Longer-term quality of care, effectiveness, and cost-effectiveness of implementing a model of care for osteoarthritis: A cluster-randomized controlled trial

OBJECTIVE

To assess the quality of care, effectiveness, and cost-effectiveness over 12 months after implementing a structured model of care for hip and knee osteoarthritis (OA) in primary healthcare as compared to usual care.

DESIGN

In this pragmatic cluster-randomized, controlled trial with a stepped-wedge cohort design, we recruited 40 general practitioners (GPs), 37 physiotherapists (PTs), and 393 patients with symptomatic hip or knee OA from six municipalities (clusters) in Norway. The model included the delivery of a 3-hour patient education and 8-12 weeks individually tailored exercise programs, and interactive workshops for GPs and PTs. At 12 months, the patient-reported quality of care was assessed by the OsteoArthritis Quality Indicator questionnaire (16 items, pass rate 0-100%, 100%=best). Costs were obtained from patient-reported and national register data. Cost-effectiveness at the healthcare perspective was evaluated using incremental net monetary benefit (INMB).

RESULTS

Of 393 patients, 109 were recruited during the control periods (control group) and 284 were recruited during interventions periods (intervention group). At 12 months the intervention group reported statistically significant higher quality of care compared to the control group (59% vs. 40%; mean difference: 17.6 (95% confidence interval [CI] 11.1, 24.0)). Cost-effectiveness analyses showed that the model of care resulted in quality-adjusted life-years gained and cost-savings compared to usual care with mean INMB €2020 (95% CI 611, 3492) over 12 months.

CONCLUSIONS

This study showed that implementing the model of care for OA in primary healthcare, improved quality of care and showed cost-effectiveness over 12 months compared to usual care.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02333656.

Adherence to a Web-based Exercise Programme: A Feasibility Study Among Patients with Hip or Knee Osteoarthritis

OBJECTIVES

To describe adherence to a 12-week web-based aerobic exercise programme, to compare characteristics between those who adhere or not, and to identify barriers for exercising in patients with hip or knee osteoarthritis.

DESIGN

Single-arm feasibility study.

SUBJECTS

Patients with hip or knee osteoarthritis in specialist healthcare, age 40-80 years, and not candidates for joint surgery.

METHODS

Adherence to a 12-week exercise programme was defined as having completed ≥ 2 exercise sessions a week for at least 8 weeks. Baseline differences between adherent and non-adherent groups in demographics, symptoms, disability, physical activity and fitness were assessed using Mann-Whitney U or χ2 tests. Reasons for not completing exercise sessions were reported in weekly diaries.  Results: A total of 29 patients (median age 64 years, 72% female) were included. Median baseline pain (numerical rating scale 0-10) was 5. Fifteen patients adhered to the exercise programme, 14 did not. Non-adherent patients were less active (p = 0.032) and had lower cardiorespiratory fitness (p = 0.031). The most frequently reported barrier to exercising was sickness. Less than 10% reported pain as a barrier.

CONCLUSION

Half of the patients with hip or knee osteoarthritis adhered to the digitally delivered exercise programme and the most frequently reported barrier for adherence was sickness, while less than 10% reported pain as a reason for not exercising.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04084834. The Regional Committee for Medical and Health Research Ethics South-East, 2018/2198.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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

Supplementary Information

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

Development and external validation of a prediction model for patient-relevant outcomes in patients with chronic widespread pain and fibromyalgia

BACKGROUND

The objective of this study was to develop prediction models and explore the external validity of the models in a large sample of patients with chronic widespread pain (CWP) and fibromyalgia (FM).

METHODS

Patients with CWP and FM referred to rehabilitation services in Norway (n=986) self-reported data on potential predictors prior to entering rehabilitation, and self-reported outcomes at one-year follow-up. Logistic regression models of improvement, worsening and work status, and a linear regression model of health-related quality of life (HRQoL), were developed using lasso regression. Externally validated estimates of model performance were obtained from the validation set.

RESULTS

The number of participants in the development and the validation sets was 771 and 215 respectively; only participants with outcome data (n = 519-532 and 185, respectively) were included in the analyses. On average, HRQoL and work status changed little over one year. The prediction models included 10-11 predictors. Discrimination (AUC statistic) for prediction of outcome at follow-up was 0.71 for improvement, 0.67 for worsening, and 0.87 for working. The median absolute error of predictions of HRQoL was 0.36 (0.22-0.51). Reasonably good predictions of working at follow-up and HRQoL could be obtained using only the baseline scores as predictors.

CONCLUSIONS

Moderately complex predictions models (10-11 predictors) generated poor to excellent predictions of patient-relevant outcomes. Simple prediction models of working and HRQoL at follow-up may be nearly as accurate and more practical.

Effects of a mindfulness-based and acceptance-based group programme followed by physical activity for patients with fibromyalgia: a randomised controlled trial

INTRODUCTION

Non-pharmacological approaches are recommended as first-line treatment for patients with fibromyalgia. This randomised controlled trial investigated the effects of a multicomponent rehabilitation programme for patients with recently diagnosed fibromyalgia in primary and secondary healthcare.

METHODS

Patients with widespread pain ≥3 months were referred to rheumatologists for diagnostic clarification and assessment of study eligibility. Inclusion criteria were age 20-50 years, engaged in work or studies at present or during the past 2 years, and fibromyalgia diagnosed according to the American College of Rheumatology 2010 criteria. All eligible patients participated in a short patient education programme before inclusion and randomisation. The multicomponent programme, a 10-session mindfulness-based and acceptance-based group programme followed by 12 weeks of physical activity counselling was evaluated in comparison with treatment as usual, that is, no treatment or any other treatment of their choice. The primary outcome was the Patient Global Impression of Change (PGIC). Secondary outcomes were self-reported pain, fatigue, sleep quality, psychological distress, physical activity, health-related quality of life and work ability at 12-month follow-up.

RESULTS

In total, 170 patients were randomised, 1:1, intervention:control. Overall, the multicomponent rehabilitation programme was not more effective than treatment as usual; 13% in the intervention group and 8% in the control group reported clinically relevant improvement in PGIC (p=0.28). No statistically significant between-group differences were found in any disease-related secondary outcomes. There were significant between-group differences in patient's tendency to be mindful (p=0.016) and perceived benefits of exercise (p=0.033) in favour of the intervention group.

CONCLUSIONS

A multicomponent rehabilitation programme combining patient education with a mindfulness-based and acceptance-based group programme followed by physical activity counselling was not more effective than patient education and treatment as usual for patients with recently diagnosed fibromyalgia at 12-month follow-up.

TRIAL REGISTRATION NUMBER

BMC Registry (ISRCTN96836577).

Criterion validity of The International Physical Activity Questionnaire-Short Form (IPAQ-SF) for use in clinical practice in patients with osteoarthritis

BACKGROUND

To tailor physical activity treatment programs for patients with osteoarthritis, clinicians need valid and feasible measurement tools to evaluate habitual physical activity. The widely used International Physical Activity Questionnaire-Short Form (IPAQ-SF) is not previously validated in patients with osteoarthritis.

PURPOSE

To assess the concurrent criterion validity of the IPAQ-SF in patients with osteoarthritis, using an accelerometer as a criterion-method.

METHOD

Patients with osteoarthritis (n = 115) were recruited at The Division of Rheumatology and Research at Diakonhjemmet Hospital (Oslo, Norway). Physical activity was measured by patients wearing an accelerometer (ActiGraph wGT3X-BT) for seven consecutive days, followed by reporting their physical activity for the past 7 days using the IPAQ-SF. Comparison of proportions that fulfilled physical activity recommendations as measured by the two methods were tested by Pearson Chi-Square analysis. Differences in physical activity levels between the IPAQ-SF and the accelerometer were analyzed with Wilcoxon Signed-Rank Test and Spearman rank correlation test. Bland-Altman plots were used to visualize the concurrent criterion validity for total- and intensity-specific physical activity levels.

