Effect of an education programme for patients with osteoarthritis in primary care--a randomized controlled trial

Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system

Objective

Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center.

Design

This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability.

Results

Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p ​= ​0.002). BMI did not significantly change (p ​= ​0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 ​h weekly) and serving 953 patients over four years demonstrated OAMP sustainability.

Conclusions

OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Assessing the Awareness Regarding Osteoarthritis and Its Related Risk Factors Among Women in Aseer Central Hospital

Background Osteoarthritis (OA) is the most common form of arthritis worldwide and is characterized by the gradual loss of joint cartilage, leading to stiffness, discomfort, and restricted movement. This research aims to assess the knowledge of obese women in the Aseer region regarding OA and its associated risk factors. OA predominantly affects the knees, hands, and hips, with knee OA being particularly significant due to its high incidence rate and early onset in obese women. In Saudi Arabia, there are varying levels of awareness among the population, but no study has focused on obese females. This study seeks to address this gap and enhance the understanding of OA in this demographic. Methodology A cross-sectional research design was employed using a self-administrated questionnaire collected by a group of trained data collectors who distributed the questionnaires throughout the clinics of Aseer central hospital. The questionnaire was divided into two sections. The first section collected demographic data about the participants, and the second section was a 20-item questionnaire about OA and its related risk factors. The study was conducted in the Aseer region. A total of 278 subjects (female) were included in the study. Statistical analysis was performed using SPSS version 27.0.1.0 (IBM Corp., Armonk, NY, USA). Results This study analyzed the sociodemographic characteristics of 278 participants. All participants were female, were young to middle-aged adults, and had a collegiate education. On average, participants were overweight, with varying knowledge levels about OA. While some correctly identified symptoms and risk factors. Many participants responded with "I Don't Know" regarding joint stiffness as a symptom (37.7%). Comparing knowledge among different body mass index groups revealed no significant differences, except for misconceptions about the cause of OA among overweight individuals (39.06%). Conclusions This study's findings underscore the practical implications for patient education and healthcare strategies. The varying levels of awareness among obese women in the Aseer region regarding OA emphasize the need for increased education and targeted health promotion interventions. Addressing misconceptions and improving knowledge can enhance treatment plans and contribute to better patient outcomes. Understanding these knowledge gaps is crucial for improving patient education, healthcare strategies, and OA management.

Systematic Review of Non-surgical Therapies for Osteoarthritis of the Hand: An Update

Hand osteoarthritis is a common disease with significant morbidity. This review aimed to update our earlier systematic reviews which included all published randomized controlled trials evaluating pharmacological and non-pharmacological therapies in patients with hand osteoarthritis. A total of 133 randomized controlled trials evaluating pharmacological and nonpharmacological therapies in hand osteoarthritis were reviewed. Overall, the methodological quality of randomized controlled trials has improved since the last update. Almost all new studies described their methods for randomization, blinding, and allocation concealment. However, studies continued to underreport features specific to hand osteoarthritis, such as pattern of joint involvement and number of affected joints. Standardized outcome assessments for pain and function were commonly presented, but measures of other hand osteoarthritis specific outcomes, such as health-related quality of life and patient global assessments, continued to be underreported. Future trials should consistently report on hand osteo arthritis specific features and outcome assessments in order to make clinically relevant conclusions about the efficacy of the diverse treatment options available.

Self-care behaviors in older adults suffering from knee osteoarthritis: Application of theory of planned behavior

Background

Osteoarthritis is one of the main reasons causing disablement. Educational intervention for self-care behaviors of patients suffering from knee osteoarthritis is important because its effect on quality of patient life decreases the economic burden of disorder on society and family. This study aimed to investigate the effect of educational intervention based on the theory of planned behavior (TPB) on promoting self-care behaviors in elderly patients suffering from knee osteoarthritis.

Methods

This quasi-experimental study was performed on 200 elderlies suffering from knee osteoarthritis in the rheumatology clinics of Shiraz, Iran, in 2019. The subjects were divided into two groups (100 experimental and 100 control). Before and after 4 months, both experimental and control groups filled a questionnaire. After administering a pre-test to both groups, only the experimental group was trained based on the TPB constructs on self-care behaviors in elderly people suffering from knee osteoarthritis in eight sessions by presenting educational films and images, power points, and group discussions for solving problems.

Results

The mean age of the experimental group was 67.25 ± 3.64, and the mean age of the control group was 66.12 ± 3.50. The average scores of attitudes, subjective norms, perceived behavioral control, intention, and behavior before the educational intervention did not have significant differences in experimental and control groups, however, 4 months after the educational intervention, the paired t-test indicated significant enhancement in every construct in the experimental group, but no significant changes in the control group.

Conclusion

According to the results, the educational intervention increased the self-care behaviors of patients suffering from knee osteoarthritis based on the theory of planned behavior. Therefore, the results of this study can be used in theory-based intervention strategies for self-care behaviors of patients suffering from knee osteoarthritis.

The effect of education on pain and functionality on patients with musculoskeletal dysfunctions of the upper limb: a systematic review

ABSTRACT This study verifies the effects of patient education (PE) in patients with musculoskeletal disorders of the upper limb (UL) on pain and/or functionality. The PubMed, Cochrane, PEDro, SciELO, and LILACS databases were independently searched by two reviewers, from the beginning of the publications until April 2021. We included randomized clinical trials with individuals with musculoskeletal disorders of the UL with pain and/or functionality outcomes, who have undergone intervention with PE. Reviewers independently determined study eligibility, extracted data, and assessed methodological quality using the PEDro scale. We included eight studies, totaling 603 participants. Compared to the controlled group, the PE intervention showed better results in three studies for pain relief and/or functionality improvement. Apparently, PE is more effective when combined with exercise.

O efeito da educação na dor e funcionalidade em pacientes com disfunções musculoesqueléticas do membro superior: uma revisão sistemática

RESUMO Este estudo teve como objetivo verificar os efeitos da educação ao paciente (EP) em pacientes com disfunções musculoesqueléticas do membro superior (MS) para os desfechos de dor e/ou funcionalidade. Dois revisores realizaram independentemente buscas nas bases de dados PubMed, Cochrane, PEDro, SciELO e LILACS, considerando o período desde o início das publicações nessas bases até abril de 2021. Foram incluídos ensaios clínicos randomizados com seres humanos com disfunções musculoesqueléticas no MS; que tenham realizado intervenção com EP; e com desfechos de dor e/ou funcionalidade. Os revisores, separadamente, determinaram a elegibilidade dos estudos, extraíram dados e avaliaram a qualidade metodológica por meio da escala PEDro. Oito estudos foram incluídos nesta revisão, totalizando 603 participantes. A EP teve resultados superiores em três dos estudos no alívio da dor e/ou melhora da função em relação ao grupo comparativo. Sugere-se que a EP é mais eficaz quando associada a exercícios.

