Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight

Loss of body weight is dose-dependently associated with reductions in symptoms of hip osteoarthritis

BACKGROUND/OBJECTIVES

While weight loss is recommended for managing hip osteoarthritis (OA), most evidence comes from knee OA studies, limiting its applicability to hip OA. This study addresses this gap by examining the effects of weight loss on hip OA symptoms.

DESIGN AND SETTING

A retrospective audit of routinely collected healthcare data from participants enrolled in the Osteoarthritis Healthy Weight for Life (OAHWFL) program, designed for individuals with knee or hip OA.

PARTICIPANTS

In total, 1714 adults with hip OA were selected from the OAHWFL program; 1408 completed the initial 18-week weight loss phase, while 306 did not complete it. After 18 weeks, participants transitioned to an indefinite weight maintenance phase.

EXPOSURE

Percentage change in body weight from baseline at 18 weeks.

OUTCOMES

Changes in the five subscales of the Hip Disability and Osteoarthritis Outcome Score (HOOS) (Pain, Activity Limitations in Daily Living, Stiffness and Range of Motion, Sports and Recreation Function, and Hip-related Quality of Life) from baseline to 18 weeks.

STATISTICS

Linear regression, adjusted for sex and baseline values of age, weight, and respective HOOS scores, assessed the relationship between percentage weight change (analyzed as both a continuous variable and in categories: ≤2.5%, >2.5-5.0%, >5.0-7.5%, >7.5-10%, and >10% of baseline weight) and changes in all five HOOS subscales.

RESULTS

At baseline, participants had a mean age of 65.14 years, 70% were female, and 78% were individuals with obesity (Body Mass Index ≥30 kg/m2). A statistically significant dose-response relationship was observed between weight loss and improvements in all HOOS subscales, with the greatest improvement in the Hip-related Quality of Life subscale (14.42 points, 31.14%) for >10% weight loss.

CONCLUSION

Our findings suggest that weight loss is associated with reduced symptoms of hip OA, supporting weight loss as an effective treatment strategy for hip OA.

Weight change patterns across adulthood are associated with the risk of osteoarthritis: a population-based study

BACKGROUND

Body weight has been recognized as a driving factor of osteoarthritis. Few studies had investigated the association between weight status across adulthood and risk of osteoarthritis (OA). This study investigates the association of weight change patterns across adulthood (lasting at least 25 years) with the risk of OA from the National Health and Nutrition Examination Survey (NHANES) 2013-2018.

METHODS

The study assessed the relationship between weight change across adulthood and OA in 7392 individuals aged > 50 spanning a minimum of 25 years. Multivariate linear regression analyses were utilized to detect the association between weight change patterns and self-reported OA. Restricted cubic splines (RCS) were used to examine the nonlinear relationship between absolute weight change and OA risk.

RESULTS

From 10 years ago to survey, the risk of OA was 1.34-fold (95% CI 1.07-1.68) in people changed from obese to non-obese, 1.61-fold (95% CI 1.29-2.00) in people change from non-obese to obese, and 1.82-fold (95% CI 1.49-2.22) in stable obese people compared with people who were at stable normal weight. Similar patterns were also observed at age 25 years to baseline and age 25 years to 10 years before the baseline. The dose-response association of RCS found a U-shaped relationship between absolute weight change and OA risk.

CONCLUSIONS

The study suggests that weight patterns across adulthood are associated with the risk of OA. These findings stressed important to maintain a normal weight throughout adulthood, especially to prevent ignored weight gain in early adulthood to reduce OA risk later.

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

A mixed methods approach to investigating physical activity in people with obesity participating in a chronic care programme awaiting total knee or hip arthroplasty

AIMS

To describe patient-reported physical activity and step count trajectory and explore perceived barriers and enablers to physical activity amongst people with obesity participating in a chronic care programme whilst awaiting arthroplasty.

DESIGN

Convergent parallel mixed-method study.

METHOD

A patient cohort derived from a longitudinal sample of adults with end-stage osteoarthritis and obesity from a chronic care programme whilst awaiting primary total knee or hip arthroplasty (n = 97) was studied. Physical activity was measured at baseline (entry to the wait list) and before surgery (9-12 months waiting time) using the Lower Extremity Activity Scale (LEAS) and activity monitors (activPAL™). A subset of participants completed in-depth semi-structured interviews 6 months after being waitlisted to explore perceived barriers and enablers to physical activity. Themes were inductively derived and then interpreted through the COM-B model.

RESULTS

Baseline LEAS and activPAL™ data were available from 97 and 63 participants, respectively. The proportion of community ambulant individuals reduced from 43% (95% CI 33%-53%) at baseline to 17% (95% CI 9%-28%) pre-surgery. Paired activPAL™ data (n = 31) for step count, upright time, and stepping time remained unchanged. Twenty-five participants were interviewed. Five themes underpinning physical activity were mapped to the COM-B model components of capability (physical capability), opportunity (accessibility and social norms), and motivation (self-efficacy and beliefs and physical activity).

CONCLUSIONS

Participation in a chronic care programme did not improve physical activity levels for people with obesity awaiting arthroplasty. Programs cognisant of the COM-B model components may be required to address the natural trajectory of declining physical activity levels while awaiting arthroplasty.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Identifying strategies that support equitable person-centred osteoarthritis care for diverse women: content analysis of guidelines

INTRODUCTION

Women are disproportionately impacted by osteoarthritis (OA) but less likely than men to access early diagnosis and management, or experience OA care tailored through person-centred approaches to their needs and preferences, particularly racialized women. One way to support clinicians in optimizing OA care is through clinical guidelines. We aimed to examine the content of OA guidelines for guidance on providing equitable, person-centred care to disadvantaged groups including women.

METHODS

We searched indexed databases and websites for English-language OA-relevant guidelines published in 2000 or later by non-profit organizations. We used manifest content analysis to extract data, and summary statistics and text to describe guideline characteristics, person-centred care (PCC) using a six-domain PCC framework, OA prevalence or barriers by intersectional factors, and strategies to improve equitable access to OA care.

RESULTS

We included 36 OA guidelines published from 2003 to 2021 in 8 regions or countries. Few (39%) development panels included patients. While most (81%) guidelines included at least one PCC domain, guidance was often brief or vague, few addressed exchange information, respond to emotions and manage uncertainty, and none referred to fostering a healing relationship. Few (39%) guidelines acknowledged or described greater prevalence of OA among particular groups; only 3 (8%) noted that socioeconomic status was a barrier to OA care, and only 2 (6%) offered guidance to clinicians on how to improve equitable access to OA care: assess acceptability, availability, accessibility, and affordability of self-management interventions; and employ risk assessment tools to identify patients without means to cope well at home after surgery.

