Monitoring healthy people 2010 arthritis management objectives: education and clinician counseling for weight loss and exercise

Developing a Primary Care-Focused Intervention to Engage Patients With Osteoarthritis in Physical Activity: A Stakeholder Engagement Qualitative Study

Physical activity (PA) is important for managing osteoarthritis (OA), but many patients are inactive. Research is needed on strategies to leverage clinical encounters to engage patients in PA. Guided by the socioecological model of health behavior, this study aimed to engage stakeholders in the process of refining an Osteoarthritis Physical Activity Care Pathway (OA-PCP). Six focus groups and seven individual interviews were conducted with key stakeholders. Focus groups were specific to stakeholder roles and included patients with OA, support partners, and clinic personnel (n = 6 focus groups). Interview participants were local and national PA program representatives (n = 7 interviews). Data were analyzed by thematic analysis. Themes identified in the data included ways the OA-PCP can help patients with OA address challenges to PA engagement, strategies for connecting patients with PA resources, methods for implementing OA-PCP into clinical settings and potential use of PA trackers in the OA-PCP program. Stakeholders' comments were summarized into key recommendations for OA-PCP. Some recommendations reinforced and led to refinements in planned aspects of OA-PCP, including tailoring to individual patients, involvement of a support partner, and addressing pain with PA. Other recommendations resulted in larger changes for OA-PCP, including the addition of three email- or mail-based contacts and not requiring use of a PA tracker. The refined OA-PCP program is being evaluated in an exploratory trial, with the ultimate goal of establishing a PA program for OA that can be successfully implemented in clinical settings.

Benefits and promotion of physical activity in rheumatoid arthritis

PURPOSE OF REVIEW

The aim of this article is to describe the benefits of physical activity and exercise on rheumatoid arthritis disease activity, functioning, and symptoms; and offer recommendations for promotion of physical activity and exercise among people with rheumatoid arthritis.

RECENT FINDINGS

In addition to well-known benefits of exercise such as improving cardiovascular health and metabolic syndrome and reducing obesity, exercise has consistently shown rheumatoid arthritis-specific benefits. Exercise and increases in physical activity improve clinically measured disease activity, reduce symptoms such as fatigue and pain, and improve function and mental health. In spite of these benefits, most people with rheumatoid arthritis are inactive. Patient barriers to engaging in physical activity may include fears of joint damage, rheumatoid arthritis symptoms, and lack of understanding that physical activity improves the symptoms that may be barriers. However, the greatest barrier to healthy levels of physical activity among individuals with rheumatoid arthritis appears to be the lack of direction from healthcare providers.

SUMMARY

Exercise is safe and highly beneficial for people with rheumatoid arthritis. Because receiving recommendations from healthcare providers may be the factor most strongly associated with engaging in physical activity or exercise, providers are encouraged to give patients positive messages about the benefits of physical activity and the extremely low risks of harm.

Marketing Self-management Education: Lessons on Messaging and Framing

Objective Self-management education (SME) refers to educational interventions that help individuals with chronic diseases maintain or improve their quality of life. To help increase SME participation, the US Centers for Disease Control and Prevention conducted audience research to assess feasibility of a campaign to market SME as a chronic disease management strategy and increase future receptivity to specific SME programs. Methods Twenty focus groups were conducted in 3 rounds across 8 cities with men and women ages 45-75 with a variety of, or multiple, chronic conditions. Data were analyzed to identify cross-cutting themes and assess differences by sex, race/ethnicity, and location. Results Findings revealed that although people with chronic disease are not aware of SME, it is feasible to deliver motivating messages about SME, and content need not be condition- or intervention-specific. Concepts viewed most positively by focus groups incorporated positive tone, empowering language, specific references to health, relatable images, and a website for more information. Conclusion This qualitative work suggests SME marketing strategies will be most effective by providing background information, framing messages positively, using clear relatable language, and making it easy for potential participants to find a program.

Gaps in appropriate use of treatment strategies in osteoarthritis

Optimal management of osteoarthritis (OA) requires a combination of therapies, with behavioral (e.g., exercise and weight management) and rehabilitative components at the core, accompanied by pharmacological treatments and, in later stages, consideration of joint replacement surgery. Although multiple sets of OA treatment guidelines have been developed, there are gaps in the implementation of these recommendations. Key areas of concern include the underuse of exercise, weight management, and other behavioral and rehabilitation strategies as well as the overuse of opioid analgesics. In this review, we describe the major categories of treatment strategies for OA, including self-management, physical activity, weight management, physical therapy and other rehabilitative therapies, pharmacotherapies, and joint replacement surgery. For each category, we discuss the current evidence base to report on appropriate use, data regarding adherence to treatment recommendations, and potential approaches to optimize use.