Effects of Patient Education on Pain and Function and Its Impact on Conservative Treatment in Elderly Patients with Pain Related to Hip and Knee Osteoarthritis: A Systematic Review

(1) Background: Patient education (PE), exercise therapy, and weight management are recommended as first-line interventions for hip and knee osteoarthritis (OA). Evidence supporting the effectiveness of exercise therapy and weight management in people with lower-limb OA has been synthesized in recent studies. However, according to the Osteoarthritis Research Society International, PE is often considered a standard of care and the inclusion of this as a first-line intervention for people with knee OA in clinical practice guidelines is often supported by limited evidence. The aim of this review is to evaluate the effects of PE on pain and function and how it impacts on conservative treatment. (2) Methods: This is a literature review of studies investigating the effect of patient education on pain and function and its impact on conservative treatment in elderly patients with pain related to hip and knee OA. PRISMA guidelines were followed during the design, search, and reporting stages of this review. The search was carried out in the PubMed database. (3) Results: A total of 1732 studies were detected and analyzed by performing the proposed searches in the detailed database. After removing duplicates and analyzing the titles and abstracts of the remaining articles, 20 studies were ultimately selected for this review. Nineteen of these twenty articles showed positive results in pain or function in patients with pain related to hip and knee OA. (4) Conclusions: PE seems to be effective in reducing pain and improving function in patients with pain related to hip and knee OA. Furthermore patient education seems to positively impact the conservative treatment with which it can be associated.

A community-centric multi-disciplinary education program with the 8-section brocade Tai Chi therapy for patients with osteoarthritis of the knee - a pilot study

Background

Osteoarthritis (OA) of the knee is one of the most common chronic degenerative joint diseases, and a multi-disciplinary approach to educating patients with OA knee are effective in symptoms management. Tai Chi exercise is a novel approach to relieving knee OA symptoms. Combining both educational program and Tai Chi has not yet been explored.

Methods

Multi-disciplinary education program included a total of 4-week 2-h weekly talks delivered by different health professionals with live demonstrations. This was then followed by a 1-h Tai Chi class (Baduanjin). Results from IPAQ (Physical activity level), WOMAC (evaluate knee OA conditions), and SF-36v2 (quality of life) were collected at the first class of education program, 3 and 6 months after the end of Tai Chi class. CSQ-8 (program effectiveness) was administered on the last day of Tai Chi class.

Results

One hundred and twelve patients joined the program. The overall attendance was over 90% with close-to-zero dropout rate. Satisfaction scored high in 85% of patients. WOMAC pain scores (p = 0.04) and SF-36v2 emotional role (p = 0.02) were statistically decreasing (improving) at 6 months after the program. SF-36v2 physical role and mental health tended to improve with time.

Conclusions

Combining both multidisciplinary education program program and Tai Chi exercise for knee OA patients was proven feasible. This program received high satisfaction, high attendance and very low dropout rates without any adverse event. Patients’ pain and emotion were significantly improved. A large-scale randomized trial introducing a control group is recommended.

Trial registration

Registry: ClinicalTrials.gov

Registration number: NCT04204213

Date of registration: 18/12/2019 (Retrospectively registered)

Briggs A, Cottrell E, Doyle F, Dziedzic K, Finney A, Murphy P, Paskins Z, Sheridan E, Swaithes L, P. French H. Barriers and facilitators to the implementation of osteoarthritis management programmes in primary or community care settings: a systematic review and qualitative framework synthesis protocol

Despite consistent international guidelines for osteoarthritis (OA) management, evidence-based treatments are underutilised. OA management programmes (OAMPs) are being implemented internationally to address this evidence-practice gap. An OAMP is defined as a 'model of evidence-based, non-surgical OA care that has been implemented in a real-world setting'. Our objective is to identify, synthesise and appraise qualitative research identifying anticipated or experienced micro (individual/behavioural), meso (organisational) or macro (context/system) level barriers or facilitators to the implementation of primary or community care-based OAMPs. Five electronic databases will be searched for papers published between 2010 and 2021. Qualitative or mixed-methods studies that include qualitative data on the anticipated or experienced barriers or facilitators to the implementation of primary or community care-based OAMPs, from the perspective of service users or service providers, will be included. The review will be reported using the PRISMA and ENTREQ guidelines. A data extraction form will be used to provide details of the included studies. Data will be analysed and identified barriers and facilitators will be mapped onto an appropriate implementation framework, such as the Theoretical Domains Framework. The appropriate JBI critical appraisal tools will be used to assess methodological quality, while the GRADE-CERQual approach will be used to assess confidence in the findings. Translation of evidence-based guidelines into practice is challenging and reliant on the quality of implementation. By comparing and contrasting anticipated and experienced barriers, this review will determine the extent of congruence between the two, and provide valuable insights into the views and experiences of key stakeholders involved in the implementation of OAMPs. The mapping of identified barriers and facilitators to behaviour change theory will enhance the applicability and construct validity of our findings and will offer significant utility for future development and implementation of OAMPs. Registration: This protocol was registered with PROSPERO (CRD42021255698) on 15/07/21.

Patient education improves pain and function in people with knee osteoarthritis with better effects when combined with exercise therapy: a systematic review

QUESTION

Is patient education effective as a standalone intervention or combined with other interventions for people with knee osteoarthritis?

DESIGN

Systematic review of randomised controlled trials. MEDLINE, EMBASE, SPORTDiscus, CINAHL and Web of Science were searched from inception to April 2020. The Cochrane Risk of Bias tool was used for included studies, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to interpret certainty of results.

PARTICIPANTS

People with knee osteoarthritis.

INTERVENTION

Any patient education intervention compared with any non-pharmacological comparator.

OUTCOME MEASURES

Primary outcomes were self-reported pain and function.

RESULTS

Twenty-nine trials involving 4,107 participants were included, informing low to very-low certainty evidence. Nineteen of 28 (68%) pooled comparisons were not statistically significant. Patient education was superior to usual care for pain (SMD -0.35, 95% CI -0.56 to -0.14) and function in the short term (-0.31, 95% CI -0.62 to 0.00), but inferior to exercise therapy for pain in the short term (0.77, 95% CI 0.07 to 1.47). Combining patient education with exercise therapy produced superior outcomes compared with patient education alone for pain in the short term (0.44, 95% CI 0.19 to 0.69) and function in the short (0.81, 95% CI 0.54 to 1.08) and medium term (0.39, 95% CI 0.15 to 0.62). When using the Western Ontario and McMaster Universities Osteoarthritis Index for these comparisons, clinically important differences indicated that patient education was inferior to exercise therapy for pain in the short term (MD 1.56, 95% CI 0.14 to 2.98) and the combination of patient education and exercise therapy for function in the short term (8.94, 95% CI 6.05 to 11.82).

CONCLUSION

Although patient education produced statistically superior short-term pain and function outcomes compared with usual care, differences were small and may not be clinically important. Patient education should not be provided as a standalone treatment and should be combined with exercise therapy to provide statistically superior and clinically important short-term improvements in function compared with education alone.

REGISTRATION

PROSPERO CRD42019122004.