CONCLUSIONS

This study revealed that OA guidelines do not support clinicians in caring for diverse persons with OA who face disadvantages due to intersectional factors that influence access to and quality of care. Developers could strengthen OA guidelines by incorporating guidance for PCC and for equity that could be drawn from existing frameworks and tools, and by including diverse persons with OA on guideline development panels. Future research is needed to identify multi-level (patient, clinician, system) strategies that could be implemented via guidelines or in other ways to improve equitable, person-centred OA care.

PATIENT OR PUBLIC CONTRIBUTION

This study was informed by a team of researchers, collaborators, and thirteen diverse women with lived experience, who contributed to planning, and data collection, analysis and interpretation by reviewing study materials and providing verbal (during meetings) and written (via email) feedback.

Investigation of the association of weight loss with radiographic hip osteoarthritis in older community-dwelling female adults

OBJECTIVE

Most guidelines recommending weight loss for hip osteoarthritis are based on research on knee osteoarthritis. Prior studies found no association between weight loss and hip osteoarthritis, but no previous studies have targeted older adults. Therefore, we aimed to determine whether there is any clear benefit of weight loss for radiographic hip osteoarthritis in older adults because weight loss is associated with health risks in older adults.

METHODS

We used data from white female participants aged ≥65 years from the Study of Osteoporotic Fractures. Our exposure of interest was weight change from baseline to follow-up at 8 years. Our outcomes were the development of radiographic hip osteoarthritis (RHOA) and the progression of RHOA over 8 years. Generalized estimating equations (clustering of 2 hips per participant) were used to investigate the association between exposure and outcomes adjusted for major covariates.

RESULTS

There was a total of 11,018 hips from 5509 participants. There was no associated benefit of weight loss for either of our outcomes. The odds ratios (95% confidence intervals) for the development and progression of RHOA were 0.99 (0.92-1.07) and 0.97 (0.86-1.09) for each 5% weight loss, respectively. The results were consistent in sensitivity analyses where participants were limited to those who reported trying to lose weight and who also had a body mass index in the overweight or obese range.

CONCLUSION

Our findings suggest no associated benefit of weight loss in older female adults in the structure of the hip joint as assessed by radiography.

Association of Change in Body Mass Index With Incidence and Progression of the Structural Defects of Hip Osteoarthritis: Data From the Osteoarthritis Initiative and the Cohort Hip and Cohort Knee study

OBJECTIVE

To define the association between change in body mass index (BMI) and the incidence and progression of structural defects of hip osteoarthritis as assessed by radiography.

METHODS

We used data from 2 independent cohort studies: the Osteoarthritis Initiative (OAI) and the Cohort Hip and Cohort Knee (CHECK) study. Our exposure was change in BMI from baseline to 4-5 years' follow-up. Our outcomes were the incidence and progression of structural defects of hip osteoarthritis as assessed using a modified Croft grade in OAI and the Kellgren/Lawrence grade in the CHECK study. To study incidence, we created incidence cohorts of hips without definite overall structural defects at baseline (i.e., grade <2) and then investigated the odds of hips having definite overall structural defects at follow-up (i.e., grade ≥2). To study progression, we created progression cohorts of hips with definite overall structural defects at baseline (i.e., grade ≥2) and then investigated the odds of having a grade increase of ≥1 from baseline to follow-up.

RESULTS

There was a total of 5,896 and 1,377 hips in the incidence cohorts, and 303 and 129 hips in the progression cohorts for the OAI and CHECK study, respectively. Change in BMI (decrease or increase) was not associated with any change in odds of the incidence or progression of definite structural defects of hip osteoarthritis in either the OAI or CHECK cohorts.

CONCLUSION

Weight loss may not be an effective strategy for preventing, slowing, or delaying the structural defects of hip osteoarthritis over 4-5 years.

Association Between Change in Body Mass Index and Knee and Hip Replacements: A Survival Analysis of Seven to Ten Years Using Multicohort Data

OBJECTIVE

To define the association between change in body mass index (BMI) and the risk of knee and hip replacement.

METHODS

We used data from 3 independent cohort studies: the Osteoarthritis Initiative (OAI), the Multicenter Osteoarthritis Study (MOST), and the Cohort Hip and Cohort Knee (CHECK) study, which collected data from adults (45-79 years of age) with or at risk of clinically significant knee osteoarthritis. We conducted Cox proportional hazards regression analysis with clustering of both knees and hips per person to determine the association between change in BMI (our exposure of interest) and the incidence of primary knee and hip replacement over 7-10 years' follow-up. Change in BMI (in kg/m2 ) was calculated between baseline and the last follow-up visit before knee or hip replacement, or for knees and hips that were not replaced, the last follow-up visit.

RESULTS

A total of 16,362 knees from 8,181 participants, and 16,406 hips from 8,203 participants, were eligible for inclusion in our knee and hip analyses, respectively. Change in BMI was positively associated with the risk of knee replacement (adjusted hazard ratio [HRadj ] 1.03 [95% confidence interval (95% CI) 1.00-1.06]) but not hip replacement (HRadj 1.00 [95% CI 0.95-1.04]). The association between change in BMI and knee replacement was independent of participants' BMI category at baseline (i.e., normal, overweight, or obese).

CONCLUSION

Public health strategies incorporating weight loss interventions could reduce the burden of knee but not hip replacement surgery.

Effects of Physical Exercises Alone on the Functional Capacity of Individuals with Obesity and Knee Osteoarthritis: A Systematic Review

Simple Summary

Osteoarthritis is a degenerative joint disease that affects millions of people around the world. Knee osteoarthritis is one of the causes of more significant functional disability among people with it. Currently, obesity is identified as one of the main risk factors for the onset of the disease due to excess load on the joints of the lower limbs, especially the knees. The association of measures, such as weight reduction through diets and exercise, can alleviate symptoms and increase the physical condition of people affected by these clinical conditions. However, many individuals with obesity have difficulty adhering to diet programs and need to improve in order to perform their functional activities. The aim of this systematic review was to evaluate the results of several physical exercise programs conducted without the association of diet, demonstrating the improvement of the functional capacity of individuals with these concomitant clinical conditions, presenting another proposal to reduce the symptoms of the disease in this population.