Effect of Comprehensive Behavioral and Exercise Intervention on Physical Function and Activity Participation After Total Knee Replacement: A Pilot Randomized Study

OBJECTIVE

To test the feasibility of a comprehensive behavioral intervention (CBI) program that combines intense exercises with an education program, to be implemented at a later stage (3 months) following total knee replacement (TKR), and to get a first impression of the effects of the CBI as compared to a standard of care exercise (SCE) program on the outcomes of physical function and physical activity.

METHODS

A total of 44 subjects participated in a 3-month program of either CBI or SCE, followed by 3 months of a home exercise program. Outcomes of physical function and physical activity were measured at baseline and at 6-month followup. Analysis of variance was used to compare statistical differences between groups, whereas responder analyses were used for clinically important differences.

RESULTS

The CBI was found to be safe and well tolerated. As compared to the SCE group, the CBI group had less pain (P = 0.035) and better physical function based on the Short Form 36 health survey (P = 0.017) and the single-leg stance test (P = 0.037). The other outcome measures did not demonstrate statistically significant differences between the 2 groups. Results from the responder analysis demonstrated that the CBI group had a 36% higher rate of responders in physical function as compared to the SCE group. Also, the CBI group had 23% more responders in the combined domains of physical function and physical activity.

CONCLUSION

The CBI program is feasible and improves physical function and physical activity in patients several months after TKR. Larger pragmatic randomized trials are needed to confirm the results of this study.

Self-Management Education Participation Among US Adults With Arthritis: Who's Attending?

OBJECTIVE

Self-management education (SME) programs teach people with chronic conditions skills to manage their health conditions. We examined patterns in SME program participation among US adults with arthritis ages ≥18 years.

METHODS

Respondents with arthritis were those who reported ever being diagnosed with arthritis by a doctor or health care provider. We analyzed 2014 National Health Interview Survey data to estimate the percentage (unadjusted and age-standardized) who ever attended an SME program overall and for selected subgroups, representativeness of SME participants relative to all adults with arthritis, and trends in SME course participation.

RESULTS

In 2014, 1 in 9 US adults with arthritis (11.3% [95% confidence interval (95% CI) 10.4-12.3]; age-standardized 11.4% [95% CI 10.0-12.9]) had ever participated in an SME program. SME participation (age-standardized) was highest among those with ≥8 health care provider visits in the past 12 months (16.0% [95% CI 13.1-19.4]). Since 2002, the number of adults with arthritis who have ever participated in SME has increased by 1.7 million, but the percentage has remained constant.

CONCLUSION

Despite its many benefits, SME participation among US adults with arthritis remains persistently low. By recommending that their patients attend SME programs, health care providers can increase the likelihood that their patients experience SME program benefits.

Obesity Trends Among US Adults With Doctor-Diagnosed Arthritis 2009-2014

OBJECTIVE

Arthritis and obesity are common co-occurring conditions that can increase disability and the risk of adverse outcomes (e.g., total knee replacement).

METHODS

We estimated recent obesity trends among adults with arthritis from 2009 to 2014, overall and by various sociodemographic and health characteristics using data from National Health Interview Survey, an ongoing, nationally representative, in-person household self-reported survey of the noninstitutionalized civilian US. A secondary aim was to examine the distribution of body mass index categories among adults with and without arthritis.

RESULTS

Obesity prevalence did not change significantly over time among middle-aged and younger adults with doctor-diagnosed arthritis either overall (P = 0.925 for both groups) or by demographic and health characteristics. Among older adults with doctor-diagnosed arthritis, the unadjusted obesity prevalence was 29.4% in 2009 and 34.3% in 2014; after adjusting for all demographic and health characteristics, there was a significant relative increase in obesity prevalence (15% [95% confidence interval 6-25]) and over time (P = 0.001). The age-standardized prevalence of obesity and the obesity subclasses I, II, and III among adults with doctor-diagnosed arthritis (compared with adults without doctor-diagnosed arthritis) was 40.3% versus 26.3%, 20.1% versus 16.4%, 10.4% versus 6.2%, and 9.8% versus 3.6%, respectively (P < 0.001 for all 4 comparisons).

CONCLUSION

Obesity increased significantly over time among older adults with arthritis and remains high when compared with adults without arthritis. A greater dissemination of interventions focused on physical activity and diet are needed in order to reduce adverse outcomes associated with obesity and arthritis.

Group Versus Individual Physical Therapy for Veterans With Knee Osteoarthritis: Randomized Clinical Trial

BACKGROUND

Efficient approaches are needed for delivering nonpharmacological interventions for management of knee osteoarthritis (OA).

