Predictors of response to physical therapy intervention in patients with primary hip osteoarthritis

Exploration of heterogeneity of treatment effects across exercise-based interventions for knee osteoarthritis

Objective

Variability exists in the degree of improvement patients experience following exercise-based interventions (EBIs) for knee osteoarthritis (KOA), but understanding of this heterogeneity is limited. Using a machine learning approach, this study leveraged data from two randomized controlled trials (RCTs) to identify patient characteristics contributing to differential treatment effects.

Design

The RCTs enrolled n ​= ​621 patients and evaluated three EBIs (group-based physical therapy (PT), individual PT, and a Stepped Exercise Program) and an education control group. The primary outcome was change in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from baseline to end of treatment. Predictors included 25 demographic, clinical, and psychosocial characteristics. Three metalearners with three machine learning algorithms each and a simple interpretable model-based regression tree were used to identify subgroups with differential treatment effects. Fit was evaluated with holdout/validation data using root mean square error and mean absolute error.

Results

The regression tree model outperformed all 9 metalearner models. Tree results suggested group-based PT yielded the largest improvement in mean WOMAC score. Only two subgroups were identified: baseline WOMAC score≤44 versus >44. Group-based PT was the optimal treatment regardless of baseline WOMAC score, but results were more ambiguous for patients with higher initial WOMAC score. For all 3 EBIs, patients with higher baseline WOMAC score made greater improvements.

Conclusion

Results suggest individuals with moderate or greater KOA symptoms may benefit more from EBIs than those with less severe symptoms and that group-based PT is a promising approach for KOA.

The addition of body weight supported treadmill training to manual therapy and exercise in the management of Hip osteoarthritis: A case series

BACKGROUND AND PURPOSE

Patients with mild-to-moderate hip OA can present with pain, a decline in function, altered gait mechanics, and pain with ambulation. Body weight supported treadmill training (BWSTT) has been utilized for patients with total hip arthroplasty, hip fracture, and lumbar spinal stenosis. The purpose of this case series was to report the outcomes of patients with hip OA that received guideline adherent physical therapy care with the addition of BWSTT. Our aim was to assess changes in pain, disability, and physical performance.

CASE DESCRIPTIONS

Seven patients participated in eight 1-h treatment sessions consisting of: manual therapy, therapeutic exercise, and BWSTT. Pre- and post-treatment outcome measures included: average pain rating via the Numeric Pain Rating Scale (NPRS), Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), and the Global Rate of Change (GROC). Physical performance measures included: 6-minute walk test (6MWT), stair climbing test, and 5 time sit-stand.

OUTCOMES

The mean improvement in NPRS score for all subjects was 2.9 points. Mean improvement on the WOMAC was 18.5 + 24.8 pts, and the mean GROC score was +5.0 indicating a rating of "quite a bit better." The mean increase in 6MWT distance was 60.5 + 80.1 meters (median 39 m, range -3 to 230).

CONCLUSIONS

Though patients participating in a multimodal rehabilitation approach including manual therapy, exercise, and BWSTT demonstrated clinically important improvements in pain and function, these changes may not correspond with gait endurance improvements in the short term.

Baseline knee osteoarthritis radiographic severity as a predictor of symptom response to diet and exercise program: A secondary analysis

OBJECTIVE

To investigate whether baseline joint space narrowing (JSN) predicted disease remission, knee pain, and physical function changes in persons with knee osteoarthritis (OA).

METHODS

This study is a secondary analysis of a two-armed randomized controlled trial. Participants were aged ≥50 years (n = 171) with a body mass index ≥28 kg/m2 and radiographic medial tibiofemoral OA. Participants in the intervention group received diet and exercise programs and special treatment (cognitive behavioral therapy, knee brace, and muscle strengthening exercises) according to the disease remission. Remission of pain and remission of patient global assessment of disease activity and/or functional impairment were used to define the disease remission. The control group were provided with an education pamphlet. The primary outcome was disease remission at 32 weeks, and the secondary outcomes were the changes in knee pain and physical function at 20 and 32 weeks. Baseline JSN was scored from 0 to 3, and the association between baseline JSN and outcomes was assessed using multiple regression.

RESULTS

There was no association of baseline JSN with disease remission at 32 weeks when the disease remission has been achieved. The baseline JSN grade 3 was associated with changes in knee pain at 20 weeks (p < .05). There was no association between baseline JSN and physical function.

