Physiotherapy management of hip osteoarthritis

Effect of Early Postoperative Gait Parameters After Total Hip Arthroplasty on Forgotten Joint Score-12 at 2-Year Follow-Up

Purpose: This study aimed to elucidate the relationship between early postoperative gait parameters after total hip arthroplasty (THA) and the Forgotten Joint Score-12 (FJS-12) score at the 2-year follow-up after surgery. In addition, the cutoff gait parameter values for predicting discomfort using specific FJS-12 subitems were evaluated. Methods: Among 313 patients who underwent THA between April and December 2019, 44 (14.0%) who responded to the FJS-12 questionnaire at 2 years postoperatively were included in this study. Gait parameters, including walking speed, stride length, and their coefficients of variation (CVs), were measured at 13.8 ± 3.6 (mean ± standard deviation) days postoperatively. The FJS-12 was used to evaluate patients at 2 years after surgery. The correlation between the FJS-12 score and gait parameters was analyzed using Spearman's rank correlation coefficient. To determine the significant predictors of the FJS-12 score, multiple regression analysis was performed after adjusting for age as a covariate. Furthermore, receiver operating characteristic curves were used to determine the cutoff gait parameter values for predicting discomfort using specific FJS-12 subitems. Results: The FJS-12 score was significantly positively correlated with walking speed (rs = 0.38, p < 0.05) and stride length (rs = 0.51, p < 0.01). Meanwhile, the FJS-12 score was significantly negatively correlated with the CVs of walking speed (rs = -0.34, p < 0.05) and stride length (rs = -0.35, p < 0.05). Based on multiple regression analysis, stride length was a significant predictor of discomfort assessed using the FJS-12 score (β = 0.48, p < 0.01). According to the receiver operating characteristic curves, the cutoff stride length values for predicting discomfort using the FJS-12 subitems 9, 10, 11, and 12 showed moderate accuracy (area under the curve > 0.7). Conclusions: Improved walking ability of patients who underwent THA through early rehabilitation is linked to joint discomfort and patient satisfaction in daily life 2 years postoperatively.

Bisphosphonates show no association with preventing, slowing, or delaying radiographic changes and pain in hip osteoarthritis: A 4-year study in female adults using data from the Osteoarthritis Initiative Study

OBJECTIVE

This study aimed to investigate the association of bisphosphonates with outcomes related to radiographic changes and pain in hip osteoarthritis (OA) over 4 years.

METHODS

This study examined data from the Osteoarthritis Initiative (OAI), which included 4088 hips from 2057 participants. Bisphosphonate users were identified as those who reported usage at least three times, including at baseline and during the subsequent 1, 2, 3, and 4-year follow-up visits. Non-users were participants who did not use bisphosphonates in the 5 years preceding the baseline and at subsequent follow-up visits. Generalized estimating equations were performed to assess the association between bisphosphonate use and outcomes related to radiographic changes and pain in hip OA over a 4-year follow-up.

RESULTS

The analysis revealed no statistically significant difference between bisphosphonate users and non-users concerning outcomes related to radiographic changes and pain in hip OA over 4 years. Specifically, the odds ratios for the incidence and transition of radiographic hip OA were 0.55 (95% Confidence Interval [CI]: 0.26 to 1.17) and 0.78 (95% CI: 0.47 to 1.28), respectively. Furthermore, the odds ratios for the development and resolution of frequent hip pain were 1.04 (95% CI: 0.76 to 1.42) and 0.99 (95% CI: 0.72 to 1.36), respectively.

CONCLUSION

The findings from this longitudinal study do not suggest an association between bisphosphonate use and the prevention, slowing, or delay of development and transition of radiographic changes or pain in hip OA over a 4-year follow-up.

Retrospective Evaluation of Cryopreserved Human Umbilical Cord Tissue Allografts in the Supplementation of Cartilage Defects Associated with Hip Osteoarthritis

Background: Osteoarthritis is a chronic disorder that affects the synovial joints by the progressive loss of articular cartilage. In the hip, the largest weight-bearing joint, the deterioration of articular cartilage and acetabular labrum can cause pain, diminishing the quality of life for patients. This study presents changes in reported pain scales from patients who received Wharton's jelly applications to cartilage deterioration in the hip from the observational retrospective repository at Regenative Labs. Methods: Sixty-nine patients were selected based on inclusion criteria with patient-reported pain scales, including the Numeric Pain Rating Scale and the Western Ontario and McMaster University Osteoarthritis Index, collected at the initial application, 30, and 90-day follow-up visits. Thirteen patients received a second allograft application and had additional follow-up visits at 120 and 180 days. Results: Five of the six scales used showed a statistically significant improvement in average scores across the cohort. The greatest improvements were observed in the NPRS with a 31.36% improvement after 90 days and a 44.64% improvement for patients with two applications after 180 days. The minimal clinically important difference (MCID) was also calculated to determine the perceived value of care for each patient with 44.9% of patients exceeding the MCID and 78.3% reporting at least one level of improvement. Conclusions: The positive outcomes for the patients in this cohort suggest WJ to be a promising alternative care option for patients with structural tissue degeneration in the hip refractory to the current standard of care.

Investigation of the Associations of Smoking With Hip Osteoarthritis: A Baseline Cross-Sectional and Four- to Five-Year Longitudinal Multicohort Study

OBJECTIVE

This study aimed to investigate the effect of smoking on the prevalence, incidence, and progression of hip osteoarthritis (OA). We used data from the Osteoarthritis Initiative (OAI) and the Cohort Hip and Cohort Knee (CHECK) studies.

METHODS

We analyzed 9,386 hips from 4,716 participants (OAI cohort) and 1,954 hips from 977 participants (CHECK cohort). The primary exposure was smoking status at baseline, categorized as current, former, or never smoker. Outcomes of radiographic hip OA (RHOA) and symptomatic hip OA were evaluated both cross-sectionally at baseline and longitudinally over a 4- to 5-year follow-up, with adjustments for major covariates.