RESULTS

In total, 93 patients provided complete physical activity data, mean (SD) age was 65 (8.7) years, 87% were women. According to the IPAQ-SF, 57% of the patients fulfilled the minimum physical activity recommendations compared to 31% according to the accelerometer (p = 0.043). When comparing the IPAQ-SF to the accelerometer we found significant under-reporting of total physical activity MET-minutes (p = < 0.001), sitting (p = < 0.001) and walking (p < 0.001), and significant over-reporting of moderate-to-vigorous physical activity (p < 0.001). For the different physical activity levels, correlations between the IPAQ-SF and the accelerometer ranged from rho 0.106 to 0.462. The Bland-Altman plots indicated an increased divergence between the two methods with increasing time spent on moderate-to-vigorous intensity physical activity.

CONCLUSION

Physical activity is a core treatment of osteoarthritis. Our finding that patients tend to over-report activity of higher intensity and under-report low-intensity activity and sitting-time is of clinical importance. We conclude that the concurrent criterion validity of the IPAQ-SF was weak in patients with osteoarthritis.

Responsiveness and Interpretability of 2 Measures of Physical Function in Patients With Spondyloarthritis

BACKGROUND

Maintenance or improvement of physical function is an important treatment target in the management of patients with axial spondyloarthritis (axSpA); measurement tools that can detect changes in physical function are therefore important.

OBJECTIVES

The objective of this study was to compare responsiveness and interpretability of the patient-reported Bath Ankylosing Spondylitis Functional Index (BASFI) and the Ankylosing Spondylitis Performed-Based Improvement (ASPI) in measuring change in physical function after exercise in patients with axSpA.

DESIGN

This was a sub-study of 58 patients nested within a randomized controlled trial comparing the effect of 12 weeks of exercise with usual care.

METHODS

Responsiveness and interpretability were assessed according to the Consensus-based Standards for the selection of health status Measurement Instrument. Responsiveness was assessed by testing 8 predefined hypotheses for ASPI and BASFI. Interpretability was assessed by: (1) using patients' reported change as an anchor ("a little better" = minimal important change) and (2) by categorizing patients with a 20% improvement as responders.

RESULTS

For ASPI and BASFI, 5 of 8 (63%) versus 2 of 8 (25%) of the predefined hypotheses for responsiveness were confirmed. The minimal important change values for improvement in physical function were 3.7 seconds in ASPI and 0.8 points (on a scale from 0 to 10) for BASFI. In the intervention group, 21 of 30 (70%) and 13 of 30 (43%) of the patients were categorized as responders measured with ASPI and BASFI, respectively. There was a tendency towards a floor effect in BASFI, as 8 of 58 (14%) patients scored the lowest value at baseline.

LIMITATIONS

This study was limited by its moderate sample size.

CONCLUSIONS

Our findings suggest that ASPI is preferable over BASFI when evaluating physical function after exercise interventions in patients with axSpA.

Low adherence to exercise may have influenced the proportion of OMERACT-OARSI responders in an integrated osteoarthritis care model: secondary analyses from a cluster-randomised stepped-wedge trial

BACKGROUND

To address the well-documented gap between hip and knee osteoarthritis (OA) treatment recommendations and current clinical practice, a structured model for integrated OA care was developed and evaluated in a stepped-wedge cluster-randomised controlled trial. The current study used secondary outcomes to evaluate clinically important response to treatment through the Outcome Measures in Rheumatology Clinical Trials clinical responder criteria (OMERACT-OARSI responder criteria) after 3 and 6 months between patients receiving the structured OA care model vs. usual care. Secondly, the study aimed to investigate if the proportion of responders in the intervention group was influenced by adherence to the exercise program inherent in the model.

METHODS

The study was conducted in primary healthcare in six Norwegian municipalities. General practitioners and physiotherapists received training in OA treatment recommendations and use of the structured model. The intervention group attended a physiotherapist-led OA education program and performed individually tailored exercises for 8-12 weeks. The control group received usual care. Patient-reported pain, function and global assessment of disease activity during the last week were evaluated using 11-point numeric rating scales (NRS 0-10). These scores were used to calculate the proportion of OMERACT-OARSI responders. Two-level mixed logistic regression models were fitted to investigate differences in responders between the intervention and control group.

RESULTS

Two hundred eighty-four intervention and 109 control group participants with hip and knee OA recruited from primary care in six Norwegian municipalities. In total 47% of the intervention and 35% of the control group participants were responders at 3 or 6 months combined; showing an uncertain between-group difference (OR_adjusted 1.38 (95% CI 0.41, 4.67). In the intervention group, 184 participants completed the exercise programme (exercised ≥2 times/week for ≥8 weeks) and 55% of these were classified as responders. In contrast, 28% of the 86 non-completers were classified as responders.

CONCLUSIONS

The difference in proportion of OMERACT-OARSI responders at 3 and 6 months between the intervention and control group was uncertain. In the intervention group, a larger proportion of responders were seen among the exercise completers compared to the non-completers.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02333656. Registered 7. January 2015.

Correction: Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial

[This corrects the article DOI: 10.1371/journal.pmed.1002949.].

Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial

BACKGROUND

To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. The objective of this study was to assess the effectiveness of this model in primary care.

METHODS AND FINDINGS

We conducted a cluster-randomised controlled trial with stepped-wedge cohort design in 6 Norwegian municipalities (clusters) between January 2015 and October 2017. The randomised order was concealed to the clusters until the time of crossover from the control to the intervention phase. The intervention was implementation of the SAMBA model, facilitated by interactive workshops for general practitioners and physiotherapists with an update on OA treatment recommendations. Patients in the intervention group attended a physiotherapist-led OA education and individually tailored exercise programme for 8-12 weeks. The primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0-100, 100 = optimal quality) at 6 months. Secondary outcomes included patient-reported referrals to physiotherapy, magnetic resonance imaging (MRI), and orthopaedic surgeon consultation; patients' satisfaction with care; physical activity level; and proportion of patients who were overweight or obese (body mass index ≥ 25 kg/m2). In all, 40 of 80 general practitioners (mean age [SD] 50 [12] years, 42% females) and 37 of 64 physiotherapists (mean age [SD] 42 [8] years, 65% females) participated. They identified 531 patients, of which 393 patients (mean age [SD] 64 [10] years, 71% females) with symptomatic hip or knee OA were included. Among these, 109 patients were recruited during the control periods (control group), and 284 patients were recruited during interventions periods (intervention group). The patients in the intervention group reported significantly higher quality of care (score of 60 versus 41, mean difference 18.9; 95% CI 12.7, 25.1; p < 0.001) and higher satisfaction with OA care (odds ratio [OR] 12.1; 95% CI 6.44, 22.72; p < 0.001) compared to patients in the control group. The increase in quality of care was close to, but below, the pre-specified minimal important change. In the intervention group, a higher proportion was referred to physiotherapy (OR 2.5; 95% CI 1.08, 5.73; p = 0.03), a higher proportion fulfilled physical activity recommendations (OR 9.3; 95% CI 2.87, 30.37; p < 0.001), and a lower proportion was referred to an orthopaedic surgeon (OR 0.3; 95% CI 0.08, 0.80; p = 0.02), as compared to the control group. There were no significant group differences regarding referral to MRI (OR 0.6; 95% CI 0.13, 2.38; p = 0.42) and proportion of patients who were overweight or obese (OR 1.3; 95% CI 0.70, 2.51; p = 0.34). Study limitations include the imbalance in patient group size, which may have been due to an increased attention to OA patients among the health professionals during the intervention phase, and a potential recruitment bias as the patient participants were identified by their health professionals.

CONCLUSIONS

In this study, a structured model in primary care resulted in higher quality of OA care as compared to usual care. Future studies should explore ways to implement the structured model for integrated OA care on a larger scale.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02333656.

The Maternal and Paternal Effects on Clinically and Surgically Defined Osteoarthritis

OBJECTIVE

It is currently unknown whether osteoarthritis (OA) is inherited mainly from the mother, father, or both. This study was undertaken to explore the effect of maternal and paternal factors on hip, knee, and hand OA in offspring.