CONCLUSION

Baseline JSN severity predicted changes in knee pain but not the disease remission or changes in physical functions. Identification of baseline radiographic severity may be helpful in identifying differences in response to diet and exercise programs in knee OA.

Factors associated with clinically relevant pain reduction after a self-management program including education and exercise for people with knee and/or hip osteoarthritis: Data from the BOA register

AIM

To examine the associations between individual- and disease-related factors and the odds of reaching a clinically relevant pain reduction in people with knee and/or hip osteoarthritis (OA) who underwent a first-line self-management program.

MATERIALS AND METHODS

An observational registry-based study including people with knee (n = 18,871) and hip (n = 7,767) OA who participated in a self-management program including education and exercise and had data recorded in the Better Management of patients with Osteoarthritis (BOA) register. We used multivariable logistic regression models to study the association between sex, age, body mass index (BMI), education, comorbidity, pain frequency, walking difficulties, willingness to undergo surgery and the odds of reaching a clinically relevant pain reduction (decrease of >33% on a 0-10 NRS scale) 3 and 12 months after the intervention. All analyses were stratified by joint (knee/hip).

RESULTS

Both in the short- and long-term follow-up, a younger age (18-65 years), a lower BMI (< 25), a higher level of education (university), the absence of comorbidities impacting the ability to walk, less frequent pain and not being willing to undergo surgery were associated with higher odds of reaching a clinically relevant pain reduction in people with knee OA. We found similar results for people with hip OA, but with larger uncertainty in the estimates (wider 95% CI).

CONCLUSION

Our study suggests that early fist line self-management interventions delivered when people have unilateral hip or knee OA with less frequent pain and are unwilling to undergo surgery, may be important for reaching a clinically relevant pain reduction after participation. Providing the most appropriate treatment to the right patient at the right time is a step in reducing the burden of OA for society and the patient.

Predictors of Treatment Response to Progressive Resistance Training for Adolescents With Cerebral Palsy

OBJECTIVE

The aim of the study was to examine the variability in plantar-flexor muscle strength changes after progressive resistance training for adolescents with cerebral palsy (CP) and to identify baseline variables associated with change in muscle strength.

METHODS

Thirty-three adolescents with CP were randomized to a 10-week progressive resistance training program as part of a randomized controlled trial (STAR trial). The associations between muscle strength at 10 weeks (n = 30 adolescents) and 22 weeks (n = 28 adolescents) and biomechanical and neuromuscular baseline characteristics, motor function, and fidelity to the program were examined with multivariable linear regression.

RESULTS

Changes in plantar-flexor muscle strength from baseline ranged from -47.7% to 192.3% at 10 weeks and -54.3% to 198.4% at 22 weeks. Muscle activation was the only variable associated with change in strength at 10 weeks and 22 weeks. A model containing peak muscle activity and baseline muscle strength explained 49.1% of the variation in change in muscle strength (R2 = 0.491) at 10 weeks and 49.2% of the variation in change muscle strength at 22 weeks (R2 = 0.492).

CONCLUSION

Assessing levels of muscle activation may be able to identify responders to a progressive resistance training program for adolescents with CP. These findings are a first step toward developing tools that can inform decision making in the clinical setting.

IMPACT

Due to the heterogenous nature of CP, it is challenging to assess the efficacy of strength training programs in individuals with CP and to understand the variability in outcomes among participants. This study provides a better understanding of the factors that predict response to an exercise program so that resistance training can be directed to those who will potentially benefit from it.

LAY SUMMARY

There is wide variability in how well young people with CP respond to resistance training. If you are a young person with CP, your physical therapist can measure the amount of gastrocnemius muscle activity you have, so as to get an indication of how well you will respond.

Prognostic Factors for Health Outcomes After Exercise Therapy and Education in Individuals With Knee and Hip Osteoarthritis With or Without Comorbidities: A Study of 37,576 Patients Treated in Primary Care

OBJECTIVE

To identify prognostic factors for health outcomes following an 8-week supervised exercise therapy and education program for individuals with knee and hip osteoarthritis (OA) alone or with concomitant hypertension, heart or respiratory disease, diabetes mellitus, or depression.