RESULTS

No significant differences were observed between current or former smokers and never smokers for any of the outcomes examined, either at baseline or at the 4- to 5-year follow-up. In the cross-sectional analysis, the odds ratios with 95% confidence intervals for the prevalence of RHOA for current and former smokers were 1.29 (0.68-2.46) and 0.99 (0.70-1.40) in the OAI cohort and 1.38 (0.78-2.44) and 0.85 (0.54-1.32) in the CHECK cohort, respectively. In the longitudinal analysis, odds ratio with 95% confidence intervals for the incidence of RHOA were 1.03 (0.23-4.50) and 0.92 (0.46-1.85) in the OAI cohort and 0.61 (0.34-1.11) and 1.00 (0.69-1.44) in the CHECK cohort, respectively.

CONCLUSION

Our study found no clear association between smoking and the prevalence, incidence, or progression of RHOA or symptomatic hip OA, either at baseline or over a 4- to 5-year period.

Effects of device-performed and manual hip traction and vibration therapy in older adults with symptomatic hip osteoarthritis: A randomized single-blind controlled trial

BACKGROUND

Traction-and-vibration-therapy (TVT) relieves pain in participants with hip osteoarthritis. Hip TVT is usually performed manually by the physiotherapist.

OBJECTIVE

A medical device was developed to perform hip-TVT in order to investigate effects on hip disability, pain intensity, recovery of balance and functional mobility in older adults with hip osteoarthritis and also to reduce physiotherapists' workload and help standardize treatment of hip TVT.

METHODS

In a block-randomized 3-month controlled trial involving 28 older adult participants with symptomatic primary hip osteoarthritis (SPHOA), one group (n= 10) received device-performed TVT, one (n= 10) manual TVT, and one (n= 8) sham/placebo therapy. Hip disability (Harris Hip Score), pain intensity (visual-analog-scale), recovery of balance and gait (Functional Gait Assessment) and functional mobility (Timed-Up-and-Go-test) were assessed at baseline, after 3 weeks without intervention, and after 3-month intervention.

RESULTS

The Device TVT and Manual TVT groups exhibited superior outcomes compared to the Placebo group in terms of hip disability (p= 0.005 and p< 0.001, respectively), pain intensity (p= 0.002 and p< 0.001, respectively), and functional mobility (TUG) (p= 0.012 and p= 0.011, respectively). Furthermore, the recovery of balance and gait (FGA) showed a significant improvement in the Device TVT group when compared to the Placebo group (p= 0.043). The effect sizes ranged from 0.17 to 0.51, indicating moderate to large effects.

CONCLUSION

Device-performed-TVT is comparable to manual hip-TVT for reducing pain and improving mobility in older adults with SPHOA, and may be beneficial in terms of reducing physiotherapists' workload and better therapy standardization.

Strength Training vs. Aerobic Training for Managing Pain and Physical Function in Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis

(1) Background: Strength training (ST) and aerobic training (AT) are the most recommended interventions in patients with knee OA. These recommendations are supported by high-quality evidence, but it is still unknow whether one type of exercise is superior to the other. Thus, the aim was to investigate whether one type of exercise (ST or AT) is superior to the other for improving pain and physical function in patients with knee osteoarthritis. (2) Methods: A systematic review and meta-analysis was carried out following the PRISMA statement. The search strategy was conducted in PubMed, PEDro, Scopus, Web of Science and Cochrane Library databases. Randomized controlled trials comparing ST and AT on pain intensity and physical function in patients with knee osteoarthritis were included. Methodological quality and risk of bias were assessed with a PEDro scale and risk-of-bias tool, respectively. The certainty of evidence was evaluated using GRADE guidelines. (3) Results: Four studies (6 publications) were included. The qualitative and quantitative synthesis showed that ST produces no more improvement in pain intensity (SMD after intervention: 0.02; 95%CI: -0.15, 0.19; I2: 0%; three studies; 426 patients) and physical function (SMD after intervention: 0.07; 95%CI: -0.10, 0.24; I2: 0%; three studies; 426 patients) compared to AT in patients with knee osteoarthritis. The certainty of evidence was rated as very low. (4) Conclusions: Both type of exercises showed clinical benefits in people with knee osteoarthritis, but no differences between ST and AT were found.

Subgrouping individuals with migraine associated neck pain for targeted management

INTRODUCTION

Neck pain is one of the most common and burdensome symptoms associated with migraine. Many individuals with migraine and neck pain seek neck treatment, but evidence for such treatment is limited. Most studies have treated this population as a homogenous group, providing uniform cervical interventions that have yet to show clinically important effects. However, different neurophysiological and musculoskeletal mechanisms can underlie neck pain in migraine. Targeting treatment to specific underlying mechanisms may therefore be the key to improving treatment outcomes. Our research characterised neck pain mechanisms and identified subgroups based on cervical musculoskeletal function and cervical hypersensitivity. This suggests that specific management aimed towards addressing mechanisms relevant to each subgroup might be beneficial.

PURPOSE

This paper explains our research approach and findings to date. Potential management strategies for the identified subgroups and future research directions are discussed.

IMPLICATIONS

Clinicians should perform skilled physical examination with the aim of identifying if patterns of cervical musculoskeletal dysfunction and or hypersensitivity are present in the individual patient. There is currently no research into treatments differentiated for subgroups to address specific underlying mechanisms. It is possible that neck treatments addressing musculoskeletal impairments may be most beneficial for those subgroups where neck pain is primarily due to musculoskeletal dysfunction. Future research should define treatment aims and select specific subgroups for targeted management to determine which treatments are most effective for each subgroup.

TRIAL REGISTRATION

Not applicable.

Possible Duration of WISH-type Hip Brace Use: Prognostic Value of Timed Up and Go Test

Objectives:

The WISH-type S-form hip brace (WISH brace) has significantly improved hip function and functional mobility in patients with hip osteoarthritis (OA). However, most patients later undergo surgery. The main purpose of this study was to evaluate how long the orthosis can be effectively used by patients with hip OA, and to reveal the associated prognostic factors.

Methods:

This prospective study examined the survival curve of the equipment by using surgery as an endpoint and investigated how the duration of use affects patients. Harris Hip Score, muscle strength, and the Timed Up and Go test (TUG) were evaluated as prognostic factors.

Results:

By drawing the survival curves of 26 patients, approximately one third were expected to be still using the brace after 7 years. A rapid decrease in use was observed at around 1 year. A significant difference between patients with and without bracing at 1 year was found for the TUG result with the unaffected leg inside (ULI) at the start of bracing. A cut-off value of 9.5 s for the TUG with ULI significantly differentiated patients with and without bracing at 1 year, suggesting a possible predictor of brace survivorship in the early phase.

Conclusions:

The TUG with ULI with a cut-off value of 9.5 s, or at most 10 s, may be a possible predictor of persistence of brace use in the early phase.

The Effectiveness of Dry Needling in Patients with Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUND

Osteoarthritis is one of the most common degenerative joint diseases. The main symptoms of the osteoarthritis have been linked to the presence of myofascial trigger points in the soft tissues. Dry needing (DN) is the most investigated technique for the treatment of myofascial trigger points. Thus, the aim of this study was to evaluate the effectiveness of DN in pain and physical function in patients with osteoarthritis in the short-, medium- and long-term.

METHODS

PubMed, Cochrane Library, PEDro, Web of Science, and SCOPUS databases were searched in September 2022. Randomized controlled trials involving DN compared to non-pharmacological interventions, sham techniques or no additional treatment were selected. Quality of the studies was assessed with PEDro scale and risk of bias with Cochrane Collaboration tool. Meta-analyses were conducted using fixed or random effects models according to the Cochrane handbook for systematic reviews of interventions.

RESULTS

Seven studies were included in the meta-analysis involving 291 patients with osteoarthritis. The methodological quality of the included studies ranged from fair to high. DN showed significant improvements in pain intensity (SMD = -0.76; 95% CI: -1.24, -0.29; I²: 74%) and physical function (SMD = -0.98; 95% CI: -1.54, -0.42; I²: 75%) in the short-term. No differences were found in the medium- or long-term. The risk of bias, heterogeneity, and imprecision of the results downgraded the level of evidence to very low.

CONCLUSIONS

Very low-quality evidence suggests a positive effect of DN for reducing pain intensity and improving physical function in the short term in patients with osteoarthritis. Further investigation is needed to determine a medium- and long-term effects.

Comparison of dry needling and self-stretching in muscle extensibility, pain, stiffness, and physical function in hip osteoarthritis: A randomized controlled trial

BACKGROUND AND PURPOSE

Patients with hip osteoarthritis (OA) present myofascial trigger points in the hip muscles that may reduce muscle extensibility, provoke pain and stiffness, and decrease physical function. The purpose of the study was to compare the effects of dry needling (DN) intervention with a self-stretching protocol on muscle extensibility, pain, stiffness, and physical function in patients with hip OA.

MATERIALS AND METHODS

A single-blinded randomised controlled trial was designed. Thirty-eight participants with hip OA were randomly assigned to the DN group (n = 19) or the stretching group (n = 19). The DN group received three sessions of DN, and the stretching group followed a 3-week protocol. Hip muscle extensibility was the primary outcome and was measured using the Ely test, the modified Ober test, and the Active Knee Extension test. Pain, stiffness, and physical function were the secondary outcomes measured with the WOMAC questionnaire. The variables were assessed before and after treatment by blinded examiners.

RESULTS

DN was more effective than self-stretching for improving hip flexor and abductor muscles extensibility (p < 0.05). DN and self-stretching techniques improved hip extensor muscles extensibility, pain, stiffness, and physical function in patients with hip OA (<0.05). The DN group showed large effect sizes in all the variables (d > 0.8).

CONCLUSION

Three sessions of DN were more effective than three weeks of self-stretching to improve hip muscle extensibility in patients with hip OA. DN and self-stretching techniques decreased pain and stiffness and improved physical function in patients with hip OA.

Highlighting the Benefits of Rehabilitation Treatments in Hip Osteoarthritis

Background and objectives: Due to its frequency and possible complications, hip arthrosis or hip osteoarthritis (hip OA) has a high social impact, its advanced stages eventually leading to irreversible lesions involving major complications or surgery. In the early stages, conservative treatment plays a key role in the prophylaxis of complications and in slowing down the degenerative process. The association between an appropriate drug therapy (DT) and a rehabilitation treatment (RT)—including individualized physical therapy (PT) and adapted occupational therapy (OT)—provides good results. Our objective was to highlight the benefits of associating RT with DT in patients with hip OA. Materials and Methods: An observational follow-up study was conducted between 2018−2021, which included 100 patients with hip OA divided into two groups: the study group—group A (50 subjects who complied with RT) and the control group—group B (who did not comply with RT). To evaluate them, the evolution of the Lequesne hip index (LHI), Tinetti test (TT) and the hip joint mobility: flexion (FH) and abduction (AH) were monitored before the beginning of the study (T0) and after one-year (T1) for each patient. The mean values of the parameters, the standard deviations, the frequency intervals, as well as the tests of statistical significance were calculated using the Student method (t-test) and χ2, ANOVA (Bonferroni) being used to compare the means. Results: Compared to the evolution of group B, improvements were observed in group A, as follows: in LHI group A (p = 0.023) vs. group B (p = 0.650); in TT group A (p = 0.011) vs. group B (p < 0.001); in FH group A (p = 0.001) vs. group B (p = 0.025); in AH group A (p = 0.001) vs. group B (p < 0.001). BMI changes were non-significant in both groups A (p = 0.223) and B (p = 0.513). Evaluating group A, the most significant improvements of the studied parameters were observed in the age group 41−50 years. Conclusions: The study reveals the benefits of combining RT with DT in patients with especially early-stage hip OA, aged up to 50 years old.

Global, regional, and national burdens of hip osteoarthritis from 1990 to 2019: estimates from the 2019 Global Burden of Disease Study

BACKGROUND

Hip osteoarthritis is a common disabling condition of the hip joint and is associated with a substantial health burden. We assessed the epidemiological patterns of hip osteoarthritis from 1990 to 2019 by sex, age, and socio-demographic index (SDI).

METHODS

Age-standardized rates (ASRs) were obtained for the incidence and disability-adjusted life years (DALYs) of hip osteoarthritis from 1990 to 2019 for 21 regions, encompassing a total of 204 countries and territories. The estimated annual percentage changes (EAPCs) of ASRs were calculated to evaluate the trends in the incidence and DALYs of hip osteoarthritis over these 30 years.

RESULTS

Globally, from 1990 to 2019, the age-standardized incidence rate (ASIR) of hip osteoarthritis increased from 17.02 per 100,000 persons to 18.70 per 100,000 persons, with an upward trend in the EAPC of 0.32 (0.29-0.34), whereas the age-standardized DALY rate increased from 11.54 per 100,000 persons to 12.57 per 100,000 persons, with an EAPC of 0.29 (0.27-0.32). In 2019, the EAPCs of the ASIR and age-standardized DALY rate of hip osteoarthritis were positively associated with the SDI of hip osteoarthritis. In 1990 and 2019, the incidence of hip osteoarthritis was unimodally distributed across different age groups, with a peak incidence in the 60-64-year-old age group, whereas the DALYs increased with age.

CONCLUSIONS

The incidence and DALYs of hip osteoarthritis have been increasing globally. The EAPCs of the ASIR and age-standardized DALY rate were particularly significant in developed regions and varied across nations and regions, indicating the urgent need for governments and medical institutions to increase the awareness regarding risk factors, consequences of hip osteoarthritis.

Efficacy of Exercise-Based Rehabilitation Programs for Improving Muscle Function and Size in People with Hip Osteoarthritis: A Systematic Review with Meta-Analysis

Objective: To determine the effect of exercise-based rehabilitation programs on hip and knee muscle function and size in people with hip osteoarthritis. Methods: Seven databases were systematically searched in order to identify studies that assessed muscle function (strength or power) and size in people with hip osteoarthritis after exercise-based rehabilitation programs. Studies were screened for eligibility and assessed for quality of evidence using the GRADE approach. Data were pooled, and meta-analyses was completed on 7 of the 11 included studies. Results: Six studies reported hip and/or knee function outcomes, and two reported muscle volumes that could be included in meta-analyses. Meta-analyses were conducted for four strength measures (hip abduction, hip extension, hip flexion, and knee extension) and muscle size (quadriceps femoris volume). For hip abduction, there was a low certainty of evidence with a small important effect (effect size = 0.28, 95% CI = 0.01, 0.54) favouring high-intensity resistance interventions compared to control. There were no other comparisons or overall meta-analyses that identified benefits for hip or knee muscle function or size. Conclusion: High-intensity resistance programs may increase hip abduction strength slightly when compared with a control group. No differences were identified in muscle function or size when comparing a high versus a low intensity group. It is unclear whether strength improvements identified in this review are associated with hypertrophy or other neuromuscular factors.

Appropriateness of hip osteoarthritis management in clinical practice compared with the American Academy of Orthopaedic Surgeons (AAOS) criteria

Purpose

The American Academy of Orthopaedic Surgeons (AAOS) developed the appropriate use criteria (AUC) for the management of hip osteoarthritis (OA) to guide surgeons in making decisions based on the best available evidence. This study aimed to assess the applicability of the AUC by comparing the actual treatment provided at our institution with the AUC recommendations.

Methods

A retrospective review of 115 patients who were diagnosed and treated for hip OA at our institution between December 2017 and December 2019 was performed. Data were collected and entered into the AUC application to determine the rate of appropriateness of the provided treatment according to the AUC recommendations. Then, the actual provided treatments were compared with the AUC recommendations to determine the agreement between the two.

Results

There were 115 patients, with a mean age of 50.08 years (range, 30–80 years). The most frequent patient characteristics were middle age (40–65 years) with function-limiting pain at moderate to long distances, minimal hip OA on X-ray examination, mild range of motion limitation, and presence of modifiable risk factors for negative outcomes. The overall rate of appropriateness and in agreement with the AUC recommendations was 100% for conservative treatments and 80.1% for surgical treatments.

Conclusions

This study shows that the majority of the hip OA treatments provided at our institution were appropriate and in agreement with the AUC recommendations. Furthermore, the AUC can be easily accessed through a free web application using a computer or smartphone to obtain the recommended treatment for any patient with hip OA.

Could the Evaluation of Muscle Strength Imbalances Be Used as a Predictor of Total Hip Arthroplasty?

Loss of muscle strength characterizes the period before total hip arthroplasty (THA). Little is known about whether muscle strength imbalances caused by muscle strength decline could be considered another clinical predictor for THA. This study aimed to determine whether muscle imbalances may be used as a clinical predictor for THA surgery. Thirty-six participants were enrolled in the study. Eighteen patients had THA (THA group), while 18 were healthy elders (CON group). Ipsilateral (H/Q) and bilateral (% Def) muscle imbalances of the knee were assessed. THA patients showed impairment of the extensors on the affected extremity compared to those unaffected. A comparison between the groups proved there were weakened flexors in the THA group on both extremities. A comparison of the imbalances revealed a significant bilateral imbalance of the extensors and ipsilateral imbalance of both extremities in the THA group. We computed two logistic regressions using bilateral and ipsilateral imbalance as the predictors of THA surgery. We found that bilateral extensor imbalance may be used as a predictor for THA (Nagelkerke R² = 0.22). A decrease of the bilateral extensors imbalance by 8% decreases the probability of THA by 8%. The most interesting finding is that the evaluation of the bilateral extensor imbalance may be used as another clinical predictor for THA.

The impact of mobilization on hip osteoarthritis

BACKGROUND

Osteoarthritis is one of the most common joint disorders. It causes pain, stiffness and a decreased range of motion which have a significant impact on daily activities and gait, consequently leading to disability.

OBJECTIVE

The aim of this study is to compare hip mobilization with non-weight bearing exercises.

METHODS

A total of 57 females aged between 55-65 were divided into 2 groups. In the control group non-weight bearing exercises were conducted, whereas the research group received hip mobilization.

RESULTS

The Lequesne index significantly improved in the research group as compared with the control group. Hip function improved both in the control and research groups. Active hip extension increased by 0.54, while active abduction rose by 2.14 after non-weight bearing exercises. In the control group after mobilization both passive and active hip extension increased significantly by 3.53, active abduction by 5 and passive by 4.41, while active and passive internal rotation by 3.82 and 4.56, respectively. In both groups pain decreased.

CONCLUSIONS

Mobilization increases hip range of motion, decreases pain and improves hip function more than non-weight bearing exercises.

Effects of the WISH-type S-form Hip Brace on Muscle Strength in Patients with Osteoarthritis of the Hip: A Short-term Longitudinal Study

Background

The WISH-type S-form hip brace (WISH brace) has been shown to significantly improve hip function, functional mobility, and gait biomechanics in patients with hip osteoarthritis. The aim of the current study was to evaluate the effects of the WISH brace over time on the strength of muscles around the hip and knee joints.

Methods

A prospective short-term longitudinal study with a 6-month follow-up was conducted. Muscle strengths were measured using a handheld dynamometer.

Results

The muscle strengths of hip flexion, hip abduction, and knee extension were lower in the affected limb than in the unaffected limb, whereas hip adduction muscle strength was reduced to the same extent in both the affected and unaffected limbs. This short-term longitudinal study revealed that only hip adduction and knee extension exhibited significant interaction between legs and time when measurement was performed without the WISH brace. Furthermore, the inherent hip abduction muscle strength of the affected limb was improved by the WISH brace so that the strength became the same as the unaffected limb.

Conclusions

Improvement in abduction muscle strength of the affected limb by daily walking exercise with the WISH brace, which occurred with little interaction with the unaffected limb, may improve hip function.

Is Heel Height Associated with Pain Exacerbations in Hip Osteoarthritis Patients?-Results from a Case-Crossover Study

The etiology of osteoarthritis (OA) pain exacerbations is not well understood. The purpose of this study is to evaluate the association of heel height and duration of wearing shoes with higher heels with pain exacerbations in people with hip OA. Eligible participants with symptomatic hip OA were instructed to complete online questionnaires every 10 days over a 90-day follow-up period. They were required to complete the questionnaire whenever they were experiencing hip pain exacerbation. Of 252 participants recruited, 137 (54.4%) contributed both case and control period data, and were included in the analysis. Wearing shoes with a heel height ≥ 2.5 cm during the past 24 h was associated with lower odds of pain exacerbations (OR: 0.54, 95% CI: 0.30 to 0.99). A longer duration (>6 h) of wearing shoes with heel height ≥ 2.5 cm was also associated with a lower risk of hip pain exacerbations (p for linear trend = 0.003). Wearing shoes with heel height ≥ 2.5 cm and longer duration in the past 24 h may be protective against hip pain exacerbations in people with symptomatic hip OA. Given the observational study nature, it would be prudent for this to be replicated in an independent data set.

Can the Pain Attitudes and Beliefs Scales be adapted for use in the context of osteoarthritis with general practitioners and physiotherapists?

BACKGROUND

Conservative, first-line treatments (exercise, education and weight-loss if appropriate) for hip and knee joint osteoarthritis are underused despite the known benefits. Clinicians' beliefs can affect the advice and education given to patients, in turn, this can influence the uptake of treatment. In New Zealand, most conservative OA management is prescribed by general practitioners (GPs; primary care physicians) and physiotherapists. Few questionnaires have been designed to measure GPs' and physiotherapists' osteoarthritis-related health, illness and treatment beliefs. This study aimed to identify if a questionnaire about low back pain beliefs, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), can be adapted to assess GP and physiotherapists' beliefs about osteoarthritis.

METHODS

This study used a cross-sectional observational design. Data were collected anonymously from GPs and physiotherapists using an online survey. The survey included a study-specific demographic and occupational characteristics questionnaire and the PABS-PT questionnaire adapted for osteoarthritis. All data were analysed using descriptive statistics, and the PABS-PT data underwent principal factor analysis.

RESULTS

In total, 295 clinicians (87 GPs, 208 physiotherapists) participated in this study. The principal factor analysis identified two factors or subscales (categorised as biomedical and behavioural), with a Cronbach's alpha of 0.84 and 0.44, respectively.

CONCLUSIONS

The biomedical subscale of the PABS-PT appears appropriate for adaptation for use in the context of osteoarthritis, but the low internal consistency of the behavioural subscale suggests this subscale is not currently suitable. Future research should consider the inclusion of additional items to the behavioural subscale to improve internal consistency or look to develop a new, osteoarthritis-specific questionnaire.

TRIAL REGISTRATION

This trial was part of the primary author's PhD, which began in 2012 and therefore this study was not registered.

Plantar pressure distribution during standing in women with end-stage hip osteoarthritis

BACKGROUND

Patients with hip osteoarthritis (OA) experience abnormal movement patterns and reduced loading of the affected leg. The plantar contacts the ground and receives force from the ground. Plantar pressure distribution may differ in patients with hip OA compared to healthy adults and may influence physical functioning in these patients.

RESEARCH QUESTION

We investigated whether plantar pressure distribution during standing differed between patients with hip OA and healthy adults. We also analyzed the relationship between plantar pressure distribution and walking ability and the factors affecting plantar pressure distribution.

METHODS

Maximum plantar pressure distribution during standing for 20 seconds was investigated in patients with hip OA (n = 62; OA group) and in healthy adults (n = 53; Control group). Statistical comparisons between these groups were made using Fisher's exact test and residual analysis. In the OA group, leg length discrepancy, range of hip extension, leg loading, knee extensor strength, and 10 m walking time were assessed; multiple linear regression and logistic regression analyses were used to examine the relationships between these factors and maximum plantar pressure distribution.

RESULTS

Maximum plantar pressure distribution was different between the OA and control groups. In the OA group, maximum plantar pressure distribution was one of the significant predictors of 10 m walking time. Additionally, leg length discrepancy was a significant predictor of maximum plantar pressure distribution in this group.

SIGNIFICANCE

During standing, the proportion of patients for whom the maximum plantar pressure region was the heel tended to be lower in the group with hip OA compared to the healthy adults. Plantar pressure distribution may have an importance for evaluating walking ability in patients with hip OA. Correcting leg length discrepancy and loading under the heel could adjust plantar pressure distribution in patients with hip OA.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain

Neck pain, whether from a traumatic event such as a motor vehicle crash or of a non-traumatic nature, is a leading cause of worldwide disability. This narrative review evaluated the evidence from systematic reviews, recent randomised controlled trials, clinical practice guidelines, and other relevant studies for the effects of rehabilitation approaches for chronic neck pain. Rehabilitation was defined as the aim to restore a person to health or normal life through training and therapy and as such, passive interventions applied in isolation were not considered. The results of this review found that the strongest treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence. The review also provided suggestions for promising future directions for clinical practice and research.

Principles of diagnostic sonography in iliopsoas tendon pathology: A case report

This article describes the diagnostic value of musculoskeletal sonography in the management of tendon pathology and outlines a clinical example of its scope of utilization. Herein we describe the case of a 65-year-old man who sought rehabilitation services for left groin pain following a period of intense trekking and uphill walking. He presented with left hip flexor weakness and local tenderness over the left iliopsoas tendon with negative findings on neurological evaluation. Additionally, he presented with left hip capsule and hip flexor tightness with left gluteus maximus and gluteus medius weakness. The left hip capsule tightness was predominantly in the posterior fibres, with restriction of hip internal rotation. The clinical picture overall was suggestive of the presence of risk parameters for iliopsoas tendinopathy. Plain radiographs of the hip revealed mild degenerative changes with a mild pincer impingement. While his clinical and radiological picture was suggestive of degenerative and soft tissue pathology of the hip, a real-time sonographic study was useful in the quantitative confirmation of a partial tear of the left iliopsoas tendon. Additionally, a repeat sonographic study performed four weeks later, revealed a healing iliopsoas tendon seen as a decrease in the width of the hypoechoic presentation of the tear. To summarize, the value of musculoskeletal sonography as a diagnostic tool as well as the assessment of the progression of tendon healing is discussed. Sonography is safe, noninvasive, and does not use ionizing radiation. It is steadily gaining popularity in the diagnosis of tendon lesions.

Hip Osteoarthritis: A Primer

The objective of this article is to deliver a concise up-to-date review on hip osteoarthritis. We describe the epidemiology (disease distribution), etiologies (associated risk factors), symptoms, diagnosis and classification, and treatment options for hip osteoarthritis. A quiz serves to assist readers in their understanding of the presented material.

Effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis. A systematic review

OBJECTIVE

The purpose of this review was to identify the effects of non-pharmacological conservative treatment on pain, range of motion and physical function in patients with mild to moderate hip osteoarthritis.

DESIGN

A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

SETTING

We searched MEDLINE, PEDro, Scopus and the Cochrane Library databases for randomized controlled trials related to non-pharmacological conservative treatments for hip osteoarthritis with the following keywords: "hip osteoarthritis," "therapeutics," "physical therapy modalities," and "combined physical therapy". The PEDro scale was used for methodological quality assessment and the Oxford Centre of Evidence-Based Medicine scale was used to assess the level of evidence. Outcomes measures related to pain, hip range of motion and physical function were extracted from these studies.

RESULTS

Twelve studies met the inclusion criteria. Most of the studies showed high level of evidence and only two showed low level of evidence. High quality of evidence showed that manual therapy and exercise therapy are effective in improving pain, hip range of motion and physical function. However, high quality studies based on combined therapies showed controversy in their effects on pain, hip range of motion and physical function.

CONCLUSIONS

Exercise therapy and manual therapy and its combination with patient education provides benefits in pain and improvement in physical function. The effects of combined therapies remain unclear. Further investigation is necessary to improve the knowledge about the effects of non-pharmacological conservative treatments on pain, hip range of motion and physical function.

A mixed methods exploration of physiotherapist's approaches to analgesic use among patients with hip osteoarthritis

OBJECTIVE

To explore how physiotherapists currently address analgesic use among patients with hip osteoarthritis, and their beliefs about the acceptability of prescribing for these patients.

METHODS

A cross-sectional questionnaire was mailed to 3126 UK-based physiotherapists. Approaches to analgesic use among patients with hip osteoarthritis were explored using a case vignette. Semi-structured telephone interviews were undertaken with 21 questionnaire responders and analysed thematically.

SETTING

UK.

PARTICIPANTS

Physiotherapists who had treated a patient with hip osteoarthritis in the previous 6 months.

RESULTS

Questionnaire response: 53% (n=1646). One thousand one hundred forty eight physiotherapists reported treating a patient with hip osteoarthritis in the last 6 months (applicable responses), of whom nine (1%) were non-medical prescribers. Nearly all physiotherapists (98%) reported that they would address analgesic use for the patient with hip osteoarthritis, most commonly by signposting them to their GP (83%). Fifty six percent would discuss optimal use of current medication, and 33%, would discuss use of over-the-counter medications. Interviews revealed that variations in physiotherapists' approaches to analgesic use were influenced by personal confidence, patient safety concerns, and their perceived professional remit. Whilst many recognised the benefits of analgesia prescribing for both patients and GP workload, additional responsibility for patient safety was a perceived barrier.

CONCLUSIONS

How physiotherapists currently address analgesic use with patients with hip osteoarthritis is variable. Although the potential benefits of independent prescribing were recognised, not all physiotherapist want the additional responsibility. Further guidance supporting optimisation of analgesic use among patients with hip OA may help better align care with best practice guidelines and reduce GP referrals.

Associations between type and severity of hip pathology with pre-operative patient reported outcome measures

BACKGROUND

The relationship between hip pathology and patient reported outcome responses following hip surgery has been previously investigated. No studies have investigated the relationship between pathology and patient reported outcome responses prior to surgery.

OBJECTIVES

(1) Determine the prevalence of chondral and labral pathology identified during hip arthroscopy. (2) Determine the association between intra-articular findings and patient reported outcome scores in a pre-arthroscopy hip pain population.

METHODS

Sixty-seven (22 female) participants scheduled for hip arthroscopy after clinical examination and radiographic assessment completed a series of patient reported outcomes (Hip Disability and Osteoarthritis Outcome Score; International Hip Outcome Tool; Pain on Activity; Visual Analogue Scale). Pathology discovered/addressed during arthroscopy was classified. Univariable and multivariable linear regression models were used to assess the relationship between demographics, pathology and patient reported outcome responses.

RESULTS

Ninety-one percent of participants had labral pathology; 76% had acetabular chondropathy and 31% had femoral head chondropathy. Across the ten patient reported outcome subscales, severe femoral head chondropathy and large labral tears had the greatest number of significant associations with patient reported outcome scores. The strongest association was with 'Hip Disability and Osteoarthritis Outcome Score symptoms and stiffness' subscale, where severe femoral head chondropathy explained 22% of variability in symptoms and stiffness, when adjusted for Body Mass Index and presence of pincer morphology (p=0.002).

CONCLUSION

Severe femoral head chondropathy and large labral tears along with a high prevalence of labral pathology and acetabular chondropathy were relatively common findings during hip arthroscopy. Severe femoral head chondropathy and large labral tears are most associated with patient reported outcome's, however, at best only explain 22% of the variability.

Targeted gluteal exercise versus sham exercise on self-reported physical function for people with hip osteoarthritis (the GHOst trial - Gluteal exercise for Hip Osteoarthritis): a protocol for a randomised clinical trial

BACKGROUND

Clinical practice guidelines recommend exercise as the first line of management for hip osteoarthritis, yet high-quality evidence from Cochrane reviews suggest only slight benefits for pain and physical function; and no benefit on quality of life (low-quality evidence). However, the scope of physical impairments identified in people with hip osteoarthritis may not have been adequately addressed with targeted rehabilitation options in previous randomised controlled trials (RCTs). Potential targeted options include gait retraining to address spatio-temporal impairments in walking; motor control training to address deep gluteal (gluteus minimus) dysfunction; and progressive, high-intensity resistance exercises to address atrophy of the gluteal muscles. The aim of this study is to investigate the effect of a targeted gluteal rehabilitation programme that incorporates gait retraining, motor control and progressive, high-intensity resistance-strength training, to address physical activity levels and self-reported physical function in people with mild to moderate disability from hip osteoarthritis.

METHODS

Ninety people diagnosed with mild to moderately disabling hip osteoarthritis will be recruited and randomised to receive one of two exercise programmes (sham or GHOst programme). Interventions will be 12 weeks in duration, with weekly, supervised physiotherapy sessions, and daily home exercises. Both groups will receive standardised education. Outcomes will be assessed at baseline, 7 weeks, 13 weeks (primary time-point) and 25 weeks. The primary outcome will be self-reported physical function measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes include physical activity measured with a tri-axial accelerometer, physical function tests, self-reported physical activity, isometric hip-muscle strength tests, hip-related patient-reported outcome measures, pain thoughts and depressive symptoms, quality of life, global rating of change, gluteal-muscle activity (electromyography (EMG)) and gluteal-muscle size and adiposity (magnetic resonance imaging (MRI)).

DISCUSSION

This will be the first study to compare a targeted gluteal rehabilitation programme to a sham exercise programme. The targeted GHOst programme includes exercises designed to address gait impairments as well as gluteal-muscle atrophy and dysfunction.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ID: ACTRN12617000970347 . Registered retrospectively on 5 July 2017. Protocol version 3.0.

How Do Physical Therapists in the United Kingdom Manage Patients With Hip Osteoarthritis? Results of a Cross-Sectional Survey

BACKGROUND

Hip osteoarthritis (OA) is common, painful, and disabling. Physical therapists have an important role in managing patients with hip OA; however, little is known about their current management approach and whether it aligns with clinical guideline recommendations.

OBJECTIVE

The objective of this study is to describe United Kingdom (UK) physical therapists' current management of patients with hip OA and to determine whether it aligns with clinical guidelines.

DESIGN

The design is a cross-section questionnaire.

METHODS

A questionnaire was mailed to 3126 physical therapists in the UK that explored physical therapists' self-reported management of a patient with hip OA using a case vignette and clinical management questions.

RESULTS

The response rate was 52.7% (n = 1646). In total, 1148 (69.7%) physical therapists had treated a patient with hip OA in the last 6 months and were included in the analyses. A treatment package was commonly provided incorporating advice, exercise (strength training 95.9%; general physical activity 85.4%), and other nonpharmacological modalities, predominantly manual therapy (69.6%), and gait retraining (66.4%). There were some differences in reported management between physical therapists based in the National Health Service (NHS) and non-NHS-based physical therapists, including fewer treatment sessions being provided by NHS-based therapists.

LIMITATIONS

Limitations include the potential for nonresponder bias and, in clinical practice, physical therapists may manage patients with hip OA differently.

CONCLUSION

UK-based physical therapists commonly provide a package of care for patients with hip OA that is broadly in line with current clinical guidelines, including advice, exercise, and other nonpharmacological treatments. There were some differences in clinical practice between NHS and non-NHS-based physical therapists, but whether these differences impact on clinical outcomes remains unknown.

