised physical activity on prescription and individualised advice in patients with hip or knee osteoarthritis: A randomised controlled trial

OBJECTIVE

Compare the long-term effects of two different individualised physical activity interventions in hip or knee osteoarthritis patients.

DESIGN

Randomised, assessor-blinded, controlled trial.

SETTING

Primary care.

SUBJECTS

Patients with clinically verified hip or knee osteoarthritis, <150 min/week with moderate or vigorous physical activity, aged 40-74.

INTERVENTION

The advice group (n = 69) received a 1-h information and goalsetting session for individualised physical activity. The prescription group (n = 72) received information, goalsetting, individualised written prescription, self-monitoring, and four follow-ups.

MAIN MEASURES

Physical activity, physical function, pain and quality of life at baseline, 6, 12 and 24 months.

RESULTS

There were only minor differences in outcomes between the two groups. For self-reported physical activity, the advice group had improved from a mean of 102 (95% CI 74-130) minutes/week at baseline to 214 (95% CI 183-245) minutes/week at 24 months, while the prescription group had improved from 130 (95% CI 103-157) to 176 (95% CI 145-207) minutes/week (p = 0.01 between groups). Number of steps/day decreased by -514 (95% CI -567-462) steps from baseline to 24 months in the advice group, and the decrease in the prescription group was -852 (95% CI -900-804) steps (p = 0.415 between groups). Pain (HOOS/KOOS) in the advice group had improved by 7.9 points (95% CI 7.5-8.2) and in the prescription group by 14.7 points (95% CI 14.3-15.1) from baseline to 24 months (p = 0.024 between groups).

CONCLUSIONS

There is no evidence that individualised physical activity on prescription differs from individualised advice in improving long-term effects in patients with hip or knee osteoarthritis.

A Systematic Review of Physical Activity and Sedentary Behavior Patterns in an Osteoarthritic Population

OBJECTIVE

To explore physical activity (PA) and sedentary behaviors (SB) in individuals with lower limb (LL) Osteoarthritis (OA) and the influence of age, sex, and body mass index (BMI) on these behaviors.

DESIGN

Systematic review search: PubMed, Cochrane Library, ScienceDirect, and CINAHL databases were searched from inception until July 2023. Study criteria: Studies that reported quantifiable device-based or self-reported data for PA and SB variables in adults clinically diagnosed with LL OA were included.

DATA SYNTHESIS

A synthesis of PA and SB levels for those diagnosed with LL OA and the influence age, sex, and BMI have on these behaviors.

RESULTS

From the 1930 studies identified through the electronic search process, 48 met the inclusion criteria. PA guidelines were met by 33% of the sample population that measured moderate and moderate to vigorous PA. No studies reported 75 minutes per week or more of vigorous PA. Additionally, 58% of the population reporting SB were sedentary for 8 hours per day or more. Also, increasing age, BMI, and the female sex were identified as negative influences on PA levels. There were numerous methodological inconsistencies in how data were collected and reported, such as various activity monitor cut points for PA and SB bout duration.

CONCLUSION

Adults with LL OA may be at an increased risk of noncommunicable diseases due to low PA and high SB levels. It is important to consider age, sex, and BMI when investigating behavior patterns in those with LL OA.

Effects of Exercise-Based Interventions on Physical Activity Levels in Persons With Parkinson's Disease: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Parkinson's disease (PD) is the most common neurodegenerative movement disorder. Symptom severity leads to devastating consequences such as falls, immobility, impaired quality of life, and reduced general activity. Adopting a sedentary lifestyle creates a vicious circle, as physical inactivity can negatively affect the clinical domains of PD. Despite the recognition of the disease-modifying potential of physical activity (PA), achieving adequate exercise levels can be challenging for individuals with PD. This study aimed to investigate the repercussions of exercise-based interventions to improve PA levels in persons with PD through a systematic review with meta-analysis.

METHODS

A search was conducted from database inception to February 2021 across 3 databases: PubMed, Web of Science, and Scopus. Randomized controlled trials were included if they involved persons with PD, outcome measures associated with PA levels, and an exercise-based intervention. Two reviewers performed independent data extraction and methodologic quality assessment of the studies using the Downs and Black quality checklist.

RESULTS

A total of 6 studies were included in the study (1251 persons with PD). Four intervention types were identified: balance, strength, aerobic, and multimodal exercise (combination of several types of exercise programs). The meta-analysis showed that exercise interventions have a positive effect on PA (standard mean difference = 0.50, 95% CI =-0.02, 1.00; P = .06). The risk of bias was generally low.

CONCLUSIONS

The findings support the use of exercise-based interventions (aerobic exercise, balance exercise, strength exercise, and/or multimodal exercise) to improve PA levels. However, the limited number of studies and the heterogeneity of the interventions do not allow us to draw a definitive conclusion.

Effect of In-Person Delivered Behavioural Interventions in People with Multimorbidity: Systematic Review and Meta-analysis

BACKGROUND

To investigate the effect of in-person delivered behavioural interventions in people with multimorbidity and which behaviour change techniques (BCTs), targeting lifestyle behaviours, are associated with better outcomes.

METHODS

Systematic review of randomised controlled trials. We searched MEDLINE, EMBASE, CENTRAL, and CINAHL and screened reference list of reviews including people with multimorbidity, registries, and citation tracking of included studies. Meta-analyses using random-effects model to assess the effect of behavioural interventions and meta-regression analyses and effectiveness ratios to investigate the impact of mediators on effect estimates. Cochrane 'Risk of Bias Tool' 2.0 and the GRADE assessment to evaluate the overall quality of evidence.

RESULTS

Fourteen studies involving 1,378 people. Behavioural interventions had little to no effect on physical activity (standardised mean difference 0.38, 95% CI -0.12-0.87) and the effect on weight loss was uncertain (BMI mean difference -0.17, 95% CI -1.1-0.83) at the end-treatment follow-up. Small improvements were seen in health-related quality of life (SMD 0.29, 95% CI 0.17-0.42) and physical function (SMD 0.42, 95% CI 0.12-0.73), and moderate improvements were seen for depression symptoms (SMD -0.70, 95% CI -0.97-0.42). Studies using the BCTs 'action planning' and 'social support (practical)' reported greater physical activity and weight loss.

CONCLUSIONS

Behavioural interventions targeting lifestyle behaviours may improve health-related quality of life and physical function, and reduce depression, whereas little to no effect was achieved on physical activity and weight loss in people with multimorbidity. However, the evidence for physical activity and weight loss were of low quality and the end-treatment benefits diminished over time.

Loneliness is Associated With Lower Coping Self-Efficacy Among Older Adults

To address the gap of lacking research on the association between coping self-efficacy and loneliness, this study examined this relationship to inform future research and intervention on loneliness. Using data from 151 community-dwelling older adults ages 65 and older, we estimated multivariate logistic regression models with age, race/ethnicity, sex, body mass index, chronic disease composite score, social support, coping self-efficacy, and depression symptoms. Loneliness was reported in 32.1% of participants and negatively associated with coping self-efficacy (OR = 0.68, 95% CI: 0.50-0.93) while controlling for age, race, sex, chronic disease composite score, and body mass index. Our findings suggest that coping self-efficacy may be a target for intervention involving loneliness in future research; however, the causal relationship between coping self-efficacy and loneliness should be explored further.

Changes in physical activity and the association between pain and physical activity - a longitudinal analysis of 17,454 patients with knee or hip osteoarthritis from the GLA:D® registry

OBJECTIVE

Investigate change in physical activity following an 8-week education and exercise therapy program for patients with knee/hip osteoarthritis, focusing on those with low physical activity level. Furthermore, to evaluate associations between changes in pain intensity and physical activity.