METHODS

We included individuals with knee and/or hip OA from the Good Life With OsteoArthritis in Denmark (GLA:D) program. GLA:D consists of 2 patient education sessions and 12 supervised exercise therapy sessions. Before GLA:D, participants self-reported any comorbidities and were categorized into 8 comorbidity groups. Twenty-one potential prognostic factors (demographic information, clinical data, and performance-based physical function) gathered from participants and clinicians before the program were included. Outcomes were physical function using the 40-meter Fast-Paced Walk Test (FPWT), health-related quality of life using the 5-level EuroQol 5-domain (EQ-5D-5L) index score, and pain intensity using a visual analog scale (VAS; range 0-100) assessed before and immediately after the GLA:D program. Within each comorbidity group, associations of prognostic factors with outcomes were estimated using multivariable linear regression.

RESULTS

Data from 35,496 (40-meter FPWT) and 37,576 (EQ-5D-5L and VAS) participants were included in the analyses. Clinically relevant associations were demonstrated between age, self-efficacy, self-rated health, and pain intensity and change in 40-meter FPWT, EQ-5D-5L, or VAS scores across comorbidity groups. Furthermore, anxiety, education, physical function, and smoking were associated with outcomes among subgroups having depression or diabetes mellitus in addition to OA.

CONCLUSION

Age, self-efficacy, self-rated health, and pain intensity may be prognostic of change in health outcomes following an 8-week exercise therapy and patient education program for individuals with OA, irrespective of comorbidities.

Effectiveness of Dry Needling Therapy on Pain, Hip Muscle Strength, and Physical Function in Patients With Hip Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To investigate the short-term effects of dry needling (DN) on physical function, pain, and hip muscle strength in patients with hip osteoarthritis (OA).

DESIGN

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

SETTING

Private practice physiotherapy clinic.

PARTICIPANTS

Patients with unilateral hip OA (N=45) were randomly allocated to a DN group, sham DN group, or control group.

INTERVENTIONS

Patients in the DN and sham groups received 3 treatment sessions. Three active myofascial trigger points (MTrPs) were treated in each session with DN or a sham needle procedure. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae, and gluteus minimus muscles.

MAIN OUTCOME MEASURES

Physical function was assessed with the Western Ontario and McMaster Universities (WOMAC) physical function subscale, the timed Up and Go test, and the 40-meter self-paced walk test. Intensity of hip pain related to physical function was evaluated using the visual analog scale and WOMAC pain subscale. The maximal isometric force of hip muscles was recorded with a handheld dynamometer.

RESULTS

Significant group by time interactions were shown for physical function, pain, and hip muscle force variables. Post hoc tests revealed a significant reduction in hip pain and significant improvements in physical function and hip muscle strength in the DN group compared with the sham and control groups. The DN group showed within- and between-groups large effect sizes (d>0.8).

CONCLUSIONS

DN therapy in active MTrPs of the hip muscles reduced pain and improved hip muscle strength and physical function in patients with hip OA. DN in active MTrPs of the hip muscles should be considered for the management of hip OA.

Application of Heterogeneity of Treatment Effect Methods: Exploratory Analyses of a Trial of Exercise-Based Interventions for Knee OA

OBJECTIVE

To evaluate heterogeneity of treatment effects (HTE) in a trial of exercise-based interventions for knee osteoarthritis (OA).

METHODS

Participants (n=350) were randomized to standard physical therapy (PT; n=140), Internet-Based Exercise Training (IBET; n=142), or wait list control (WL; n=68). We applied QUalitative INteraction Trees (QUINT), a sequential partitioning method, and Generalized Unbiased Interaction Detection and Estimation (GUIDE), a regression tree approach, to identify subgroups with greater improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score over 4-months. Predictors included 24 demographic, clinical and psychosocial characteristics. We conducted internal validation to estimate optimism (bias) in the range of mean outcome differences among arms.

RESULTS

Both QUINT and GUIDE indicated that for participants with lower body mass index (BMI), IBET was better than PT (improvements of WOMAC ranged from 6.3 to 9.1 points lower) and for those with higher BMI and longer duration of knee OA, PT was better than IBET (WOMAC improvement was 6.3 points). In GUIDE analyses comparing PT or IBET to WL, participants not employed had improvements in WOMAC ranging from 1.8 to 6.8 points lower with PT or IBT vs. WL. From internal validation, there were large corrections to the mean outcome differences among arms; however, after correction some differences remained in the clinically meaningful range.