Abstract

The association between obesity and knee osteoarthritis (KOA) is reported in the literature. The inflammatory factors described in obesity associated with mechanical overload on the knee joint lead to KOA development and reduced functional capacity in these individuals. Most physical exercise (PE) protocols associate a diet program to improve the functional capacity of individuals with concomitant KOA and obesity. There is a lack of published protocols performing PE alone, which would be without an associated diet program in individuals with both clinical conditions. In this systematic review, the authors summarize the effects of the application of PE alone, describing each protocol and reporting the improvement in the function of people with these clinical conditions. This investigation was conducted according to the PRISMA guidelines and registered in PROSPERO. Five databases (MEDLINE/PubMed, PEDro, Scopus, CINAHL and Web of Science) were used up to July 2022 and ten studies, including 534 participants, met the inclusion criteria. The PEDro scale, Cochrane collaborations and ROBINS-I tools were used to evaluate the methodological quality and risk of bias. It was concluded that PE performed alone seems to provide an improvement in the functional capacity of these individuals even without an associated diet plan in the condition of obesity.

Association of Decrease in Body Mass Index With Reduced Incidence and Progression of the Structural Defects of Knee Osteoarthritis: A Prospective Multi-Cohort Study

OBJECTIVE

To define the association between change in body mass index (BMI) and the incidence and progression of the structural defects of knee osteoarthritis as assessed by radiography.

METHODS

Radiographic analyses of knees at baseline and at 4-5 years of follow-up were obtained from the following 3 independent cohort studies: the Osteoarthritis Initiative (OAI) study, the Multicenter Osteoarthritis Study (MOST), and the Cohort Hip and Cohort Knee (CHECK) study. Logistic regression analyses using generalized estimating equations, with clustering of both knees within individuals, were used to investigate the association between change in BMI from baseline to 4-5 years of follow-up and the incidence and progression of knee osteoarthritis.

RESULTS

A total of 9,683 knees (from 5,774 participants) in an "incidence cohort" and 6,075 knees (from 3,988 participants) in a "progression cohort" were investigated. Change in BMI was positively associated with both the incidence and progression of the structural defects of knee osteoarthritis. The adjusted odds ratio (OR) for osteoarthritis incidence was 1.05 (95% confidence interval [95% CI] 1.02-1.09), and the adjusted OR for osteoarthritis progression was 1.05 (95% CI 1.01-1.09). Change in BMI was also positively associated with degeneration (i.e., narrowing) of the joint space and with degeneration of the femoral and tibial surfaces (as indicated by osteophytes) on the medial but not on the lateral side of the knee.

CONCLUSION

A decrease in BMI was independently associated with lower odds of incidence and progression of the structural defects of knee osteoarthritis and could be a component in preventing the onset or worsening of knee osteoarthritis.

Effect of Dietary Weight Loss and Macronutrient Intake on Body Composition and Physical Function in Adults with Knee Osteoarthritis: A Systematic Review

Overweight and obesity increase the risk of development and progression of knee osteoarthritis (OA), with higher levels of fat mass and lower levels of lean mass associated with poorer functional status. The aim was to assess changes in weight, body composition and physical function following weight loss or weight maintenance interventions in knee OA. A comprehensive search of four databases was conducted. The risk of bias was assessed using the Quality Criteria Checklist for primary research. Primary outcomes included weight, body composition and physical function; secondary outcomes were lipids, inflammatory biomarkers and muscle strength. Eleven studies were included utilizing diet and exercise (n = 4) or diet-only (n = 7) interventions, two of which were weight maintenance studies. Most studies (n = 10) reported improvements in physical function with significant weight loss, while the change in strength reported in three studies was variable. The diet and exercise studies reported an average reduction in weight of 6.7% and lean mass of 1.6 kg, with greater improvements in physical function. The diet-only studies, including weight maintenance interventions, reported greater average weight loss (7.8%) and reduction in LM (2.0 kg). Overall, better retention of lean mass and muscle strength was observed in participants with higher protein intake (≥37% of energy) and subsequently improved physical function.

Weight loss is associated with reduced risk of knee and hip replacement: a survival analysis using Osteoarthritis Initiative data

OBJECTIVE

To describe the association between body weight change and the risk of knee replacement and hip replacement.

DESIGN

Time-to-event survival analysis from a population-based cohort of participants who had or were at risk of clinically significant knee osteoarthritis at baseline.

SETTING

Data from the Osteoarthritis Initiative (OAI), which collected data from four clinical centres in the United States.

PARTICIPANTS

A total of 8069 knees from 4081 participants, and 8076 hips from 4064 participants (59.3% female) aged 45-79 years, with mean ± SD body mass index (BMI) of 28.7 ± 4.8 kg/m², were included in the knee and hip analyses, respectively.

EXPOSURE

Body weight change from baseline as a percentage of baseline at repeated follow-up visits over 8 years.

MAIN OUTCOME MEASURE

Incidence of primary knee or hip replacement during 8-year follow-up.

RESULTS

Body weight change had a small, positive, linear association with the risk of knee replacement (adjusted hazard ratio [HR] 1.02; 95% confidence interval [CI] 1.00-1.04). Body weight change was also positively and linearly associated with the risk of hip replacement in hips that were persistently painful at baseline (adjusted HR 1.03; 95% CI 1.01-1.05), but not in hips that were not persistently painful at baseline. There were no significant interactions between body weight change and baseline BMI in the association with knee or hip replacement.

CONCLUSIONS

In people with or at risk of clinically significant knee osteoarthritis, every 1% weight loss was associated with a 2% reduced risk of knee replacement and - in those people who also had one or more persistently painful hips - a 3% reduced risk of hip replacement, regardless of baseline BMI. Public health strategies that incorporate weight loss interventions have the potential to reduce the burden of knee and hip replacement surgery.

Quality and content analysis of clinical practice guidelines which include nonpharmacological interventions for knee osteoarthritis

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for knee osteoarthritis (OA) guide the provision of high-quality healthcare for people with knee OA, which may improve outcomes. Our aim was to evaluate the quality of and content within recently published CPGs for people with knee OA.

METHODS

CPGs (2014-2019) that described recommendations for nonpharmacological interventions for knee OA were included in the analysis. Two pairs of evaluators used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the quality of guideline development. CPG content was reviewed and summarized for comparison.