Effects of self-management education programmes on self-efficacy for osteoarthritis of the knee: a systematic review of randomised controlled trials

BACKGROUND

Enhancing self-efficacy to manage symptoms and functions is an important aspect of self-management for patients with knee osteoarthritis (OA). Many reports have investigated the effects of self-management education programmes for arthritis patients. However, a study that exclusively focuses on patients with OA in the same joints is required to clarify the effects of self-management programmes because individuals with knee OA experience physical and psychological difficulties different from those experienced by individuals with other arthritis diseases. Furthermore, previous studies have reported a wide range of delivery styles of self-management education programmes. This systematic review aimed to evaluate the effects of group-based and face-to-face self-management education programmes conducted by health professionals targeting self-efficacy for knee OA exclusively.

METHODS

The MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PEDro databases were searched to identify quantitative measures used in randomised controlled trials (RCTs) to assess the effects of self-management education programmes targeting self-efficacy in patients with knee OA. We included studies in which medical professional-delivered self-management education programmes were conducted in a group-based and face-to-face manner in community or outpatient settings.

RESULTS

Seven RCTs from five countries were included in this review. Our retrieved studies included various types of self-management education programmes such as cognitive behavioural counselling, pain management education, physical education, weight management education, and arthritis self-efficacy management education, and control arms. They assessed various aspects of self-efficacy, including pain, physical function, arthritis symptoms excluding pain, weight management, mobility, and self-regulation. The total score of the Arthritis Self-Efficacy Scale was also measured. Some studies have reported beneficial effects of group-based and face-to-face self-management education programmes on self-efficacy for management of pain and other symptoms and for self-regulatory, knee OA. However, the results of the included studies were varied and inconsistent.

CONCLUSIONS

The current review only included seven studies, and there was a wide range of clinical heterogeneity among these studies. Thus, the effects of group-based and face-to-face self-management education programmes conducted by health professionals on self-efficacy for knee OA exclusively are inconclusive to date. Therefore, high-quality studies are required to provide significant information on clinicians, patients, and healthcare professionals in the future.

Physical activity and health-related quality of life in men and women with hip and/or knee osteoarthritis before and after a supported self-management programme - a prospective observational study

PURPOSE

To study differences between men and women in physical activity (PA) and health-related quality of life (HRQoL) before and after participating in a supported osteoarthritis (OA) self-management programme.

MATERIALS AND METHODS

A prospective observational study using data from a Swedish National Quality Register. Patients recorded between 2008 and 2013 with hip and/or knee OA with data at baseline, at 3 and 12 months follow-up (n = 7628) were included. Outcome measures were patient-reported PA and HRQoL (EQ-5D-3L).

RESULTS

A greater proportion of men (p = 0.002) changed to being physically active ≥150 min/week at 3 months follow-up. The proportion of women being physically active ≥150 min/week was larger than for men at baseline (p = 0.003) and at follow-up at 12 months (p = 0.035). Women reported lower HRQoL than men at baseline (p < 0.001), at follow-up at 3 (p < 0.001) and 12 months (p = 0.010). There were no differences between men and women in change in HRQoL at 3 (p = 0.629) and 12 months (p = 0.577) follow-up.

CONCLUSIONS

This study showed differences between men and women in PA and HRQoL before and after participating in a supported OA self-management programme. These differences should be considered when supporting PA and HRQoL.Implications for rehabilitationMen with hip and/or knee osteoarthritis (OA) might need more support during rehabilitation in order to maintain or even increase physical activity (PA) in the long run.Women with hip and/or knee OA might need more support during rehabilitation in order to maintain or even increase health-related quality of life (HRQoL) in the long run.Booster sessions might be suggested in order to enable both men and women with hip and/or knee OA to sustain improvements in PA and HRQoL after participating in a supported OA self-management programme.

The feasibility and effectiveness of internet-based rehabilitation for patients with knee osteoarthritis: A study protocol of randomized controlled trial in the community setting

BACKGROUND

Internet-based rehabilitation can ease the progression of chronic diseases. There had been studies on internet-based rehabilitation of knee osteoarthritis (OA), but them were conducted at home and ignored the potential benefits in the community setting. This study will explore the feasibility and effectiveness of internet-based rehabilitation accompanies wearable devices in the community setting for the patients with knee OA.

METHODS

An assessor-blinded randomized controlled feasibility trial will be performed to study the feasibility and effectiveness of internet-based rehabilitation program for the patients with knee OA in the community setting. Forty participants with knee OA will be recruited and randomly allocated into internet-based rehabilitation group (IRG) or control group (CG). The interventions of IRG will be performed in the community setting via web-based platform and wearable devices. The outcome measures will be conducted at baseline, and post-intervention 6 weeks, 12 weeks during the study. The feasibility will be tested by the proportion of participants who will complete the internet-based rehabilitation program within 12 weeks in IRG as well as the compliance and satisfaction. Additionally, the effectiveness of internet-based rehabilitation will be assessed by the Western Ontario and McMaster Universities Osteoarthritis Index, 11-point Numerical Rating Scale and Short Form-36 quality-of-life questionnaire.

CONCLUSION

The internet-based rehabilitation program and community-based interventions is feasible and efficacy to ameliorate the osteoarthritic pain and promote the physical function and quality of life for the patients with knee OA in the community setting.

TRIAL REGISTRATION NUMBER

The study was registered in the clinical trial registry ChiCTR2000033397.

Effect of self-management program on outcome of adult knee osteoarthritis

BACKGROUND & AIM

Chronic disease is a major concern with an aging population, and arthritis is one of the most prevalent chronic diseases affecting 10% of the population. Self-management can be appropriate to relieve the outcome of osteoarthritis as one of the most suitable approaches in people with chronic diseases. This study aimed to determine the effect of self-management education programs on the outcome of knee osteoarthritis in adult patients.

METHODS

Eighty participants were randomized into either control (40) or intervention (40) groups. Initially, demographic data and outcome of knee osteoarthriti datas were collected. The intervention group was then offered a self-management program. After completing the education, the KOOS questionnaire was completed by both groups. The intervention group practiced the self-management program for 8 weeks at their homes. The outcome of knee osteoarthritis in the two groups was then reassessed and compared.

RESULTS

There was no significant difference in the total score of the outcome of knee osteoarthritis before the training of the self-management education program (P > 0.05) between the two groups. After implementation of the self-management education program, the two groups demonstrated significant differences in scores for pain, symptoms, activities of daily living, sport and recreation function, and quality of life (P < 0.001).

CONCLUSION

Self-management education can improve all outcomes of knee osteoarthritis. Adherence to the proper diet and the use of pain reduction methods along with exercise improve the effects of knee osteoarthritis.

Which Interventions Enhance Pain Self-efficacy in People With Chronic Musculoskeletal Pain? A Systematic Review With Meta-analysis of Randomized Controlled Trials, Including Over 12 000 Participants

OBJECTIVE

To find out which interventions enhance pain self-efficacy in people with chronic musculoskeletal pain and to evaluate the reporting of interventions designed to enhance pain self-efficacy.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

PubMed, Embase, Scopus, PsycINFO, CINAHL, PEDro, and the Cochrane Central Register of Controlled Trials were searched from inception up to September 2019.