CONCLUSION

Results suggest there may be subgroups who experience greater improvement in symptoms from PT or IBET, and this could guide referrals and future trials. However, uncertainty persists for specific treatment effect size estimates and how they apply beyond this study sample.

i-CONTENT tool for assessing therapeutic quality of exercise programs employed in randomised clinical trials

OBJECTIVE

When appraising the quality of randomised clinical trial (RCTs) on the merits of exercise therapy, we typically limit our assessment to the quality of the methods. However, heterogeneity across studies can also be caused by differences in the quality of the exercise interventions (ie, 'the potential effectiveness of a specific intervention given the potential target group of patients')-a challenging concept to assess. We propose an internationally developed, consensus-based tool that aims to assess the quality of exercise therapy programmes studied in RCTs: the international Consensus on Therapeutic Exercise aNd Training (i-CONTENT) tool.

METHODS

Forty-nine experts (from 12 different countries) in the field of physical and exercise therapy participated in a four-stage Delphi approach to develop the i-CONTENT tool: (1) item generation (Delphi round 1), (2) item selection (Delphi rounds 2 and 3), (3) item specification (focus group discussion) and (4) tool development and refinement (working group discussion and piloting).

RESULTS

Out of the 61 items generated in the first Delphi round, consensus was reached on 17 items, resulting in seven final items that form the i-CONTENT tool: (1) patient selection; (2) qualified supervisor; (3) type and timing of outcome assessment; (4) dosage parameters (frequency, intensity, time); (5) type of exercise; (6) safety of the exercise programme and (7) adherence to the exercise programme.

CONCLUSION

The i-CONTENT-tool is a step towards transparent assessment of the quality of exercise therapy programmes studied in RCTs, and ultimately, towards the development of future, higher quality, exercise interventions.

Responders to Exercise Therapy in Patients with Osteoarthritis of the Hip: A Systematic Review and Meta-Analysis

The Outcome Measures in Rheumatology workgroup (OMERACT), together with the Osteoarthritis Research Society International (OARSI) developed the OMERACT-OARSI responder criteria. These criteria are used to determine if a patient with osteoarthritis (OA) ‘responds’ to therapy, meaning experiences a clinically relevant effect of therapy. Recently, more clinical OA trials report on this outcome and most OA trials have data to calculate the number of responders according to these criteria. A systematic review and meta-analysis were performed on the response to exercise therapy, compared to no or minimal intervention in patients with hip OA using the OMERACT-OARSI responder criteria. The literature was searched for relevant randomized trials. If a trial fit the inclusion criteria, but number of responders was not reported, the first author was contacted. This way the numbers of responders of 14 trials were collected and a meta-analysis on short term (directly after treatment, 12 trials n = 1178) and long term (6–8 months after treatment, six trials n = 519) outcomes was performed. At short term, the risk difference (RD) was 0.14 (95% confidence interval (CI) 0.06–0.22) and number needed to treat (NNT) 7.1 (95% CI 4.5–17); at long term RD was 0.14 (95% CI 0.07–0.20) and NNT 7.1 (95% CI 5.0–14.3). Quality of evidence was moderate for the short term and high for the long term. In conclusion, 14% more hip OA patients responded to exercise therapy than to no therapy.

Predictors of pain interference and potential gain from intervention in community dwelling adults with joint pain: A prospective cohort study

INTRODUCTION

There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain.

METHODS

A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained.

RESULTS

Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4).

CONCLUSIONS

There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated.

Enhanced recovery in usual health care improves functional recovery after total knee arthroplasty

BACKGROUND

The success of total knee arthroplasty (TKA) is determined by an effective surgical procedure as well as a well-organized clinical care pathway. Research has shown that day-of-surgery mobilization decreases length of stay (LOS) and complication rates. We developed, implemented, and evaluated a new clinical care pathway for patients undergoing TKA, that included early mobilization, using 'Lean Six Sigma (LSS)', with the aim of accelerating functional recovery and reducing LOS.

METHODS

Data derived from physical therapy reports and LOS were compared between the old (n = 85) and the new (n = 85) clinical care pathways for time to functional recovery (using the modified Iowa Level of Assistance Scale), LOS and joint-related readmission. Group differences were evaluated using Mann-Whitney and Chi-Square tests. The clinical care pathway was redesigned using LSS-methods.