METHOD

Data from the Good Life with osteoArthritis in Denmark (GLA:D®) registry, at baseline, immediately after completion, and 12 months after entering the program was used. Measures of interest were UCLA activity scale (1-10) and Visual Analog Scale for pain intensity (0-100 mm). Changes in physical activity levels (low 1-4, moderate 5-6, and high 7-10) over three time points were investigated. Asymmetric fixed effects regression models were used to evaluate the association between clinically relevant change in pain (≥15 mm) and change in physical activity level from baseline to 12 months.

RESULTS

37% with low activity level at baseline (n = 4,836) and 69% of all patients (n = 17,454) reached or maintained at least a moderate physical activity level at follow-ups. Surprisingly, both an improvement (β = 1.44, P < 0.001) and a worsening (β = 1.18, P < 0.001) in pain intensity was associated with increased physical activity in low activity patients. For all patients a similar trend was observed (β = 0.51, P < 0.001 and β = 0.11, P = 0.215, respectively).

CONCLUSION

In low active knee or hip OA patients, a third of patients participating in an education and exercise therapy program reached and maintained at least a moderate physical activity level for 1 year. The improvement in physical activity was not dependent on pain reduction.

Effect of exercise and/or educational interventions on physical activity and pain in patients with hip/knee osteoarthritis: A systematic review with meta-analysis

OBJECTIVE

To investigate the effectiveness of exercise and/or educational intervention on physical activity and pain in patients with hip/knee osteoarthritis (OA) using systematic review and meta-analysis.

METHODS

We searched randomized controlled trials that investigated physical activity and pain and compared exercise and/or educational intervention with usual care in patients with hip/knee OA in MEDLINE (PubMed), ProQuest, Scopus, and the Physiotherapy Evidence Database (PEDro), including all those published by April 30, 2022 and written in English. Studies that newly applied analgesics after onset of the intervention were excluded. The revised Cochrane risk-of-bias tool for randomized trials was used to assess the methodological qualities. The random-effects model was used for meta-analysis with standard mean differences using RevMan version 5.4. The body of evidence for each study was synthesized using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Twenty studies including 2,350 patients were included (7 exercise studies, 8 educational intervention studies and 5 combination studies). The meta-analysis demonstrated that there is very low evidence that combination therapy of exercise and educational intervention improve the physical activity level at the endpoint (4 articles; SMD 0.33, 95% CI 0.04 to 0.51, P = 0.03). Low evidence was observed for combination therapy reducing pain (4 articles; SMD -0.15, 95% CI -0.29 to -0.02, P = 0.03).

DISCUSSION

The current evidence indicated that combination therapy of exercise and educational intervention leads to improved physical activity and pain reduction in hip/knee OA patients, but the risk of bias in each study, especially in allocation concealment, downgraded the evidence level. These findings support the use of a combination therapy of exercise and educational intervention to promote physical activity levels in patients with hip/knee OA.

TRAIL REGISTRATION

There was no financial support for this research. The protocol was registered at the International Prospective Register of Systematic Reviews (registration code: CRD42020205804).

Physical activity, sedentary behaviour and well-being: experiences of people with knee and hip osteoarthritis

Living with knee and hip osteoarthritis (OA) means living with pain and difficulty in movement. Given the beneficial effects of physical activity (PA) and reduction of sedentary behaviour (SB), these behaviours need to be understood in the context of individuals' daily lives and sense of well-being. Twelve individuals (age: 43-79 years; 67% female) with knee and/or hip OA purposively selected (e.g., age, OA duration, OA severity) participated in semi-structured interviews. Data was analysed using inductive thematic analysis. PA and SB were narrated as multifaceted experiences with two overarching themes, PA negotiations (valuing mobility, the burden of osteoarthritis, keep going, the feel-good factor), SB negotiations (the joy of sitting, a lot is too bad, the osteoarthritis confines), and two overlapping themes (the life context, finding a balance). Physical and psychological aspects of PA and SB experiences were interwoven. Participants valued mobility and were proactively trying to preserve it by keeping active. A constant negotiation among the OA burden, the need to enjoy life and life circumstances was underlying PA behaviour. Prescription and encouragement of a physically active lifestyle in this population should be linked to mobility-related personal values and sense of well-being, while addressing concerns around OA-safety and normalizing PA trade-offs.

Experiences of activity monitoring and perceptions of digital support among working individuals with hip and knee osteoarthritis - a focus group study

Background

Mobile health (mHealth), wearable activity trackers (WATs) and other digital solutions could support physical activity (PA) in individuals with hip and knee osteoarthritis (OA), but little is described regarding experiences and perceptions of digital support and the use of WAT to self-monitor PA. Thus, the aim of this study was to explore the experiences of using a WAT to monitor PA and the general perceptions of mHealth and digital support in OA care among individuals of working age with hip and knee OA.

Methods

We conducted a focus group study where individuals with hip and knee OA (n = 18) were recruited from the intervention group in a cluster-randomized controlled trial (C-RCT). The intervention in the C-RCT comprised of 12-weeks use of a WAT with a mobile application to monitor PA in addition to participating in a supported OA self-management program. In this study, three focus group discussions were conducted. The discussions were transcribed and qualitative content analysis with an inductive approach was applied.

Results

The analysis resulted in two main categories: A WAT may aid in optimization of PA, but is not a panacea with subcategories WATs facilitate PA; Increased awareness of one’s limitations and WATs are not always encouraging, and the second main category was Digital support is an appreciated part of OA care with subcategories Individualized, early and continuous support; PT is essential but needs to be modernized and Easy, comprehensive, and reliable digital support.

Conclusion

WATs may facilitate PA but also aid individuals with OA to find the optimal level of activity to avoid increased pain. Digital support in OA care was appreciated, particularly as a part of traditional care with physical visits. The participants expressed that the digital support should be easy, comprehensive, early, and continuous.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14065-0.

The AktiWeb study: feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis

Background

Patient organisations may be an under-utilised resource in follow-up of patients requiring long-term exercise as part of their disease management. The purpose of this study was to explore the feasibility of a web-based exercise program delivered by a patient organisation to patients with hip and/or knee osteoarthritis (OA).

Methods

In this pre–post feasibility study, patients aged 40–80 years with hip and/or knee OA were recruited from Diakonhjemmet Hospital. The 12-week intervention was delivered through a patient organisation’s digital platform. Feasibility was evaluated by proportion of eligible patients enrolled, proportion of enrolled patients who provided valid accelerometer data at baseline, and proportion completing the cardiorespiratory exercise test according to protocol at baseline and completed follow-up assessments. Patient acceptability was evaluated for website usability, satisfaction with the initial exercise level and comprehensibility of the exercise program. Change in clinical outcomes were assessed for physical activity, cardiorespiratory fitness and patient-reported variables.

Results

In total, 49 eligible patients were identified and 35 were enrolled. Thirty (86%) of these attended baseline assessments and provided valid accelerometer data and 18 (51%) completed the maximal cardiorespiratory exercise test according to protocol. Twenty-two (63%) patients completed the follow-up questionnaire, and they rated the website usability as ‘acceptable’ [median 77.5 out of 100 (IQR 56.9, 85.6)], 19 (86%) reported that the initial exercise level was ‘just right’ and 18 (82%) that the exercise program was ‘very easy’ or ’quite easy’ to comprehend. Improvement in both moderate to vigorous physical activity (mean change 16.4 min/day; 95% CI 6.9 to 25.9) and cardiorespiratory fitness, VO_2peak (mean change 1.83 ml/kg/min; 95% CI 0.29 to 3.36) were found in a subgroup of 8 patients completing these tests. Across all patient-reported outcomes 24–52% of the patients had a meaningful improvement (n = 22).