OBJECTIVE

This trial compared group-based versus individual physical therapy interventions for management of knee OA.

DESIGN AND METHODS

Three hundred twenty patients with knee OA at the VA Medical Center in Durham, North Carolina, (mean age=60 years, 88% male, 58% nonwhite) were randomly assigned to receive either the group intervention (group physical therapy; six 1-hour sessions, typically 8 participants per group) or the individual intervention (individual physical therapy; two 1-hour sessions). Both programs included instruction in home exercise, joint protection techniques, and individual physical therapist evaluation. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; range=0-96, higher scores indicate worse symptoms), measured at baseline, 12 weeks, and 24 weeks. The secondary outcome measure was the Short Physical Performance Battery (SPPB; range=0-12, higher scores indicate better performance), measured at baseline and 12 weeks. Linear mixed models assessed the difference in WOMAC scores between arms.

RESULTS

At 12 weeks, WOMAC scores were 2.7 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% confidence interval [CI]=-5.9, 0.5; P=.10), indicating no between-group difference. At 24 weeks, WOMAC scores were 1.3 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-4.6, 2.0; P=.44), indicating no significant between-group difference. At 12 weeks, SPPB scores were 0.1 points lower in the group physical therapy arm compared with the individual physical therapy arm (95% CI=-0.5, 0.2; P=.53), indicating no difference between groups.

LIMITATIONS

This study was conducted in one VA medical center. Outcome assessors were blinded, but participants and physical therapists were not blinded.

CONCLUSIONS

Group physical therapy was not more effective than individual physical therapy for primary and secondary study outcomes. Either group physical therapy or individual physical therapy may be a reasonable delivery model for health care systems to consider.

A population analysis of self-management and health-related quality of life for chronic musculoskeletal conditions

Background

There is growing policy emphasis on self‐management as an essential component of musculoskeletal chronic care models. Underpinning this drive is the assumption that with correct ‘informational’ framing people will better manage their condition's progression and thereby maintain quality of life.

Objective

To assess associations between self‐management behaviours and health‐related quality of life for people with chronic musculoskeletal conditions.

Design

Using survey data from health census and follow‐up structured telephone interviews, linear regression (cumulatively adjusted for potential confounders) and logistic regression examined associations between use of specific self‐management behaviours and quality of life.

Setting and participants

A total of 885 respondents (2012) who indicated still having a musculoskeletal condition reported in a 2010 health census (Port Lincoln, South Australia).

Variables

Specific self‐management activities, age, sex, education, marital status, smoking, comorbidities and pain.

Outcome measure

EQ‐5D‐5L.

Results

Exercise (63%) and diet (19%) were the most commonly reported self‐management activities used to manage musculoskeletal conditions. About 24% reported not using any specific self‐management activities. Involvement in self‐management showed no association with quality of life, with and without adjustment for confounders. Diet had a negative association with quality of life as did use of formal support (self‐management course or community group support).

Discussion

Taking a real‐world perspective, these findings raise important questions about how people currently engage with self‐management activities and the kinds of outcomes that can be expected from undertaking these activities. The timing of people's uptake of self‐management within the musculoskeletal disease continuum is an issue requiring further attention in both research and practice.

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.

Clinic variation in recruitment metrics, patient characteristics and treatment use in a randomized clinical trial of osteoarthritis management

Background

The Patient and PRovider Interventions for Managing Osteoarthritis (OA) in Primary Care (PRIMO) study is one of the first health services trials targeting OA in a multi-site, primary care network. This multi-site approach is important for assessing generalizability of the interventions. These analyses describe heterogeneity in clinic and patient characteristics, as well as recruitment metrics, across PRIMO study clinics.

Methods

Baseline data were obtained from the PRIMO study, which enrolled n = 537 patients from ten Duke Primary Care practices. The following items were examined across clinics with descriptive statistics: (1) Practice Characteristics, including primary care specialty, numbers and specialties of providers, numbers of patients age 55+, urban/rural location and county poverty level; (2) Recruitment Metrics, including rates of eligibility, refusal and randomization; (3) Participants’ Characteristics, including demographic and clinical data (general and OA-related); and (4) Participants’ Self-Reported OA Treatment Use, including pharmacological and non-pharmacological therapies. Intraclass correlation coefficients (ICCs) were computed for participant characteristics and OA treatment use to describe between-clinic variation.