RESULTS

After implementation of the new pathway, median time to functional recovery improved from 4 (2-5) to 2 days (1-8)(P < 0.001) and LOS from 7 (5-11) to 4 days (3-12)(P < 0.001), joint-related readmission declined (3.5-2.4%)(P = 0.65).

CONCLUSION

Implementation of the new clinical care pathway accelerated functional recovery and reduced LOS for patients undergoing TKA. Future research should focus on having multiple discharge moments per day which might encourage patients to achieve functional recovery as soon as possible.

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

Background

Osteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.

Objectives

The overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.

Data sources

The North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.

Methods

Workstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.

Results

This programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.

Conclusions

Implementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.

Limitations

The key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.

Future work recommendations

(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.

Trial registration

Current Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Moderators of Effects of Internet-Delivered Exercise and Pain Coping Skills Training for People With Knee Osteoarthritis: Exploratory Analysis of the IMPACT Randomized Controlled Trial

Background

Internet-delivered exercise, education, and pain coping skills training is effective for people with knee osteoarthritis, yet it is not clear whether this treatment is better suited to particular subgroups of patients.

Objective

The aim was to explore demographic and clinical moderators of the effect of an internet-delivered intervention on changes in pain and physical function in people with knee osteoarthritis.

Methods

Exploratory analysis of data from 148 people with knee osteoarthritis who participated in a randomized controlled trial comparing internet-delivered exercise, education, and pain coping skills training to internet-delivered education alone. Primary outcomes were changes in knee pain while walking (11-point Numerical Rating Scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index function subscale) at 3 and 9 months. Separate regression models were fit with moderator variables (age, gender, expectations of outcomes, self-efficacy [pain], education, employment status, pain catastrophizing, body mass index) and study group as covariates, including an interaction between the two.

Results

Participants in the intervention group who were currently employed had significantly greater reductions in pain at 3 months than similar participants in the control group (between-group difference: mean 2.38, 95% CI 1.52-3.23 Numerical Rating Scale units; interaction P=.02). Additionally, within the intervention group, pain at 3 months reduced by mean 0.53 (95% CI 0.28-0.78) Numerical Rating Scale units per unit increase in baseline self-efficacy for managing pain compared to mean 0.11 Numerical Rating Scale units (95% CI –0.13 to 0.35; interaction P=.02) for the control group.

Conclusions

People who were employed and had higher self-efficacy at baseline were more likely to experience greater improvements in pain at 3 months after an internet-delivered exercise, education, and pain coping skills training program. There was no evidence of a difference in the effect across gender, educational level, expectation of treatment outcome, or across age, body mass index, or tendency to catastrophize pain. Findings support the effectiveness of internet-delivered care for a wide range of people with knee osteoarthritis, but future confirmatory research is needed.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12614000243617; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365812&isReview=true (Archived by WebCite at http://www.webcitation.org/6z466oTPs)

The therapeutic validity and effectiveness of physiotherapeutic exercise following total hip arthroplasty for osteoarthritis: A systematic review

Objective

To assess the therapeutic validity and effectiveness of physiotherapeutic exercise interventions following total hip arthroplasty (THA) for osteoarthritis.

Data sources

The databases Embase, MEDLINE, Cochrane Library, CINAHL and AMED were searched from inception up to February 2017.

Eligibility criteria

Articles reporting results of randomized controlled trials in which physiotherapeutic exercise was compared with usual care or with a different type of physiotherapeutic exercise were included, with the applied interventions starting within six months after THA. Only articles written in English, German or Dutch were included.

Study appraisal

Therapeutic validity (using the CONTENT scale) and risk of bias (using both the PEDro scale and the Cochrane Collaboration’s tool) were assessed by two researchers independently. Characteristics of the physiotherapeutic exercise interventions and results about joint and muscle function, functional performance and self-reported outcomes were extracted.

Results

Of the 1124 unique records retrieved, twenty articles were included. Only one article was considered to be of high therapeutic validity. Description and adequacy of patient selection were the least reported items. The majority of the articles was considered as having potentially high risk of bias, according to both assessment tools. The level of therapeutic validity did not correspond with the risk of bias scores. Because of the wide variety in characteristics of the physiotherapeutic exercise and control interventions, follow-up length and outcome measures, limited evidence was found on the effectiveness of physiotherapeutic exercise following THA.

