Investigations on the physiotherapy management of people following first-time patellar dislocation

Background: First-time patellar dislocation (FTPD) is a disabling musculoskeletal disorder. Whilst physiotherapy is considered the cornerstone treatment in FTPD, its evidence-base is limited. Three studies were undertaken to develop knowledge on this area. Study 1: All 306 National Health Service acute hospitals with an accident and emergency and/or an orthopaedic department were sent a fourteen-item questionnaire pertaining to the management of FTPD. Physiotherapists reported they most commonly assessed this population for reduced quadriceps or vastus medialis oblique (VMO) capacity, patellar maltracking and excessive patellar glide. Reassurance, proprioceptive, knee mobility, quadriceps and VMO-specific exercises were the most commonly cited treatments. Study 2: Ninety people who had experienced recurrent patellar instability completed a questionnaire which assessed the frequency with which they perceived patellar instability during various activities. Sporting and multidirectional activities were frequently associated with patellar instability. Females and those without a family history of patellar instability reported more frequent patellar instability symptoms compared to males, or those with a family history of this disorder. The results were used to construct the Norwich Patellar Instability Score. Study 3: A pragmatic multi-centre randomised controlled trial was conducted to compare the prescription of a general quadriceps exercise and rehabilitation programme (n=15) to a VMO-specific exercise and rehabilitation regime (n=12). Whilst Lysholm Knee Score was statistically different between the groups (p=0.02) this was not clinically significant. The general quadriceps exercise group reported a statistically significantly greater Tegner Level of Activity Score at six weeks (p=0.03) but not at six months (p=0.42). There was no significant difference between the groups for isometric knee extension, Short Form-12 or recurrent patellar dislocation at either follow-up (p>0.05). Conclusions: The studies undertaken have significantly developed the evidence-base in this field. Further investigations are recommended to further inform the clinical decision-making of physiotherapists who manage people following FTPD

Association between osteoarthritis and cardiovascular disease: systematic review and meta-analysis

Background: To examine for a possible relationship between osteoarthritis and cardiovascular disease (CVD). Design: A systematic review and meta-analysis Methods: Published and unpublished literature from: MEDLINE, EMBASE, CINAHL, the Cochrane Library, OpenGrey and clinical trial registers. Search to 22nd November 2014. Cohort, case-control, randomised and non-randomised controlled trial papers reporting the prevalence of CVD in osteoarthritis were included. Results: Fifteen studies with 32,278,744 individuals were eligible. Pooled prevalence for overall CVD pathology in people with osteoarthritis was 38.4% (95% Confidence interval (CI): 37.2% to 39.6%). Individuals with osteoarthritis were almost three times as likely to have heart failure (Relative Risk (RR): 2.80; 95% CI: 2.25 to 3.49) or ischaemic heart disease (RR: 1.78; 95% CI: 1.18 to 2.69) compared to matched non-osteoarthritis cohorts. No significant difference was detected between the two groups for the risk of experiencing myocardial infarction or stroke. There was a three-fold decrease in the risk of experiencing a transient ischaemic attack in the osteoarthritis cohort compared to the non-osteoarthritis group. Conclusions: Prevalence of CVD in patients with OA is significant. There was an observed increased risk of incident heart failure and ischaemic heart disease in people with OA compared to matched controls. However the relationship between OA and CVD is not straight-forward and there is a need to better understand the potential common pathways linking pathophysiological mechanisms

Trajectory of social isolation following hip fracture: an analysis of the English Longitudinal Study of Ageing (ELSA) cohort