Conclusion

A web-based exercise program delivered by a patient organisation was found to be feasible and acceptable in patients with hip and/or knee OA.

Trial registration

ClinicalTrials.gov, NCT04084834 (registered 10 September 2019). The Regional Committee for Medical and Health Research Ethics south-east, 2018/2198. URL: Prosjekt #632074 - Aktiv med web-basert støtte. - Cristin (registered 7 June 2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01110-3.

The Effectiveness of Interventions and Intervention Components for Increasing Physical Activity and Reducing Sedentary Behaviour in People With Persistent Musculoskeletal Pain: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis investigated the effectiveness of physical activity (PA) and sedentary behavior (SB) interventions on PA and SB levels in people with persistent musculoskeletal pain. We explored the effectiveness of behavior change techniques (BCTs), the use of behavior change theory and non-PA/SB outcomes. Randomized controlled trials of PA or SB interventions for people with persistent musculoskeletal pain were eligible. Twenty-three studies were included. Quality of evidence was assessed using the GRADE approach. Meta-analysis demonstrated a small effect for PA post-intervention (Hedge's g = .321, CI .136-.507, P = .001, very low-quality evidence). There was no effect for longer-term follow-up PA (low quality evidence) or SB outcomes (very low-quality evidence). There was a small effect for studies with low risk-of-bias at longer-term follow-up PA. Self-report PA outcomes, PA and education interventions, non-self-selected PA, a combination of supervised and unsupervised PA and a combination of individual and group-based interventions had larger effects. Heterogeneity was moderate to considerable. Risk-of-bias, assessed using Cochrane risk-of-bias tool (version two), was generally low. Five promising BCTs were identified: "adding objects to the environment," "goal setting (outcome)," "action planning," "monitoring outcome(s) of behaviour by others without feedback" and "feedback on outcome(s) of behaviour." In conclusion, there is evidence for a modest benefit for PA interventions immediately post-intervention, however the quality of evidence is very low. There was no evidence for longer-term follow-up PA or SB. Higher quality studies of PA and SB interventions that use objective measures are needed. PROSPERO registration: CRD42020180260. PERSPECTIVE: This review investigated the effects of physical activity and sedentary behavior interventions on physical activity and sedentary behavior levels in people with persistent musculoskeletal pain. Current evidence shows a modest benefit for interventions on physical activity post-intervention but not at longer-term follow-up or on sedentary behavior at any time-point, however quality of evidence is low to very low.

Delay and Effort-Based Discounting, and the Role of Bodily Awareness, In People Experiencing Long-Term Pain: A Cross-Sectional Study

Pain interventions typically include effortful exercise and long-term treatment - ie, short-term costs (effort) with delayed benefit (improved pain and/or function). Thus, understanding if long-term pain influences decision-making in context of delays and effort is essential given clear relevance to treatment uptake and/or adherence. We evaluated delay and effort attitudes in those experiencing chronic pain (n = 391) and in pain-free controls (n = 263). Additionally, we investigated the role of bodily sensation awareness and/or interpretation as potential contributing factors to altered decision-making. Volunteers completed three discounting questionnaires, assessing the influence of temporal delays (gains, losses) and effort on devaluation of monetary outcomes. Individuals with chronic pain had more short-sighted decisions for monetary gains, but not losses, and decreased willingness to undertake effort for monetary gains than the No Pain group. The Pain group had higher bodily sensation awareness and while this related to higher impulsivity, delay and effort discounting, neither awareness nor interpretation of bodily sensations interacted with pain levels or explained group differences in discounting behavior. These findings suggest that impaired delay and effort-based discounting is present in people with chronic pain, and that this may be driven by pain-induced changes, but not pain-induced enhancements in bodily sensation awareness and/or interpretation. Exploring the utility of interventions targeting discounting behavior is warranted. Data availability: Study materials are available here: https://osf.io/zexm7/?view_only=c9848597361c41808c612874da6f33b7. PERSPECTIVE: People with chronic pain make more short-sighted decisions (prefer less reward sooner) and decreased willingness to undertake effort (prefer less reward with little effort) for monetary gains than people without pain. Interventions targeting discounting behavior may help improve both uptake and adherence for evidence-based, effortful treatments, such as exercise.

Complex Lifestyle and Psychological Intervention in Knee Osteoarthritis: Scoping Review of Randomized Controlled Trials

Knee osteoarthritis (OA) causes pain, disability and poor quality of life in the elderly. The primary aim was to identify and map out the current evidence for randomised controlled trials (RCTs) on complex lifestyle and psychosocial interventions for knee OA. The secondary aim was to outline different components of complex lifestyle and psychosocial interventions. Our scoping review searched five databases from 2000 to 2021 where complex lifestyle or psychosocial interventions for patients with knee OA were compared to other interventions. Screening and data extraction were performed by two review authors independently and discrepancies resolved through consensus and in parallel with a third reviewer. A total of 38 articles were selected: 9 studied the effectiveness of psychological interventions; 11 were on self-management and lifestyle interventions; 18 looked at multifaceted interventions. This review highlights the substantial variation in knee OA interventions and the overall lack of quality in the current literature. Potential areas of future research, including identifying prognostic social factors, stratified care models, transdisciplinary care delivery and technology augmented interventions, have been identified. Further high-quality RCTs utilizing process evaluations and economic evaluation in accordance with the MRC guidelines are critical for the development of evidence-based knee OA programs globally.

Physical activity on prescription in patients with hip or knee osteoarthritis: A randomized controlled trial

OBJECTIVE

To evaluate whether physical activity on prescription, comprising five sessions, was more effective in increasing physical activity than a one-hour advice session after six months.

DESIGN

Randomized, assessor-blinded, controlled trial.

SETTING

Primary care.

SUBJECTS

Patients with clinically verified osteoarthritis of the hip or knee who undertook less than 150 minute/week of moderate physical activity, and were aged 40-74 years.

INTERVENTIONS

The advice group (n = 69) received a one-hour session with individually tailored advice about physical activity. The physical activity on prescription group (n = 72) received individually tailored physical activity recommendations with written prescription, and four follow-ups during six months.

MAIN MEASURES

Patients were assessed at baseline and six months: physical activity (accelerometer, questionnaires); fitness (six-minute walk test, 30-second chair-stand test, maximal step-up test, one-leg rise test); pain after walking (VAS); symptoms (HOOS/KOOS); and health-related quality of life (EQ-5D).

RESULTS

One hundred four patients had knee osteoarthritis, 102 were women, and mean age was 60.3 ± 8.3 years. Pain after walking decreased significantly more in the prescription group, from VAS 31 ± 22 to 18 ± 23. There was no other between groups difference. Both groups increased self-reported activity minutes significantly, from 105 (95% CI 75-120) to 165 (95% CI 135-218) minute/week in the prescription group versus 75 (95% CI 75-105) to 150 (95% CI 120-225) in the advice group. Also symptoms and quality of life improved significantly in both groups.

CONCLUSION

Individually tailored physical activity with written prescription and four follow-ups does not materially improve physical activity level more than advice about osteoarthritis and physical activity.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02387034).

The EPIPHA-KNEE trial: Explaining Pain to target unhelpful pain beliefs to Increase PHysical Activity in KNEE osteoarthritis - a protocol for a multicentre, randomised controlled trial with clinical- and cost-effectiveness analysis

Background

Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program.

Methods

Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes.

Discussion

We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04561-6.