STUDY SELECTION CRITERIA

Randomized controlled trials evaluating pain self-efficacy as a primary or secondary outcome in chronic musculoskeletal pain.

DATA SYNTHESIS

We used the Cochrane risk of bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate the risk of bias and the certainty of the evidence, respectively.

RESULTS

Sixty randomized controlled trials were included (12 415 participants). There was a small effect of multicomponent, psychological, and exercise interventions improving pain self-efficacy at follow-ups of 0 to 3 months, a small effect of exercise and multicomponent interventions enhancing pain self-efficacy at follow-ups of 4 to 6 months, and a small effect of multicomponent interventions improving pain self-efficacy at follow-ups of 7 to 12 months. No interventions improved pain self-efficacy after 12 months. Self-management interventions did not improve pain self-efficacy at any follow-up time. Risk of bias, the nature of the control group, and the instrument to assess pain self-efficacy moderated the effects of psychological therapies at follow-ups of 7 to 12 months. The certainty of the evidence for all included interventions was low, due to serious risk of bias and indirectness. No trial reported the intervention in sufficient detail to allow full replication.

CONCLUSION

There was low-quality evidence of a small effect of multicomponent exercise and psychological interventions improving pain self-efficacy in people with chronic musculoskeletal pain. J Orthop Sports Phys Ther 2020;50(8):418-430. doi:10.2519/jospt.2020.9319.

The knowledge and self-management educational needs of older adults with knee osteoarthritis: A qualitative study

Knee osteoarthritis (KOA) is closely related with ageing, physical disability and functional dependency. The course of KOA is considered progressive and irreversible. Engagement with self-management may, however, minimize the impact of KOA. To be fully engaged with self-management activities, knowledge about KOA is a prerequisite. There is limited empirical data on older adults’ understanding on KOA and their information needs about KOA. Therefore, the aims of this study were to explore older adults’ knowledge about KOA and their perspectives on the information required to enable self-management. Three focus groups were conducted with 16 older adults with KOA. The sample consisted of three men and thirteen women with the mean age 73.2 years (range from 61 to 89). Thematic content analysis revealed two themes which were understanding about KOA and information needed about KOA. Participants’ knowledge about KOA varied between individuals with many expressing that they needed more information about KOA. A targeted strategy is needed to educate older adults about KOA in order to support and prepare them for self-management.

The Better Management of Patients with Osteoarthritis Program: Outcomes after evidence-based education and exercise delivered nationwide in Sweden

We evaluated a structured education- and exercise-based self-management program for patients with knee or hip osteoarthritis (OA), using a registry-based study of data from 44,634 patients taken from the Swedish “Better Management of Patients with Osteoarthritis” registry. Outcome measures included a numeric rating scale (NRS), EuroQol five dimension scale (EQ-5D), Arthritis self-efficacy scale (ASES-pain and ASES-other symptoms), pain frequency, any use of OA medication, desire for surgery, fear–avoidance behavior, physical activity, and sick leave were reported at baseline, 3 and 12 month. Changes in scale variables were analyzed using general linear models for repeated measures and changes in binary variables by McNamara’s test. All analyses were stratified by joint. At the 3-month follow-up, patients with knee (n = 30686) and hip (n = 13948) OA reported significant improvements in the NRS-pain, the EQ-5D index, the ASES-other symptoms, and ASES-pain scores with standardized effect size (ES) ranges for patients with knee OA of 0.25–0.57 and hip OA of 0.15–0.39. Significantly fewer patients reported pain more than once weekly, took OA medication, desired surgery, showed fear–avoidance behavior, and were physically inactive. At the 12-month follow-up, patients with knee (n = 21647) and hip (n = 8898) OA reported significant improvements in NRS-pain, EQ-5D index, and a decrease in ASES-other symptoms and ASES-pain scores with an ES for patients with knee OA of –0.04 to 0.43 and hip OA of –0.18 to 0.22. Significantly fewer patients reported daily pain, desired surgery (for hip OA), reported fear–avoidance behavior, and reported sick leave. Following these interventions, patients with knee and hip OA experienced significant reductions in symptoms and decreased willingness to undergo surgery, while using less OA medication and taking less sick leave. The results indicate that offering this program as the first-line treatment for OA patients may reduce the burden of this disease.

The effect of education and supervised exercise on physical activity, pain, quality of life and self-efficacy - an intervention study with a reference group

BACKGROUND

Individuals with knee and hip osteoarthritis (OA) are less physically active than people in general, and many of these individuals have adopted a sedentary lifestyle. In this study we evaluate the outcome of education and supervised exercise on the level of physical activity in individuals with knee or hip OA. We also evaluate the effect on pain, quality of life and self-efficacy.

METHODS

Of the 264 included individuals with knee or hip OA, 195 were allocated to the intervention group. The intervention group received education and supervised exercise that comprised information delivered by a physiotherapist and individually adapted exercises. The reference group consisted of 69 individuals with knee or hip OA awaiting joint replacement and receiving standard care. The primary outcome was physical activity (as measured with an accelerometer). The secondary outcomes were pain (Visual Analog Scale), quality of life (EQ-5D), and self-efficacy (Arthritis Self-Efficacy Scale, pain and other symptoms subscales). Participants in both groups were evaluated at baseline and after 3 months. The intervention group was also evaluated after 12 months.

RESULTS

No differences were found in the number of minutes spent in sedentary or in physical activity between the intervention and reference groups when comparing the baseline and 3 month follow-up. However, there was a significant difference in mean change (mean diff; 95% CI; significance) between the intervention group and reference group favoring the intervention group with regard to pain (13; 7 to 19; p < 0.001), quality of life (- 0.17; - 0.24 to - 0.10; p < 0.001), self-efficacy/other symptoms (- 5; - 10 to - 0.3; p < 0.04), and self-efficacy/pain (- 7; - 13 to - 2; p < 0.01). Improvements in pain and quality of life in the intervention group persisted at the 12-month follow-up.

CONCLUSIONS

Participation in an education and exercise program following the Swedish BOA program neither decreased the average amount of sedentary time nor increased the level of physical activity. However, participation in such a program resulted in decreased pain, increased quality of life, and increased self-efficacy.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov. Registration number: NCT02022566 . Retrospectively registered 12/18/2013.

Improved Hand Function, Self-Rated Health, and Decreased Activity Limitations: Results After a Two-Month Hand Osteoarthritis Group Intervention

OBJECTIVE

To evaluate the effects on hand function, activity limitations, and self-rated health of a primary care hand osteoarthritis (OA) group intervention. Hand OA causes pain, impaired mobility, and reduced grip force, which cause activity limitations. OA group interventions in primary care settings are sparsely reported.

METHODS

Sixty-four individuals with hand OA agreed to participate; 15 were excluded due to not fulfilling the inclusion criteria. The 49 remaining (90% female) participated in an OA group intervention at a primary care unit with education, paraffin wax bath, and hand exercise over a 6-week period. Data were collected at baseline, end of intervention, and after 1 year. Instruments used were the Grip Ability Test (GAT), the Signals of Functional Impairment (SOFI), dynamometry (grip force), hand pain at rest using a visual analog scale (VAS), the Patient-Specific Functional Scale (PSFS), the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH), and the EuroQol VAS (EQ VAS). Data were analyzed using nonparametric statistics.