METHODS

Participants from the Musculoskeletal Pain in Ullensaker Study (MUST) (69% female; mean ± SD age 64 ± 9 years) and a Norwegian OA twin study (Nor-Twin) (56% female; 49 ± 11 years) reported whether their mother and/or father had OA. Using a recurrence risk estimation approach, we calculated whether maternal and paternal OA increased the risk of 1) surgically defined hip and knee OA (i.e., total joint replacement) and 2) clinically defined hip, knee, and hand OA (i.e., the American College of Rheumatology criteria) using logistic regression. Relative risks (RRs) with 95% confidence intervals (95% CIs) were calculated.

RESULTS

Maternal OA consistently increased the risk of offspring OA across different OA locations and severities. Having a mother with OA increased the risk of any OA in daughters (RR 1.13 [95% CI 1.02-1.25] in the MUST cohort; RR 1.44 [95% CI 1.05-1.97] in the Nor-Twin cohort) but not (or with less certainty) in sons (RR 1.16 [95% CI 0.95-1.43] in the MUST cohort; RR 1.31 [95% CI 0.71-2.41] in the Nor-Twin cohort). Having a father with OA was less likely to increase the risk of any OA in daughters (RR 1.00 [95% CI 0.85-1.16] in the MUST cohort; RR 1.52 [95% CI 0.94-2.46] in the Nor-Twin cohort) and sons (RR 1.08 [95% CI 0.83-1.41] in the MUST cohort; RR 0.93 [95% CI 0.35-2.48] in the Nor-Twin cohort).

CONCLUSION

OA in the mother increased the risk of surgically and clinically defined hip, knee, and hand OA in offspring, particularly in daughters. Our findings imply that heredity of OA may be linked to maternal genes and/or maternal-specific factors such as the fetal environment.

Mindfulness- and acceptance-based interventions for patients with fibromyalgia - A systematic review and meta-analyses

Objectives

To analyze health effects of mindfulness- and acceptance-based interventions, including mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT). Additionally, we aimed to explore content and delivery components in terms of procedure, instructors, mode, length, fidelity and adherence in the included interventions.

Methods

We performed a systematic literature search in the databases MEDLINE, PsychINFO, CINAHL, EMBASE, Cochrane Central and AMED from 1990 to January 2019. We included randomized and quasi-randomized controlled trials analyzing health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia compared to no intervention, wait-list control, treatment as usual, or active interventions. MBSR combined with other treatments were included. Predefined outcomes were pain, fatigue, sleep quality, psychological distress, depression, anxiety, mindfulness, health-related quality of life and work ability. The Template for Intervention Description and Replication (TIDieR) checklist and guide was used to explore content and delivery components in the interventions. Meta-analyses were performed, and GRADE was used to assess the certainty in the evidence.

Results

The search identified 4430 records, of which nine original trials were included. The vast majority of the participants were women. The analyses showed small to moderate effects in favor of mindfulness- and acceptance-based interventions compared to controls in pain (SMD -0.46 [95% CI -0.75, -0.17]), depression (SMD -0.49 [95% CI -0.85, -0.12]), anxiety (SMD -0.37 [95% CI -0.71, -0.02]), mindfulness (SMD -0.40 [-0.69, -0.11]), sleep quality (SMD -0.33 [-0.70, 0.04]) and health-related quality of life (SMD -0.74 [95% CI -2.02, 0.54]) at end of treatment. The effects are uncertain due to individual study limitations, inconsistent results and imprecision.

Conclusion

Health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia are promising but uncertain. Future trials should consider investigating whether strategies to improve adherence and fidelity of mindfulness- and acceptance-based interventions can improve health outcomes.

Abstract P4-14-08: Serum concentrations of tamoxifen and Z-endoxifen may predict sexual dysfunction in the 2nd year of adjuvant endocrine treatment

Background and rationale: Side effects of adjuvant treatment with tamoxifen (tam) may impair Quality of Life (QoL) and have been suggested as an independent variable for discontinuation of tam1. There are large inter-patient variabilities in prevalence and severance of side effects among tam users. Therefore, there is a need for biological markers that can predict side effects. A potential biological predictor is the serum concentrations of tam and/or its metabolites. In this prospective observational study we have analyzed serum concentrations of tam and 9 metabolites over 3 years. Patients Reported Outcome Measures (PROM) were obtained to elucidate possible associations between side effects, adherence and tam metabolism.

Methods: Breast cancer patients using adjuvant tam (20mg/d) were recruited through the Prospective Breast Cancer Biobank project between 2011 and 2016. Inclusion criteria were ER positive status, ≥ 6 months tam use, tumor size of ≥0.1 cm and being able to read and write Norwegian. Concentration levels of tam and metabolites in serum were analyzed by LC-MS/MS2 and adherence data were collected through the Norwegian prescription database. PROM-data comprised of validated questioners reporting side effects of endocrine treatment and QoL. Statistical analyses comprised non-parametric tests, logistic regression, chi square tests and the Benjamin-Hochberg procedure to correct for multiple testing.

Results: Associations between metabolite concentrations and side effects were run as a cross sectional analysis (N=149) and separate analysis of each year of follow-up with 85, 77 and 65 patients at the 1st, 2nd and 3rd year respectively. We found that 78 % of patients reported side effects, 66 % reported mood swings, 21 % reported severe hot flushes and 71 % reported decreased libido. When analyzing years separately, we found that on the 2nd year patients experiencing vaginal dryness had significantly higher levels of tamoxifen (P=0.032, after correction for multiple testing and adjustment for clinical relevant variables) compared to patients not experiencing vaginal dryness. Also, on year 2 the patients in the lower quartile of Z-endoxifen (≤17.9 nM) had significantly lower libido (p=0.015) compared to patients with Z-endoxifen levels &gt;17.9 nM after adjustment for clinical relevant variables and correction for multiple testing. Analyses regarding adherence are not complete and more results will be presented in the poster.

Discussion: Our data indicates that high serum concentrations of tam and low concentrations of Z-endoxifen are associated with vaginal dryness and sexual dysfunction. Patients reporting “very low libido” had the highest levels of tam, suggesting that slow metabolic conversion and accumulation of tam may contribute to sexual dysfunction. Our results were only significant in the second year of follow-up, possibly because patients wait to resume sexual activity after diagnosis, chemo and surgery. After receiving advice (i.e. lubricants), the symptoms are often reduced in the subsequent follow-up (3rd year). In conclusion, our results indicate that monitoring tam serum concentrations may be used to predict side effects.

1 Owusu C. et al. JCO. 2008

2 Helland T. et al. BCR. 2017

Citation Format: Helland T, Haugstøyl ME, Hagen KB, Kvaløy JT, Lunde S, Lode K, Lind RA, Gripsrud BH, Bifulco E, Gebreslase NS, Jonassen J, Hustad SS, Aas T, Lende TH, Lien EA, Janssen EA, Mellgren G, Søiland H. Serum concentrations of tamoxifen and Z-endoxifen may predict sexual dysfunction in the 2nd year of adjuvant endocrine treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-08.

High intensity exercise for 3 months reduces disease activity in axial spondyloarthritis (axSpA): a multicentre randomised trial of 100 patients

Background

Exercise is considered important in the management of patients with rheumatic diseases, but the effect of high intensity exercises on disease activity is unknown.

Objective

To investigate the effectiveness of high intensity exercises on disease activity in patients with axial spondyloarthritis (axSpA).

Method

Assessor blinded multicentre randomised controlled trial. 100 patients (aged from their 20s to their 60s) with axSpA were randomly assigned to an exercise group or to a no-intervention control group. The exercise group performed cardiorespiratory and muscular strength exercises at high intensity over 3 months. The control group received standard care and was instructed to maintain their usual physical activity level. Primary outcome was disease activity measured with the Ankylosing Spondylitis (AS) Disease Activity Scale (ASDAS, higher score=worst) and the Bath AS Disease Activity Index (BASDAI, 0–10, 10=worst). Secondary outcomes were inflammatory markers, physical function and cardiovascular (CV)-health. There was patient involvement in the design and reporting of this study.