Results

Study clinics varied considerably across all measures, with notable differences in numbers of patients age 55+ (1,507-5,400), urban/rural location (ranging from “rural” to “small city”), and proportion of county households below poverty level (12%-26%). Among all medical records reviewed, 19% of patients were initially eligible (10%-31% across clinics), and among these, 17% were randomized into the study (13%-21% across clinics). There was considerable between-clinic variation, as measured by the ICC (>0.01), for the following patient characteristics and OA treatment use variables: age (means: 60.4-66.1 years), gender (66%-88% female), race (16%-61% non-white), low income status (5%-27%), presence of hip OA (26%-68%), presence both knee and hip OA (23%-61%), physical therapy for knee OA (24%-61%) and hip OA (0%-71%), and use of knee brace with metal supports (0%-18%).

Conclusions

Although PRIMO study sites were part of one primary care practice network in one health care system, clinic and patient characteristics varied considerably, as did OA treatment use. This heterogeneity illustrates the importance of including multiple, diverse sites in trials for knee and hip OA, to enhance the generalizability and evaluate potential for real-world implementation.

Trial registration

Clinical Trial Registration Number: NCT 01435109

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-413) contains supplementary material, which is available to authorized users.

Self-reported arthritis burden and management in South Carolina

OBJECTIVE

Arthritis has garnered national attention as the leading cause of disability, yet it is important to survey the burden and management of this disabling condition at the state and local levels. This study explored the self-reported burden and management of arthritis in South Carolina using state-based data relative to other prominent chronic diseases.

METHODS

Data from 9580 adults in South Carolina who participated in the 2009 Behavioral Risk Factor Surveillance System were used to quantify the self-reported burden and management of arthritis within the past year.

RESULTS

Estimates indicate that 31% (3043) of adults in South Carolina were diagnosed as having arthritis in 2009. The burden of arthritis was evident with 49% (1954) of the individuals with arthritis experiencing activity limitations, 39% (1500) reported arthritis affected their employment, 92% (3705) reported living with pain, and 44% (1787) reported restricted social activities. Self-reported arthritis management included advice to lose weight (37%), encouragement to exercise (57%), and limited education on proper management (11%). The majority (75%) of individuals reported that arthritis interferes with their ability to accomplish what they want.

CONCLUSIONS

Arthritis is more prevalent and burdensome for individuals in South Carolina when compared with national estimates. These findings suggest that there are potential educational opportunities to increase awareness of the disease and its burden, as well as improve education and disease management.

The impact of lifestyle medicine continuing education on provider knowledge, attitudes, and counseling behaviors

BACKGROUND

There is a need for effective continuing medical education (CME) programs to increase healthcare providers' knowledge and skills in lifestyle medicine so that healthcare providers are better equipped to assist patients in adopting and maintaining healthier lifestyle behaviors.

AIMS

To evaluate the impact of five live face-to-face CME programs in lifestyle medicine on providers' barriers, knowledge, confidence, and professional counseling behaviors.

METHODS

200 participants completed researcher-generated surveys before and 90 days after each CME program. Paired t-tests measured significant changes for all outcome variables, and regression analyses assessed predictors of these changes.

RESULTS

Barriers that were targeted during the programs, i.e. lack of knowledge/skills, lack of materials, and perceived poor patient compliance showed highly significant improvement. Participants also reported significant changes in knowledge, confidence, and counseling behaviors in the areas of exercise and stress management. Some improvements occurred in areas that the CME programs did not target as much, i.e. nutrition, smoking, and weight management. The greatest predictor of change was the baseline level of scores. Those participants who could most benefit from change did show the largest improvements.

CONCLUSIONS

Live CME programs can be effective in educating healthcare providers about topics within the rapidly expanding field of lifestyle medicine.

Perceived versus actual factors associated with adoption and maintenance of an evidence-based physical activity program

The public health burden of arthritis requires the dissemination of evidence-based physical activity (PA) programs for arthritis. This study examined perceived vs. actual factors related to the adoption and maintenance of PA programs and Fit and Strong! Six focus groups (n = 46) were conducted in two states with potential Fit and Strong! providers. Key informant interviews (n = 18) were conducted with actual Fit and Strong! providers. Participant interest was a primary motivator for PA program adoption in both focus groups and key informant interviews. Fit and Strong's evidence base was a motivator for adoption among focus group participants. The primary perceived barrier to adopting Fit and Strong! among focus group participants was cost/resource limitations compared to scheduling among key informants. Evidence-based programs need to craft different messages to deal with barriers perceived and experienced by providers engaged in specific stages of the translation process.

A public health approach to addressing arthritis in older adults: the most common cause of disability

Arthritis is highly prevalent and is the leading cause of disability among older adults in the United States owing to the aging of the population and increases in the prevalence of risk factors (e.g., obesity). Arthritis will play a large role in the health-related quality of life, functional independence, and disability of older adults in the upcoming decades. We have emphasized the role of the public health system in reducing the impact of this large and growing public health problem, and we have presented priority public health actions.