Background: social isolation is defined as a lack of meaningful and sustained communication or interactions with social networks. There is limited understanding on the prevalence of social isolation and loneliness in people following hip fracture and no previous understanding of how this changes over time. Objective: to determine the prevalence and trajectory of social isolation and loneliness before a hip fracture, during the recovery phase and a minimum of 2 years post-hip fracture in an English population. Methods: data were from the English Longitudinal Study of Ageing (ELSA) cohort (2004/5–2014/15). The sample comprised of 215 participants who had sustained a hip fracture. Measures of social isolation and loneliness were analysed through multilevel modelling to determine their trajectories during three-time intervals (pre-fracture; interval at hip fracture and recovery; minimum 2 years post-fracture). The prevalence of social isolation and loneliness were determined pre- and post-fracture. Results: prevalence of social isolation was 19% post-hip fracture and loneliness 13% post-hip fracture. There was no statistically significant change in social isolation pre-fracture compared to a minimum of 2 years post-fracture (P = 0.78). Similarly, there was no statistically significant change in loneliness pre-fracture compared to a minimum of 2 years post-fracture (P = 0.12). Conclusion: this analysis has determined that whilst social isolation and loneliness do not change over time following hip fracture, these remain a significant problem for this population. Interventions are required to address these physical and psychological health needs. This is important as they may have short and longer term health benefits for people post-hip fracture

Medication taking in people with hip and knee osteoarthritis: An analysis of the English Longitudinal Study of Ageing

Objectives: Osteoarthritis (OA) is a highly prevalent condition seen across primary care services. Although evidence‐based guidelines have encouraged the prescription of medications, including analgesics, for this population, there remains uncertainty as to which types of individuals actually take prescribed or over‐the‐counter medications. The purpose of the present study was to determine whether there is a difference in characteristics between people who take medicines for OA compared with those who do not. Methods: A cross‐sectional analysis of the English Longitudinal Study of Ageing (ELSA) cohort was undertaken. Individuals who reported hip and/or knee OA pain were included. Data on medication taking were self‐reported and collected as part of the ELSA data collection programme. Logistic regression analyses were undertaken to determine the relationship between potential predictors (demographic, pathology‐specific, psychological, social and functional) and whether individuals took medications for their OA symptoms. Results: A total of 654 participants reported OA: 543 medicine takers and 111 nontakers. Individuals who had access to a car (odds ratio [OR]: 56.2; 95% confidence interval [CI]: 3.35 to 941.36), those with a greater duration of hip pain (OR: 5.79; 95% CI: 1.40 to 24.0) and those who achieved 10 chair raises at greater speed (OR: 1.08; 95% CI: 1.03 to 1.14) were more likely to take OA medicines. Conclusions: The study identified predictors for medication taking in individuals with hip and/or knee OA. Strategies are now warranted to provide better support to these individuals, to improve health and well‐being for this long‐term, disabling condition

Changes in social isolation and loneliness following total hip and knee arthroplasty: longitudinal analysis of the English Longitudinal Study of Ageing (ELSA) cohort

Objective: To determine the prevalence and change in social isolation and loneliness in people before and after THA and TKA in England. Design: The English Longitudinal Study of Ageing dataset, a prospective study of community-dwelling older adults, was used to identify people who had undergone primary THA or TKA because of osteoarthritis. Social isolation was assessed using the ELSA Social Isolation Index. Loneliness was evaluated using the Revised University of California, Los Angeles (UCLA) Loneliness Scale. The prevalence of social isolation and loneliness were calculated and multilevel modelling was performed to assess the potential change of these measures before arthroplasty, within a two-year operative-recovery phase and a following two-year follow-up. Results: The sample consisted of 393 people following THA and TKA. The prevalence of social isolation and loneliness changed from 16.9% and 18.8% pre-operative to 21.8% and 18.9% at the final post-operative follow-up respectively. This was not a statistically significant change for either measure (p=0.15; p=0.74). There was a significant difference in social isolation at the recovery phase compared to the pre-operative phase (p=0.01), where people following arthroplasty reported an increase in social isolation (16.9% to 21.4%). There was no significant difference between the assessment phases in respect to UCLA Loneliness Scale score (p≥0.74). Conclusions: Given the negative physical and psychological consequences which social isolation and loneliness can have on individuals following THA or TKA, clinicians should be mindful of this health challenge for this population. The reported prevalence of social isolation and loneliness suggests this is an important issue