Results

97 of the 100 (97%) randomised patients completed the measurements after the intervention. There was a significant treatment effect of the intervention on the primary outcome (ASDAS: −0.6 [–0.8 to –0.3], p<0.001 and BASDAI: −1.2 [–1.8 to –0.7], p<0.001). Significant treatment effects were also seen for inflammation, physical function and CV-health.

Conclusion

High intensity exercises reduced disease symptoms (pain, fatigue, stiffness) and also inflammation in patients with axSpA. It improves patients’ function and CV health. This debunks concerns that high intensity exercise might exacerbate disease activity in patients with axSpA.

Trial registration number

NCT02356874.

Effects of a community-based multicomponent rehabilitation programme for patients with fibromyalgia: protocol for a randomised controlled trial

INTRODUCTION

People with fibromyalgia (FM) suffer from symptoms such as widespread pain, non-refreshing sleep, fatigue and reduced quality of life. Effects of pharmacological treatment are questionable and non-pharmacological treatments are recommended as first-line therapy. To date the majority of patients with FM in Norway are not offered any targeted treatment. The aim of this randomised controlled trial is to investigate the effects of a community-based multicomponent rehabilitation programme comprising an acceptance-based and mindfulness-based group intervention, the Vitality Training Programme (VTP), followed by tailored physical activity counselling.

MATERIALS AND METHODS

General practitioners refer potential participants to a rheumatologist in specialist healthcare for diagnostic clarification and assessment of comorbidities. Inclusion criteria are widespread pain/FM ≥3 months, age 20-50 and work participation (minimum part-time) within the last 2 years. The intervention group attends the VTP comprising 10 weekly 4 hour group sessions plus a booster session after 6 months. Thereafter, they receive 12 weeks of individually tailored physical exercise counselled by physiotherapists at community-based Healthy Life Centers. The control group follows treatment as usual. The primary outcome is Patient Global Impression of Change. Secondary outcomes include self-reported pain, fatigue and sleep quality, psychological distress, mindfulness, health-related quality of life, physical activity, work ability and exercise beliefs and habits. To achieve a power of 80% and allow for 10% dropout, 70 participants are needed in each arm. All analyses will be conducted on intention-to-treat bases and measured as differences between groups at 12 months follow-up.

ETHICS AND DISSEMINATION

The study is approved and granted by the Norwegian South-Eastern Regional Health Authority (reference 2016015). Ethics approval was obtained from Regional Committee for Medical and Health Research Ethics (reference 2015/2447/REK sør-øst A). Results will be submitted to appropriate journals and presented in relevant conferences and social media.

TRIAL REGISTRATION

ISRCTN 96836577.

Exercise for Hand Osteoarthritis: A Cochrane Systematic Review

OBJECTIVE

To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand osteoarthritis (OA).

METHODS

Systematic review using Cochrane Collaboration methodology. Six electronic databases were searched up until September 2015.

INCLUSION CRITERIA

randomized or controlled clinical trials comparing therapeutic exercise versus no exercise, or comparing different exercise programs.

MAIN OUTCOMES

hand pain, hand function, finger joint stiffness, quality of life, adverse events, and withdrawals because of adverse effects. Risk of bias and quality of the evidence were assessed.

RESULTS

Seven trials were included in the review, and up to 5 trials (n = 381) were included in the pooled analyses with data from postintervention. Compared to no exercise, low-quality evidence indicated that exercise may improve hand pain [5 trials, standardized mean difference (SMD) -0.27, 95% CI -0.47 to -0.07], hand function (4 trials, SMD -0.28, 95% CI -0.58 to 0.02), and finger joint stiffness (4 trials, SMD -0.36, 95% CI -0.58 to -0.15) in people with hand OA. Quality of life was evaluated by 1 study (113 participants) showing very low-quality evidence for no difference. Three studies reported on adverse events, which were very few and not severe.

CONCLUSION

Pooled results from 5 studies with low risk of bias showed low-quality evidence for small to moderate beneficial effects of exercise on hand pain, function, and finger joint stiffness postintervention. Estimated effect sizes were small, and whether they represent a clinically important change may be debated.

Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis

OBJECTIVE

To investigate the effects of cardiorespiratory and strength exercises on disease activity for patients with inflammatory rheumatic diseases (IRDs).

DESIGN

A systematic review with meta-analysis registered at PROSPERO (CRD42015020004).

PARTICIPANTS

Patients with IRDs.

DATA SOURCES

The databases MEDLINE, AMED, Embase and CINAHL were searched from inception up to April 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Trials were included if they were randomised controlled trials of adults with IRDs, comparing the effect of cardiorespiratory and strength exercises with usual care on disease activity and followed the American College of Sports Medicine's exercise recommendations. The primary outcome was disease activity in terms of inflammation, joint damage and symptoms.

DATA SYNTHESIS

Data were pooled in a random-effect model for all outcomes, and standardised mean differences (SMDs) were calculated. The quality of evidence was evaluated according to the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Twenty-six trials with a total of 1286 participants were included. There was high to moderate quality evidence, for a small beneficial effect on disease activity scores (0.19 (95% CI 0.05 to 0.33), p<0.01) and joint damage (SMD 0.27 (95% CI 0.07 to 0.46), p<0.01). Furthermore, moderate quality evidence for a small beneficial effect on erythrocyte sedimentation rate (SMD 0.20 (95% CI 0.0 to 0.39), p=0.04) and for no effect on C reactive protein (SMD -0.14 (95% CI -0.37 to 0.08), p=0.21). Beneficial effects were also seen for symptoms.

CONCLUSIONS

The results of this review suggest beneficial effects of exercises on inflammation, joint damage and symptoms in patients with IRDs.

Genetic factors contribute more to hip than knee surgery due to osteoarthritis - a population-based twin registry study of joint arthroplasty

OBJECTIVE

To explore and quantify the relative strengths of the genetic contribution vs the contribution of modifiable environmental factors to severe osteoarthritis (OA) having progressed to total joint arthroplasty.

DESIGN

Incident data from the Norwegian Arthroplasty Registry were linked with the Norwegian Twin Registry on the National ID-number in 2014 in a population-based prospective cohort study of same-sex twins born 1915-60 (53.4% females). Education level and height/weight were self-reported and Body Mass Index (BMI) calculated. The total follow-up time was 27 years for hip arthroplasty (1987-2014, 424,914 person-years) and 20 years for knee arthroplasty (1994-2014, 306,207 person-years). We estimated concordances and the genetic contribution to arthroplasty due to OA in separate analyses for the hip and knee joint.

RESULTS

The population comprised N = 9058 twin pairs (N = 3803 monozygotic (MZ), N = 5226 dizygotic (DZ)). In total, 73% (95% confidence intervals (CI) = 66-78%) and 45% (95% CI = 30-58%) of the respective variation in hip and knee arthroplasty could be explained by genetic factors. Zygosity (as a proxy for genetic factors) was associated with hip arthroplasty concordance over time when adjusted for sex, age, education and BMI (HR = 2.98, 95% CI = 1.90-4.67 for MZ compared to DZ twins). Knee arthroplasty was to a greater extent dependent on BMI when adjusted for zygosity and the other covariates (HR = 1.15, 95% CI = 1.02-1.29).

CONCLUSION

Hip arthroplasty was strongly influenced by genetic factors whereas knee arthroplasty to a greater extent depended on a high BMI. The study may imply there is a greater potential for preventing progression of knee OA to arthroplasty in comparison with hip OA.

Long term type 1 diabetes is associated with hand pain, disability and stiffness but not with structural hand osteoarthritis features - The Dialong hand study

OBJECTIVE

To explore whether having long-term type 1 diabetes (>45 years) is associated with a higher prevalence of radiographic hand OA, erosive hand OA and increased hand pain, disability and stiffness.