RESULTS

Ten CPGs were identified for inclusion in the quality and content analysis (seven newly developed and three recently updated). Overall CPG scores ranged between 42% and 100%. Six CPGs were found to be high-quality. Exercise was the only intervention recommended by all CPGs that we appraised. Weight-management and education were the next most frequently recommended interventions. Inter-rater reliability scores were high in domain 1: scope and purpose, (P-value = .001, intraclass correlation coefficient [ICC] = 0.90, 95% confidence interval [CI] = 0.62-0.98), domain 3: rigor of development (P-value = .000, ICC = 0.95, 95% CI = 0.80-0.99) and domain 5: applicability (P-value = .001, ICC = 0.91, 95% CI = 0.64-0.98).

CONCLUSION

Several CPGs have been developed or recently updated since 2014. Over half of the ten CPGs we appraised were deemed to be high-quality. Exercise, education, and weight-management advice are interventions that were most commonly recommended by CPGs.

Physical function after dietary weight loss in overweight and obese adults with osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Osteoarthritis (OA) is associated with functional limitations that can impair mobility and reduce quality of life in affected individuals. Excess body weight in OA can exacerbate impaired physical function, highlighting the importance of weight management in this population. The aim of this systematic review was to compare the effects of different dietary interventions for weight loss on physical function in overweight and obese individuals with OA.

DESIGN

A comprehensive search of five databases was conducted to identify relevant articles for inclusion. Studies were included that examined the effect of dietary weight loss interventions, with or without exercise, on physical function in adults with OA who were overweight or obese. Quality and risk of bias were assessed using the Quality Criteria Checklist for primary research. Primary and secondary outcomes were extracted, including change in weight and physical function which included performance-based and self-report measures.

RESULTS

Nineteen relevant studies were included, which incorporated lifestyle interventions (n 8), diet in combination with meal replacements (DMR; n 5) and very low-energy diets (VLED; n 6) using meal replacements only. Pooled data for eight RCT indicated a mean difference in Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical function of 12·4 and 12·5 % following DMR or VLED interventions, respectively; however, no statistically significant change was detected for lifestyle interventions.

CONCLUSIONS

Our findings suggest that partial use of meal replacements is as effective as their sole use in the more restrictive VLED. Both dietary interventions are more effective than lifestyle programmes to induce significant weight loss and improvements in physical function.

Assessment of diagnostic criteria for the identification of central sensitization in patients with osteoarthritis pain: Results from a Delphi survey

To assess diagnostic criteria and currently used tools for the identification of central sensitization (CS) in patients with joint pain due to osteoarthritis (OA).Qualitative, cross-sectional and multicenter study based on a 2-round Delphi surveyPublic and private medical centers attending patients with joint pain.A total of 113 specialists in traumatology, physical medicine and rehabilitation, pain management, rheumatology, primary care physicians and geriatrics were enrolled in the study.Participants completed an ad-hoc 26-item questionnaire available from a microsite in Internet.The questionnaire was divided into 6 sections with general data on CS, impact of CS in patients with knee osteoarthritis (KOA), diagnostic criteria for CS, non-pharmacological and pharmacological treatment of CS and usefulness of the concept of CS in the integral management of patients with KOA. Consensus was defined as 75% agreement.Diagnostic criteria included pain of disproportionate intensity to the radiological joint lesion (agreement 86.7%), poor response to usual analgesics (85.8%), progression of pain outside the site of the lesion (76.1%) and concurrent anxiety and depression (76.1%). Based on the opinion of the specialists, about 61% of patients with KOA present moderate-to-severe pain, 50% of them show poor response to conventional analgesics, and 40% poor clinical-radiological correlation. Patients with KOA and CS showed higher functional disability and impairment of quality of life than those without CS (88.5%) and have a poor prognosis of medical, rehabilitation and surgical treatment (86.7%). Early diagnosis and treatment of CS may preserve function and quality of life during all steps of the disease (90.3%).The management of patients with osteoarthritis pain and CS requires the consideration of the intensity of pain related to the joint lesion, response to analgesics, progression of pain to other areas and concurrent anxiety and depression to establish an adequate therapeutic approach based on diagnostic criteria of CS.

A critical review of weight loss recommendations before total knee arthroplasty

OBJECTIVE

Increased infection risk after total knee arthroplasty (TKA) in patients with a higher body mass index (BMI), particularly a BMI ≥40kg/m², suggests that BMI reduction (through weight loss) prior to TKA may be important. However, the impact of weight loss on TKA risk reduction is unclear. Furthermore, weight loss could have detrimental consequences with respect to muscle loss and development of sarcopenic obesity, whereby a potential weight loss paradox in adults with advanced knee OA and obesity may be present. Using a critical review approach, we examined the current evidence supporting weight loss in adults with obesity and advanced knee osteoarthritis (OA). We focused on three key areas: (1) TKA complication risk with severe obesity compared to obesity (BMI ≥40kg/m² versus 30.0-39.9kg/m²); (2) weight loss recommendations for individuals with advanced knee OA; and (3) TKA outcomes after pre-surgical weight loss.

METHODS

Medline and CINAHL databases were examined from Jan 2010 to May 2020 to identify high-level and/or clinically-influential evidence (systematic reviews, meta-analyses and clinical practice guidelines).

RESULTS

The literature does not show a clear relationship between weight loss and reduction in TKA complications, and no indication that a patients' individual risk is lowered by reducing their BMI from a threshold of ≥40kg/m² to ≤39.9kg/m². Studies that have found a benefit of weight loss for knee OA have not included patients with higher BMIs (≥40kg/m²) or more advanced knee OA. Furthermore, there is unclear evidence of a benefit of pre-surgical weight loss on TKA outcomes. These are important evidence gaps, suggesting that recommendations for BMI reduction prior to TKA should be tempered by the current uncertainty in the literature.

CONCLUSION

Evidence to support a benefit of weight loss prior to TKA is lacking. Until knowledge gaps are clarified, it is recommended that practitioners consider individual patient needs and risk before recommending weight loss (and therefore BMI reduction).

Better Knee, Better Me™: effectiveness of two scalable health care interventions supporting self-management for knee osteoarthritis - protocol for a randomized controlled trial

Background

Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese.

Methods

Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m² and < 41 kg/m² and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed.

Discussion

This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).