Aerobic capacity and fatigability are associated with activity levels in women with hip osteoarthritis

Physical activity is important for physical function and pain relief in people with lower extremity osteoarthritis (OA). Unfortunately, people with OA are not as active as their peers without OA. The objective of this study was to determine whether aerobic capacity and fatigability are associated with physical activity in women with hip OA. We conducted a cross-sectional analysis of 36 women with hip OA. We assessed aerobic fitness as predicted VO₂ max from a 6-min walk test. We assessed fatigability using a treadmill test. Finally, we assessed self-reported physical activity using the UCLA activity scale and quantified steps per day and activity intensity using accelerometers. We used Pearson correlations to determine associations. We used regression analysis to determine whether fatigability mediated the association between aerobic fitness and physical activity. On average, subjects were moderately active via the UCLA score (5.2 ± 1.3 out of 10). Aerobic fitness (R = 0.582, p < .001) and fatigability (R = 0.516, p =.003) were significantly correlated with UCLA scores. However, aerobic fitness was the best predictor of UCLA scores, as well as sedentary time, and time spent in light activity. Fatigability was not a mediator between aerobic fitness and UCLA scores. Aerobic fitness and fatigability may be modifiable barriers to physical activity in people with OA. Future interventional studies should examine whether improving aerobic fitness improves physical activity or fatigability.

Influence of the physical activity in the elderly people diagnosed with knee osteoarthritis during the pandemic period caused by COVID-19

Introduction. Knee osteoarthritis is considered to be a chronic disease that affects the joints by causing pain, joint stiffness and decreased functional capacity. Regular physical activity can keep and increase functional capacity, it can reduce pain by improving movement behavior. The disruption of the sedentary behavior of the elderly patients with knee osteoarthritis can lead to improved physical function and general health. The purpose of this paper is to point out the role of physical activity in the elderly people diagnosed with knee osteoarthritis during the COVID-19 pandemic. Material and method. A total of 155 patients diagnosed (clinical and imaging) with knee ostoarthritis, who were treated on an outpatient basis, from May to September 2020, were studied. The parameters assessed in the study were pain, joint stiffness, the ability to carry out daily activities, anxiety and quality of life. Results and discussion.The studied group of patients was homogeneous in terms of the weight by age group and gender. Higher values were recorded in the study group in the evaluation of patients based on scales, the results being statistically significant, with value for p<0.05, which means that the hypothesis was validated. Conclusions. Patients of the study group recorded improvementin of functional capacity, joint stability and static and dynamic balance, which allowed a faster reintegration into the family and society. Keywords: physical activity, pain, elderly people, knee osteoarthritis,

Walking energetics and abductor strength are associated with physical activity in older women with hip osteoarthritis

BACKGROUND

Osteoarthritis (OA) can hinder physical activity in older adults for reasons that are not fully understood. Functional barriers may exist such as reduced muscle strength around the affected joint, potentially affecting physical activity. Aging-associated declines in energy capacity may also be exacerbated by OA. These factors may work together to influence physical activity in people with OA.

RESEARCH QUESTION

Our objective was to evaluate the combined role of walking energetics and hip abductor strength on physical activity in older women with hip OA.

METHODS

We evaluated 30 women with moderately symptomatic hip OA (61 ± 10 yrs; 30.7 ± 4.9 kg/m²) in this cross-sectional observational study. We measured physical activity using the UCLA activity score and quantified activity frequency and intensity using accelerometers worn for seven days (7 ± 2 days). We used a portable oxygen exchange system to measure energy used during walking at preferred speeds (relative to total energy capacity assessed using a six-minute walk test) and a dynamometer to measure hip abductor strength. We used Pearson correlations and regression analysis to test our hypotheses.

RESULTS

Greater energy used during walking was associated with lower self-reported physical activity (R=-0.626, p < 0.001), more sedentary time (R = 0.567, p = 0.002), and less light activity time (R=-0.644, p < 0.001). Lower hip abductor strength was associated with lower self-reported physical activity (R = 0.406, p = 0.039). While there was no association between hip abductor strength and energy used during walking, together these variables predicted 55.5 % of the variance in self-reported physical activity.

SIGNIFICANCE

Results suggest intervention targets to promote physical activity in this population.

A pain science education and walking program to increase physical activity in people with symptomatic knee osteoarthritis: a feasibility study

Supplemental Digital Content is Available in the Text.

This feasibility study of contemporary pain science education to increase activity levels in people with painful knee osteoarthritis supports progression to a larger trial.

Introduction:

Nine of 10 people with knee osteoarthritis are inactive. Unhelpful pain beliefs may negatively influence physical activity levels. Targeting these unhelpful pain beliefs, through contemporary pain science education (PSE), may provide benefit.

Objectives:

To evaluate the feasibility of conducting a clinical trial to determine the effect of adding PSE (vs adding sham ultrasound) to an individualised, physiotherapist-led education and walking program in people with painful knee osteoarthritis.

Methods:

Twenty participants were randomised (1:1) into the PSE group or Control group, each receiving 4 in-person weekly treatments, then 4 weeks of at-home activities (weekly telephone check-in). Clinical outcomes and physical activity (7 days of wrist-worn accelerometry) were assessed at baseline, 4 (clinical outcomes only), 8, and 26 weeks. A priori feasibility criteria for recruitment, intervention adherence, viability of wrist-based accelerometry, and follow-up retention were set. Perceived intervention credibility, acceptability, and usefulness from participants and clinicians were assessed (ratings, written/verbal feedback).

Results:

Most feasibility criteria were met. On average, 7 adults/wk were eligible, with 70% recruited. Treatment compliance was high (in-person: 80% PSE; 100% Control; at-home: 78% PSE; 75% Control). Wrist-based accelerometry had >75% valid wear-time. Sufficient follow-up rates were not achieved (26 weeks: 65%). Participant and clinician feedback highlighted that PSE was too complex and did not match patient expectations of “physiotherapy”, that sham ultrasound was problematic (clinician), but that both treatments had high credibility, acceptability, and usefulness.

Conclusions:

Progression to a full trial is warranted. Strategies to increase participant retention, refine the PSE content/delivery, and replace/remove the sham intervention are required.

Changes in physical inactivity during supervised educational and exercise therapy in patients with knee osteoarthritis: A prospective cohort study

BACKGROUND

Physical inactivity is a global problem and patients with knee osteoarthritis (OA) are predisposed to inactivity and its health-related consequences. Current guidelines recommend exercise as primary treatment but whether this affects time spent physically inactive is unknown. The objective was to investigate changes in physical inactivity among individuals with knee OA following an educational and exercise program.

METHODS

Pragmatic prospective cohort study performed in six physical therapy clinics in Denmark offering a nationwide education and exercise program for knee OA. The program consists of physiotherapy guided education and group-based or home exercise sessions, performed biweekly for approximately eight weeks. The exercises target knee and hip joint stability as well as focus on increasing muscle strength. Primary outcome was time spent physically inactive (min/day), measured with a tri-axial accelerometer mounted on the lateral side of the thigh during the entire exercise program duration. OA symptoms were assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

Thirty-two individuals with knee OA were analyzed. From baseline to post-intervention, no changes occurred in average time spent physically inactive (mean change: +16.2 min [95% CI -15.7 to 48.1]; P = 0.31), but statistically significant improvements in KOOS pain (+6.7 points [95% CI 2.3 to 11.0]; P = 0.0032) and KOOS function (+5.8 points [95% CI 1.9 to 9.7]; P = 0.0046) were found.

CONCLUSIONS

Participating and completing a widely adopted education and exercise program are not associated with spontaneous improvements in physical inactivity despite changes in self-reported pain and function. Interventions specifically targeting physical inactivity are needed. Registration number: www.clinicaltrials.gov: NCT03125954.