Conclusion

The insufficient therapeutic validity and potentially high risk of bias in studies involving physiotherapeutic exercise interventions limit the ability to assess the effectiveness of these interventions following THA. Researchers are advised to take both quality scores into account when developing and reporting studies involving physiotherapeutic exercise. Uniformity in intervention characteristics and outcome measures is necessary to enhance the comparability of clinical outcomes between trials.

Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA): a systematic review update and individual participant data meta-analysis protocol

INTRODUCTION

Knee and hip osteoarthritis (OA) is a leading cause of disability worldwide. Therapeutic exercise is a recommended core treatment for people with knee and hip OA, however, the observed effect sizes for reducing pain and improving physical function are small to moderate. This may be due to insufficient targeting of exercise to subgroups of people who are most likely to respond and/or suboptimal content of exercise programmes. This study aims to identify: (1) subgroups of people with knee and hip OA that do/do not respond to therapeutic exercise and to different types of exercise and (2) mediators of the effect of therapeutic exercise for reducing pain and improving physical function. This will enable optimal targeting and refining the content of future exercise interventions.

METHODS AND ANALYSIS

Systematic review and individual participant data meta-analyses. A previous comprehensive systematic review will be updated to identify randomised controlled trials that compare the effects of therapeutic exercise for people with knee and hip OA on pain and physical function to a non-exercise control. Lead authors of eligible trials will be invited to share individual participant data. Trial-level and participant-level characteristics (for baseline variables and outcomes) of included studies will be summarised. Meta-analyses will use a two-stage approach, where effect estimates are obtained for each trial and then synthesised using a random effects model (to account for heterogeneity). All analyses will be on an intention-to-treat principle and all summary meta-analysis estimates will be reported as standardised mean differences with 95% CI.

ETHICS AND DISSEMINATION

Research ethical or governance approval is exempt as no new data are being collected and no identifiable participant information will be shared. Findings will be disseminated via national and international conferences, publication in peer-reviewed journals and summaries posted on websites accessed by the public and clinicians.

PROSPERO REGISTRATION NUMBER

CRD42017054049.

Wearable sensors to predict improvement following an exercise intervention in patients with knee osteoarthritis

Background

Muscle strengthening exercises consistently demonstrate improvements in the pain and function of adults with knee osteoarthritis, but individual response rates can vary greatly. Identifying individuals who are more likely to respond is important in developing more efficient rehabilitation programs for knee osteoarthritis. Therefore, the purpose of this study was to determine if pre-intervention multi-sensor accelerometer data (e.g., back, thigh, shank, foot accelerometers) and patient reported outcome measures (e.g., pain, symptoms, function, quality of life) can retrospectively predict post-intervention response to a 6-week hip strengthening exercise intervention in a knee OA cohort.

Methods

Thirty-nine adults with knee osteoarthritis completed a 6-week hip strengthening exercise intervention and were sub-grouped as Non-Responders, Low-Responders, or High-Responders following the intervention based on their change in patient reported outcome measures. Pre-intervention multi-sensor accelerometer data recorded at the back, thigh, shank, and foot and Knee Injury and Osteoarthritis Outcome Score subscale data were used as potential predictors of response in a discriminant analysis of principal components.

Results

The thigh was the single best placement for classifying responder sub-groups (74.4%). Overall, the best combination of sensors was the back, thigh, and shank (81.7%), but a simplified two sensor solution using the back and thigh was not significantly different (80.0%; p = 0.27).

Conclusions

While three sensors were best able to identify responders, a simplified two sensor array at the back and thigh may be the most ideal configuration to provide clinicians with an efficient and relatively unobtrusive way to use to optimize treatment.

Electronic supplementary material

The online version of this article (10.1186/s12984-017-0309-z) contains supplementary material, which is available to authorized users.

Predictors of response to prefabricated foot orthoses or rocker-sole footwear in individuals with first metatarsophalangeal joint osteoarthritis

BACKGROUND

Osteoarthritis of the first metatarsophalangeal joint (1st MTPJ OA) is a common and disabling condition commonly managed with footwear and orthotic interventions. The objective of this study was to identify factors associated with a successful treatment response in people with 1st MTPJ OA provided with prefabricated orthoses or rocker-sole footwear as part of a randomised clinical trial.