Level of obesity is directly associated with the clinical and functional consequences of knee osteoarthritis

Obesity is one of the most important risk factors of knee osteoarthritis (KOA), but its impact on clinical and functional consequences is less clear. The main objective of this cross-sectional study was to describe the relation between body mass index (BMI) and clinical expression of KOA. Participants with BMI ≥ 25 kg/m² and KOA completed anonymous self-administered questionnaires. They were classified according to BMI in three groups: overweight (BMI 25-30 kg/m²), stage I obesity (BMI 30-35 kg/m²) and stage II/III obesity (BMI ≥ 35 kg/m²). The groups were compared in terms of pain, physical disability, level of physical activity (PA) and fears and beliefs concerning KOA. Among the 391 individuals included, 57.0% were overweight, 28.4% had stage I obesity and 14.6% had stage II/III obesity. Mean pain score on a 10-point visual analog scale was 4.3 (SD 2.4), 5.0 (SD 2.6) and 5.2 (SD 2.3) with overweight, stage I and stage II/III obesity, respectively (p = 0.0367). The mean WOMAC function score (out of 100) was 36.2 (SD 20.1), 39.5 (SD 21.4) and 45.6 (SD 18.4), respectively (p = 0.0409). The Knee Osteoarthritis Fears and Beliefs Questionnaire total score (KOFBEQ), daily activity score and physician score significantly differed among BMI groups (p = 0.0204, p = 0.0389 and p = 0.0413, respectively), and the PA level significantly differed (p = 0.0219). We found a dose-response relation between BMI and the clinical consequences of KOA. Strategies to treat KOA should differ by obesity severity. High PA level was associated with low BMI and contributes to preventing the clinical consequences of KOA.

Intra-articular and extra-articular platelet-rich plasma injections for knee osteoarthritis: A 26-week, single-arm, pilot feasibility study

AIM

Platelet Rich Plasma (PRP) is an emerging therapy for knee osteoarthritis (KOA). Studies have evaluated the effectiveness of intra-articular PRP, which ignores extra-articular tissue dysfunction and may provide incomplete treatment of KOA. The study aimed to pilot test a leukocyte-rich (mononuclear cells) PRP injection protocol for primary KOA, which consisted of single intra-articular injection and extra-articular injections on the medial coronary and medial collateral ligaments.

METHODS

A prospective 26-week single-arm uncontrolled feasibility pilot study. Patients (N = 12) with primary KOA as defined by the American Rheumatology Association, with moderate to severe medial knee pain which failed conservative management, were recruited in a university primary care clinic and received a single session of PRP injection in week 1. The primary outcome was the feasibility of the protocol at 26 weeks as defined by rates of recruitment, compliance, retention, dropout, side effects or adverse events; and treatment satisfaction. Secondary outcomes included the Western Ontario McMaster University Osteoarthritis Index, the Intermittent and Constant Osteoarthritis Pain total and subscales, objective physical function tests and EuroQol-5D.

RESULTS

Twelve of 40 potential patients were recruited in 3 months period (recruitment rate 30%, x2 = 3.33, P = 0.068). All participants adhered to the protocol and completed the follow up assessment with no dropouts (dropout rate 0%, X2= 2.67, P = 0.103). Satisfaction was high; no related adverse events were reported. Most secondary outcomes showed statistically significant improvement.

CONCLUSIONS

Concomitant intra-articular and extra-articular PRP injections were feasible and produced preliminary favourable outcomes.

Development of the Translating Allied Health Knowledge (TAHK) Framework

BACKGROUND

While evidence-based practice is a familiar concept to allied health clinicians, knowledge translation (KT) is less well known and understood. The need for a framework that enables allied health clinicians to access and engage with KT was identified. The aim of this paper is to describe the development of the Translating Allied Health Knowledge (TAHK) Framework.

METHODS

An iterative and collaborative process involving clinician and academic knowledge partners was utilised to develop the TAHK Framework. Multiple methods were utilised during this process, including a systematic literature review, steering committee consultation, mixed methods survey, benchmarking and measurement property analysis.

RESULTS

The TAHK Framework has now been finalised, and is described in detail. The framework is structured around four domains - Doing Knowledge Translation, Social Capital for Knowledge Translation, Sustaining Knowledge Translation and Inclusive Knowledge Translation - under which 14 factors known to influence allied health KT are classified. The formulation of the framework to date has laid a rigorous foundation for further developments, including clinician support and outcome measurement.

CONCLUSION

The method of development adopted for the TAHK Framework has ensured it is both evidence and practice based, and further amendments and modifications are anticipated as new knowledge becomes available. The Framework will enable allied health clinicians to build on their existing capacities for KT, and approach this complex process in a rigorous and systematic manner. The TAHK Framework offers a unique focus on how knowledge is translated by allied health clinicians in multidisciplinary settings.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

OBJECTIVES

To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs).

DESIGN

Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations.

ELIGIBILITY CRITERIA

Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.

DATA SOURCES

Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories.

RESULTS

6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work.

CONCLUSION

These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

The use of information and communication technologies by arthritis health professionals to disseminate a self-management program to patients: a pilot randomized controlled trial protocol

Design and objective: This paper describes the protocol for a three-arm, single-blind, parallel design randomized controlled trial (RCT) to investigate the perceived usability of Facebook to share information from an evidence-based arthritis self-management program with patients compared with email or an educational website after two weeks.

A systematic critical review of physical activity aspects in clinical guidelines for multiple sclerosis

OBJECTIVE

This paper aims to evaluate the quality of clinical guidelines (CGs) for MS and to critically appraise physical activity-related recommendations.

DATA SOURCES

Medical databases (MEDLINE, TRIP), clearinghouses, and guideline developers. An expert was asked to confirm if the list of CGs was complete.

STUDY SELECTION

Evidence-based CGs specific to MS with recommendations including aspects of rehabilitation or physical activity were included.

DATA EXTRACTION

Two reviewers independently first assessed the methodological quality of the CGs based on the 23 items of the Appraisal of Guidelines for Research and Evaluation Instrument version two (AGREE II) and second evaluated the physical activity-related content quality using an instrument containing 14 items that was used for the development of the National Recommendations for Physical Activity in Germany.

DATA SYNTHESIS

For the AGREE II domains and the criteria for content quality, standardized domain scores were calculated.

RESULTS

Three CGs were included. The average scores for the methodological quality of the domains were: scope and purpose (91%), stakeholder involvement (81%), rigor of development (78%), clarity of presentation (93%), applicability (53%), and editorial independence (83%). The mean scores for physical activity-related content quality did not exceed 56% for any criteria.

CONCLUSIONS

Overall, this critical review shows that the methodological quality of CGs were moderate to good but physical activity-related content quality was heterogeneous and low. Results emphasize the need for more specific physical activity recommendations that incorporate multiple aspects of physical activity prescription.

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis

OBJECTIVE:

To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis.

METHODS:

A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05).

RESULTS:

Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength.

CONCLUSION:

Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

What is the evidence for a role for diet and nutrition in osteoarthritis?