RESULTS

Hand function, activity limitation, and self-rated health significantly improved from baseline to end of intervention, grip force (right hand: P < 0.001; left hand: P = 0.008), SOFI (P = 0.011), GAT (P < 0.001), hand pain at rest (P < 0.001), PSFS (1: P = 0.008, 2: P < 0.001, and 3: P = 0.004), Quick-DASH (P = 0.001), and EQ VAS (P = 0.039), and the effects were sustained after 1 year.

CONCLUSION

The hand OA group intervention in primary care improves hand function, activity limitation, and self-rated health. The benefits are sustained 1 year after completion of the intervention.

Persons' various experiences of learning processes in patient education for osteoarthritis, a qualitative phenomenographic approach

Background: Patient education (PE) is a core treatment of osteoarthritis (OA) with the aim to increase persons' knowledge, self-efficacy, and empowerment. Objective: To describe person's various experiences of learning processes in PE for OA. Design: Phenomenography. Method: Semi-structured interviews were performed with the same persons, pre- (11) and post- (9) education. Results: Various experiences on learning processes were found and were described in an outcome space. Achieving knowledge describes self-regulated learning and strongly relates to Control, which describes a high order cognitive learning skill, and minor to Confirm, which describes a cognitive learning skill based on recognition and application. Receiving knowledge describes the expectancy of learning regulated from the educator and strongly relates to Comply, which describes a low-order cognitive learning skill, and minor to Confirm. Conclusion: Different experiences of motivation and learning impact on persons' learning processes which, in turn, influence the persons' capability to accomplish self-efficacy and empowerment. The outcome space may serve as a basis for discussions between healthcare educators involved in PE to better understand what learning implies and to develop PE further.

Systematic review of non-surgical therapies for osteoarthritis of the hand: an update

OBJECTIVE

To update our earlier systematic reviews which evaluated all published randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological therapies in patients with hand osteoarthritis (OA). Surgical therapies were not evaluated.

DESIGN

RCTs published between March 2008 and December 2015 were added to the previous systematic reviews.

RESULTS

A total of 95 RCTs evaluating various pharmacological and non-pharmacological therapies in hand OA were analyzed in this update. Generally, the methodological quality of these RCTs has improved since the last update, with more studies describing their methods for randomization, blinding, and allocation concealment. However, RCTs continue to be weakened by a lack of consistent case definition and a lack of standardized outcome assessments specific to hand OA. The number and location of evaluated hand joints continues to be underreported, and only 25% of RCTs adequately described the method used to ensure allocation concealment. These remain major weaknesses of published RCTs. A meta-analysis could not be performed because of marked study heterogeneity, insufficient statistical data available in the published RCTs, and a small number of identical comparators.

CONCLUSION

Hand OA is a complex area in which to study the efficacy of therapies. There has been an improvement in the overall design and conduct of RCTs, however, additional large RCTs with a more robust methodological approach specific to hand OA are needed in order to make clinically relevant conclusions about the efficacy of the diverse treatment options available.

The effectiveness of braces and orthoses for patients with knee osteoarthritis: A systematic review of Japanese-language randomised controlled trials

BACKGROUND

Knee osteoarthritis is common. The evidence regarding the effectiveness of braces and orthoses for patients with knee osteoarthritis is inconclusive according to English-language literature. English-language reviews to date have not included Japanese-language studies.

OBJECTIVES

This study aimed to collect and synthesise Japanese-language randomised controlled trials investigating the effectiveness of braces and orthoses for patients with knee osteoarthritis.

STUDY DESIGN

Systematic review.

METHODS

Eight databases were systematically searched from inception to 29 July 2015. Only Japanese-language randomised controlled trials were included. Risk of bias was assessed using Physiotherapy Evidence Database scale. A meta-analysis was not appropriate due to the heterogeneity in the included studies.

RESULTS

Seven randomised controlled trials with low to high risks of bias were included. Six of seven included studies were conducted by the same author group. Limited evidence supported the positive effects of short-lever elastic knee braces to improve pain and functional disability in specific outcomes. No evidence was found to support the use of foot orthoses, such as laterally wedged insoles, medial arch support and metatarsal arch pad.

CONCLUSION

Our systematic review found no conclusive evidence about the effectiveness of any braces and orthoses for patients with medial knee osteoarthritis. Future Japanese-language studies should address methodological flaws exposed in this review and strengthen the international evidence base. Clinical relevance This is the first systematic review of Japanese-language randomised controlled trials investigating orthoses for patients with knee osteoarthritis. Clinicians can consider the use of short-lever elastic knee braces to improve specifically pain on squat or walking. Evidence found in this review does not support the use of foot orthoses.

Improving the self-management of chronic pain: COping with persistent Pain, Effectiveness Research in Self-management (COPERS)

Background

Chronic musculoskeletal pain is a common problem that is difficult to treat. Self-management support interventions may help people to manage this condition better; however, there is limited evidence showing that they improve clinical outcomes. Our overarching research question was ‘Does a self-management support programme improve outcomes for people living with chronic musculoskeletal pain?’.

Aim

To develop, evaluate and test the clinical effectiveness and cost-effectiveness of a theoretically grounded self-management support intervention for people living with chronic musculoskeletal pain.

Methods

In phase 1 we carried out two systematic reviews to synthesise the evidence base for self-management course content and delivery styles likely to help those with chronic pain. We also considered the psychological theories that might underpin behaviour change and pain management principles. Informed by these data we developed the Coping with persistent Pain, Evaluation Research in Self-management (COPERS) intervention, a group intervention delivered over 3 days with a top-up session after 2 weeks. It was led by two trained facilitators: a health-care professional and a layperson with experience of chronic pain. To ensure that we measured the most appropriate outcomes we reviewed the literature on potential outcome domains and measures and consulted widely with patients, tutors and experts. In a feasibility study we demonstrated that we could deliver the COPERS intervention in English and, to increase the generalisability of our findings, also in Sylheti for the Bangladeshi community. In phase 2 we ran a randomised controlled trial to test the clinical effectiveness and cost-effectiveness of adding the COPERS intervention to a best usual care package (usual care plus a relaxation CD and a pain toolkit leaflet). We recruited adults with chronic musculoskeletal pain largely from primary care and musculoskeletal physiotherapy services in two localities: east London and Coventry/Warwickshire. We collected follow-up data at 12 weeks (self-efficacy only) and 6 and 12 months. Our primary outcome was pain-related disability (Chronic Pain Grade disability subscale) at 12 months. We also measured costs, health utility (European Quality of Life-5 Dimensions), anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], coping, pain acceptance and social integration. Data on the use of NHS services by participants were extracted from NHS electronic records.