METHODS

In total N = 96 persons with type 1 diabetes diagnosed before 1970 were included (mean [SD] age: 62.2 [7.4], mean [SD] HbA1c: 7.43 [0.80] and N = 49 [51%] men). Regular measurements of their HbA1c were obtained till 2015. We included N = 69 healthy controls without any diabetes (mean [SD] age: 63.0 [7.0], mean [SD] HbA1c: 5.41 [0.32], N = 29 [42%] men). The groups were compared for radiographic hand OA (Kellgren-Lawrence grade ≥2 in ≥1 joint) and erosive hand OA (central erosions in ≥1 joint), Australian/Canadian index (AUSCAN) for hand pain, disability and stiffness using regression analyses adjusted for age, sex, educational level and waist circumference.

RESULTS

We found no associations between having long term type 1 diabetes and more prevalent radiographic hand OA (OR = 0.83, 95% CI = 0.38-1.81). We found a trend towards higher prevalence of erosive hand OA in diabetes patients (OR = 2.96, 95% CI = 0.82-10.64). Strong and consistent associations were observed between long term type 1 diabetes and increased hand pain (B = 2.78, 95% CI = 1.65-3.91), disability (B = 5.30, 95% CI = 3.48-7.12) and stiffness (B = 2.00, 95% CI = 1.33-2.67). These associations were particularly strong for women and participants below the median age of 61 years.

CONCLUSION

Long-term type 1 diabetes was not associated with radiographic hand OA, but was strongly associated with hand pain, disability and stiffness. The association between diabetes and erosive hand OA warrants further investigation.

Smoking and alcohol use are associated with structural and inflammatory hand osteoarthritis features

OBJECTIVES

To explore whether smoking and alcohol use are associated with hand osteoarthritis (OA) features in two different OA cohorts.

METHOD

We studied 530 people with radiographic hand OA from the Musculoskeletal pain in Ullensaker STudy (MUST) and 187 people from the Oslo hand OA cohort [mean (sd) age 65 (8.0) and 62 (5.7) years, 71% and 91% women, respectively]. Smoking, alcohol use and hand pain were self-reported. Participants underwent conventional hand radiographs and ultrasound examination of 30 hand joints. The Kellgren-Lawrence sum score for radiographic OA severity (0-120 scale) and the proportion of participants having at least one joint with grey-scale synovitis (grade ≥1) were calculated. We studied whether smoking and alcohol use were cross-sectionally associated with radiographic OA, synovitis, and pain using adjusted linear and logistic regression analyses.

RESULTS

Smoking was associated with less radiographic OA in both cohorts [β = -4.71, 95% confidence interval (CI) -8.36 to -1.06 for current smoking in MUST and β = -0.15, 95% CI -0.29 to -0.02 for smoking pack-years in the Oslo hand OA cohort]. Stratified analyses indicated that the association was present in men only. Being a monthly drinker (examined in MUST only) was significantly associated with present synovitis compared to never drinkers (odds ratio = 2.35, 95% CI 1.27 to 4.34) (no gender differences). Neither smoking nor alcohol was associated with hand pain.

CONCLUSIONS

Smoking was associated with less radiographic hand OA whereas alcohol consumption was associated with present joint inflammation in hand OA. Future longitudinal studies are needed to explore the causal associations and explanatory mechanisms behind gender differences.

Exercise for hand osteoarthritis

BACKGROUND

Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand-related activities of daily living. Currently, no cure for OA is known, and non-pharmacological modalities are recommended as first-line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain.

OBJECTIVES

To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function.

SEARCH METHODS

We searched six electronic databases up until September 2015.

SELECTION CRITERIA

All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals).

MAIN RESULTS

We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress abstract. It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self-reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self-reported outcomes. Two studies with high drop-out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self-reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.Low-quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).Four studies (369 participants) indicated that exercise improved hand function (SMD -0.28, 95% CI -0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI -0.2 to 4.6; NNTB 9).One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI -3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD -0.36, 95% CI -0.58 to -0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).Three studies reported intervention-related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low-quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.Included studies did not measure radiographic joint structure changes. Two studies provided six-month follow-up data (220 participants), and one (102 participants) provided 12-month follow-up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium- and long-term follow-up.The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self-reported. Self-reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions.

AUTHORS' CONCLUSIONS

When we pooled results from five studies, we found low-quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.

Aiming for a healthier life: a qualitative content analysis of rehabilitation goals in patients with rheumatic diseases

PURPOSE

To explore and describe rehabilitation goals of patients with rheumatic diseases during rehabilitation stays, and examine whether goal content changed from admission to discharge.

METHOD

Fifty-two participants were recruited from six rehabilitation centers in Norway. Goals were formulated by the participants during semi-structured goal-setting conversations with health professionals trained in motivational interviewing. An inductive qualitative content analysis was conducted to classify and quantify the expressed goals. Changes in goal content from admission to discharge were calculated as percentage differences. Goal content was explored across demographic and contextual characteristics.

RESULTS

A total of 779 rehabilitation goals were classified into 35 categories, within nine overarching dimensions. These goals varied and covered a wide range of topics. Most common at admission were goals concerning healthy lifestyle, followed by goals concerning symptoms, managing everyday life, adaptation, disease management, social life, and knowledge. At discharge, goals about knowledge and symptoms decreased considerably, and goals about healthy lifestyle and adaptation increased. The health profession involved and patient gender influenced goal content.

CONCLUSIONS

The rehabilitation goals of the patients with rheumatic diseases were found to be wide-ranging, with healthy lifestyle as the most prominent focus. Goal content changed between admission to, and discharge from, rehabilitation stays. Implications for rehabilitation Rehabilitation goals set by patients with rheumatic diseases most frequently concern healthy lifestyle changes, yet span a wide range of topics. Patient goals vary by gender and are influenced by the profession of the health care worker involved in the goal-setting process. To meet the diversity of patient needs, health professionals need to be aware of their potential influence on the actual goal-setting task, which may limit the range of topics patients present when they are asked to set rehabilitation goals. The proposed framework for classifying goal content has the capacity to detect changes in goals occurring during the rehabilitation process, and may be used as a clinical tool during goal-setting conversations for this patient group.

Hereditary and environmental factors causing total joint replacement due to hip and knee osteoarthritis – a twin registry based prospective cohort study

The relative contribution of genetic factors and more modifiable environmental factors to a clinicallyrelevant osteoarthritis (OA) diagnosis is unkown. In this paper we present an ongoing study on the geneticcontribution to total joint replacement (TJR) due to hip and knee OA and effects of lifestyle and lifestylerelated conditions on TJR due to OA. We have linked data on incident OA from the Norwegian ArthroplastyRegistry were l with the Norwegian Twin Registry on the National ID number in 2014, thus obtaining apopulation based cohort of same-sex twins born 1915-60. Data on height, weight and lifestyle were selfreportededin questionnaires conducted between 1978 and 1992. The monozygotic (MZ) and dizygotic(DZ) concordances as well as the genetic contribution vs. contribution of more modifiable, environmentalfactors to arthroplasty will be examined in separate analyses for the hip and the knee joint. The samplecomprised N=18058 twins (N=3803 MZ and N=5226 DZ pairs) including N=9650 (53.4%) females and amean (SD) age of 38 (12.3) years at questionnaire response. Some preliminary analyses have been performedshowing a higher concordance for TJR due to hip OA among MZ (0.36) than DZ twins (0.16), which maybe consistent with a genetic contribution to hip OA. TJR due to hip OA may be determined by geneticfactors. Results for the knee joint as well as final results from hereditary analyses and co-twin controlanalyses of will be published consecutively from 2016.

Rasch analysis of the Norwegian version of the Arthritis Self-Efficacy Scale (ASES)

OBJECTIVES

To apply the Rasch model to the Norwegian version of the Arthritis Self-Efficacy Scale (ASES).

METHOD

The ASES was included in a self-administered questionnaire sent to 224 patients attending one of three rehabilitation centres for rheumatic diseases in Norway in 2009. The fit of the ASES to the Rasch model was assessed together with hypothesized associations with the Modified Health Assessment Questionnaire (MHAQ), the 36-item Short Form Health Survey (SF-36), the numerical rating scale (NRS) for pain, and NRS fatigue.