Trajectory of physical activity following total hip and knee arthroplasty: data from the English Longitudinal Study of Ageing (ELSA) cohort

Purpose: To determine the prevalence and trajectory of physical activity levels in people before and after total hip (THA) and total knee arthroplasty (TKA).  Materials and Methods: An analysis of the English Longitudinal Study of Ageing (ELSA) (2004/5 to 2014/15) cohort study, a prospective study of community-dwelling older adults. 201 people who received a THA or TKA for the management of osteoarthritis were identified. Physical activity was assessed through the frequency of engagement in sedentary, mild, moderate and high physical activity levels pre-operatively, during the recovery phase and a minimum of two years’ post-operatively.  Results: There was a statistically significant decrease in physical activity from the pre-arthroplasty phase to the operative-recovery phase (p<0.01), and a significant increase in physical activity from the operative-recovery phase to final follow-up (p=0.05). However, overall there was no significant change in physical activity from pre-operatively to final follow-up where prevalence altered from 8% (95% Confidence Intervals (CI): 5% to 12%) to 13% (95% CI: 9% to 18%)(p=0.15). Increasing age, male gender and greater depressive symptoms were explanatory variables associated with physical inactivity (p<0.02).  Conclusion: Physical activity does not increase following THA or TKA. A proportion of the arthroplasty population remain physically inactive

Trajectory of physical activity after hip fracture: An analysis of community-dwelling individuals from the English Longitudinal Study of Ageing

Introduction: To analyse physical activity participation in a community-dwelling people in England with hip fracture the interval prior to fracture, in the fracture recovery period, and a minimum of two years post-fracture. Materials and methods: 215 individuals were identified from the English Longitudinal Study of Ageing cohort (2002–2014) who sustained a hip fracture following a fall and for whom data were available on physical activity participation relating to the period pre-fracture, within-fracture recovery phase and post-fracture (minimum of two years). Physical activity was assessed using the validated ELSA physical activity questionnaire. Prevalence of ‘low’ physical activity participation was calculated and multi-level modelling analyses were performed to explore physical activity trajectories over the follow-up phase, and whether age, depression, gender and frailty were associated with physical activity participation. Results: Prevalence of low physical activity participation within two years prior to hip fracture was 16.7% (95% Confidence Intervals (CI): 11.6% to 21.8%). This increased at the final follow-up phase to 21.3% (95% CI: 15.1% to 27.6%). This was not a statistically significant change (P = 0.100). Age (P = 0.005) and frailty (P < 0.001) were statistically significant explanatory variables (P = 0.005) where older age and greater frailty equated to lower physical activity participation. Neither gender (P = 0.288) nor depression (P = 0.121) were significant explanatory variables. Conclusion: Physical activity levels do not significantly change between pre-fracture to a minimum of two years post-hip fracture for community-dwelling individuals. This contrasts with previous reports of reduced mobility post-hip fracture, suggesting that ‘physical activity’ and ‘mobility’ should be considered as separate outcomes in this population

Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing

Introduction: Musculoskeletal pain is a prevalent health challenge for all age groups worldwide, but most notably in older adults. Social isolation is the consequence of a decrease in social network size with a reduction in the number of social contacts. Loneliness is the psychological embodiment of social isolation and represents an individual’s perception of dissatisfaction in the quality or quantity of their social contacts. This study aims to determine whether a relationship exists between musculoskeletal pain and social isolation and loneliness. Methods: A cross-sectional analysis of the English Longitudinal Study of Ageing (ELSA) cohort was undertaken. ELSA is a nationally representative sample of the non-institutionalised population of individuals aged 50 years and over based in England. Data were gathered on social isolation through the ELSA Social Isolation Index, loneliness through the University of California, Los Angeles (UCLA) Loneliness Scale and musculoskeletal pain. Data for covariates included physical activity, depression score, socioeconomic status, access to transport and demographic characteristics. Logistic regression analyses were undertaken to determine the relationship between social isolation and loneliness with pain and the additional covariates. Results: A total of 9299 participants were included in the analysis. This included 4125 (44.4%) males, with a mean age of 65.8 years. There was a significant association where social isolation was lower for those in pain (odd ratio (OR): 0.87; 95% confidence intervals (CI): 0.75 to 0.99), whereas the converse occurred for loneliness where this was higher for those in pain (OR: 1.15; 95% CI: 1.01 to 1.31). Age, occupation, physical activity and depression were all associated with increased social isolation and loneliness. Conclusion: People who experience chronic musculoskeletal pain are at greater risk of being lonely, but at less risk of being socially isolated. Health professionals should consider the wider implications of musculoskeletal pain on individuals, to reduce the risk of negative health implications associated with loneliness from impacting on individual’s health and well-being