Results

We recruited 703 participants with a mean age of 60 years (range 19–94 years); 81% were white and 67% were female. Depression and anxiety symptoms were common, with mean HADS depression and anxiety scores of 7.4 [standard deviation (SD) 4.1] and 9.2 (SD 4.6), respectively. Intervention participants received 85% of the course content. At 12 months there was no difference between treatment groups in our primary outcome of pain-related disability [difference –1.0 intervention vs. control, 95% confidence interval (CI) –4.9 to 3.0]. However, self-efficacy, anxiety, depression, pain acceptance and social integration all improved more in the intervention group at 6 months. At 1 year these differences remained for depression (–0.7, 95% CI –1.2 to –0.2) and social integration (0.8, 95% CI, 0.4 to 1.2). The COPERS intervention had a high probability (87%) of being cost-effective compared with usual care at a threshold of £30,000 per quality-adjusted life-year.

Conclusions

Although the COPERS intervention did not affect our primary outcome of pain-related disability, it improved psychological well-being and is likely to be cost-effective according to current National Institute for Health and Care Excellence criteria. The COPERS intervention could be used as a substitute for less well-evidenced (and more expensive) pain self-management programmes. Effective interventions to improve hard outcomes in chronic pain patients, such as disability, are still needed.

Trial registration

Current Controlled Trials ISRCTN22714229.

Funding

The project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 14. See the NIHR Journals Library website for further project information.

Multidisciplinary approaches to managing osteoarthritis in multiple joint sites: a systematic review

Background

The National Institute for Health and Care Excellence’s Osteoarthritis (OA) guidelines recommended that future research should consider the benefits of combination therapies in people with OA across multiple joint sites. However, the clinical effectiveness of such approaches to OA management is unknown. This systematic review therefore aimed to identify the clinical and cost effectiveness of multidisciplinary approaches targeting multiple joint sites for OA in primary care.

Methods

A systematic review of randomised controlled trials. Computerised bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, PsychINFO, BNI, HBE, HMIC, AMED, Web of Science and Cochrane). Studies were included if they met the following criteria; a randomised controlled trial (RCT), a primary care population with OA across at least two different peripheral joint sites (multiple joint sites), and interventions undertaken by at least two different health disciplines (multidisciplinary). The Cochrane ‘Risk of Bias’ tool and PEDro were used for quality assessment of eligible studies. Clinical and cost effectiveness was determined by extracting and examining self-reported outcomes for pain, function, quality of life (QoL) and health care utilisation. The date range for the search was from database inception until August 2015.

Results

The search identified 1148 individual titles of which four were included in the review. A narrative review was conducted due to the heterogeneity of the included trials. Each of the four trials used either educational or exercise interventions facilitated by a range of different health disciplines. Moderate clinical benefits on pain, function and QoL were reported across the studies. The beneficial effects of exercise generally decreased over time within all studies. Two studies were able to show a reduction in healthcare utilisation due to a reduction in visits to a physiotherapist or a reduction in x-rays and orthopaedic referrals. The intervention that showed the most promise used educational interventions delivered by GPs with reinforcement by practice nurses.

Conclusions

There are currently very few studies that target multidisciplinary approaches suitable for OA across multiple joint sites, in primary care. A more consistent approach to outcome measurement in future studies of this nature should be considered to allow for better comparison.

The PLE(2)NO self-management and exercise program for knee osteoarthritis: Study Protocol for a Randomized Controlled Trial

Background

International recommendations suggest exercise and self-management programs, including non-pharmacological treatments, for knee osteoarthritis (KOA) because they can benefit pain relief and improve function and exercise adherence. The implementation of a combined self-management and exercise program termed PLE²NO may be a good method for controlling KOA symptoms because it encourages the development of self-efficacy to manage the pathology. This study will assess the effects of a self-management and exercise program in comparison to an educational intervention (control program) on symptoms, physical fitness, health-related quality of life, self-management behaviors, self-efficacy, physical activity level and coping strategies.

Methods/Design

This PLE²NO study is a single-blinded, randomized controlled trial of elderly (aged above 60 yrs old) patients with clinical and radiographic KOA. The patients will be allocated into either an educational group (control) or a self-management and exercise group (experimental). All participants will receive a supplement of chondroitin and glucosamine sulfates. This paper describes the protocol that will be used in the PLE²NO program.

Discussion

This program has several strengths. First, it involves a combination of self-management and exercise approaches, is available in close proximity to the patients and occurs over a short period of time. The latter two characteristics are crucial for maintaining participant adherence. Exercise components will be implemented using low-cost resources that permit their widespread application. Moreover, the program will provide guidance regarding the effectiveness of using a self-management and exercise program to control KOA symptoms and improve self-efficacy and health-related quality of life.

Trial registration

NCT02562833 (09/23/2015)

Effectiveness of an Integrated Multidisciplinary Osteoarthritis Outpatient Program versus Outpatient Clinic as Usual: A Randomized Controlled Trial

Objective.

Osteoarthritis (OA) is one of the leading causes of pain and disability. Given the constraint in the provision of care, there is a need to develop and assess effectiveness of new treatment models. The objective was to compare satisfaction with and effectiveness of a new integrated multidisciplinary outpatient program with usual care in an outpatient clinic for patients with OA.

Methods.

Patients with clinical OA referred to a rheumatology outpatient clinic were randomized to a 3.5-h multidisciplinary group-based educational program followed by individual consultations, or to usual care. The primary outcome was satisfaction with the health service evaluated on a numerical rating scale (0 = extremely unsatisfied, 10 = extremely satisfied) after 4 months. Secondary outcomes included health-related quality of life measures.

Results.

Of 391 patients, 86.4% (n = 338) were women, and mean age was 61.2 (SD 8.0) years. At 4 months, patients who received integrated multidisciplinary care were significantly more satisfied with the health service compared with controls, with a mean difference of −1.05 (95% CI −1.68 to −0.43, p < 0.001). Among secondary outcomes, only self-efficacy with other symptoms scale (10–100) improved significantly in the multidisciplinary group compared with controls at 4 months (3.59, 95% CI 0.69–6.5, p = 0.02). At 12 months, the Australian/Canadian Hand Osteoarthritis Index pain (0–10) and fatigue scores (0–10) were slightly worse in the multidisciplinary group with differences of 0.38 (95% CI 0.06–0.71, p = 0.02) and 0.55 (95% CI 0.02–1.07, p = 0.04), respectively.

Conclusion.

Patients receiving an integrated multidisciplinary care model were more satisfied with healthcare than those receiving usual care, whereas there were no clinically relevant improvements in health outcomes.

OARSI guidelines for the non-surgical management of knee osteoarthritis

OBJECTIVE

To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide.

METHOD

Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores.

RESULTS

Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation).

CONCLUSION

These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.

Self-management education programmes for osteoarthritis

BACKGROUND

Self-management education programmes are complex interventions specifically targeted at patient education and behaviour modification. They are designed to encourage people with chronic disease to take an active self-management role to supplement medical care and improve outcomes.

OBJECTIVES

To assess the effectiveness of self-management education programmes for people with osteoarthritis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PyscINFO, SCOPUS and the World Health Organization (WHO) International Clinical Trial Registry Platform were searched, without language restriction, on 17 January 2013. We checked references of reviews and included trials to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials of self-management education programmes in people with osteoarthritis were included. Studies with participants receiving passive recipients of care and studies comparing one type of programme versus another were excluded.