As current treatment options in OA are very limited, OA patients would benefit greatly from some ability to self-manage their condition. Since diet may potentially affect OA, we reviewed the literature on the relationship between nutrition and OA risk or progression, aiming to provide guidance for clinicians. For overweight/obese patients, weight reduction, ideally incorporating exercise, is paramount. The association between metabolic syndrome, type-2 diabetes and OA risk or progression may partly explain the apparent benefit of dietary-lipid modification resulting from increased consumption of long-chain omega-3 fatty-acids from oily fish/fish oil supplements. A strong association between OA and raised serum cholesterol together with clinical effects in statin users suggests a potential benefit of reduction of cholesterol by dietary means. Patients should ensure that they meet the recommended intakes for micronutrients such as vitamin K, which has a role in bone/cartilage mineralization. Evidence for a role of vitamin D supplementation in OA is unconvincing.

Poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review

Objectives

Undertake a systematic critical appraisal of contemporary clinical practice guidelines (CPGs) for common musculoskeletal (MSK) pain conditions: spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis) and shoulder.

Design

Systematic review of CPGs (PROSPERO number: CRD42016051653).

Included CPGs were written in English, developed within the last 5 years, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.

Data sources and method of appraisal

Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used for critical appraisal.

Results

4664 records were identified, and 34 CPGs were included. Most were for osteoarthritis (n=12) or low back pain (n=11), most commonly from the USA (n=12). The mean overall AGREE II score was 45% (SD=19.7). Lowest mean domain scores were for applicability (26%, SD=19.5) and editorial independence (33%, SD=27.5). The highest score was for scope and purpose (72%, SD=14.3). Only 8 of 34 CPGS were high quality: for osteoarthritis (n=4), low back pain (n=2), neck (n=1) and shoulder pain (n=1).

The use of social media by arthritis health professionals to disseminate a self-management program to patients: A feasibility study

Objective

The objective of this study was to determine the feasibility of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis self-management program by arthritis health professionals to their patients.

Methods

The feasibility study comprised a single arm, pre-post design that included a convenience sample of 78 arthritis health professionals across Canada. Assessments were performed at baseline, two-weeks post-intervention, and at three-months follow-up using online questionnaires. The primary outcome measure was change in perceived usability of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis program with patients at two-weeks post-intervention using an instrument based on an extended version of the Technology Acceptance Model 2. Comparisons with baseline were assessed using t-test analyses.

Results

Statistically significant improvements from baseline were seen for all items of the Technology Acceptance Model 2 domains: perceived ease of use (four items), intention to use (two items) and output quality (two items) domains. Variable results were seen for the job relevance, perceived usefulness, voluntariness, and result demonstrability domains of the Technology Acceptance Model 2. There were no statistically significant improvements for the subjective norm and image domains.

Conclusions

Facebook may provide arthritis health professionals with an additional option of how to best share evidence-based information to allow their patients to successfully self-manage their arthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs

OBJECTIVE

To identify effective mind-body exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning non-traditional land-based exercises for knee osteoarthritis.

METHODS

A systematic search and adapted selection criteria included comparative controlled trials with mind-body exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement).

RESULTS

The four high-quality studies identified demonstrated that various mind-body exercise programs are promising for improving the management of knee osteoarthritis. Hatha Yoga demonstrated significant improvement for pain relief (Grade B) and physical function (Grade C+). Tai Chi Qigong demonstrated significant improvement for quality of life (Grade B), pain relief (Grade C+) and physical function (Grade C+). Sun style Tai Chi gave significant improvement for pain relief (Grade B) and physical function (Grade B).

CONCLUSION

Mind-body exercises are promising approaches to reduce pain, as well as to improve physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs

OBJECTIVES

To identify effective aerobic exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis.

METHODS

A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement).

RESULTS

The five high-quality studies included demonstrated that various aerobic training exercises are generally effective for improving knee osteoarthritis within a 12-week period. An aerobic exercise program demonstrated significant improvement for pain relief (Grade B), physical function (Grade B) and quality of life (Grade C+). Aerobic exercise in combination with strengthening exercises showed significant improvement for pain relief (3 Grade A) and physical function (2 Grade A, 2 Grade B).

CONCLUSION

A short-term aerobic exercise program with/without muscle strengthening exercises is promising for reducing pain, improving physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs

OBJECTIVE

To identify effective strengthening exercise programs and provide rehabilitation teams and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis.

METHODS

A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+ or D-) was based on statistical significance ( p < 0.5) and clinical importance (⩾15% improvement).

RESULTS

The 26 high-quality studies identified demonstrated that various strengthening exercise programs with/without other types of therapeutic exercises are generally effective for improving knee osteoarthritis management within a six-month period. Strengthening exercise programs demonstrated a significant improvement for pain relief (four Grade A, ten Grade B, two Grade C+), physical function (four Grade A, eight Grade B) and quality of life (three Grade B). Strengthening in combination with other types of exercises (coordination, balance, functional) showed a significant improvement in pain relief (three Grade A, 11 Grade B, eight Grade C+), physical function (two Grade A, four Grade B, three Grade C+) and quality of life (one Grade A, one Grade C+).

CONCLUSION

There are a variety of choices for strengthening exercise programs with positive recommendations for healthcare professionals and knee osteoarthritis patients. There is a need to develop combined behavioral and muscle-strengthening strategies to improve long-term maintenance of regular strengthening exercise programs.

Recommendations for acupuncture in clinical practice guidelines of the national guideline clearinghouse

OBJECTIVE

To organize the clinical practice guidelines (CPGs) related to acupuncture included in the National Guideline Clearinghouse (NGC) to systematically summarize the diseases and disorders most commonly treated with acupuncture, the strength of recommendations for acupuncture and the quality of evidence.

METHODS

The NGC database was systematically searched for guidelines that included acupuncture as an intervention. Two independent reviewers studied the summaries and the full texts of the guidelines and included guidelines based on the inclusion and exclusion criteria. Thirty-nine guidelines were collected with 80 recommendations. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess the quality of these guidelines.

RESULTS

Of the 80 recommendations on acupuncture, 49 recommendations were clearly for acupuncture, 25 recommendations were against acupuncture and 6 recommendations did not indicate any clear recommendations, 37 recommendations were for painful diseases/disorders, and 12 recommendations were for non-painful diseases/disorders. Locomotor system disorders were the most common in the painful diseases/disorders category. Out of all the recommendations for acupuncture, most recommendations (87.76%) were weak in strength, and most of the evidence (40.84%) was of low quality.