RESULTS

A total of 145 (64.7%) patients responded to the questionnaire. The two scales of other symptoms and pain showed good fit to the Rasch model with no evidence for differential item functioning (DIF) according to eight sociodemographic and disease-related variables. The Person Separation Index (PSI), which is equivalent to Cronbach's alpha, ranged from 0.74 to 0.78. Correlations with scores for other instruments were as hypothesized: ASES pain had the highest correlations with SF-36 pain and NRS pain and ASES other symptoms had the highest correlations with other aspects of the SF-36 and NRS fatigue.

CONCLUSIONS

The ASES had good fit to the Rasch model and correlations with other instrument scores that followed hypotheses, lending further support to the application of the instrument in patients with rheumatic diseases.

Aquatic exercise for the treatment of knee and hip osteoarthritis

BACKGROUND

Osteoarthritis is a chronic disease characterized by joint pain, tenderness, and limitation of movement. At present, no cure is available. Thus only treatment of the person's symptoms and treatment to prevent further development of the disease are possible. Clinical trials indicate that aquatic exercise may have advantages for people with osteoarthritis. This is an update of a published Cochrane review.

OBJECTIVES

To evaluate the effects of aquatic exercise for people with knee or hip osteoarthritis, or both, compared to no intervention.

SEARCH METHODS

We searched the following databases up to 28 April 2015: the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library Issue 1, 2014), MEDLINE (from 1949), EMBASE (from 1980), CINAHL (from 1982), PEDro (Physiotherapy Evidence Database), and Web of Science (from 1945). There was no language restriction.

SELECTION CRITERIA

Randomized controlled clinical trials of aquatic exercise compared to a control group (e.g. usual care, education, social attention, telephone call, waiting list for surgery) of participants with knee or hip osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included trials. We analysed the pooled results using standardized mean difference (SMD) values.

MAIN RESULTS

Nine new trials met the inclusion criteria and we excluded two earlier included trials. Thus the number of participants increased from 800 to 1190 and the number of included trials increased from six to 13. Most participants were female (75%), with an average age of 68 years and a body mass index (BMI) of 29.4. Osteoarthritis duration was 6.7 years, with a great variation of the included participants. The mean aquatic exercise duration was 12 weeks. We found 12 trials at low to unclear risk of bias for all domains except blinding of participants and personnel. They showed that aquatic exercise caused a small short term improvement compared to control in pain (SMD -0.31, 95% CI -0.47 to -0.15; 12 trials, 1076 participants) and disability (SMD -0.32, 95% CI -0.47 to -0.17; 12 trials, 1059 participants). Ten trials showed a small effect on quality of life (QoL) (SMD -0.25, 95% CI -0.49 to -0.01; 10 trials, 971 participants). These effects on pain and disability correspond to a five point lower (95% CI three to eight points lower) score on mean pain and mean disability compared to the control group (scale 0 to 100), and a seven point higher (95% CI 0 to 13 points higher) score on mean QoL compared with control group (scale 0 to 100). No included trials performed a radiographic evaluation. No serious adverse events were reported in the included trials with relation to aquatic exercise.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and QoL in people with knee and hip OA. The conclusions of this review update does not change those of the previous published version of this Cochrane review.

Patient-reported quality indicators for osteoarthritis: a patient and public generated self-report measure for primary care

PLAIN ENGLISH SUMMARY

People with osteoarthritis desire high quality care, support and information. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators can be used to benefit patients by measuring whether minimum standards of quality care are being met from a patient perspective. The aim of this study was to describe how a Research User Group (RUG) worked alongside researchers to co-produce a set of self-reported quality indicators for people with osteoarthritis when visiting their general practitioner or practice nurse (primary care). These were required in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE quality standards for OA. This article describes the public involvement in the MOSAICS study. This was 1) the co-development by RUG members and researchers of an Osteoarthritis Quality Indicators United Kingdom (OA QI (UK)) questionnaire for use in primary care, and 2) the comparison of the OA QI (UK) with a similar questionnaire developed in Norway. This study shows how important and effective a research user group can be in working with researchers in developing quality care indicators for osteoarthritis for use in a research study and, potentially, routine use in primary care. The questionnaire is intended to benefit patients by enabling the assessment of the quality of primary care for osteoarthritis from a patient's perspective. The OA QI (UK) has been used to examine differences in the quality of osteoarthritis care in four European countries.

ABSTRACT

Background People with osteoarthritis (OA) desire high quality care, support and information about OA. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators (QI) can be used to benefit patients by measuring whether minimum standards of quality care (e.g. NICE quality standards) are being met from a patient perspective. A Research User Group (RUG) worked with researchers to co-produce a set of self-report, patient-generated QIs for OA. The QIs were intended for use in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE guidelines. We report on 1) the co-development of the OA QI (UK) questionnaire for primary care; and 2) the comparison of the content of the OA QI (UK) questionnaire with a parallel questionnaire developed in Norway for the Musculoskeletal Pain in Ullensaker (MUST) study. Methods Researchers were invited to OA RUG meetings. Firstly, RUG members were asked to consider factors important to patients consulting their general practitioner (GP) for OA and then each person rated their five most important. RUG members then discussed these in relation to a systematic review of OA QIs in order to form a list of OA QIs from a patient perspective. RUG members suggested wording and response options for a draft OA QI (UK) questionnaire to assess the QIs. Finally RUG members commented on draft and final versions of the questionnaire and how it compared with a translated Norwegian OA-QI questionnaire. Results RUG members (5 males, 5 females; aged 52-80 years) attended up to four meetings. RUG members ranked 20 factors considered most important to patients consulting their GP for joint pain. Following discussion, a list of eleven patient-reported QIs for OA consultations were formed. RUG members then suggested the wording and response options of 16 draft items - four QIs were split into two or more questionnaire items to avoid multiple dimensions of care quality within a single item. On comparison of this to the Norwegian OA-QI questionnaire, RUG members commented that both questionnaires contained seven similar QIs. The RUG members and researchers agreed to adopt the Norwegian OA-QI wording for four of these items. RUG members also recommended adopting an additional seven items from the Norwegian OA-QI with some minor word changes to improve their suitability for patients in the UK. One other item from the draft OA QI (UK) questionnaire was retained and eight items were excluded, resulting in a 15-item final version. Conclusions This study describes the development of patient-reported quality indicators for OA primary care derived by members of a RUG group, working in partnership with the research team throughout the study. The OA QI (UK) supports the NICE quality standards for OA and they have been successfully used to assess the quality of OA consultations in primary care in the MOSAICS study. The OA QI (UK) has the potential for routine use in primary care to assess the quality of OA care provided to patients. Ongoing research using both the UK and Norwegian OA-QI questionnaires is assessing the self-reported quality of OA care in different European populations.

Individual and joint effects of risk factors for onset widespread pain and obesity - a population-based prospective cohort study

BACKGROUND

Widespread musculoskeletal pain (WSP) and obesity frequently co-occur and may have shared risk factors. We aimed to investigate whether four dichotomized risk factors individually or jointly increase the risk for the onset of WSP and onset of obesity.

METHODS

Persons aged 34-76 years in 2004 living in Ullensaker municipality, Norway, responded to questionnaires in 2004 and 2010 (n = 1553). Using causal interaction analyses, we examined whether baseline obesity and WSP, poor sleep quality, mental distress and poor physical fitness jointly increased the risk of new onset WSP (≥3 pain sites leading to disability the last year) and new onset obesity (self-reported BMI ≥30 kg/m(2) ) in persons without WSP (n = 1270) or without obesity (n = 1300) at baseline respectively.