DATA COLLECTION AND ANALYSIS

In addition to standard methods we extracted components of the self-management interventions using the eight domains of the Health Education Impact Questionnaire (heiQ), and contextual and participant characteristics using PROGRESS-Plus and the Health Literacy Questionnaire (HLQ). Outcomes included self-management of osteoarthritis, participant's positive and active engagement in life, pain, global symptom score, self-reported function, quality of life and withdrawals (including dropouts and those lost to follow-up). We assessed the quality of the body of evidence for these outcomes using the GRADE approach.

MAIN RESULTS

We included twenty-nine studies (6,753 participants) that compared self-management education programmes to attention control (five studies), usual care (17 studies), information alone (four studies) or another intervention (seven studies). Although heterogeneous, most interventions included elements of skill and technique acquisition (94%), health-directed activity (85%) and self-monitoring and insight (79%); social integration and support were addressed in only 12%. Most studies did not provide enough information to assess all PROGRESS-Plus items. Eight studies included predominantly Caucasian, educated female participants, and only four provided any information on participants' health literacy. All studies were at high risk of performance and detection bias for self-reported outcomes; 20 studies were at high risk of selection bias, 16 were at high risk of attrition bias, two were at high risk of reporting bias and 12 were at risk of other biases. We deemed attention control as the most appropriate and thus the main comparator.Compared with attention control, self-management programmes may not result in significant benefits at 12 months. Low-quality evidence from one study (344 people) indicates that self-management skills were similar in active and control groups: 5.8 points on a 10-point self-efficacy scale in the control group, and the mean difference (MD) between groups was 0.4 points (95% confidence interval (CI) -0.39 to 1.19). Low-quality evidence from four studies (575 people) indicates that self-management programmes may lead to a small but clinically unimportant reduction in pain: the standardised mean difference (SMD) between groups was -0.26 (95% CI -0.44 to -0.09); pain was 6 points on a 0 to 10 visual analogue scale (VAS) in the control group, treatment resulted in a mean reduction of 0.8 points (95% CI -0.14 to -0.3) on a 10-point scale, with number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 5 to 23). Low-quality evidence from one study (251 people) indicates that the mean global osteoarthritis score was 4.2 on a 0 to 10-point symptom scale (lower better) in the control group, and treatment reduced symptoms by a mean of 0.14 points (95% CI -0.54 to 0.26). This result does not exclude the possibility of a clinically important benefit in some people (0.5 point reduction included in 95% CI). Low-quality evidence from three studies (574 people) showed no signficant difference in function between groups (SMD -0.19, 95% CI -0.5 to 0.11); mean function was 1.29 points on a 0 to 3-point scale in the control group, and treatment resulted in a mean improvement of 0.04 points with self-management (95% CI -0.10 to 0.02). Low-quality evidence from one study (165 people) showed no between-group difference in quality of life (MD -0.01, 95% CI -0.03 to 0.01) from a control group mean of 0.57 units on 0 to 1 well-being scale. Moderate-quality evidence from five studies (937 people) shows similar withdrawal rates between self-management (13%) and control groups (12%): RR 1.11 (95% CI 0.78 to 1.57). Positive and active engagement in life was not measured.Compared with usual care, moderate-quality evidence from 11 studies (up to 1,706 participants) indicates that self-management programmes probably provide small benefits up to 21 months, in terms of self-management skills, pain, osteoarthritis symptoms and function, although these are of doubtful clinical importance, and no improvement in positive and active engagement in life or quality of life. Withdrawal rates were similar. Low to moderate quality evidence indicates no important differences in self-management , pain, symptoms, function, quality of life or withdrawal rates between self-management programmes and information alone or other interventions (exercise, physiotherapy, social support or acupuncture).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence indicates that self-management education programmes result in no or small benefits in people with osteoarthritis but are unlikely to cause harm.Compared with attention control, these programmes probably do not improve self-management skills, pain, osteoarthritis symptoms, function or quality of life, and have unknown effects on positive and active engagement in life. Compared with usual care, they may slightly improve self-management skills, pain, function and symptoms, although these benefits are of unlikely clinical importance.Further studies investigating the effects of self-management education programmes, as delivered in the trials in this review, are unlikely to change our conclusions substantially, as confounding from biases across studies would have likely favoured self-management. However, trials assessing other models of self-management education programme delivery may be warranted. These should adequately describe the intervention they deliver and consider the expanded PROGRESS-Plus framework and health literacy, to explore issues of health equity for recipients.

Arthritis self-efficacy scale scores in knee osteoarthritis: a systematic review and meta-analysis comparing arthritis self-management education with or without exercise

STUDY DESIGN

Systematic literature review and meta-analysis.

OBJECTIVE

To evaluate studies that used arthritis self-management education alone or with exercise to improve Arthritis Self-Efficacy Scale scores of patients with knee osteoarthritis.

BACKGROUND

Increasing self-efficacy may improve patient knee osteoarthritis symptom management and function.

METHODS

MEDLINE (1946-March 2013), CINAHL (1981-March 2013), and PsycINFO (1967-March 2013) databases were searched.

RESULTS

Twenty-four studies, including 3163 subjects (women, n = 2547 [80.5%]; mean ± SD age, 65.3 ± 6.5 years), met the inclusion criteria. A meta-analysis was performed to compare the standardized mean difference effect sizes (Cohen d) of randomized controlled studies that used the Arthritis Self-Efficacy Scale pain (13 studies, n = 1906), other symptoms (13 studies, n = 1957), and function (5 studies, n = 399) subscales. Cohen d effect sizes were also calculated for cohort studies that used the Arthritis Self-Efficacy Scale pain (10 studies, n = 1035), other symptoms (9 studies, n = 913), and function (3 studies, n = 141) subscales. Both randomized controlled studies and cohort studies were grouped by intervention type (intervention 1, arthritis self-management education alone; intervention 2, arthritis self-management education with exercise), and effect sizes were compared (Mann-Whitney U tests, P<.05). Interventions that used arthritis self-management education with exercise displayed higher methodological quality scale scores (76.8 ± 13.1 versus 61.6 ± 19.6, P = .03). Statistically significant standardized effect-size differences between intervention 1 and intervention 2 were not observed.

CONCLUSION

Small to moderate effect sizes were observed regardless of whether the intervention included exercise. Exercise interventions used in conjunction with arthritis self-management education programs need to be developed to better enhance the self-efficacy of patients with knee osteoarthritis.

LEVEL OF EVIDENCE

Therapy, level 2b-.

Supervised training and home-based rehabilitation in patients with stabilized ankylosing spondylitis on TNF inhibitor treatment: a controlled clinical trial with a 12-month follow-up

OBJECTIVE

To assess the 12-month's follow-up effects on pain, mobility, and physical function outcomes of a supervised training and home-based rehabilitation for ankylosing spondylitis patients stabilized with TNF-inhibitor therapy.

DESIGN

Controlled clinical trial (sequentially determined allocation) with 12-months' follow-up.

SETTING

Patients' homes.