CONCLUSIONS

In the National Guideline Clearinghouse, the recommendations for acupuncture focus on painful diseases/disorders. The recommendations in the guidelines are not high in strength, and most of the evidence is moderate or low in quality.

Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis

Objectives:

The primary objective is to identify effective land-based therapeutic exercise interventions and provide evidence-based recommendations for managing hip osteoarthritis. A secondary objective is to develop an Ottawa Panel evidence-based clinical practice guideline for hip osteoarthritis.

Methods:

The search strategy and modified selection criteria from a Cochrane review were used. Studies included hip osteoarthritis patients in comparative controlled trials with therapeutic exercise interventions. An Expert Panel arrived at a Delphi survey consensus to endorse the recommendations. The Ottawa Panel hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) considered the study design (level I: randomized controlled trial and level II: controlled clinical trial), statistical significance ( p < 0.5), and clinical importance (⩾15% improvement).

Results:

Four high-quality studies were included, which demonstrated that variations of strength training, stretching, and flexibility exercises are generally effective for improving the management of hip osteoarthritis. Strength training exercises displayed the greatest improvements for pain (Grade A), disability (Grades A and C+), physical function (Grade A), stiffness (Grade A), and range of motion (Grade A) within a short time period (8–24 weeks). Stretching also greatly improved physical function (Grade A), and flexibility exercises improved pain (Grade A), range of motion (Grade A), physical function (Grade A), and stiffness (Grade C+).

Conclusion:

The Ottawa Panel recommends land-based therapeutic exercise, notably strength training, for management of hip osteoarthritis in reducing pain, stiffness and self-reported disability, and improving physical function and range of motion.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Foot Care in the Management of Juvenile Idiopathic Arthritis

OBJECTIVE

To create evidence-based guidelines evaluating foot care interventions for the management of juvenile idiopathic arthritis (JIA).

DATA SOURCES

An electronic literature search of the following databases from database inception to May 2015 was conducted: MEDLINE (Ovid), EMBASE (Ovid), Cochrane CENTRAL, and clinicaltrials.gov.

STUDY SELECTION

The Ottawa Panel selection criteria targeted studies that assessed foot care or foot orthotic interventions for the management of JIA in those aged 0 to ≤18 years. The Physiotherapy Evidence Database scale was used to evaluate study quality, of which only high-quality studies were included (score, ≥5). A total of 362 records were screened, resulting in 3 full-text articles and 1 additional citation containing supplementary information included for the analysis.

DATA EXTRACTION

Two reviewers independently extracted study data (intervention, comparator, outcome, time period, study design) from the included studies by using standardized data extraction forms. Directed by Cochrane Collaboration methodology, the statistical analysis produced figures and graphs representing the strength of intervention outcomes and their corresponding grades (A, B, C+, C, C-, D+, D, D-). Clinical significance was achieved when an improvement of ≥30% between the intervention and control groups was present, whereas P>.05 indicated statistical significance. An expert panel Delphi consensus (≥80%) was required for the endorsement of recommendations.

DATA SYNTHESIS

All included studies were of high quality and analyzed the effects of multidisciplinary foot care, customized foot orthotics, and shoe inserts for the management of JIA. Custom-made foot orthotics and prefabricated shoe inserts displayed the greatest improvement in pain intensity, activity limitation, foot pain, and disability reduction (grades A, C+).

CONCLUSIONS

The use of customized foot orthotics and prefabricated shoe inserts seems to be a good choice for managing foot pain and function in JIA.

Obesity and chronic pain: systematic review of prevalence and implications for pain practice

The combination of obesity and pain may worsen a patient's functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.

Systematic analysis of the quality of the scientific evidence and conflicts of interest in osteoarthritis of the hip and knee practice guidelines

OBJECTIVE

To determine the validity of the hip and knee osteoarthritis guidelines.

METHODS

A systematic search of PubMed using a combination of Mesh and text terms with limitations to guidelines was performed to identify hip and knee osteoarthritis guidelines. The study was performed from April 17, 2014 to October 1, 2014. Guidelines were reviewed for graded levels of evidence, methods used to grade the evidence, and disclosures of conflicts of interest. Additionally, guidelines were also assessed for key quality measures using the AGREE II system for assessing the quality of guidelines.

RESULTS

A total of 13 guidelines relevant to the diagnosis and/or treatment of hip/knee osteoarthritis was identified. The 180 recommendations reviewed were supported by 231 pieces of evidence. In total, 35% (n = 80; range: 0-26) were supported by level A evidence, 15% (n = 35; range: 0-10) were by level B, and 50% (n = 116; range: 0-62) were by level C. Median age of the guidelines was 4 years (±4.8; range: 0-16) with no comments on planned updates. In total, 31% of the guidelines included patients in the development process. Only one guideline incorporated cost consideration, and only 15% of the guidelines addressed the surgical management of osteoarthritis. Additionally, 46% of guidelines did not comment on conflicts of interest (COI). When present, there was an average 29.8 COI. Notably, 82% of the COI were monetary support/consulting.

CONCLUSIONS

In total, 50% of the hip/knee osteoarthritis guideline recommendations are based on lower quality evidence. Nearly half the guidelines fail to disclose relevant COI and when disclosed, multiple potential COI are present. Future hip/knee osteoarthritis guideline development committees should strive to improve the transparency and quality of evidence used to formulate practice guidelines.

Association Between Physical Therapy and Risk of Coronary Artery Disease and Dyslipidemia Among Osteoarthritis Patients: A Nationwide Database Study

OBJECTIVE

To provide empirical evidence on the effect of early physical therapy (PT) within the first year of osteoarthritis (OA) diagnosis on reduction in OA-related comorbidities in patients with OA.

DESIGN

Retrospective cohort study.

SETTING

The study was conducted using a nationally representative sample of 1 million National Health Insurance enrollees.

PARTICIPANTS

Newly diagnosed patients with OA (N=13,545). One-to-one propensity score matching was used to match patients who received PT within the first year of OA diagnosis (PT group; n=3403) with an equal number of patients with OA who did not receive PT (non-PT group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The 4-year cumulative risk of comorbidities including coronary artery disease (CAD), diabetes mellitus, dyslipidemia, osteoporosis, gastrointestinal tract ulcer, and renal failure was estimated. A Cox proportional hazards regression analysis was performed to identify the dose-response relation between the PT dosage and the risk of OA-related comorbidities.