Movement behaviour patterns in patients with hip and/or knee osteoarthritis in the physical therapy setting: a cross-sectional study

Background

Osteoarthritis is one of the most common chronic joint diseases, mostly affecting the knee or hip through pain, joint stiffness and decreased physical functioning in daily life. Regular physical activity (PA) can help preserve and improve physical functioning and reduce pain in patients with osteoarthritis. Interventions aiming to improve movement behaviour can be optimized by tailoring them to a patients’ starting point; their current movement behaviour. Movement behaviour needs to be assessed in its full complexity, and therefore a multidimensional description is needed.

Objectives

The aim of this study was to identify subgroups based on movement behaviour patterns in patients with hip and/or knee osteoarthritis who are eligible for a PA intervention. Second, differences between subgroups regarding Body Mass Index, sex, age, physical functioning, comorbidities, fatigue and pain were determined between subgroups.

Methods

Baseline data of the clinical trial ‘e-Exercise Osteoarthritis’, collected in Dutch primary care physical therapy practices were analysed. Movement behaviour was assessed with ActiGraph GT3X and GT3X+ accelerometers. Groups with similar patterns were identified using a hierarchical cluster analysis, including six clustering variables indicating total time in and distribution of PA and sedentary behaviours. Differences in clinical characteristics between groups were assessed via Kruskall Wallis and Chi² tests.

Results

Accelerometer data, including all daily activities during 3 to 5 subsequent days, of 182 patients (average age 63 years) with hip and/or knee osteoarthritis were analysed. Four patterns were identified: inactive & sedentary, prolonged sedentary, light active and active. Physical functioning was less impaired in the group with the active pattern compared to the inactive & sedentary pattern. The group with the prolonged sedentary pattern experienced lower levels of pain and fatigue and higher levels of physical functioning compared to the light active and compared to the inactive & sedentary.

Conclusions

Four subgroups with substantially different movement behaviour patterns and clinical characteristics can be identified in patients with osteoarthritis of the hip and/or knee. Knowledge about these subgroups can be used to personalize future movement behaviour interventions for this population.

Trial registration

Dutch clinical trial registration number of e-Exercise Osteoarthritis: NTR4224.

Collaborative model of care between Orthopaedics and allied healthcare professionals trial (CONNACT) - a feasibility study in patients with knee osteoarthritis using a mixed method approach

Background

Osteoarthritis is a leading cause of global disability resulting in significant morbidity and cost to the healthcare system. Current guidelines recommend lifestyle changes such exercises and weight loss as first line treatment prior to surgical consideration. Our current model of care is inefficient with suboptimal allied health intervention for effective behaviour changes. A 12-week community based, individualized, multidisciplinary new model of care for knee osteoarthritis was developed in light of current deficiencies.

Methods

The primary aim of this study was to determine the feasibility of a full randomized controlled trial evaluating this new model of care using pre-defined progression criteria. The secondary aim was to optimize the intervention and study design through a process evaluation. A pilot exploratory, parallel arm, single blinded randomized trial design using a mixed method approach was utilized. Progression criteria for a full trial including key domains of patient recruitment and retention, outcome measure acceptability and improvement, adverse events were developed. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 12-weeks. Secondary outcomes included quality of life, functional and psychological assessments. Semi-structured interviews were conducted with the patients at 12-weeks.

Results

20 patients (3 males, 17 females) were randomized (10 intervention, 10 control). Intervention arm patients reported better improvements in their knee function, quality of life, psychological outcome, dietary improvement and weight loss compared to the control arm at 12-weeks. Semi-structured interviews revealed several themes pertaining to feasibility and intervention optimization. 5 out of the 6 progression criteria’s domains were met (recruitment criteria not met).

Conclusion

This pilot has demonstrated the feasibility of a full randomized control trial investigating the potential effectiveness of the new proposed model of care for knee osteoarthritis using pre-defined progression criteria and process evaluation. Results from the qualitative study were used to modify and improve the intervention content, delivery model and study design for a large effectiveness-implementation hybrid randomized control trial that is currently underway.

Trial registration

Retrospectively registered on 18 January 2019 at http://clinicaltrial.gov ID: NCT03809975.

Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach.

OBJECTIVE

This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA.

METHODS

A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence.

RESULTS

A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.18 and SMD -0.26, 95% CI -0.35 to -0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD -0.10, 95% CI -0.17 to 0.03 and SMD -0.17, 95% CI -0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach.

CONCLUSIONS

Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes.

Psychosocial Mechanisms of Cognitive-Behavioral-Based Physical Therapy Outcomes After Spine Surgery: Preliminary Findings From Mediation Analyses

OBJECTIVE

Changing Behavior through Physical Therapy (CBPT), a cognitive-behavioral-based program, has been shown to improve outcomes after lumbar spine surgery in patients with a high psychosocial risk profile; however, little is known about potential mechanisms associated with CBPT treatment effects. The purpose of this study was to explore potential mediators underlying CBPT efficacy after spine surgery.

METHODS

In this secondary analysis, 86 participants were enrolled in a randomized trial comparing a postoperative CBPT (n = 43) and education program (n = 43). Participants completed validated questionnaires at 6 weeks (baseline) and 3 and 6 months following surgery for back pain (Brief Pain Inventory), disability (Oswestry Disability Index), physical health (12-Item Short-Form Health Survey), fear of movement (Tampa Scale for Kinesiophobia), pain catastrophizing (Pain Catastrophizing Scale), and pain self-efficacy (Pain Self-Efficacy Questionnaire). Parallel multiple mediation analyses using Statistical Package for the Social Sciences (SPSS) were conducted to examine whether 3- and 6-month changes in fear of movement, pain catastrophizing, and pain self-efficacy mediate treatment outcome effects at 6 months.

RESULTS

Six-month changes, but not 3-month changes, in fear of movement and pain self-efficacy mediated postoperative outcomes at 6 months. Specifically, changes in fear of movement mediated the effects of CBPT treatment on disability (indirect effect = -2.0 [95% CI = -4.3 to 0.3]), whereas changes in pain self-efficacy mediated the effects of CBPT treatment on physical health (indirect effect = 3.5 [95% CI = 1.2 to 6.1]).

CONCLUSIONS

This study advances evidence on potential mechanisms underlying cognitive-behavioral strategies. Future work with larger samples is needed to establish whether these factors are a definitive causal mechanism.

IMPACT

Fear of movement and pain self-efficacy may be important mechanisms to consider when developing and testing psychologically informed physical therapy programs.

Effectiveness of text messages for decreasing inactive behaviour in patients with knee osteoarthritis: a pilot randomised controlled study

Background

One of the big contributors to physical inactivity in the elderly population is osteoarthritis (OA) of the knee. Digital motivation seems to have a positive effect on individual physical inactivity level, but limited evidence exists on the effects of digital motivation on patients with knee OA.

Objective

To investigate if motivational text messages reduce time spent physically inactive in patients with knee OA.

Method

This study was designed as an unblinded pilot randomised controlled trial, randomising participants equally (1:1) to an intervention group (motivational text messages) or control group (no intervention). Participants were recruited from six physical therapy clinics in Denmark. Inclusion criteria were age ≥ 18, diagnosed with knee OA, owner of a smartphone or tablet, and participating or commencing participation in the GLA:D® program. The primary outcome was time spent physically inactive, measured with a tri-axial accelerometer mounted on the lateral side of the thigh. Data on OA symptoms were obtained using the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire.

Results

A total of 49 participants were screened, and 38 participants were included and randomised to either the intervention group (n = 19) or the control group (n = 19). No statistically significant difference between the two groups was found in average change of time spent physically inactive (mean difference 13.2 min/day [95% CI − 41.0 to 67.3]; P = 0.63), time spent standing (mean difference 3.0 min/day [95% CI − 22.7 to 28.7]; P = 0.81), or time spent moving (mean difference − 20.4 min/day [95% CI − 63.0 to 22.3]; P = 0.34) nor was there any difference in change between the two groups on KOOS.

Conclusion

Motivational text messages have seemed to have no effect on overall time spent physically inactive.

Trial registration

clinicaltrials.gov, NCT03339011. Registered 9 November 2017

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0494-6) contains supplementary material, which is available to authorized users.

The impact of physical activity level on the short- and long-term pain relief from supervised exercise therapy and education: a study of 12,796 Danish patients with knee osteoarthritis

OBJECTIVES

It is unknown if people with knee osteoarthritis (OA) who are already physically active benefit from exercise therapy. To study the impact of physical activity level on pain relief, post-intervention and 12 months following exercise therapy and education.

METHOD

The analyses included 12,796 patients with knee OA from the Good Life with osteoArthritis in Denmark (GLA:D^®) program. GLA:D^® consists of 12 sessions of supervised neuromuscular exercise and two sessions of education delivered by trained physical therapists. The impact of physical activity level on change in knee pain intensity (0-100) immediately post-intervention and at 12 months was estimated using a mixed-effects model adjusted for age, sex, body mass index (BMI), educational level and comorbidity. Physical activity level was assessed using the University of California, Los Angeles (UCLA) activity scale.

RESULTS

Physically inactive patients had worse baseline pain compared to patients with low to very high physical activity level (6-15 points worse; P < 0.001). Pain decreased by 13.4 points (95% CI; 9.7 to 17.1) following the treatment program and by 12.8 points (7.7-18.0) at 12 months in the inactive patients, with similar improvements in patients with higher levels of physical activity (P = 0.278 to 0.851).

CONCLUSION

In patients with knee OA, similar and persistent long-term pain relief was found from supervised exercise therapy and education regardless of the initial physical activity level. Patients with high to very high levels of physical activity can expect pain relief from supervised exercise therapy and education similar to that of more physically inactive patients.

Effectiveness of a Blended Physical Therapist Intervention in People With Hip Osteoarthritis, Knee Osteoarthritis, or Both: A Cluster-Randomized Controlled Trial

BACKGROUND

Integrating physical therapy sessions and an online application (e-Exercise) might support people with hip osteoarthritis (OA), knee OA, or both (hip/knee OA) in taking an active role in the management of their chronic condition and may reduce the number of physical therapy sessions.

OBJECTIVE

The objective of this study was to investigate the short- and long-term effectiveness of e-Exercise compared to usual physical therapy in people with hip/knee OA.

DESIGN

The design was a prospective, single-blind, multicenter, superiority, cluster- randomized controlled trial.

SETTING

The setting included 143 primary care physical therapist practices.

PARTICIPANTS

The participants were 208 people who had hip/knee OA and were 40 to 80 years of age.

INTERVENTION

e-Exercise is a 3-month intervention in which about 5 face-to-face physical therapy sessions were integrated with an online application consisting of graded activity, exercise, and information modules. Usual physical therapy was conducted according to the Dutch physical therapy guidelines on hip and knee OA.

MEASUREMENTS

Primary outcomes, measured at baseline after 3 and 12 months, were physical functioning and free-living physical activity. Secondary outcome measures were pain, tiredness, quality of life, self-efficacy, and the number of physical therapy sessions.

RESULTS

The e-Exercise group (n = 109) received, on average, 5 face-to-face sessions; the usual physical therapy group (n = 99) received 12. No significant differences in primary outcomes between the e-Exercise group and the usual physical therapy group were found. Within-group analyses for both groups showed a significant improvement in physical functioning. After 3 months, participants in the e-Exercise group reported an increase in physical activity; however, no objectively measured differences in physical activity were found. With respect to secondary outcomes, after 12 months, sedentary behavior significantly increased in the e-Exercise group compared with the usual physical therapy group. In both groups, there were significant improvements for pain, tiredness, quality of life, and self-efficacy.

LIMITATIONS

The response rate at 12 months was 65%.

CONCLUSIONS

The blended intervention, e-Exercise, was not more effective than usual physical therapy in people with hip/knee OA.

A feasibility study of brain-targeted treatment for people with painful knee osteoarthritis in tertiary care

Purpose: To assess the feasibility and clinical impact of brain-targeted treatment (BT; aiming to target sensorimotor processing) in knee osteoarthritis patients attending tertiary care. Methods: Randomized replicated case series. The study involved three phases, each of 2 weeks duration: (1) no-treatment phase; (2) BT phase (left/right judgments and touch discrimination training); and (3) usual care (education, strengthening, and stretching training). Primary outcomes were: timely recruitment; number of participants completing the interventions; treatment compliance and barriers; follow-up rates; and treatment impact on pain and function. Fear-avoidance beliefs and clinical measures of cortical body representation (tactile acuity and left/right judgment performance) were secondary outcomes. Results: A total of 5% (19/355) of all assessed patients were eligible to participate and of these, 58% (11/19) agreed to participate. Ten patients completed the study, and 9 were successfully followed up, with treatment compliance varying between interventions. Compliance was poor for the touch discrimination component of BT. No significant effects were observed for pain relief or knee function after any treatment. A positive impact of treatment was found for fear-avoidance beliefs (usual care vs. washout, p = 0.007; BT vs. washout, p = 0.029) and left/right judgment accuracy (usual care vs. washout; p = 0.006). Conclusions: Clear barriers were identified to implementing BT in tertiary care for knee osteoarthritis. Access to all available services (especially the use of interpreters), and treatment options that do not require additional assistance to perform (e.g., touch discrimination training) represent the main lessons learned.

Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis

Synopsis Osteoarthritis (OA) of the hip and knee is among the leading causes of global disability, highlighting the need for early, targeted, and effective treatment. The benefits of exercise therapy in people with hip and knee OA are substantial and supported by high-quality evidence, underlining that it should be part of first-line treatment in clinical practice. Furthermore, unlike other treatments for OA, such as analgesia and surgery, exercise therapy is not associated with risk of serious harm. Helping people with OA become more physically active, along with structured exercise therapy targeting symptoms and impairments, is crucial, considering that the majority of people with hip and knee OA do not meet physical activity recommendations. Osteoarthritis is associated with a range of chronic comorbidities, including type 2 diabetes, cardiovascular disease, and dementia, all of which are associated with chronic low-grade inflammation. Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced anti-inflammatory effects. Patient education may be crucial to ensure long-term adherence and sustained positive effects on symptoms, impairments, physical activity levels, and comorbidities. J Orthop Sports Phys Ther 2018;48(6):439-447. Epub 18 Apr 2018. doi:10.2519/jospt.2018.7877.

Aerobic exercise interventions reduce blood pressure in patients after stroke or transient ischaemic attack: a systematic review and meta-analysis

OBJECTIVE

Secondary vascular risk reduction is critical to preventing recurrent stroke. We aimed to evaluate the effect of exercise interventions on vascular risk factors and recurrent ischaemic events after stroke or transient ischaemic attack (TIA).

DESIGN

Intervention systematic review and meta-analysis.

DATA SOURCES

OVID MEDLINE, PubMed, The Cochrane Library, Web of Science, The National Institute for Health and Care Excellence, TRIP Database, CINAHL, PsycINFO, SCOPUS, UK Clinical Trials Gateway and the China National Knowledge Infrastructure were searched from 1966 to October 2017.

ELIGIBILITY CRITERIA

Randomised controlled trials evaluating aerobic or resistance exercise interventions on vascular risk factors and recurrent ischaemic events among patients with stroke or TIA, compared with control.

RESULTS

Twenty studies (n=1031) were included. Exercise interventions resulted in significant reductions in systolic blood pressure (SBP) -4.30 mm Hg (95% CI -6.77 to -1.83) and diastolic blood pressure -2.58 mm Hg (95% CI -4.7 to -0.46) compared with control. Reduction in SBP was most pronounced among studies initiating exercise within 6 months of stroke or TIA (-8.46 mm Hg, 95% CI -12.18 to -4.75 vs -2.33 mm Hg, 95% CI -3.94 to -0.72), and in those incorporating an educational component (-7.81 mm Hg, 95% CI -14.34 to -1.28 vs -2.78 mm Hg, 95% CI -4.33 to -1.23). Exercise was also associated with reductions in total cholesterol (-0.27 mmol/L, 95% CI -0.54 to 0.00), but not fasting glucose or body mass index. One trial reported reductions in secondary vascular events with exercise, but was insufficiently powered.

SUMMARY

Exercise interventions can result in clinically meaningful blood pressure reductions, particularly if initiated early and alongside education.

What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review

OBJECTIVES

To conduct a systematic review of interventions used to improve exercise adherence in older people, to assess the effectiveness of these interventions and to evaluate the behavioural change techniques underpinning them using the Behaviour Change Technique Taxonomy (BCTT).

DESIGN

Systematic review.

METHODS

A search was conducted on AMED, BNI, CINAHL, EMBASE, MEDLINE and PsychINFO databases. Randomised controlled trials that used an intervention to aid exercise adherence and an exercise adherence outcome for older people were included. Data were extracted with the use of a preprepared standardised form. Risk of bias was assessed with the Cochrane Collaboration's tool for assessing risk of bias. Interventions were classified according to the BCTT.

RESULTS

Eleven studies were included in the review. Risk of bias was moderate to high. Interventions were classified into the following categories: comparison of behaviour, feedback and monitoring, social support, natural consequences, identity and goals and planning. Four studies reported a positive adherence outcome following their intervention. Three of these interventions were categorised in the feedback and monitoring category. Four studies used behavioural approaches within their study. These were social learning theory, socioemotional selectivity theory, cognitive behavioural therapy and self-efficacy. Seven studies did not report a behavioural approach.

CONCLUSIONS

Interventions in the feedback and monitoring category showed positive outcomes, although there is insufficient evidence to recommend their use currently. There is need for better reporting, use and the development of theoretically derived interventions in the field of exercise adherence for older people. Robust measures of adherence, in order to adequately test these interventions would also be of use.

PROSPERO REGISTRATION NUMBER

CRD42015020884.

The effectiveness of interventions aimed at increasing physical activity in adults with persistent musculoskeletal pain: a systematic review and meta-analysis

BACKGROUND

Individuals with persistent musculoskeletal pain (PMP) have an increased risk of developing co-morbid health conditions and for early-mortality compared to those without pain. Despite irrefutable evidence supporting the role of physical activity in reducing these risks; there has been limited synthesis of the evidence, potentially impacting the optimisation of these forms of interventions. This review examines the effectiveness of interventions in improving levels of physical activity and the components of these interventions.

METHODS

Randomised and quasi-randomised controlled trials were included in this review. The following databases were searched from inception to March 2016: CENTRAL in the Cochrane Library, Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two reviewers independently screened citations, assessed eligibility, extracted data, assessed risk of bias and coded intervention content using the behaviour change taxonomy (BCTTv1) of 93 hierarchically clustered techniques. GRADE was used to rate the quality of the evidence.

RESULTS

The full text of 276 articles were assessed for eligibility, twenty studies involving 3441 participants were included in the review. Across the studies the mean number of BCTs coded was eight (range 0-16); with 'goal setting' and 'instruction on how to perform the behaviour' most frequently coded. For measures of subjective physical activity: interventions were ineffective in the short term, based on very low quality evidence; had a small effect in the medium term based on low quality evidence (SMD 0.25, 95% CI 0.01 to 0.48) and had a small effect in the longer term (SMD 0.21 95% CI 0.08 to 0.33) based on moderate quality evidence. For measures of objective physical activity: interventions were ineffective - based on very low to low quality evidence.

CONCLUSIONS

There is some evidence supporting the effectiveness of interventions in improving subjectively measured physical activity however, the evidence is mostly based on low quality studies and the effects are small. Given the quality of the evidence, further research is likely/very likely to have an important impact on our confidence in effect estimates and is likely to change the estimates. Future studies should provide details on intervention components and incorporate objective measures of physical activity.

Effect of Land-Based Generic Physical Activity Interventions on Pain, Physical Function, and Physical Performance in Hip and Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to evaluate the effects of land-based generic physical activity interventions on pain, physical function, and physical performance in individuals with hip/knee osteoarthritis, when compared with a control group that received no intervention, minimal intervention, or usual care.

METHODS

A systematic search for randomized controlled trials on 11 electronic databases (from their inception up until April 30, 2016) identified 27 relevant articles. According to the compendium of physical activities, interventions were categorized into: recreational activities (tai chi/Baduajin-6 articles), walking (9 articles), and conditioning exercise (12 articles).

RESULTS

Meta-analysis for recreational activity (n = 3) demonstrated significant mean difference (MD) of -9.56 (95% confidence interval [CI], -13.95 to -5.17) for physical function (Western Ontario and McMaster Universities Arthritis Index) at 3 mos from randomization. Pooled estimate for walking intervention was not significant for pain intensity and physical performance but was significant for physical function (n = 2) with a MD of -10.38 (95% CI, -12.27 to -8.48) at 6 mos. Meta-analysis for conditioning exercise was significant for physical function (n = 3) with a MD of -3.74 (95% CI, -5.70 to -1.78) and physical performance (6-minute walk test) with a MD of 42.72 m (95% CI, 27.78, 57.66) at 6 mos. The timed stair-climbing test (n = 2) demonstrated a significant effect at 18 mos with a MD of -0.49 secs (95% CI, -0.75 to -0.23).

CONCLUSION

Very limited evidence to support recreational activity and walking intervention was found for knee osteoarthritis, in the short-term on pain and physical function, respectively.

Enjoyment of exercise among people with arthritis: An inductive thematic analysis

Past research into exercise among people with long-term health conditions has paid surprisingly little attention to the concept of enjoyment. This study explored enjoyment of exercise among people with arthritis. Semi-structured interviews were held with 12 participants aged 20-85 years. The transcripts were analysed using inductive thematic analysis. Four themes were identified: enjoyment of exercise in relation to other people, benefits of exercise in relation to enjoyment, working around barriers to enjoy exercise and finding an enjoyable balance to exercise. These themes highlight the relevance of enjoyment and how it could feature in advice about exercise for people with arthritis.

Effectiveness of physical activity interventions in achieving behaviour change maintenance in young and middle aged adults: A systematic review and meta-analysis

BACKGROUND

Physical activity (PA) interventions are generally effective in supporting short-term behaviour change, but increases are not always maintained. This review examined the effectiveness of PA interventions for behaviour change maintenance in young and middle-aged adults, and investigated which Behaviour Change Techniques (BCTs) and other intervention features were associated with maintenance.