SUBJECTS

A total of 69 subjects were allocated to either a rehabilitation programme (rehabilitation group, n = 22), an educational-behavioural programme (educational group, n = 24), and to neither programme (control group, n = 23).

INTERVENTIONS

Rehabilitation programme included supervised training and home exercises (stretching, strengthening, aerobic, chest, and spine/hip joint flexibility exercises); educational-behavioural programme included information on ankylosing spondylitis, pain and stress mechanisms, and control.

MAIN MEASURES

Spinal pain intensity, Bath Ankylosing Spondylitis Metrology Index, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Disease Activity Index, chest expansion, and cervical and lumbar spine active range of motion measured by a pocket goniometer.

RESULTS

At baseline, the three groups exhibited comparable demographic characteristics and basal evaluations. Intra-group changes in the rehabilitation group from baseline to 12 months yielded statistically significant gains (p < 0.05) for all outcomes. At 12-months follow-up, compared with the control and educational-behavioural, the rehabilitation group exhibited significant differences in chest expansion (p = 0.001 and p < 0.001), Bath Ankylosing Spondylitis Disease Activity Index (p = 0.012 and p = 0.050), and in some goniometric measurements as cervical rotation (p = 0.007 and p = 0.014), toraco-lumbar rotation (p = 0.009 and p = 0.050), and total cervical movements (p = 0.009 and p = 0.001).

CONCLUSION

In comparison with the educational-behavioural programme or no intervention, supervised training and home exercises improved long-term outcome in patients with ankylosing spondylitis.

Patient education with or without manual therapy compared to a control group in patients with osteoarthritis of the hip. A proof-of-principle three-arm parallel group randomized clinical trial

OBJECTIVE

To investigate the effectiveness of a patient education (PE) program with or without the added effect of manual therapy (MT) compared to a minimal control intervention (MCI).

METHODS

In a single-center university hospital setting, a total of 118 patients with clinical and radiographic unilateral hip osteoarthritis (OA) from primary care were randomized into one of three groups: PE, PE plus MT or MCI. The PE was taught by a physiotherapist involving five sessions. The MT was delivered by a chiropractor involving 12 sessions and the MCI included a home stretching program. Primary outcome was self-reported pain severity on an 11-box numeric rating scale (NRS) immediately following a 6-week intervention period. Patients were followed for 1 year.

RESULTS

Primary analysis included 111 patients (94%). In the combined group (PE + MT), a clinically relevant reduction in pain severity compared to the MCI of 1.90 points (95% confidence interval (CI) 0.9-2.9) was achieved. Effect size (Cohen's d) for the PE + MT minus the MCI was 0.92 (95% CI 0.41-1.42). Number needed to treat for PE + MT was 3 (95% CI 2-7). No difference was found between the PE and MCI groups, with mean difference 0.0 (95% CI -1.0 to 1.0). At 12 months, not including patients receiving hip surgery the statistically significant difference favoring PE + MT was maintained.

CONCLUSIONS

For primary care patients with OA of the hip, a combined intervention of MT and PE was more effective than a MCI. PE alone was not superior to the MCI.

TRIAL REGISTRATION

clinicaltrials.govNCT01039337.

Defining the content of an opportunistic osteoarthritis consultation with primary health care professionals: a Delphi consensus study

OBJECTIVE

To define the core content for an opportunistic consultation between a health care professional (HCP) and a patient with osteoarthritis (OA) in primary care.

METHODS

An ideas generation round and a 2-round Delphi postal consensus study allowed participants to rank the importance of tasks for an opportunistic consultation. The study was conducted with a lay group (n = 18) and 3 groups of HCPs (n = 30 for general practitioners, n = 19 for practice nurses, and n = 37 for allied health professionals).

RESULTS

The ideas generation round formulated 35 consultation tasks. There was a 50% response rate to the 2-round postal exercise (n = 52). Consensus was reached on 12 tasks for an opportunistic OA consultation using a >80% level of agreement across all groups. Three of these consultation tasks were defined at 100%. The 3 tasks were questions asked by the HCP about how things are going with the condition, the type and amount of pain the patient has, and whether the patient is taking regular analgesia.

CONCLUSION

In a Delphi study to define the content of an opportunistic primary care OA consultation, 12 consultation tasks provided the content of a comprehensive consultation. Three of these tasks with 100% agreement could be adopted in any multidisciplinary consultation for OA in primary care. Inquiring about the condition, the type and amount of pain the patient has, and whether analgesia is being taken forms a core set of questions that are considered important by both lay and health professional groups in an opportunistic consultation.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Development of a brief multidisciplinary education programme for patients with osteoarthritis

Background

Osteoarthritis (OA) is a prevalent progressive musculoskeletal disorder, leading to pain and disability. Patient information and education are considered core elements in treatment guidelines for OA; however, there is to our knowledge no evidence-based recommendation on the best approach, content or length on educational programmes in OA. Objective: to develop a brief, patient oriented disease specific multidisciplinary education programme (MEP) to enhance self-management in patients with OA.

Method

Twelve persons (80% female mean age 59 years) diagnosed with hand, hip or knee OA participated in focus group interviews. In the first focus group, six participants were interviewed about their educational needs, attitudes and expectations for the MEP. The interviews were transcribed verbatim and thereafter condensed.

Based on results from focus group interviews, current research evidence, clinical knowledge and patients' experience, a multidisciplinary OA team (dietist, nurse, occupational therapist, pharmacist, physical therapist and rheumatologist) and a patient representative developed a pilot-MEP after having attended a work-shop in health pedagogics. Finally, the pilot-MEP was evaluated by a second focus group consisting of four members from the first focus group and six other experienced patients, before final adjustments were made.

Results

The focus group interviews revealed four important themes: what is OA, treatment options, barriers and coping strategies in performing daily activities, and how to live with osteoarthritis. Identified gaps between patient expectations and experience with the pilot-programme were discussed and adapted into a final MEP. The final MEP was developed as a 3.5 hour educational programme provided in groups of 6-9 patients. All members from the multidisciplinary team are involved in the education programme, including a facilitator who during the provision of the programme ensures that the individual questions are addressed. As part of an ongoing process, a patient representative regularly attends the MEP and gives feedback concerning content and perceived value.

Conclusion

A MEP has been developed to enhance self-management in patients with OA attending a multidisciplinary OA outpatient clinic. The effectiveness of the MEP followed by individual consultations with members of the multidisciplinary team is currently evaluated in a randomised controlled trial with respect to patient satisfaction and functioning.

Physiatric approaches to pain management in osteoarthritis: a review of the evidence of effectiveness

SUMMARY Osteoarthritis (OA), which is highly prevalent in the general population, is one of the leading causes of pain and physical disability. A large number of nonpharmacological interventions are available for the management of pain in patients with OA. These include education and self-management, weight reduction, various forms of exercises, physical agents/modalities, complementary therapies, manual therapy, unloading strategies such as braces and orthoses, and balneotherapy. The aim of this article is to assess the evidence of effectiveness of nonpharmacological interventions pertaining to physiatry to identify best practices for pain management in OA.