Physiotherapy management of lower limb osteoarthritis

© The Author 2017. Published by Oxford University Press. Background Osteoarthritis (OA) of the lower limb affects millions of people worldwide, and results in pain and reduced function. We reviewed guidelines and Cochrane reviews for physical therapy interventions to manage the condition. Sources of data Evidence from meta-analyses and systematic reviews was included. We also identified the recommendations from guidelines relevant to practice in the UK. Areas of agreement There is strongest evidence to support the use of exercise to improve pain, function and quality of life. Areas of controversy There is limited evidence to support the use of some commonly utilized physiotherapy interventions. National Institute for Health and Clinical Excellence do not recommend the use of acupuncture. Growing points Programmes that include single exercise type may be more beneficial than combined strengthening and aerobic interventions. Areas timely for developing research Further research is required to determine how to facilitate long-term engagement with exercise to sustain the beneficial effects on pain, function and quality of life. Studies that investigate packages of care, combining interventions require further investigation

Exercise for lower limb osteoarthritis : systematic review incorporating trial sequential analysis and network meta-analysis

Objective: To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis. Data sources: Nine electronic databases searched from inception to March 2012. Study selection: Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis. Data extraction: Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness. Results: 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference −0.63, 95% credible interval −1.16 to −0.10). Conclusions: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis

Identification and evaluation of self-reported physical activity instruments in adults with osteoarthritis: a systematic review.

OBJECTIVETo identify and evaluate the measurement properties of self-report physical activity (PA) instruments suitable for those with osteoarthritis (OA).METHODSA comprehensive two-stage systematic review using multiple electronic databases from inception until July 2018. Stage One sought to identify all self-reported PA instruments used in populations with joint pain attributable to OA in the foot, knee, hip or hand. Stage Two searched for and appraised studies investigating the measurement properties of the instruments identified. For both stages all articles were screened for study eligibility criteria, completed data extraction using the Qualitative Attributes and Measurement Properties of Physical Activity Questionnaires (QAPAQ) checklist, and conducted methodology quality assessments using a modified COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. Measurement properties for each physical activity instrument were evaluated and combined using narrative synthesis.RESULTSStage One identified 23 unique self-report PA instruments. Stage Two identified 53 studies that evaluated the measurement properties of 13 of the 23 instruments identified. Instrument reliability varied from inadequate to adequate (ICC==0.7). Instrument construct and criterion validity assessment demonstrated small to moderate correlations with direct measures of PA. Responsiveness was assessed in only 1 instrument and was unable to detect changes in comparison to accelerometers.CONCLUSIONWhile many instruments were identified as potentially suitable for use in individuals with OA, none demonstrated adequate measurement properties across all domains of reliability, validity and responsiveness. Further high-quality assessment of self-reported PA instruments is required before such measures can be recommended for use in OA research

The attitudes towards, and beliefs about, physical activity in people with osteoarthritis and comorbidity: A qualitative investigation

OBJECTIVE: To investigate the attitudes towards, and beliefs about, physical activity (PA) in older adults with osteoarthritis (OA) and comorbidity to understand experiences and seek ways to improve PA participation. METHODS: Semi-structured interviews with adults aged =45, with self-reported OA and comorbidity (N = 17). Face-to-face interviews explored participant perspectives regarding; (1) attitudes and beliefs about PA in the context of OA and comorbidity and (2) how people with OA and comorbidity could be encouraged to improve and maintain PA levels. Data were transcribed verbatim and inductive thematic analysis was undertaken using a framework approach. RESULTS: Participants did not conceptualise multiple long-term conditions (LTCs) together and instead self-prioritised OA over other LTCs. Barriers to PA included uncertainty about both the general management of individual LTCs and the effectiveness of PA for their LTCs; and, negative perceptions about their health, ageing and PA. Participants experienced dynamic and co-existing barriers to PA, and problematized this as a multi-level process, identifying a barrier, then a solution, followed by a new barrier. Facilitators of PA included social support and support from knowledgeable healthcare professionals (HCPs), together with PA adapted for OA and comorbidity and daily life. PA levels could be increased through targeted interventions to increase self-efficacy for managing OA alongside other LTCs and self-efficacy for PA. CONCLUSION: People with OA and comorbidity experience complicated PA barriers. To increase PA levels, tailored PA interventions could include HCP and social support to anticipate and overcome multi-level PA barriers and target increased self-efficacy for LTC management and PA

Self-Report Measures of Physical Activity.