METHODS

Six databases (Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Web of Science) were systematically searched. Eligibility criteria were controlled trials investigating the effectiveness of PA interventions with adult (mean age 18-64 years) non-clinical populations using validated measures of PA behaviour at baseline and ≥six months' post-baseline. Results were pooled in meta-analyses using standardised mean differences (SMD) at five time intervals (6-9, 9-15, 15-21, 21-24, >24 months). Moderator analyses investigated the influence of sample and intervention characteristics on PA maintenance at 6-9 months.

RESULTS

Sixty-two studies were included. PA interventions had a significant effect on behaviour maintenance 6-15 months post-baseline relative to controls. Interventions had a larger effect on maintenance at 6-9 months (SMD = 0.28; 95% CI: 0.20, 0.35; I² = 73%) compared to 9-15 months (SMD = 0.20; 95% CI: 0.13, 0.26; I² = 70%). Beyond 15 months, PA measurements were infrequent with little evidence supporting maintenance. Moderator analyses showed some BCTs and intervention settings moderated PA outcomes at 6-9 months. A multivariable meta-regression model showed interventions using the BCTs 'Prompt self-monitoring of behavioural outcome' (b = 1.46, p < 0.01) and 'Use of follow-up prompts' (b = 0.38, p < 0.01) demonstrated greater effectiveness at promoting PA maintenance at 6-9 months. Interventions implemented in primary care (versus community or workplace/university) settings (b = -0.13, p = 0.10) tended to demonstrate less effectiveness.

CONCLUSIONS

This review provides evidence of some effective BCTs for maintaining behaviour to 15 months. Greater consideration must be given to how future interventions encourage and measure maintenance of changes, and investigate broader psychological, social and environmental influences of PA behaviour.

PROSPERO REGISTRATION

PROSPERO 2015:CRD42015025462.

Physical Activity Interventions for Increasing Objectively Measured Physical Activity Levels in Patients With Chronic Musculoskeletal Pain: A Systematic Review

OBJECTIVE

To investigate whether physical activity interventions increase objectively measured physical activity levels of patients with chronic musculoskeletal pain (e.g., osteoarthritis, low back pain) compared to no/minimal intervention.

METHODS

We performed a systematic review with meta-analysis searching the Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, SportDiscus, and Physiotherapy Evidence Database (PEDro) databases, and the main clinical trials registries. Quasirandomized or randomized controlled trials investigating the effect of physical activity interventions on objectively measured physical activity levels (e.g., using accelerometers or pedometers) of patients with chronic musculoskeletal pain compared with no/minimal intervention were considered eligible. Analyses were conducted separately for short-term (≤3 months), intermediate (>3 months and <12 months), and long-term (≥12 months) followups. Pooled effects were calculated using the standardized mean difference (SMD), and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used in summary conclusions.

RESULTS

Eight published trials and 6 registered trials were included. For the short-term followup, pooling of 6 trials showed no significant effect (SMD 0.34, 95% confidence interval -0.09, 0.77) between a physical activity intervention and no/minimal intervention. Similarly nonsignificant results were found for the intermediate and long-term followups. The overall evidence according to the GRADE approach was classified as low quality.

CONCLUSION

Our findings suggest that physical activity-based interventions may lead to little or no difference in objectively measured physical activity levels of patients with chronic musculoskeletal pain compared with no/minimal interventions. Given the number of registered trials, the pooled effect found in this review is likely to change once the results of these trials become available.

Morning self-efficacy predicts physical activity throughout the day in knee osteoarthritis

OBJECTIVE

The purpose of this study was to examine the within-day and cross-day prospective effects of knee osteoarthritis (OA) patients' self-efficacy to engage in physical activity despite the pain on their subsequent physical activity assessed objectively in their natural environment.

METHOD

Over 22 days, 135 older adults with knee OA reported their morning self-efficacy for being physically active throughout the day using a handheld computer and wore an accelerometer to measure moderate activity and steps.

RESULTS

Morning self-efficacy had a significant positive effect on steps and moderate-intensity activity throughout that day, above and beyond the effects of demographic background and other psychosocial factors as well as spouses' support and social control. The lagged effect of morning self-efficacy on the next day's physical activity and the reciprocal lagged effect of physical activity on the next day's self-efficacy were not significant. Positive between-person effects of self-efficacy on physical activity were found.

CONCLUSIONS

Future research should aim to better understand the mechanisms underlying fluctuations in patients' daily self-efficacy, and target patients' daily self-efficacy as a modifiable psychological mechanism for promoting physical activity. (PsycINFO Database Record

Health enhancing physical activity in patients with hip or knee osteoarthritis - an observational intervention study

Background

Osteoarthritis is one of the leading causes of inactivity worldwide. The recommended level of health enhancing physical activity (HEPA) is at least 150 min of moderate intensity physical activity per week. The purpose of this study was to explore how the proportion of patients, who reached the recommended level of HEPA, changed following a supported osteoarthritis self-management programme in primary care, and to explore how reaching the level of HEPA was influenced by body mass index (BMI), gender, age and comorbidity.

Methods

An observational study was conducted using data from a National Quality Registry in which 6810 patients in primary care with clinically verified hip or knee osteoarthritis with complete data at baseline, 3 and 12 months follow-up before December 31^st 2013 were included. HEPA was defined as self-reported physical activity of at least moderate intensity either a) at least 30 min per day on four days or more per week, or b) at least 150 min per week. HEPA was assessed at baseline, and again at 3 and 12 months follow-up. Cochran’s Q test was used to determine change in physical activity over time. The association between reaching the level of HEPA and time, age, BMI, gender, and Charnley classification was investigated using the generalized estimation equation (GEE) model.

Results

The proportion of patients who reached the level of HEPA increased by 345 patients, from 77 to 82%, from baseline to 3 months follow-up. At 12 months, the proportion of patients who reached the level of HEPA decreased to 76%. Not reaching the level of HEPA was associated with overweight, obesity, male gender and Charnley category C, i.e. osteoarthritis in multiple joint sites (hip and knee), or presence of any other disease that affects walking ability.

Conclusions

Following the supported osteoarthritis self-management programme there was a significant increase in the proportion of patients who reached the recommended level of HEPA after 3 months. Improvements were lost after 12 months. To increase physical activity and reach long-lasting changes in levels of physical activity, more follow-up sessions might be needed.

Barriers and facilitators to physical activity in people with hip or knee osteoarthritis: protocol for a systematic review of qualitative evidence

INTRODUCTION

This protocol aims to describe the objective and methods to be followed in a systematic review of qualitative studies on barriers and facilitators to physical activity (PA) in people with hip or knee osteoarthritis (OA).

METHODS AND ANALYSIS

MEDLINE, EMBASE, PhychINFO, Web of Science, CINAHL, SPORTDiscus, Scopus and grey literature sources will be electronically searched. Hand search of qualitative research-centred journals, reference screening of relevant reviews and inquiries to researchers active in the field will complement the search. Studies will be selected if they apply qualitative or mixed-methods designs to directly explore factors that correspond to engagement in PA/exercise or, the perceptions regarding PA/exercise in people with hip or knee OA. The Critical Appraisal Skills Programme Qualitative Checklist and the evaluative criteria of credibility, transferability, dependability and confirmability will be applied for the study appraisal. 2 independent reviewers will perform the search, study selection and study appraisal. Thematic synthesis will be used for synthesising the findings of the primary studies and the process and product of the synthesis will be checked by a second researcher. ConQual approach will be used for assessing the confidence in the qualitative findings.

ETHICS AND DISSEMINATION

This systematic review will inform our understanding of the PA determinants and how to optimise behaviour change in people living with hip or knee OA. The review findings will be reported in a peer-reviewed journal and presented at national or international conferences. The study raises no ethical issues.

TRIAL REGISTRATION NUMBER

CRD42016030024.