RESULTS

The mean (SD) age was 51 (12.1) years and 56% were female. The incidence of WSP and obesity were 9.1% and 5.4%. Mental distress and poor sleep quality individually and jointly with poor physical fitness increased WSP onset risk (relative excess risk due to interaction [RERI] = 1.90, 95% CI, 0.39-3.42 and RERI = 1.43, 95% CI, 0.10-2.76). Poor physical fitness individually increased the risk for new onset obesity, and baseline WSP and poor sleep quality jointly (RERI = 1.87, 95% CI, 0.49-3.24). The presence of more risk factors was dose-dependently associated with onset WSP and to a lesser extent with onset obesity.

CONCLUSION

The onset of WSP and the onset of obesity were results of joint effects of exposures. Poor physical fitness was a key covariate in increasing the risk for both conditions. WHAT DOES THIS STUDY ADD?: In a general population, the new onset of widespread pain and new onset of obesity were results of joint effects of risk factors and particularly poor physical fitness. The study may aid in the identification of patients at risk of future disability.

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.

Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial

BACKGROUND

Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8-12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model.

METHODS/DESIGN

A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants' treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER).

DISCUSSION

The results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02333656.

Self-reported quality care for knee osteoarthritis: comparisons across Denmark, Norway, Portugal and the UK

Objectives

To assess and compare patient perceived quality of osteoarthritis (OA) management in primary healthcare in Denmark, Norway, Portugal and the UK.

Methods

Participants consulting with clinical signs and symptoms of knee OA were identified in 30 general practices and invited to complete a cross-sectional survey including quality indicators (QI) for OA care. A QI was considered as eligible if the participant had checked ‘Yes’ or ‘No’, and as achieved if the participant had checked ‘Yes’ to the indicator. The median percentage (with IQR and range) of eligible QIs achieved by country was determined and compared in negative binominal regression analysis. Achievement of individual QIs by country was determined and compared using logistic regression analyses.

Results

A total of 354 participants self-reported QI achievement. The median percentage of eligible QIs achieved (checked ‘Yes’) was 48% (IQR 28%, 64%; range 0–100%) for the total sample with relatively similar medians across three of four countries. Achievement rates on individual QIs showed a large variation ranging from 11% (referral to services for losing weight) to 67% (information about the importance of exercise) with significant differences in achievement rates between the countries.

Conclusions

The results indicated a potential for improvement in OA care in all four countries, but for somewhat different aspects of OA care. By exploring these differences and comparing healthcare services, ideas may be generated on how the quality might be improved across nations. Larger studies are needed to confirm and further explore the findings.

Variation in fatigue may be poorly explained by pain: results from a longitudinal, exploratory study

It is frequently claimed that fatigue reflects pain and that strategies for alleviating fatigue in patients with ankylosing spondylitis (AS) should focus on pain management. The aim of this study was twofold: to investigate the correlation between fatigue and pain over time and to investigate the temporal relationship between fatigue and pain in patients with AS. Fatigue and pain were assessed twice a week for 35 weeks in 23 patients with AS. Data were reported with text messages on mobile phones, constituting around 70 repeated measurements per patient. To estimate correlation over time, the correlation coefficient within individuals was estimated. When estimating the temporal relationship, we lagged the independent variable and performed individual linear regression. In 16 (70 %) of the patients, ≤ 36 % of the variance in fatigue was explained by pain. The association between fatigue and pain was synchronous in time in 13 (57 %) patients, while 5 (22 %) patients reported that fatigue precedes pain by 1 week and 5 (22 %) that pain precedes fatigue by 1 week. Fatigue and pain may be two separate and independent symptoms in some patients with AS. The clinical implication is that the two symptoms should be targeted separately because it cannot always be expected that an improvement in one is followed by an improvement in the other.

Circulating levels of inflammatory cytokines and cytokine receptors in patients with ankylosing spondylitis: a cross-sectional comparative study

OBJECTIVES

Insight into the most important inflammatory pathways in ankylosing spondylitis (AS) could be of importance in risk stratification and the development of treatment strategies. Therefore, we aimed to compare circulating levels of inflammatory biomarkers between AS patients and controls, and explore associations between these biomarkers and clinical measures of disease activity.

METHOD

In a cross-sectional study, 143 AS patients were compared with 124 population controls. Blood samples were analysed by immunoassays for interleukin (IL)-6, IL-17a, IL-23, soluble tumour necrosis factor receptor 1 (sTNF-R1) and 2 (sTNF-R2), and osteoprotegerin (OPG). Disease activity was measured by the AS Disease Activity Score (ASDAS) and the Bath AS Disease Activity Index (BASDAI).

RESULTS

Analysis of covariance (ANCOVA) demonstrated elevated plasma levels of sTNF-R1 [geometrical mean 0.94 (95% CI 0.88-1.00) vs. 0.83 (95% CI 0.78-0.89) ng/mL, p < 0.01] and OPG (2.3, 95% CI 2.1-2.4 vs. 2.0, 95% CI 1.9-2.2 ng/mL, p = 0.02) and, although not significant, of IL-23 (122, 95% CI 108-139 vs. 106, 95% CI 93-120 pg/mL, p = 0.07) in AS patients vs.

CONTROLS

More AS patients had a high level of sTNF-R2 than controls (22 vs. 1, p < 0.01). No differences between the groups were seen for IL-6 and IL-17a. In patients, no significant associations were seen between inflammatory markers and disease activity measures after adjusting for personal characteristics.

CONCLUSION

Significantly higher plasma levels of sTNF-R1, sTNF-R2, and OPG and numerically but non-significantly higher levels of IL-23 were found in AS patients compared to controls, indicating that these cytokines and cytokine receptors are important inflammatory pathways. Clinical measures of disease activity were not significantly correlated with circulating inflammatory markers.

Diabetes is associated with increased hand pain in erosive hand osteoarthritis: data from a population-based study

OBJECTIVE

To explore factors related to hand pain in persons with radiographic hand osteoarthritis (OA).

METHODS

Persons in the Musculoskeletal Pain in Ullensaker Study with radiographic hand OA (≥1 joint with Kellgren/Lawrence grade ≥2) were included (n = 530). We examined the cross-sectional association between possible explanatory variables and hand pain in the entire sample and in 2 hand OA phenotypes (erosive versus nonerosive) using structural equation analyses. Outcome variables were the Australian/Canadian Hand Osteoarthritis Index (AUSCAN; range 0-20) and number of tender finger joints upon palpation (NTJ; range 0-30).

RESULTS

The mean age was 65 years (40-79 years) and 375 participants were women (71%). Diabetes mellitus, female sex, lower education status, familial OA, infrequent alcohol drinking, widespread pain, poor mental health, and higher number of finger joints with ultrasound-detected synovitis and radiographic OA were related to more hand pain in the entire sample. Stratified analyses showed that diabetes mellitus was strongly associated with AUSCAN pain (B-unstandardized coefficient = 3.81 [95% confidence interval (95% CI) 2.27, 5.35]) and NTJ (B-unstandardized coefficient = 4.16 [95% CI 2.01, 6.31]) in erosive hand OA only. In nonerosive OA, lower education status, having familial OA, and poor mental health were associated with hand OA pain. Widespread pain was associated with both outcomes in both phenotypes.

CONCLUSION

Structural and inflammatory OA changes as well as demographic factors, psychosocial factors, and diabetes mellitus were associated with pain in hand OA. The strong association between diabetes mellitus and pain in erosive hand OA should be further explored.

Perceived quality of health care services among people with osteoarthritis - results from a nationwide survey

OBJECTIVE

To assess the perceived quality of care received by people with osteoarthritis (OA) in Norway and explore factors associated with the quality of care.

METHODS

A national survey in which members of the Norwegian Rheumatism Association with OA registered as their main diagnosis completed a questionnaire. The perceived quality of care was reported on a 17-item OsteoArthritis Quality Indicator questionnaire, covering both pharmacological and non-pharmacological aspects of OA care. In addition, the four-page questionnaire covered areas related to demographic characteristics, the location and impact of the OA, and utilization and satisfaction with health care services. The quality of care is calculated as pass rates, where the numerator represents the number of indicators passed and the denominator represents the number of eligible persons.

RESULTS

In total, 1,247 participants (response rate 57%) completed the questionnaire. Mean age was 68 years (standard deviation 32) and 1,142 (92%) were women. Respondents reported OA in hand only (12.4%), hip only (7.3%), knee only (10.4%), in two locations (42%) or all three locations (27%). The overall OsteoArthritis Quality Indicator pass rate was 47% (95% confidence interval [CI] 46%-48%), and it was higher for pharmacological aspects (53% [51%-54%]) than for non-pharmacological aspects of care (44% [43%-46%]). The pass rate for the individual quality indicators ranged from 8% for "referral for weight reduction" to 81% for "receiving advice about exercises". Satisfaction with care was strongly associated with perceived quality. The pass rate for those who were "very satisfied" was 33% (25%-40%) higher than those who were "very unsatisfied" with care.

CONCLUSION

While the OA patient seems to be rather satisfied with the perceived OA care, there is still room for improvement in the quality of care. Although the quality of care in the present study is somewhat higher than in other studies, less than 50% of the recommended care has been provided.

The validity of self-reported body mass index in a population-based osteoarthritis study

Background

Obesity is a well-known risk factor for osteoarthritis (OA). The majority of obesity research in OA is performed using self-reported BMI-data, however, its validity in persons with OA is unknown. The aim of this study was to compare the validity of self-reported body mass index (BMI) in persons with and without clinical osteoarthritis (OA) in a population-based survey.

Methods

Height and weight were self-reported, and thereafter measured in 600 persons with and without clinical OA according to the American College of Rheumatology-criteria (knees, hips and/or hands). We compared the differences between measured and self-reported heights, weights and BMIs (kg/m²) for the two groups and explored whether demographic/clinical factors were associated with inaccurate reporting in the OA patients using multivariate linear regression analyses.

Results

Mean (SD) age was 64 (8.7) years and 412 (69%) were women. Participants with clinical OA (n = 449) underreported their BMI to a greater extent than participants without clinical OA (n = 151) [mean (SD) difference 1.34 (1.68) kg/m² and 0.78 (1.40) kg/m² (p = 0.000), respectively]. There was a strong dose-dependent association between higher measured BMI and greater underreporting of BMI in multivariate analyses (BMI 25–29.99 kg/m²: B = 0.40, 95% CI, 0.06, 0.77), BMI ≥ 30 kg/m²: B = 1.30, 95% CI, 0.86, 1.75) in the clinical OA patients. A higher age as well as the time interval from self-reported to measured BMI-data were associated with inaccurate reporting.

Conclusions

Researchers using self-reported height and weight data should be aware of limited agreement with actual height and weight in overweight and obese individuals with clinical OA.

Aquatic Exercises were Associated with an Acceptable State of Symptoms in Patients with Inflammatory Rheumatic Diseases: Results from a Study with Interrupted Time-Series Design

AIM OF STUDY

The aim of this study was two-fold: to compare symptoms and daily activity in patients with inflammatory rheumatic diseases across periods with and without aquatic exercises, and to examine whether the patients reached an acceptable state of symptoms during the periods with aquatic exercises.

METHODS

Thirty-six patients reported pain, fatigue, stiffness and ability to carry out daily activities across periods with and without aquatic exercises. The study has an interrupted time-series design and variables were collected with text messages on mobile phones twice a week over a period of 35 weeks.

RESULTS

There was a significant reduction in pain, fatigue, stiffness and enhanced level of daily activity (p > 0.05) during periods of aquatic exercises compared to periods without. Further, a significantly higher proportion of patients reached an acceptable state for both pain and fatigue during periods with aquatic exercises.

CONCLUSIONS

Living with an inflammatory rheumatic disease is a lifelong challenge. Pain and fatigue are considered major obstacles for daily functioning and adequate self-management strategies are requested. Based on the high proportion of patients reporting to be in an acceptable state of both pain and fatigue during periods with aquatic exercises, the intervention should be regarded as an important self-management tool rather than a treatment option assuming long-lasting effects. Copyright © 2014 John Wiley & Sons, Ltd.

Quality of hip and knee osteoarthritis management in primary health care in a Norwegian county: a cross-sectional survey

BACKGROUND

Osteoarthritis (OA) is one of the most common causes of pain and disability in the adult population. Several studies have documented discordance between general practioners (GP) practice and management recommendations, but there is limited published information about patient reported experience of quality of care. The primary aim of this study was to assess the patient perceived quality of OA management in primary health care. Secondly, we wanted to explore the factors associated with the perceived quality of OA care.

METHODS

A cross-sectional survey in six general practices in the county of Nord-Trøndelag in Norway, patients with radiologically diagnosed OA, according to ICPC codes L89, L90 or L91 or clinical signs and symptoms corresponding to OA in the hip or knee and patient-reported quality of OA care on the 17-item OsteoArthritis Quality Indicator questionnaire (OA-QI). OA-QI summary pass rates were calculated, in which the numerator represents the number with indicators passed and the denominator represents the total number of eligible persons. Associations with summary pass rates were explored with demographic, disease related and health care related factors as independent variables.

RESULTS

A total of 119 patients were included (response rate 42%). The median summary QI pass rate for all 17 QIs was 47% (Inter Quartile Range 33-65%), but there were large variation between the different items. The referral for weight reduction had the lowest pass rate (8%), whereas the highest pass rate was having received information about the importance of physical activity and exercise (84%). The median summary QI pass rates for both non-pharmacological- (QIs 1-11) and pharmacological (QIs 13-16) treatments were 50% (IQR 25-75). In bivariate regression analyses, only overall treatment satisfaction was significantly associated with QI pass rate (p = 0.001), with unstandardized beta = 6.1 (95% CI 2.7 to 9.5), i.e. a one-point increase on the five-point satisfaction scale was associated with a 6% increase in pass rate.

CONCLUSION

Considering that the median summary QI pass rate was 47%, there might be room for improvement in OA care. Advice and the referral of OA patients in need of weight reduction seem to have the greatest potential for improvement.

Effects of controlled breathing exercises and respiratory muscle training in people with chronic obstructive pulmonary disease: results from evaluating the quality of evidence in systematic reviews

Background

This paper reviews evidence and quality of Systematic Reviews (SRs) on the effects of breathing control exercises (BCEs) and respiratory muscle training (RMT) on breathlessness/dyspnea and other symptoms, and quality of life (QOL) for individuals with chronic obstructive pulmonary disease (COPD).

Methods

A search for BCE and RMT literature in COPD published between January 1, 2002 and December 31, 2013 was performed in the following databases: PubMed, Ovid, CINAHL, PsycINFO, AMED, Cochrane and PEDro. The AMSTAR criteria were used to evaluate quality.

Results

After reviewing 642 reports, seven SRs were identified on RMT and BCEs. Three SRs were of high quality, three were of moderate quality, and one was of low quality. Two high-quality SRs reported significantly beneficial effects of RMT on dyspnea, and one reported significant effects on disease-specific QOL and fatigue. In these SRs, pooled data analyses were performed with three to fourteen single randomised control trials (RCTs) included in the analysis. In one of the SRs the quality of the single RCTs were rated by the authors to be between 5–7 (with10 best) and in the other one the quality of the single RCTs were rated to be between 30-83% of the maximum score.

One high-quality SR found a significant positive effect of BCE based on pooled data analysis with two single RCTs in regard to pursed-lip breathing (PLB) on breathlessness. In this SR, one single RCT on diaphragmatic breathing (DB) and another one on yoga breathing (YB) showed effect on disease-specific QOL. The single RCTs included in the SR were rated by the authors in the SRs to be of low and moderate quality.

Conclusions

Based on three high-quality SRs performing pooled data analyses, there is evidence that RMT has effect on breathlessness, fatigue and disease-specific QOL and PLB on breathlessness. There is also evidence that single studies on DB and YB has effect on disease-specific QOL. Few RCTs are available and the variable quality of the single RCTs in the SRs, seem to require more RCTs in particular for BCEs, but also RMT before conclusions regarding effects and high quality SRs can be written.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2466-14-184) contains supplementary material, which is available to authorized users.