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Supported self-management for all with musculoskeletal pain: an inclusive approach to intervention development: the EASIER study

BackgroundSupported self-management interventions for patients with musculoskeletal (MSK) conditions may not adequately support those with limited health literacy, leading to inequalities in care and variable outcomes. The aim of this study was to develop a model for inclusive supported self-management intervention(s) for MSK pain that take account of health literacy.MethodsA mixed methods study with four work-packages was conducted: work package 1: secondary analysis of existing data to identify potential targets for intervention; work package 2: evidence synthesis to assess effective components of self-management interventions taking into account health literacy; work package 3: views of community members and healthcare professionals (HCPs) on essential components; work package 4: triangulation of findings and an online modified Delphi approach to reach consensus on key components of a logic model.FindingsFindings identified targets for intervention as self-efficacy, illness perceptions, and pain catastrophizing. A range of intervention components were identified (e.g. information in diverse formats offered at specific times, action planning and visual demonstrations of exercise). Support should be multi-professional using a combination of delivery modes (e.g. remote, face-to-face).ConclusionsThis research has developed a patient-centred model for a multi-disciplinary, multi-modal approach to supported self-management for patients with MSK pain and varying levels of health literacy. The model is evidence-based and acceptable to both patients and HCPs, with potential for significant impact on the management of MSK pain and for improving patient health outcomes. Further work is needed to establish its efficacy

A pilot study of a nurse-led integrated care review (the INCLUDE review) for people with inflammatory rheumatological conditions in primary care: feasibility study findings.

BACKGROUND: People with inflammatory rheumatological conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, polymyalgia rheumatica and giant cell arteritis are at an increased risk of common comorbidities including cardiovascular disease, osteoporosis and mood problems, leading to increased morbidity and mortality. Identifying and treating these problems could lead to improved patient quality of life and outcomes. Despite these risks being well-established, patients currently are not systematically targeted for management interventions for these morbidities. This study aimed to assess the feasibility of conducting a randomised controlled trial (RCT) of a nurse-led integrated care review in primary care to identify and manage these morbidities. METHODS: A pilot cluster RCT was delivered across four UK general practices. Patients with a diagnostic Read code for one of the inflammatory rheumatological conditions of interest were recruited by post. In intervention practices (n = 2), eligible patients were invited to attend the INCLUDE review. Outcome measures included health-related quality of life (EQ-5D-5L), patient activation, self-efficacy and treatment burden. A sample (n = 24) of INCLUDE review consultations were audio-recorded and assessed against a fidelity checklist. RESULTS: 453/789 (57%) patients responded to the invitation, although 114/453 (25%) were excluded as they either did not fulfil eligibility criteria or failed to provide full written consent. In the intervention practices, uptake of the INCLUDE review was high at 72%. Retention at 3 and 6?months both reached pre-specified success criteria. Participants in intervention practices had more primary care contacts than controls (mean 29 vs 22) over the 12?months, with higher prescribing of all relevant medication classes in participants in intervention practices, particularly so for osteoporosis medication (baseline 29% vs 12?month 46%). The intervention was delivered with fidelity, although potential areas for improvement were identified. CONCLUSIONS: The findings of this pilot study suggest it is feasible to deliver an RCT of the nurse-led integrated care (INCLUDE) review in primary care. A significant morbidity burden was identified. Early results suggest the INCLUDE review was associated with changes in practice. Lessons have been learnt around Read codes for patient identification and refining the nurse training. TRIAL REGISTRATION: ISRCTN, ISRCTN12765345

Integrating case-finding and initial management for osteoarthritis, anxiety, and depression into primary care long-term condition reviews: results from the ENHANCE pilot trial.

Background: Multimorbidity is increasingly the norm; however, primary care remains focused on single diseases. Osteoarthritis, anxiety, and depression are frequently comorbid with other long-term conditions (LTCs), but rarely prioritized by clinicians.Objectives: To test the feasibility of a randomized controlled trial (RCT) of an intervention integrating case-finding and management for osteoarthritis, anxiety, and depression within LTC reviews.Methods: A pilot stepped-wedge RCT across 4 general practices recruited patients aged >= A5 years attending routine LTC reviews. General practice nurses provided usual LTC reviews (control period), then, following training, delivered the ENHANCE LTC review (intervention period). Questionnaires, an ENHANCE EMIS-embedded template and consultation audio-recordings, were used in the evaluation.Results: General practice recruitment and training attendance reached prespecified success criteria. Three hundred and eighteen of 466 (68%) of patients invited responded; however, more patients were recruited during the control period (206 control, 112 intervention). Eighty-two percent and 78% returned their 6-week and 6-month questionnaires, respectively. Integration of the ENHANCE LTC review into routine LTC reviews varied. Case-finding questions were generally used as intended for joint pain, but to a lesser extent for anxiety and depression. Initial management through referrals and signposting were lacking, and advice was more frequently provided for joint pain. The stepped-wedge design meant timing of the training was challenging and yielded differential recruitment.Conclusion: This pilot trial suggests that it is feasible to deliver a fully powered trial in primary care. Areas to optimize include improving the training and reconsidering the stepped-wedge design and the approach to recruitment by targeting those with greatest need