RESULTS

A total of 3403 patients (25.1%) received PT within the first year of OA diagnosis. The PT group had a significantly lower 4-year cumulative risk of dyslipidemia (P=.05) and a potentially lower 4-year cumulative risk of CAD (P=.09). After adjusting for other potential confounders, the Cox proportional hazards regression analysis showed that patients with OA who received a high PT dosage had a low risk of CAD and dyslipidemia.

CONCLUSIONS

Patients with OA who received PT had a lower risk of OA-related comorbidities such as dyslipidemia or CAD.

Impact of obesity on disability, function, and physical activity: data from the Osteoarthritis Initiative

OBJECTIVES

Older adults with obesity are at risk for osteoarthritis (OA) and are predisposed to functional decline and disability. We examined the association between obesity and disability, physical activity, and quality of life at 6 years.

METHOD

Using data from the longitudinal Osteoarthritis Initiative (OAI), we analysed older adults (age ≥ 60 years) with a body mass index (BMI) at baseline ≥ 18.5 kg/m(2) (n = 2378) using standard BMI categories. Outcomes were assessed at the 6-year follow-up and included: the Late-Life Function and Disability Index (LLDI), the 12-item Short Form Health Survey (SF-12), and the Physical Activity Scale for the Elderly (PASE). Linear regression predicted outcomes based on BMI category, adjusting for age, sex, race, education, smoking, cohort status, radiographic knee OA, co-morbidity scores, and baseline scores when available.

RESULTS

Follow-up data were available for 1727 (71.9%) participants (mean age 67.9 ± 5.3 years; 61.6% female). At baseline, obese subjects compared to overweight and normal were on a greater number of medications (4.28 vs. 3.63 vs. 3.32), had lower gait speeds (1.22 vs. 1.32 vs. 1.36 m/s), higher Charlson scores (0.59 vs. 0.37 vs. 0.30), and higher Western Ontario and McMaster University OA Index (WOMAC) scores (right: 14.8 vs. 10.3 vs. 7.5; left: 14.4 vs. 9.9 vs. 7.5). SF-12 scores at 6 years were lower in obese patients than in overweight or normal [99.5 (95% CI 98.7-100.4) vs. 101.1 (95% CI 100.4-101.8) vs. 102.8 (95% CI 101.8-103.8)], as were PASE scores [115.1 (95% CI 110.3-119.8) vs. 126.2 (95% CI 122.2-130.2) vs. 131.4 (95% CI 125.8-137.0)]. The LLDI limitation component demonstrated differences in obese compared to overweight or normal [78.6 (95% CI 77.4-79.9) vs. 81.2 (95% CI 80.2-82.3) vs. 82.5 (95% CI 81.1-84.0)].

CONCLUSIONS

Obesity was associated with worse physical activity scores, lower quality of life, and higher risk of 6-year disability.

Chronic pain management in the obese patient: a focused review of key challenges and potential exercise solutions

In obese persons, general and specific musculoskeletal pain is common. Emerging evidence suggests that obesity modulates pain via several mechanisms such as mechanical loading, inflammation, and psychological status. Pain in obesity contributes to deterioration of physical ability, health-related quality of life, and functional dependence. We present the accumulating evidence showing the interrelationships of mechanical stress, inflammation, and psychological characteristics on pain. While acute exercise may transiently exacerbate pain symptoms, regular participation in exercise can lower pain severity or prevalence. Aerobic exercise, resistance exercise, or multimodal exercise programs (combination of the two types) can reduce joint pain in young and older obese adults in the range of 14%-71.4% depending on the study design and intervention used. While published attrition rates with regular exercise are high (∼50%), adherence to exercise may be enhanced with modification to exercise including the accumulation of several exercise bouts rather than one long session, reducing joint range of motion, and replacing impact with nonimpact activity. This field would benefit from rigorous comparative efficacy studies of exercise intensity, frequency, and mode on specific and general musculoskeletal pain in young and older obese persons.

Pain management and pain characteristics in obese and normal weight patients before joint replacement

RATIONALE, AIMS AND OBJECTIVES

The objective was to compare the extent of pain interference and pain medication among persons who were classified as obese [body mass index (BMI)≥ 30 kg m(-2) ] and normal weighted (BMI  ≤ 25 kg m(-2) ), before a hip or knee replacement surgery.

METHODS

Patients candidate for an orthopaedic surgery were successively enrolled, over a 6-month period, and classified in either the normal weight (BMI  ≤ 25 kg m(-2) ) or the obese (BMI ≥ 30 kg m(-2) ) categories. Data were collected using self-administered questionnaires with items concerning pain characteristics, pain medication and pain interference. Two standardized questionnaires were associated: the Brief Pain Inventory (BPI) and the Hospital Anxiety and Depression scale (HAD).

RESULTS

Fifty-two obese patients (candidates for 24 hip replacements and 28 knee replacements) and 51 non-obese (23 hip replacements and 28 knee replacements) were enrolled. Obese patients suffered from a higher rate of acute pain episodes than non-obese patients (65 versus 44%, P<0.05). Pain interference on walking distance, sleep and relations with others was higher in obese patients. HAD score showed no significant difference between groups. The use of strong opioids and of non-steroidal anti-inflammatory drugs (NSAIDs) was significantly more important in obese patients (13 versus 0% and 31 versus 14%).

CONCLUSIONS

Obese patients suffer more significantly of unrelieved chronic pain, which lowers considerably their quality of life. Pain relief is more difficult to obtain, as it requires stronger pain medication and NSAIDs.

Weight Loss Interventions for Rehabilitation Patients with Obesity

This scoping review aims to explore the contributions of rehabilitation interventions and programs to the management of obesity. Studies and review papers describing weight management for patients in rehabilitation programs were identified. Rehabilitation populations for which weight loss interventions were reported included spinal cord injury, osteoarthritis, cardiac, and psychiatric. Evidence exists to support the promotion of weight loss in patients with obesity receiving rehabilitation services. Outcomes associated with weight loss in obese rehabilitation patients include reduced pain, improved mobility, improved performance of activities of daily living, increased self-efficacy for stair climbing and walking and, increased participation in leisure activities. Despite the prevalence of obesity among groups of patients with physical and psychiatric disabilities and the evidence to support weight loss as beneficial to improve function more research is needed to determine the best way in which to provide weight loss interventions to groups of patients with neurological, musculoskeletal, and psychiatric disabilities. Research is needed to gain knowledge about discipline specific interventions and their impact on obesity management in rehabilitation populations.

A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument

Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative

PURPOSE

Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers.

METHODS

A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data.

RESULTS

Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin.

CONCLUSIONS

The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs.