The use of conventional and complementary treatments for knee osteoarthritis in the community

Co-development and testing of an extended community pharmacy model of service delivery for managing osteoarthritis: protocol for a sequential, multi-methods study (PharmOA)

BACKGROUND

Osteoarthritis is a common, painful and disabling long-term condition. Delivery of high-quality guideline-informed osteoarthritis care that successfully promotes and maintains supported self-management is imperative. However, osteoarthritis care remains inconsistent, including under use of core non-pharmacological approaches of education, exercise and weight loss. Community pharmacies are an accessible healthcare provider. United Kingdom government initiatives are promoting their involvement in a range of long-term conditions, including musculoskeletal conditions. It is not known what an enhanced community pharmacy role for osteoarthritis care should include, what support is needed to deliver such a role, and whether it would be feasible and acceptable to community pharmacy teams. In this (PharmOA) study, we aim to address these gaps, and co-design and test an evidence-based extended community pharmacy model of service delivery for managing osteoarthritis.

METHODS

Informed by the Theoretical Domains Framework, Normalisation Process Theory, and the Medical Research Council (MRC) framework for developing complex interventions, we will undertake a multi-methods study involving five phases: 1. Systematic review to summarise currently available evidence on community pharmacy roles in supporting adults with osteoarthritis and other chronic (non-cancer) pain. 2. Cross-sectional surveys and one-to-one qualitative interviews with patients, healthcare professionals and pharmacy staff to explore experiences of current, and potential extended community pharmacy roles, in delivering osteoarthritis care. 3. Stakeholder co-design to: a) agree on the extended role of community pharmacies in osteoarthritis care; b) develop a model of osteoarthritis care within which the extended roles could be delivered (PharmOA model of service delivery); and c) refine existing tools to support community pharmacies to deliver extended osteoarthritis care roles (PharmOA tools). 4. Feasibility study to explore the acceptability and feasibility of the PharmOA model of service delivery and PharmOA tools to community pharmacy teams. 5. Final stakeholder workshop to: a) finalise the PharmOA model of service delivery and PharmOA tools, and b) if applicable, prioritise recommendations for its wider future implementation.

DISCUSSION

This novel study paves the way to improving access to and availability of high-quality guideline-informed, consistent care for people with osteoarthritis from within community pharmacies.

What affects the implementation of lifestyle interventions in patients with osteoarthritis? A multidisciplinary focus group study among healthcare professionals

PURPOSE

To identify factors affecting the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA) from the perspective of primary and secondary healthcare professionals (HCPs) in the Dutch healthcare system.

METHODS

Multidisciplinary focus groups were composed. Data analysis was performed following thematic analysis. The Tailored Implementation for Chronic Diseases checklist was used to guide data analysis.

RESULTS

Four focus groups meetings were conducted with 38 participating HCPs (general practitioners (or in-training), orthopedic surgeons (or in-training), physiotherapists, dieticians, a general practice assistant, lifestyle counselors, and nurse practitioners). Influencing factors were grouped into nine themes: (1) intervention factors; (2) individual HCP factors; (3) patient factors; (4) professional interactions; (5) incentives and resources; (6) capacity for organizational change; (7) social, political and legal factors; (8) patient and HCP interactions; and (9) disease factors.

CONCLUSIONS

A wide variety of factors affecting the implementation of LIs was identified in this study, where the importance of effective interdisciplinary collaboration was emphasized by the multidisciplinary group of participants. This thorough analysis of influencing factors is an important first step toward improved implementation of LIs within OA care. Further research is required to identify the most significant targets for change in daily practice.Implications for RehabilitationThe implementation of lifestyle interventions (LIs) by healthcare professionals (HCPs) in patients with hip and/or knee osteoarthritis (OA) is affected by both individual and environmental factors.The influencing factors identified in this study can support the development of interventions aimed at improving the implementation of LIs in OA care.A multilevel approach is required when developing interventions to improve the implementation of LIs in OA care.Continued efforts of both primary and secondary HCPs and policymakers are needed in order to promote the use of LIs within OA care.

Effectiveness of interferential current therapy in patients with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials

We conducted a systematic review and meta-analysis to assess the effectiveness of interferential current therapy (IFC) in patients with knee osteoarthritis. We searched PubMed, Cochrane Library, Embase, ClinicalKey, and Scopus for relevant studies from their date of launch to March 22, 2022. We included randomized controlled trials (RCTs) in which IFC was applied to knee osteoarthritis patients and the outcomes of pain scores or functional scales were assessed. Ten RCTs with 493 patients met the inclusion criteria. Nine RCTs were included in the meta-analysis. The IFC groups exhibited significant improvements relative to the control groups for short-term pain scores (SMD = - 0.64, 95% CI - 1.04 to - 0.25, P = 0.001), long-term pain scores (SMD = - 0.36, 95% CI - 0.60 to - 0.11, P = 0.005), and short-term Western Ontario and McMaster Universities Osteoarthritis Index scores (SMD = - 0.39, 95% CI - 0.77 to - 0.02, P = 0.04). All included studies did not observe any obvious adverse effects of IFC. IFC can be recommended as a treatment for knee osteoarthritis because it improves short- and long-term pain and short-term function. However, large-scale and high-quality RCTs with longer follow-up are required to establish an appropriate standardized treatment.

Mindset is associated with future physical activity and management strategies in individuals with knee osteoarthritis

BACKGROUND

Despite the benefits of physical activity for individuals with knee osteoarthritis (KOA), physical activity levels are low in this population.

OBJECTIVES

We conducted a repeated cross-sectional study to compare mindset about physical activity among individuals with and without KOA and to investigate whether mindset relates to physical activity.

METHODS

Participants with (n = 150) and without (n = 152) KOA completed an online survey at enrollment (T1). Participants with KOA repeated the survey 3 weeks later (T2; n = 62). The mindset questionnaire, scored from 1 to 4, assessed the extent to which individuals associate the process of exercising with less appeal-focused qualities (e.g., boring, painful, isolating, and depriving) versus appeal-focused (e.g., fun, pleasurable, social, and indulgent). Using linear regression, we examined the relationship between mindset and having KOA, and, in the subgroup of KOA participants, the relationship between mindset at T1 and self-reported physical activity at T2. We also compared mindset between people who use medication for management and those who use exercise.

RESULTS

Within the KOA group, a more appeal-focused mindset was associated with higher future physical activity (β=38.72, p = 0.006) when controlling for demographics, health, and KOA symptoms. Individuals who used exercise with or without pain medication or injections had a more appeal-focused mindset than those who used medication or injections without exercise (p<0.001). A less appeal-focused mindset regarding physical activity was not significantly associated with KOA (β = -0.14, p = 0.067). Further, the mindset score demonstrated strong internal consistency (α = 0.92; T1; n = 150 and α = 0.92; T2; n = 62) and test-retest reliability (intraclass correlation coefficient (ICC) > 0.84, p < 0.001) within the KOA sample.

CONCLUSIONS

In individuals with KOA, mindset is associated with future physical activity levels and relates to the individual's management strategy. Mindset is a reliable and malleable construct and may be a valuable target for increasing physical activity and improving adherence to rehabilitation strategies involving exercise among individuals with KOA.

Implementation of a novel stratified PAthway of CarE for common musculoskeletal (MSK) conditions in primary care: protocol for a multicentre pragmatic randomised controlled trial (the PACE MSK trial)

Introduction

Musculoskeletal (MSK) conditions constitute the highest burden of disease globally, with healthcare services often utilised inappropriately and overburdened. The aim of this trial is to evaluate the effectiveness of a novel clinical PAthway of CarE programme (PACE programme), where care is provided based on people’s risk of poor outcome.

Methods and analysis

Multicentre randomised controlled trial. 716 people with MSK conditions (low back pain, neck pain or knee osteoarthritis) will be recruited in primary care. They will be stratified for risk of a poor outcome (low risk/high risk) using the Short Form Örebro Musculoskeletal Pain Screening Questionnaire (SF-ÖMSPQ) then randomised to usual care (n=358) or the PACE programme (n=358). Participants at low risk in the PACE programme will receive up to 3 sessions of guideline based care from their primary healthcare professional (HCP) supported by a custom designed website (mypainhub.com). Those at high risk will be referred to an allied health MSK specialist who will conduct a comprehensive patient-centred assessment then liaise with the primary HCP to determine further care. Primary outcome (SF 12-item PCS) and secondary outcomes (eg, pain self-efficacy, psychological health) will be collected at baseline, 3, 6 and 12 months. Cost-effectiveness will be measured as cost per quality-adjusted life-year gained. Health economic analysis will include direct and indirect costs. Analyses will be conducted on an intention-to-treat basis. Primary and secondary outcomes will be analysed independently, using generalised linear models. Qualitative and mixed-methods studies embedded within the trial will evaluate patient experience, health professional practice and interprofessional collaboration.

Ethics and dissemination

Ethics approval has been received from the following Human Research Ethics Committees: The University of Sydney (2018/926), The University of Queensland (2019000700/2018/926), University of Melbourne (1954239), Curtin University (HRE2019-0263) and Northern Sydney Local Health District (2019/ETH03632). Dissemination of findings will occur via peer-reviewed publications, conference presentations and social media.

Trial registration number

ACTRN12619000871145.

Interferential current and photobiomodulation in knee osteoarthritis: A randomized, placebo-controlled, double-blind clinical trial

OBJECTIVES

To evaluate the effects of interferential current and photobiomodulation in patients with knee osteoarthritis.

DESIGN

A randomized, placebo-controlled, double-blind clinical trial.

SETTING

Physiotherapy Clinic of City University of São Paulo.

SUBJECTS

A total of 184 patients with knee osteoarthritis were recruited and, of these, 168 were included and randomized into four groups with 42 each: interferential current, photobiomodulation, interferential current plus photobiomodulation or placebo groups. One hundred and sixty-four patients completed the study.

INTERVENTION

Patients received 12 sessions (three times a week) of treatment: 30 minutes of interferential current (active or placebo) followed by photobiomodulation (active or placebo).

MAIN MEASURES

Primary outcome: pain intensity at rest and during movement (numeric rating scale) after 12 sessions. Secondary outcomes: functional capacity (Timed Up & Go and Sit and Lift tests and Lequesne and WOMAC questionnaires), pressure pain threshold, conditioned pain modulation, and muscle strength production (isokinetic evaluation). Patients were assessed at baseline, after 12 sessions, and three and six months after the end of the treatment.

RESULTS

Interferential current plus photobiomodulation reduced pain intensity at rest and during movement compared to placebo and interferential current at all time points (P < 0.05). Photobiomodulation reduced pain intensity at rest compared to placebo at all time points (P < 0.05) and compared to interferential current at six months follow-up (P < 0.05). Photobiomodulation reduced pain intensity during movement compared to placebo at six months follow-up (P < 0.05).

CONCLUSION

Interferential current plus photobiomodulation or isolated photobiomodulation improve pain intensity in knee osteoarthritis.

The Role of Knowledge and Attitudes About Nonsteroidal Anti-inflammatory Drugs in Determining Treatment Use

OBJECTIVE

The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti-inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA).

METHODS

Surveys of 334 adults with knee and/or hip OA were analyzed in this cross-sectional study. Familiarity with and perceptions of benefits/risks of NSAID use were measured to assess associations with the use of prescription and nonprescription oral NSAIDs. Multinomial logistic regression models were adjusted for sociodemographic and clinical variables.

RESULTS

In this sample, 35.9% and 35.6% reported use of oral prescription and nonprescription-only NSAIDs, respectively. Hispanic participants, compared with non-Hispanic White participants, had lower perceived benefit (P = 0.005) and risk (P = 0.001) of prescription NSAIDs. The following were associated with prescription NSAID use instead of no NSAID use: having family/friends who used prescription (relative risk ratio [RRR] 3.91; 95% confidence interval [CI] 2.05-7.47) and over-the-counter (OTC) (RRR 3.10; 95% CI 1.65-5.83) NSAIDs for OA, understanding the consequences of using both prescription (RRR 3.50; 95% CI 1.79-6.86) and OTC (RRR 2.80; 95% CI 1.39-5.65) NSAIDs, higher perceived benefit of both prescription (RRR 2.51; 95% CI 1.71-3.66) and OTC (RRR 1.44; 95% CI 1.01-2.06) NSAIDs, and lower perceived risk of both types of NSAIDs (prescription: RRR 0.63 [95% CI 0.46-0.87]; OTC: RRR 0.53 [95% CI 0.37-0.75]). Similar results were found when we assessed the relationship between these variables and OTC NSAID use versus no oral NSAID use.

CONCLUSION

Adults with knee and/or hip OA were more likely to use NSAIDs if they were more familiar with, had an increased perceived benefit of, and had a decreased perceived risk of these drugs. Patients' perceptions and beliefs about NSAIDs should be evaluated when considering them for treatment.

Nonsteroidal Anti-Inflammatory Drug Use in Chronic Arthritis Pain: Variations by Ethnicity

PURPOSE

Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors.

METHODS

Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method.

RESULTS

Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P <0.001), less likely to have private medical insurance (P <0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]).

CONCLUSIONS

Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.

Social & psychological factors associated with oral analgesic use in knee osteoarthritis management

OBJECTIVE

Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA.

METHODS

Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy ("How confident are you filling out medical forms by yourself?"), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics.

RESULTS

In this sample (mean age 64.2 years, 23.6% women), 30.6% (n = 110) reported taking opioid analgesics for OA, 54.2% (n = 195) reported non-opioid use, and 15.3% (n = 55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs 10.5 vs 11.9, P = 0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs 24.1% vs 14.5%, P < 0.001). Health literacy did not differ by treatment group type. Having moderate-severe depression was associated with higher risk of opioid analgesic use compared to no oral analgesic use (RRR 2.96, 95%CI 1.08-8.07) when adjusted for sociodemographic and clinical factors. Neither social support nor health literacy was associated with opioid or non-opioid oral analgesic use in fully adjusted models.

CONCLUSIONS

Knee OA patients with more severe depression symptoms, compared to those without, were more likely to report using opioid analgesics for OA.

Demographic and Clinical Factors Associated With Nonsurgical Osteoarthritis Treatment Among Patients in Outpatient Clinics

OBJECTIVE

To identify patient demographic and clinical characteristics associated with osteoarthritis (OA) treatment use.

METHODS

This was a secondary data analysis of 3 clinical trials among patients with hip or knee OA conducted in Duke Primary Care practices, the Durham Veterans Affairs (VA) Health Care System, and the University of North Carolina-Chapel Hill (UNC). At baseline, participants reported sociodemographic characteristics, OA-related pain and function, and OA treatment use, including oral analgesics, topical creams, joint injections, and physical therapy. Separate, multivariable logistic models (adjusted for clustering of clinics and providers for the Duke and VA cohorts) were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the associations between participant characteristics and each type of OA treatment.

RESULTS

Oral analgesic use was reported by 70-82% of participants across the 3 cohorts. Physical therapy, knee injections, and topical creams were used by 39-52%, 55-60%, and 25-39% of Duke, VA, and UNC participants, respectively. In multivariable models, worse pain, stiffness, and function, per 5-unit increase, were associated with greater odds of using any oral analgesic for the cohorts from Duke (OR 1.18 [95% CI 1.08-1.28]) and UNC (OR 1.14 [95% CI 1.05-1.24]), but not for the VA cohort (OR 1.04 [95% CI 0.95-1.14]). For all 3 cohorts, nonwhites had higher odds of using topical creams compared to whites.

CONCLUSION

Results suggest potential underutilization of therapies other than oral analgesics. Patient characteristics may affect OA treatment use, and understanding the relationship between these factors and OA treatment preferences may improve adherence to OA treatment guidelines.

"I was really sceptical...But it worked really well": a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis

OBJECTIVE

Physiotherapists typically prescribe exercise therapy for people with osteoarthritis (OA) via face-to-face consultations. This study aimed to explore peoples' perceptions of exercise therapy delivered by physiotherapists via telephone for their knee OA.

DESIGN

A qualitative study (based on interpretivist methodology) embedded within a randomised controlled trial. Semi-structured individual interviews were conducted with 20 people with knee OA who had received exercise advice and support from one of eight physiotherapists via telephone over 6 months. Interviews were audio recorded, transcribed verbatim and thematically analysed.

RESULTS

Although people with OA were initially sceptical about receiving exercise therapy via telephone, they described mostly positive experiences, valuing the convenience and accessibility. However, some desired visual contact with the physiotherapist and suggested including video-conferencing calls or an initial in-person clinic visit. Participants valued the sense of undivided focus and attention they received from the physiotherapist and believed that they were able to communicate effectively via telephone. Participants felt confident performing their exercise program without supervision and described benefits including increased muscular strength, improved pain, and ability to perform tasks that they had not been previously able to.

CONCLUSIONS

People with knee OA held mostly positive perceptions about receiving exercise therapy from a physiotherapist via telephone, suggesting that such a service is broadly acceptable to consumers. Such services were generally not viewed as a substitute for face-to-face physiotherapy care, but rather as a new option that could increase accessibility of physiotherapy services, particularly for follow-up consultations.

Cost-effectiveness of generic celecoxib in knee osteoarthritis for average-risk patients: a model-based evaluation

OBJECTIVE

The cost-effectiveness of the recently-introduced generic celecoxib in knee OA has not been examined.

METHOD

We used the Osteoarthritis Policy (OAPol) Model, a validated computer simulation of knee OA, to evaluate long-term clinical outcomes, costs, and cost-effectiveness of generic celecoxib in persons with knee OA. We examined eight treatment strategies consisting of generic celecoxib, over-the-counter (OTC) naproxen, or prescription naproxen, with or without prescription or OTC proton-pump-inhibitors (PPIs) to reduce gastrointestinal (GI) toxicity. In the base case, we assumed that annual cost was $130 for OTC naproxen, $360 for prescription naproxen, and $880 for generic celecoxib. We considered a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) and discounted costs and benefits at 3% annually. In sensitivity analyses we varied celecoxib toxicity, discontinuation, cost, and pain level.

RESULTS

In the base case analysis of the high pain cohort (WOMAC 50), celecoxib had an incremental cost-effectiveness ratio (ICER) of $284,630/QALY compared with OTC naproxen. Only under highly favorable cost, toxicity, and discontinuation assumptions (e.g., annual cost below $360, combined with a reduction in the cardiovascular (CV) event rates below baseline values) was celecoxib likely to be cost-effective. Celecoxib might also be cost-effective at an annual cost of $600 if CV toxicity were eliminated completely. In subjects with moderate pain (WOMAC 30), at the base case CV event rate of 0.2%, generic celecoxib was only cost-effective at the lowest plausible cost ($190).

CONCLUSION

In knee OA patients with no comorbidities, generic celecoxib is not cost-effective at its current price.

Traditional and Complementary Medicine Use in Knee Osteoarthritis and its Associated Factors Among Patients in Northeast Peninsular Malaysia

Objectives

We sought to determine the prevalence of traditional and complementary medicine (TCM) use for knee osteoarthritis and its associated factors among patients attending a referral hospital in an eastern coastal state of Malaysia.

Methods

This cross-sectional study included 214 patients with knee osteoarthritis. A universal sampling method was applied to patients who attended the outpatient clinic in Hospital Universiti Sains Malaysia from May 2013 to October 2013. Participants were given a questionnaire to determine their sociodemographic information and a validated Bahasa Malaysia version of the Western Ontario and McMaster Universities Arthritis Index (WOMAC). This questionnaire was used to assess the severity of knee osteoarthritis (i.e., pain, stiffness, and disturbances in daily activity).

Results

Over half (57.9%) of patients reported using TCM to treat knee osteoarthritis. Factors associated with TCM use were gender (odd ratio (OR) = 2.47; 95% confidence interval (CI): 1.28-4.77), duration of knee osteoarthritis (OR = 1.51; 95% CI: 1.03-2.23), and the severity of knee pain (OR = 2.56; 95% CI: 1.71-3.86).

Conclusions

The prevalence of TCM use among eastern Malaysian patients with knee osteoarthritis was high. Physicians caring for these patients should be aware of these findings so that inquiries regarding TCM use can be made and patients can be appropriately counseled.

Physical Therapists' Perceptions of Telephone- and Internet Video-Mediated Service Models for Exercise Management of People With Osteoarthritis

OBJECTIVE

To investigate physical therapists' perceptions of, and willingness to use, telephone- and internet-mediated service models for exercise therapy for people with knee and/or hip osteoarthritis.

METHODS

This study used an internet-based survey of Australian physical therapists, comprising 3 sections: 1 on demographic information and 2 with 16 positively framed perception statements about delivering exercise via telephone and video over the internet, for people with hip and/or knee osteoarthritis. Levels of agreement with each statement were evaluated. Logistic regression models were used to determine therapist characteristics influencing interest in delivering telerehabilitation.

RESULTS

A total of 217 therapists spanning metropolitan, regional, rural, and remote Australia completed the survey. For telephone-delivered care, there was consensus agreement that it would not violate patient privacy (81% agreed/strongly agreed) and would save patient's time (76%), but there was less than majority agreement for 10 statements. There was consensus agreement that video-delivered care would save a patient's time (82%), be convenient for patients (80%), and not violate patient privacy (75%). Most agreed with all other perception statements about video-delivered care, except for liking no physical contact (14%). Low confidence using internet video technologies, and inexperience with telerehabilitation, were significantly associated with reduced interest in delivering telephone and/or video-based services.

CONCLUSION

Physical therapists agree that telerehabilitation offers time-saving and privacy advantages for people with osteoarthritis and perceive video-delivered care more favorably than telephone-delivered services. However, most do not like the lack of physical contact with either service model. These findings may inform the implementation of telerehabilitation osteoarthritis services and the training needs of clinicians involved in delivering care.

The chiropractic profession: a scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided

Background

Previous research has investigated utilization rates, who sees chiropractors, for what reasons, and the type of care that chiropractors provide. However, these studies have not been comprehensively synthesized. We aimed to give a global overview by summarizing the current literature on the utilization of chiropractic services, reasons for seeking care, patient profiles, and assessment and treatment provided.

Methods

Systematic searches were conducted in MEDLINE, CINAHL, and Index to Chiropractic Literature using keywords and subject headings (MeSH or ChiroSH terms) from database inception to January 2016. Eligible studies: 1) were published in English or French; 2) were case series, descriptive, cross-sectional, or cohort studies; 3) described patients receiving chiropractic services; and 4) reported on the following theme(s): utilization rates of chiropractic services; reasons for attending chiropractic care; profiles of chiropractic patients; or, types of chiropractic services provided. Paired reviewers independently screened all citations and data were extracted from eligible studies. We provided descriptive numerical analysis, e.g. identifying the median rate and interquartile range (e.g., chiropractic utilization rate) stratified by study population or condition.

Results

The literature search retrieved 14,149 articles; 328 studies (reported in 337 articles) were relevant and reported on chiropractic utilization (245 studies), reason for attending chiropractic care (85 studies), patient demographics (130 studies), and assessment and treatment provided (34 studies). Globally, the median 12-month utilization of chiropractic services was 9.1% (interquartile range (IQR): 6.7%-13.1%) and remained stable between 1980 and 2015. Most patients consulting chiropractors were female (57.0%, IQR: 53.2%-60.0%) with a median age of 43.4 years (IQR: 39.6-48.0), and were employed (median: 77.3%, IQR: 70.3%-85.0%). The most common reported reasons for people attending chiropractic care were (median) low back pain (49.7%, IQR: 43.0%-60.2%), neck pain (22.5%, IQR: 16.3%-24.5%), and extremity problems (10.0%, IQR: 4.3%-22.0%). The most common treatment provided by chiropractors included (median) spinal manipulation (79.3%, IQR: 55.4%-91.3%), soft-tissue therapy (35.1%, IQR: 16.5%-52.0%), and formal patient education (31.3%, IQR: 22.6%-65.0%).

Conclusions

This comprehensive overview on the world-wide state of the chiropractic profession documented trends in the literature over the last four decades. The findings support the diverse nature of chiropractic practice, although common trends emerged.

* Engineering Membranes for Bone Regeneration

This review is focused on the use of membranes for the specific application of bone regeneration. The first section focuses on the relevance of membranes in this context and what are the specifications that they should possess to improve the regeneration of bone. Afterward, several techniques to engineer bone membranes by using "bulk"-like methods are discussed, where different parameters to induce bone formation are disclosed in a way to have desirable structural and functional properties. Subsequently, the production of nanostructured membranes using a bottom-up approach is discussed by highlighting the main advances in the field of bone regeneration. Primordial importance is given to the promotion of osteoconductive and osteoinductive capability during the membrane design. Whenever possible, the films prepared using different techniques are compared in terms of handability, bone guiding ability, osteoinductivity, adequate mechanical properties, or biodegradability. A last chapter contemplates membranes only composed by cells, disclosing their potential to regenerate bone.

Consumer Perceptions of and Willingness to Use Remotely Delivered Service Models For Exercise Management of Knee and Hip Osteoarthritis: A Cross-Sectional Survey

OBJECTIVE

To investigate the perceptions of people with hip and/or knee osteoarthritis (OA) about the remote delivery of exercise therapy by a physical therapist.

METHODS

A survey of people age ≥45 years with a clinical diagnosis of hip and/or knee OA was conducted. The survey comprised 3 sections, including 1) demographic information, 2) statements about receiving exercise via the telephone, and 3) statements about receiving exercise via video over the internet. Data were analyzed by calculating response proportions and evaluating levels of agreement with each statement. Exploratory binomial regression analyses were performed to determine whether participant characteristics influenced perceptions of tele-rehabilitation.

RESULTS

A total of 330 people spanning metropolitan, regional, and rural Australia completed the survey. Respondents were in majority (≥50%) agreement with 13 of 17 statements, with most agreement about tele-rehabilitation saving time (telephone versus video: 78% versus 81%), being easy to use (79% versus 78%), and maintaining privacy (86% versus 82%). There was no consensus agreement with liking the lack of physical contact (telephone versus video: 20% agreement versus 22%), willingness to pay (32% versus 46%), belief that telephone-delivered exercise would be effective (45%), and belief that a physical therapist could adequately monitor OA over the telephone (42%).

CONCLUSION

People with knee and/or hip OA hold mostly positive perceptions about tele-rehabilitation, delivered via the telephone or by video over the internet, for provision of physical therapist-prescribed exercise services. There was concern about the lack of physical contact with the therapist when using tele-rehabilitation.

Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis?

OBJECTIVE

We examined the dose-response relationship between weight reduction and pain/functional improvement in persons with symptomatic knee osteoarthritis (KOA) participating in a community-based weight loss program.

METHODS

Consecutive participants with KOA and enrolled in the 18-week Osteoarthritis Healthy Weight for Life weight-loss program were selected. In this completer-type analysis, participants were assessed at baseline, 6 weeks, and 18 weeks for body weight and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales. The dose-response relationship between weight-change categories (>10%, 7.6-10%, 5.1-7.5%, 2.6-5.0%, and <2.5% of body weight loss) and change in KOOS scores was assessed by repeated-measures analysis of variance, controlling for sex and age, body mass index (BMI), and KOOS. The Western Ontario McMaster Universities Osteoarthritis Index function score derived from the KOOS was used to assess a meaningful clinical functional improvement.

RESULTS

A total of 1,383 persons (71% females) were enrolled. Mean ± SD age, height, and weight were 64 ± 8.7 years, 1.66 ± 0.09 meters, and 95.1 ± 17.2 kg, respectively. Mean ± SD BMI was 34.4 ± 5.2 kg/m(2) with 82% of participants obese at baseline. A total of 1,304 persons (94%) achieved a >2.5% reduction in body weight. There was a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% (95% confidence interval 5.2, 13.3) body weight loss to achieve a minimal clinically important improvement in function.

CONCLUSION

There is a significant dose-response relationship between percentage of weight loss and symptomatic improvement. This study confirms the feasibility of weight loss as a therapeutic intervention in KOA in a community-based setting.

GPs' attitudes, beliefs and behaviours regarding exercise for chronic knee pain: a questionnaire survey

OBJECTIVES

The aim of this study was to investigate general practitioners' (GPs) attitudes, beliefs and behaviours regarding the use of exercise for patients with chronic knee pain (CKP) attributable to osteoarthritis.

SETTING

Primary care GPs in the UK.

PARTICIPANTS

5000 GPs, randomly selected from Binley's database, were mailed a cross-sectional questionnaire survey.

OUTCOME MEASURES

GPs' attitudes and beliefs were investigated using attitude statements, and reported behaviours were identified using vignette-based questions. GPs were invited to report barriers experienced when initiating exercise with patients with CKP RESULTS: 835 (17%) GPs responded. Overall, GPs were positive about general exercise for CKP. 729 (87%) reported using exercise, of which, 538 (74%) reported that they would use both general and local (lower limb) exercises. However, only 92 (11% of all responding) GPs reported initiating exercise in ways aligning with best-evidence recommendations. 815 (98%) GPs reported barriers in using exercise for patients with CKP, most commonly, insufficient time in consultations (n=419; 51%) and insufficient expertise (n=337; 41%).

CONCLUSIONS

While GPs' attitudes and beliefs regarding exercise for CKP were generally positive, initiation of exercise was often poorly aligned with current recommendations, and barriers and uncertainties were reported. GPs' use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise, and/or by other professionals taking on this role.

What influences general practitioners' use of exercise for patients with chronic knee pain? Results from a national survey

Background

Exercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. A theoretical analysis framework, developed from sociocognitive theories, was used to underpin investigation of the key influences associated with GPs’ use of exercise for patients with CKP, to inform future interventions to optimise GPs’ use of exercise.

Methods

A cross-sectional postal questionnaire survey investigated UK GPs’ reported use of exercise based on a patient case vignette. Factors influencing GPs’ exercise use (behaviour) were examined using attitude statements, free-text questions and multiple response option questions related to factors within the analysis framework. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes/beliefs and behaviour.

Results

From a total sample of 5000 GPs, 835 (17%) returned a questionnaire. Most respondents (n = 729, 87%) reported that they would use exercise. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that GPs should prescribe all patients local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and GP-related beliefs about capabilities (prior experience of insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed that they experienced time limitations were more likely to suggest general (2.17 (1.04,4.55)), or demonstrate local (2.16 (1.06,4.42)), exercises.

Conclusion

GPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP, particularly beliefs about role, responsibilities and skills in initiating exercise, and about the efficacy of exercise. Although the low response risks response bias, these results can inform future interventions to optimise GPs’ behaviour. The role of GP uncertainty and influences on clinical decision-making need further exploration, thus an amended analysis framework is suggested, which should be tested in future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0570-4) contains supplementary material, which is available to authorized users.

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.

The clinical characteristics of older people with chronic multiple-site joint pains and their utilisation of therapeutic interventions: data from a prospective cohort study

Background

Chronic multiple-site joint pain (MSJP) is common in older people and associated with poor outcomes, yet under-researched. Our aim was to detail the clinical characteristics of people with MSJP and their utilisation of therapies.

Methods

MSJP was defined as pain in at least one large joint and one other joint for >6 weeks in the last three months. A mixed community, primary and secondary care cohort of people >50 years old underwent detailed history and examination by a single clinician. Treatment utilisation was recorded comprehensively.

Results

201 adults were recruited, 82 % women, mean age 63, BMI 31 kg/m². Median number of painful joints per patient was 6 (IQR 4–9; range 2–17); most common painful sites were knee (84 %), lower back (62 %) and shoulder (47 %). 194/201 (96 %) had an osteoarthritis (OA) diagnosis, 155/194 (80 %) also had soft tissue pathology and 72 % had back problems. 85 % had OA at multiple sites. Upper and lower limb weakness was common (90 and 77 % respectively). Lower limb weakness was significantly associated with obesity. Only 26 % had received written information about their joints. Though 79 % had attended physiotherapy, the majority (93 %) had muscle weakness. Only 36 % of overweight participants had accessed weight-loss support. Half of those with foot pain had seen a podiatrist or used appliances. Multiple concurrent pharmacological therapies were used by 47 %.

Conclusion

MSJP represents a combination of OA, back pain and soft tissue disorders; muscle weakness is extremely common. Therapies appear underutilised in people with MJSP. Identifying the reasons for this should guide effective intervention research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1049-0) contains supplementary material, which is available to authorized users.

Integrating lifestyle approaches into osteoarthritis care

As the lifetime risk, societal cost, and overall functional impact of osteoarthritis (OA) is imposing, it is imperative that clinicians provide an individualized care model for patients. Patients must be offered a multiplicity of care strategies and encouraged to embrace lifestyle approaches for self-managing the effects and symptoms of OA. Certainly, the attitude of the clinician and patient will directly influence receptivity and implementation of lifestyle approaches. This work proposes how the use of structured and routine assessments and cognitive therapy ideologies may complement a comprehensive treatment plan. Assessments described herein include objective and/or self-report measures of physical function, pain, attitude about social support, and sleep quality. Baseline assessments followed by systematic monitoring of the results may give patients and clinicians valuable insight into the effectiveness of the care plan. Empirical evidence from randomized trials with OA patients highlights the effectiveness of cognitive behavioral change strategies for addressing salient concerns for OA (pain control, mobility performance, and sleep quality). Cognitive restructuring can provide patients with renewed power in managing their disease. Cognitive therapy topics discussed presently include: 1) what is OA?, 2) effectiveness of exercise and FITT (frequency, intensity, time, and type) principles for OA patients, 3) goal-setting and barriers, and 4) translating to independent care. Woven within the discussion about cognitive therapy are ideas about how the results from baseline assessments and group-mediated dynamics might assist more favorable outcomes. There are a plethora of assessments and cognitive therapy topics that could be utilized in the care strategy that we are promoting, but the present topics were selected for their low clinician and patient burden and promising results in trials with OA patients. Clinicians who are comfortable and knowledgeable about a wider range of management tools may serve more effectively in the critical, central management process and help patients embrace personal care more successfully.

Variation in use of non-surgical treatments among osteoarthritis patients in orthopaedic practice in the Netherlands

OBJECTIVES

National and international evidence-based guidelines for hip and knee osteoarthritis (OA) recommend to start with non-surgical treatments, followed by surgical intervention if a patient does not respond sufficiently to non-surgical treatments, but there are indications that these are not optimally used. The aim of this study was to assess the extent to which all recommended non-surgical treatments were used by patients with hip or knee OA who receive(d) a total hip or knee replacement, as reported by patients and orthopaedic surgeons.

SETTING

We performed two cross-sectional internet-based surveys among patients and orthopaedic surgeons throughout the Netherlands.

PARTICIPANTS

195 OA patients either have undergone total knee arthroplasty or total hip arthroplasty no longer than 12 months ago or being on the waiting list for surgery with a confirmed date within 3 months and 482 orthopaedic surgeons were invited to participate.

PRIMARY AND SECONDARY OUTCOME MEASURES

The use of recommended non-surgical treatments including education about OA/treatment options, lifestyle advice, dietary therapy, physical therapy, acetaminophen, NSAIDs and glucocorticoid injections.

RESULTS

174 OA patients (93%) and 172 orthopaedic surgeons (36%) completed the surveys. Most recommended non-surgical treatments were given to the majority of patients (eg, 80% education about OA, 73% physical therapy, 72% acetaminophen, 80% NSAIDs). However, only 6% of patients and 10% of orthopaedic surgeons reported using a combination of all recommended treatments. Dietary therapy was used least frequently. Only 11% of overweight and 30% of obese participants reported having received dietary therapy and 28% of orthopaedic surgeons reported to prescribe dietary therapy to overweight patients.

CONCLUSIONS

While most recommended non-surgical treatments were used frequently as single therapy, the combination is used in only a small percentage of OA patients. Especially, use of dietary therapy may be improved to help patients manage their symptoms, and potentially delay the need for joint arthroplasty.

OARSI Clinical Trials Recommendations: Design and conduct of implementation trials of interventions for osteoarthritis

Rigorous implementation research is important for testing strategies to improve the delivery of effective osteoarthritis (OA) interventions. The objective of this manuscript is to describe principles of implementation research, including conceptual frameworks, study designs and methodology, with specific recommendations for randomized clinical trials of OA treatment and management. This manuscript includes a comprehensive review of prior research and recommendations for implementation trials. The review of literature included identification of seminal articles on implementation research methods, as well as examples of previous exemplar studies using these methods. In addition to a comprehensive summary of this literature, this manuscript provides key recommendations for OA implementation trials. This review concluded that to date there have been relatively few implementation trials of OA interventions, but this is an emerging area of research. Future OA clinical trials should routinely consider incorporation of implementation aims to enhance translation of findings.

Better Management of Patients with Osteoarthritis: Development and Nationwide Implementation of an Evidence-Based Supported Osteoarthritis Self-Management Programme

BACKGROUND

Information and exercise are core treatments of osteoarthritis. Self-management and coping strategies with the disease are crucial to gain benefits. We developed a supported osteoarthritis self-management programme, delivered by trained physiotherapists, to facilitate patient and healthcare compliance. The programme combined peer- and healthcare professional-delivered information, and individually adapted exercise.

METHODS

Physiotherapists were trained to deliver and evaluate the programme. Patient-reported compliance and satisfaction with the programme was assessed at three- and 12-month follow-ups.

RESULTS

Data from 20,200 consecutive patients in 320 different care centres in Sweden showed that 97% attended the theory sessions and 83% volunteered for the optional individual exercise programme. The intervention was rated as good or very good by 94% of patients. After three months, 62% reported daily use of what they had learned during the course, and 91% reported weekly use. Corresponding numbers after 12 months were 37% and 72%.

CONCLUSIONS

The supported osteoarthritis self-management programme is feasible in clinical practice, and seems useful and acceptable to patients.

Drug utilization in patients with OA: a population-based study

OBJECTIVE

Patients with OA use different drugs in their search for relief. We aimed to study the prevalence of use and combinations of different medications for OA in a population-based cohort of OA patients in Catalonia, Spain, while characterizing users of each of the drugs available, with a particular focus on cardiovascular risk factors.

METHODS

Data were obtained from the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària (SIDIAP) database, which includes electronic medical records and pharmacy invoice data for >5 million people from Catalonia. Study participants were those with a clinical diagnosis of OA in 2006-10. Drugs studied included oral and topical NSAIDs, analgesics (paracetamol, metamizole), opioids (tramadol, fentanyl), cyclooxygenase 2 (COX-2) inhibitors and symptomatic slow-acting drugs in OA. Drug utilization was described using medication possession ratios (MPRs), equivalent to the proportion of days covered with the drug of interest. The annual incidence of new users in the first year after OA diagnosis from 2006 to 2010 was estimated for all studied drugs among newly diagnosed OA patients using Poisson regression.

RESULTS

We identified 238 536 study participants. The most common regimen of treatment consisted of at least three drugs (53.9% of patients). The drugs most frequently used regularly (MPR ≥50%) were chondroitin (21.2%), glucosamine (15.8%) and oral NSAIDs (14.4%). The incidence of the use of opioids, COX-2 inhibitors and chondroitin increased over the 5 year period, whereas all others decreased.

CONCLUSION

Drug combinations are common in the treatment of OA patients, who are thus exposed to potential drug interactions, with unknown impacts on their health. The increasing use of opioids and COX-2 inhibitors is noteworthy because of the potential impact on safety and costs.

Osteoarthritis and the rule of halves

BACKGROUND

Symptomatic osteoarthritis poses a major challenge to primary health care but no studies have related accessing primary care ('detection'), receiving recommended treatments ('treatment'), and achieving adequate control ('control').

OBJECTIVE

To provide estimates of detection, treatment, and control within a single population adapting the approach used to determine a Rule of Halves for other long-term conditions.

SETTING

General population.

PARTICIPANTS

400 adults aged 50+ years with prevalent symptomatic knee osteoarthritis.

DESIGN

Prospective cohort with baseline questionnaire, clinical assessment, and plain radiographs, and questionnaire follow-up at 18 and 36 months and linkage to primary care medical records.

OUTCOME MEASURES

'Detection' was defined as at least one musculoskeletal knee-related GP consultation between baseline and 36 months. 'Treatment' was self-reported use of at least one recommended treatment or physiotherapy/hospital specialist referral for their knee problem at all three measurement points. Pain was 'controlled' if characteristic pain intensity <5 out of 10 on at least two occasions.

RESULTS

In 221 cases (55.3%; 95%CI: 50.4, 60.1) there was evidence that the current problem had been detected in general practice. Of those detected, 164 (74.2% (68.4, 80.0)) were receiving one or more of the recommended treatments at all three measurement points. Of those detected and treated, 45 (27.4% (20.5, 34.3)) had symptoms under control on at least two occasions. Using narrower definitions resulted in substantially lower estimates.

CONCLUSION

Osteoarthritis care does not conform to a Rule of Halves. Symptom control is low among those accessing health care and receiving treatment.

Complementary and alternative medicine use by patients visiting a free health clinic: A single-site, pilot study

BACKGROUND

The rate of use of complementary and alternative medicine (CAM) has been documented to fluctuate widely, can greatly impact medical outcomes, and can influence patients' adherence to conventional medicines. Health care providers should assess the prevalence of CAM use (primarily herbal medicine) in individual settings to most accurately provide appropriate patient care.

OBJECTIVES

THE AIM OF THIS STUDY WAS TO DETERMINE THE FOLLOWING: (1) differences in demographic characteristics between users and nonusers of CAM; (2) which CAM patients are using; (3) patients' sources of information concerning CAM; and (4) whether patients recall being asked about CAM use by their health care providers.

METHODS

In this single-center, pilot study, a self-administered survey concerning CAM use was made available to persons seeking care at an inner-city free health clinic (Kansas City Free Health Clinic, Kansas City, Missouri). Completed surveys were scanned into a database, and descriptive analyses were performed.

RESULTS

Three hundred eleven patients completed ≥1 question on the survey. Of those who reported race (n = 278), 168 (60.4%) were Caucasian/white, 73 (26.3%) were African American/black, and 24 (8.6%) were Hispanic/Latino. Of those who reported educational level (n = 287), 101 (35.2%) had some high school or were high school graduates or had a general equivalency development diploma, 102 (35.5%) had completed some college or vocational training, and 84 (29.3%) had completed college. Of those who reported personal annual income (n = 191), 107 (56.0%) reported up to US $15,000, and 54 (28.3%) reported >$15,000 to $30,000. A high rate of CAM use (past or present) was found among survey respondents (116/285 [40.7%]). No correlation was found between CAM use and any of the demographic characteristics studied. Of 98 patients reporting whether their CAM use was past or current, 64 (65.3%) were using CAM at the time of the survey. Friends and physicians were reported to be most supportive of CAM use (21/41 [51.2%] and 33/86 [38.4%] patients, respectively). The most common CAM products reported as being currently used were garlic and chamomile (both, 5 patients [7.1%]), and echinacea and ginseng (both, 3 patients [4.7%]).

CONCLUSION

This survey of patients using an inner-city free health clinic showed a high rate of CAM use, which could significantly impact patient outcomes.

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

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

Knee pain as the reason for encounter in general practice

Objective. Currently, an overview of the management of knee pain in general practitioner's offices is not available. The main concern of this study was to evaluate the consultation prevalence of knee pain, accompanying symptoms, the frequency of diagnostic and therapeutic procedures, and results of encounters of patients suffering from knee pain. Methods. For the SESAM 2 study cross-sectional data was collected from randomly selected patients during one year and compared with publicly available data from the Dutch Transition Project. Results. Overall, 127 out of 8,877 (1.4%) patients of the SESAM 2 study and 6,754 out of 149,238 (4.5%) patients of the Dutch Transition Project consulted for knee pain. Drug prescription, follow-up consultation, giving doctor's advice, and referral to a specialist or physiotherapist were the most frequent procedures. Osteoarthritis of the knee and other musculoskeletal diseases were the most frequent results of encounter. Overweight, age, gender, and other musculoskeletal diseases were found to be significantly associated with knee pain. Conclusion. Knee pain in general practice settings is mainly associated with chronic problems. Dangerous outcomes (as suspected fracture or thrombosis) are rare. Further research is needed in order to reduce the influence knee pain has on daily living.

Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys

This systematic review aimed to estimate the prevalence of use of complementary and alternative medicine (CAM) in the UK. Five databases were searched for English language, peer-reviewed surveys published between 1 January 2000 and 7 October 2011. In addition, relevant book chapters and files from our own departmental records were searched by hand. Eighty-nine surveys were included, with a total of 97,222 participants. Most studies were of poor methodological quality. Across surveys on CAM in general, the average one-year prevalence of use of CAM was 41.1% and the average lifetime prevalence was 51.8%. In methodologically sound surveys, the equivalent rates were 26.3% and 44%, respectively. In surveys with response rates >70%, average one-year prevalence was nearly threefold lower than in surveys with response rates between 21% and 50%. Herbal medicine was the most popular CAM, followed by homeopathy, aromatherapy, massage and reflexology. Many patients and consumers in the UK use CAM; healthcare professionals should therefore responsibly advise their patients about the use of CAM.

Prevalence of use of complementary and alternative medicine (CAM) by patients/consumers in the UK: systematic review of surveys

This systematic review aimed to estimate the prevalence of use of complementary and alternative medicine (CAM) in the UK. Five databases were searched for English language, peer-reviewed surveys published between 1 January 2000 and 7 October 2011. In addition, relevant book chapters and files from our own departmental records were searched by hand. Eighty-nine surveys were included, with a total of 97,222 participants. Most studies were of poor methodological quality. Across surveys on CAM in general, the average one-year prevalence of use of CAM was 41.1% and the average lifetime prevalence was 51.8%. In methodologically sound surveys, the equivalent rates were 26.3% and 44%, respectively. In surveys with response rates >70%, average one-year prevalence was nearly threefold lower than in surveys with response rates between 21% and 50%. Herbal medicine was the most popular CAM, followed by homeopathy, aromatherapy, massage and reflexology. Many patients and consumers in the UK use CAM; healthcare professionals should therefore responsibly advise their patients about the use of CAM.

A discrete-choice experiment of United Kingdom patients' willingness to risk adverse events for improved function and pain control in osteoarthritis

OBJECTIVE

To assess patient preferences for treatment-related benefits and risks associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the management of osteoarthritis (OA).

DESIGN

Using a chronic-illness panel in the United Kingdom, patients 45 years or older with a self-reported diagnosis of OA were eligible to participate in the study. Patient preferences were assessed using a discrete-choice experiment that compared hypothetical treatment profiles of benefits and risks consistent with NSAID use. Benefit outcomes (ambulatory pain, resting pain, stiffness, and difficulty doing daily activities) were presented on a 0-to-100 mm scale. Risk outcomes (bleeding ulcer, stroke, and myocardial infarction [MI]) were expressed as probabilities over a fixed time period. Each patient answered 10 choice tasks comparing different treatment profiles. Preference weights were estimated using a random-parameters logit model.

RESULTS

Final sample included 294 patients. Patients ranked reductions in ambulatory pain and difficulty doing daily activities (both: 6.32; 95% confidence interval [CI]: 5.0-7.6) as the most important benefit outcomes, followed by reductions in resting pain (2.80; 95% CI: 1.8-3.8) and stiffness (2.65; 95% CI: 0.9-4.4). Incremental changes (3%) in the risk of MI or stroke were assessed as the most important risk outcomes (10.00; 95% CI: 8.2-11.8; and 8.90; 95% CI: 7.3-10.5, respectively).

CONCLUSION

Patients ranked ambulatory pain as a more important benefit than resting pain; likely due to its impact on ability to do daily activities. For a 25-mm reduction, patients were willing to accept four times the risk of MI in ambulatory pain vs resting pain.

The lifetime risk of total hip and knee arthroplasty: results from the UK general practice research database

OBJECTIVE

To estimate the lifetime risk of undergoing primary total hip (THR) or knee (TKR) replacement in the UK.

METHOD

A Population-based cohort study of 25,845 patients who had undergone a THR and 23,260 patients who had undergone a TKR between 1991 and 2006, using data from the UK General Practice Research Database.