Views of general practitioners toward physiotherapy management of osteoarthritis-a qualitative study

Background: Osteoarthritis (OA) is a major cause of pain and physical disability, and general practitioners (GPs) are usually the first point of contact for patients. Physiotherapy has been shown as effective in the management of lower-limb OA. The aim was to explore the beliefs of GPs on the physiotherapy management of lower-limb OA in primary care. Methods: This is a qualitative study evaluating GP views about physiotherapy in Sheffield, South Yorkshire, UK. Participating GPs were recruited by systematic sampling, and invitation was given to GPs in 10 practices in the four localities in Sheffield. Semistructured interviews were completed and framework analysis was used to analyze the data. Results: Eight GPs were interviewed and six themes emerged from analysis of the data: perspective on OA, management strategy, views on patients, views on physiotherapy, working collaboratively, and suggestions for service improvements. GPs had a positive impression and knowledge of physiotherapy, but lacked understanding of the processes involved in treatment and limited awareness of clinical guidelines regarding the management of OA. Improvements in communication and collaborative working were critical issues suggested by the participants. Conclusion: This study found that GPs who were interviewed had a limited understanding on the role of physiotherapists and of clinical guidelines. Interprofessional communication was not as good as it should have been. A reconfiguration of the Sheffield musculoskeletal pathway may help achieve more effective collaborative working and a better outcome for patients.

Impact of Rehabilitation on Health Related Quality of Life in Patients with Hip Osteoarthritis

Hip osteoarthritis (OA) is a degenerative, progressive musculoskeletal system disease in adult individuals. Both genders demonstrate a similar prevalence at 11.5% for men and 11.6% for women. During the initial stage of hip OA, conservative treatments may significantly decrease pain, provide functional improvement and enhance health related quality of life (HRQoL).

The aims of the study were to evaluate the quality of life of patients with hip osteoarthritis and to estimate the impact of a comprehensive rehabilitation intervention on their HRQoL.

This was a prospective, observational study of 50 consecutive patients with hip osteoarthritis who were referred to an outpatient rehabilitation intervention. To assess their HRQoL before and after rehabilitation, we used the SF-36 and the Lequesne index for hip OA.

The mean age was 61.7±8.3 years, and 56% of the patients were women. After rehabilitation, the SF-36 RE and RP subscales and the Lequesne pain subscale showed the most significant improvement, although all of the SF-36 and Lequesne domains showed significant improvement. Before rehabilitation, the Lequesne ADL subscale was most correlated with the SF-36 PF subscale (rho=−0.908). After rehabilitation, the total Lequesne score was highly correlated with the SF-36 PF subscale (rho=−0.895). Age, education and the duration of disease were significantly correlated with all of the Lequesne subscales before and after rehabilitation.

This study showed that patients with hip osteoarthritis had a substantially low HRQoL, but all health dimensions showed statistically significant improvements after outpatient rehabilitation intervention.

Hip Osteoarthritis: Etiopathogenesis and Implications for Management

Highly prevalent among the elderly, hip osteoarthritis (OA) carries a heavy burden of disease. Guidelines for the management of hip OA are often extrapolated from knee OA research, despite clear differences in the etiopathogenesis and response to treatments of OA at these sites. We propose that hip OA requires specific attention separate from other OA phenotypes. Our understanding of the etiopathogenesis of hip OA has seen significant advance over the last 15 years, since Ganz and colleagues proposed femoroacetabular impingement (FAI) as an important etiological factor. This narrative review summarizes the current understanding of the etiopathogenesis of hip OA and identifies areas requiring further research. Therapeutic approaches for hip OA are considered in light of the condition’s etiopathogenesis. The evidence for currently adopted management strategies is considered, especially those approaches that may have disease-modifying potential. We propose that shifting the focus of hip OA research and public health intervention to primary prevention and early detection may greatly improve the current management paradigm.

Effects of sulfur bath on hip osteoarthritis: a randomized, controlled, single-blind, follow-up trial: a pilot study

The effects of balneotherapy were evaluated in patients with osteoarthritis of the hip. This randomized, controlled, investigator-blinded study enrolled outpatients with hip osteoarthritis according to ACR criteria. In addition to home exercise therapy, one patient group received balneotherapy for 3 weeks on 15 occasions. The mineral water used in this study is one of the mineral waters with the highest sulfide ion content (13.2 mg/L) in Hungary. The control group received exercise therapy alone. The WOMAC Likert 3.1 index and the EQ-5D quality of life self-administered questionnaire were completed three times during the study: prior to first treatment, at the end of the 3-week treatment course, and 12 weeks later. The main endpoint was achievement of Minimal Clinically Important Improvement (MCII) at 12 weeks, defined as ≥7.9 points in a normalized WOMAC function score. The intention to treat analysis included 20 controls and 21 balneotherapy patients. At 12 weeks, 17 (81 %) balneotherapy group patients had Minimal Clinically Important Improvement and 6 (30 %) of controls (p = 0.001). Comparing the results of the two groups at the end of treatment, there was a significant difference in the WOMAC stiffness score only, whereas after 12 weeks, the WOMAC pain, stiffness, function, and total scores also showed a significant difference in favor of the balneotherapy group. The difference between the two groups was significant after 12 weeks in point of EQVAS score, too. The results of our study suggest that the combination of balneotherapy and exercise therapy achieves more sustained improvement of joint function and decreases in pain than exercise therapy alone.

Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis: Synthesis of the Literature Using Behavior Change Theory

Exercise is recommended for hip and knee osteoarthritis (OA). Patient initiation of, and adherence to, exercise is key to the success of managing symptoms. This study aimed to (1) identify modifiable barriers and facilitators to participation in intentional exercise in hip and/or knee OA, and (2) synthesize findings using behavior change theory. A scoping review with systematic searches was conducted through March 2015. Two reviewers screened studies for eligibility. Barriers and facilitators were extracted and synthesized according to the Theoretical Domains Framework (TDF) by two independent reviewers. Twenty-three studies (total of 4633 participants) were included. The greatest number of unique barriers and facilitators mapped to the Environmental Context and Resources domain. Many barriers were related to Beliefs about Consequences and Beliefs about Capabilities, whereas many facilitators were related to Reinforcement. Clinicians should take a proactive role in facilitating exercise uptake and adherence, rather than trusting patients to independently overcome barriers to exercise. Strategies that may be useful include a personalized approach to exercise prescription, considering environmental context and available resources, personalized education about beneficial consequences of exercise and reassurance about exercise capability, and use of reinforcement strategies. Future research should investigate the effectiveness of behavior change interventions that specifically target these factors.

Exercise in osteoarthritis: moving from prescription to adherence

Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.