A systematic review of tranexamic acid in hip fracture surgery

Aim: To systematically examine and quantify the efficacy and safety of Tranexamic acid in hip fracture surgery.  Methods: A systematic literature search was conducted using Medline, EMBASE, AMED, CiNAHL, and the Cochrane Central Registry of Controlled Trials. Two assessors independently screened search outputs for potentially relevant articles which met the eligibility criteria. The primary outcome measure was requirement of post-operative blood transfusion. Risk of bias assessment was performed using the Cochrane Collaboration’s risk of bias tool for RCT’s and the ROBINS-I tool for observational studies. Meta-analysis was performed to estimate risk ratio (RR), risk difference (RD) and mean difference (MD) values for dichotomous and continuous data outcomes respectively. The interpretation of each outcome was made using the GRADE approach.  Results: Of 102 studies identified, seven met the inclusion criteria including a total of 770 participants (TXA: 341; Control: 429). On meta-analysis, intra-venous TXA resulted in a 46% risk reduction in blood transfusion requirement compared to a placebo/control group (RR:0.54; 95% CI: 0.35 to 0.85; I2: 78%; Inconsistency (Chi2) p=<0.0001; N=750). There was also a significantly higher post-operative haemoglobin for TXA versus placebo/control (MD:0.81; 95% CI: 0.45 to 1.18; I2: 46%; Inconsistency (Chi2) p=0.10; N=638). There was no increased risk of thromboembolic events (RD:0.01; 95% CI: -0.03, 0.05; I2: 68%; Inconsistency (Chi2) p=0.007, N=683).  Conclusion: There is moderate quality evidence that TXA reduces blood transfusion in hip fracture surgery, with low quality evidence suggesting no increased risk of thrombotic events. These findings are consistent with TXA use in other orthopaedic procedures

Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis

Objective: Osteoarthritis is a leading cause of disability. This systematic review aimed to establish the prevalence of depressive symptoms and anxiety among people with osteoarthritis in comparison to those without osteoarthritis. Method: We systematically reviewed databases including AMED, EMBASE, MEDLINE, PsycINFO, BNI, CINAHL and the Cochrane database library from their inception to January 2015. Studies presenting data on depressive symptoms and anxiety in people with osteoarthritis were included. A random and fixed-effect meta-analysis was conducted on all eligible data. Results: A total of 49 studies were included, representing 15,855 individuals (59% women; mean age 65.2 years). The evidence-base was moderate in quality. The pooled prevalence of depressive symptoms in osteoarthritis was 19.9% (95% Confidence Intervals (CI): 15.9% to 24.5%, n=10,811). The corresponding pooled prevalence was 21.3% (95% CI: 15.5% to 28.5%; n=1,226) for anxiety symptoms. The relative risk of depression among people with osteoarthritis was 1.17 (95% CI 0.69 to 2.00, 3 studies, n=941) compared to people without osteoarthritis. The relative risk of anxiety was 1.35 (95% CI: 0.51 to 3.59; 3 studies, n=733) compared to those without osteoarthritis. Conclusion: One fifth of people with osteoarthritis experience symptoms of depression and anxiety. However it is uncertain whether this is increased compared to those without osteoarthritis, with no direct evidence to support an increase in anxiety and depression in osteoarthritis