RESULTS

The estimated mortality-adjusted lifetime risk of THR at age 50 for the year 2005 was 11.6% (95% CI: 11.1, 12.1) for women and 7.1% (95% CI: 6.7, 7.5) for men. For TKR the risks were 10.8% (95% CI: 10.3, 11.3) for women and 8.1% (95% CI: 7.6, 8.5) for men. Between 1991 and 2006, the lifetime risk of THR at age 50 rose from 4.0% (95% CI: 3.5, 4.4) to 11.1% (95% CI: 10.6, 11.6) for women and for men from 2.2% (95% CI: 1.8, 2.5) to 6.6% (95% CI: 6.2, 7.0). Over the same period, for TKR the risk for women increased from 2.9% (95% CI: 2.6, 3.3) to 10.6% (95% CI: 10.1, 11.1) and for men from 1.8% (95% CI: 1.5, 2.2) to 7.7% (95% CI: 7.3, 8.2).

CONCLUSION

The lifetime risk of undergoing THR or TKR is estimated to be substantially less than the risk of developing symptomatic hip or knee osteoarthritis. For the knee, the difference between these risk estimates is particularly wide. The reasons for the size of these differences are not clear, and further work is needed to quantify the extent of latent demand for these cost-effective and established interventions among the population with symptomatic osteoarthritis of the hip or knee.

Efficacy of multimodal, systematic non-surgical treatment of knee osteoarthritis for patients not eligible for a total knee replacement: a study protocol of a randomised controlled trial

INTRODUCTION

It is recommended that non-operative treatment of knee osteoarthritis (KOA) should be individually tailored and include multiple treatment modalities. Despite these recommendations, no one has yet investigated the efficacy of combining several non-surgical treatment modalities in a randomised controlled study. The purpose of this randomised controlled study is to examine if an optimised, combined non-surgical treatment programme results in greater improvements in pain, function and quality of life in comparison with usual care in patients with KOA who are not eligible for total knee arthroplasty (TKA).

METHODS AND ANALYSIS

This study will include 100 consecutive patients from the North Denmark Region not eligible for TKA with radiographic KOA (K-L grade ≥1) and mean pain during the previous week of ≤60 mm (0-100). The participants will be randomised to receive either a 12-week non-surgical treatment programme consisting of patient education, exercise, diet, insoles, paracetamol and/or NSAIDs or usual care (two information leaflets containing information on KOA and advice regarding the above non-surgical treatment). The primary outcome will be the change from baseline to 12 months on the self-report questionnaire Knee Injury and Osteoarthritis Outcome Score (KOOS)(4) defined as the average score for the subscale scores for pain, symptoms, activities of daily living and quality of life. Secondary outcomes include the five individual KOOS subscale scores, pain on a 100 mm Visual Analogue Scale, EQ-5D, self-efficacy, pain pressure thresholds, postural control and isometric knee flexion and knee extension strength.

ETHICS AND DISSEMINATION

This study was approved by the local Ethics Committee of The North Denmark Region (N-20110085) and the protocol conforms to the principles of the Declaration of Helsinki. Data collection will be completed by April 2014. Publications will be ready for submission in the summer of 2014.

TRIAL REGISTRATION NUMBER

This study is registered with http://clinicaltrials.gov (NCT01535001).

Prevalence and factors affecting glucosamine use in Korea: a survey-based study

Glucosamine and chondroitin are widely used as pharmaceutical and dietary supplements. However, there is a lack of information regarding consumer consumption of glucosamine and chondroitin in the Republic of Korea. We investigated the prevalence and factors affecting the use of glucosamine products in the general population aged 40 years and older in the Republic of Korea. We conducted this descriptive and exploratory study using a telephone-based survey with a structured questionnaire. We randomly selected subjects using a proportional allocation method based on age, gender, and region. We started the survey on September 19, 2009, and continued the survey until we obtained 1,000 respondents who were currently taking glucosamine or chondroitin, which occured on September 30, 2009. Among the 8,135 people approached, the response rate was 29.6%. A total of 12.2% of respondents (n = 991) were current users of glucosamine, while only 0.1% (n = 9) were current users of chondroitin. Two-fifths of current glucosamine users were not diagnosed with osteoarthritis by a doctor nor did they experience arthritis pain. These participants used glucosamine to maintain and promote joint health. Information on glucosamine was mainly obtained through advertisements on television or the Internet. Seventy percent of current users indicated that they did not know the composition of the glucosamine they took. Appropriate information and guides concerning glucosamine or chondroitin usage should be provided by expert clinicians because of the accessibility of both these cartilage derivatives as supplements and medical drugs in the Republic of Korea.

A turbulent decade for NSAIDs: update on current concepts of classification, epidemiology, comparative efficacy, and toxicity

Non-steroidal anti-inflammatory drugs (NSAIDs) represent a diverse class of drugs and are among the most commonly used analgesics for arthritic pain worldwide, though long-term use is associated with a spectrum of adverse effects. The introduction of cyclooxygenase-2-selective NSAIDs early in the last decade offered an alternative to traditional NSAIDs with similar efficacy and improved gastrointestinal tolerability; however, emerging concerns about cardiovascular safety resulted in the withdrawal of two agents (rofecoxib and valdecoxib) in the mid-2000s and, subsequently, in an overall reduction in NSAID use. It is now understood that all NSAIDs are associated with some varying degree of gastrointestinal and cardiovascular risk. Guidelines still recommend their use, but little is known of how patients use these agents. While strategies and guidelines aimed at reducing NSAID-associated complications exist, there is a need for evidence-based algorithms combining cardiovascular and gastrointestinal factors that can be used to aid treatment decisions at an individual patient level.

"It looks after me": how older patients make decisions about analgesics for osteoarthritis

OBJECTIVE

To explore the key motivators behind selection of analgesics (nonsteroidal antiinflammatory drugs [NSAIDs], acetaminophen, and complementary medications [CMs]) by patients with osteoarthritis (OA).

METHODS

We performed a qualitative study in which in-depth semistructured interviews were conducted with 15 OA patients recruited from 4 general practices in Sydney, Australia. Patients were ages ≥65 years, and were currently taking or had recently taken an NSAID for OA.

RESULTS

Three key themes emerged from the data: reliance, routine, and pill load. Patients were strongly reliant upon NSAIDs because they consistently satisfied their needs. By contrast, they were much less reliant upon acetaminophen because of uncertainty or skepticism about its effectiveness. They were not reliant upon CMs but were willing to take them indefinitely because they were perceived as being without risk. Many patients took an NSAID as well as CMs as part of a "daily routine." By contrast, patients had difficulty developing a routine around using acetaminophen at the recommended maximum dose because of the implicit frequency of dosing required and an aversion to the associated "pill load."

CONCLUSION

The results highlight the importance of exploring the perceptions and preferences of patients with regard to analgesics for OA. Clinician advice regarding analgesia for OA should take account of the possible reliance of the patient upon an NSAID, their medicine routines, and their potential concern about the pill load associated, in particular, with acetaminophen.