METHODS

People with 1st MTPJ OA (n = 88) who participated in a randomised trial were allocated to receive prefabricated foot orthoses (n = 47) or rocker-sole footwear (n = 41) and completed a baseline questionnaire including information on demographics, anthropometrics, general health, pain characteristics (including the Foot Health Status Questionnaire [FHSQ] and Foot Function Index [FFI]) and perceptions of the interventions, and a clinical assessment of foot posture, range of motion, radiographic severity and in-shoe plantar pressures. Adherence was documented using diaries. At 12 weeks, participants documented their perception of improvement on a 15-point scale. Those reporting at least moderate improvement on this scale were classified as 'responders'.

RESULTS

There were 29 responders (62%) in the orthoses group and 16 responders (39%) in the rocker-sole group. In the orthoses group, responders had greater baseline pain severity while walking, a higher FFI difficulty score, and wore their orthoses more frequently. In the rocker-sole group, responders had a higher FFI stiffness score and greater radiographic severity. However, the accuracy of these variables in identifying responders in each group was modest (62 and 53%, respectively).

CONCLUSION

The response to prefabricated orthoses or rocker-sole footwear in people with 1st MTPJ OA is related to measures of increased pain and disease severity. However, the overall classification accuracy associated with these factors is not sufficient for identifying individuals who are most likely to benefit from these interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613001245785.

Can We Predict Those With Osteoarthritis Who Will Worsen Following a Chronic Disease Management Program?

OBJECTIVE

To identify predictors of worsening symptoms and overall health of the treated hip or knee joint following 26 weeks of a nonsurgical chronic disease management program for hip and knee osteoarthritis (OA) and to examine the consistency of these predictors across 3 definitions of worsening.

METHODS

This prospective cohort study followed 539 participants of the program for 26 weeks. The 3 definitions of worsening included symptomatic worsening based on change in the Western Ontario and McMaster Universities Osteoarthritis Index Global score (WOMAC-G) measuring pain, stiffness, and function; a transition scale that asked about overall health of the treated hip or knee joint; and a composite outcome including both. Multivariate logistic regression models were constructed for the 3 definitions of worsening.

RESULTS

Complete data were available for 386 participants: mean age was 66.3 years, 69% were female, 85% reported knee joint pain as primary symptom (signal joint), 46% were waitlisted for total joint arthroplasty (TJA). TJA waitlist status, signal joint, 6-Minute Walk Test (6MWT), depressive symptoms, pain, and age were independently associated with at least 1 definition of worsening. TJA waitlist status and 6MWT remained in the multivariate models for the transition and composite definitions of worsening.

CONCLUSION

Participants reporting worsening on the transition scale did not consistently meet the WOMAC-G definition of worsening symptoms. TJA waitlist status was predictive of the composite definition of worsening, a trend apparent for the transition definition. However, variables that predict worsening remain largely unknown. Further research is required to direct comprehensive and targeted management of patients with hip and knee OA.

Gait Biomechanics and Patient-Reported Function as Predictors of Response to a Hip Strengthening Exercise Intervention in Patients with Knee Osteoarthritis

Objective

Muscle strengthening exercises have been shown to improve pain and function in adults with mild-to-moderate knee osteoarthritis, but individual response rates can vary greatly. Predicting individuals who respond and those who do not is important in developing a more efficient and effective model of care for knee osteoarthritis (OA). Therefore, the purpose of this study was to use pre-intervention gait kinematics and patient-reported outcome measures to predict post-intervention response to a 6-week hip strengthening exercise intervention in patients with mild-to-moderate knee OA.

Methods

Thirty-nine patients with mild-to-moderate knee osteoarthritis completed a 6-week hip-strengthening program and were subgrouped as Non-Responders, Low-Responders, or High-Responders following the intervention based on their change in Knee injury Osteoarthritis Outcome Score (KOOS). Predictors of responder subgroups were retrospectively determined from baseline patient-reported outcome measures and kinematic gait parameters in a discriminant analysis of principal components. A 3–4 year follow-up on 16 of the patients with knee OA was also done to examine long-term changes in these parameters.

Results

A unique combination of patient-reported outcome measures and kinematic factors was able to successfully subgroup patients with knee osteoarthritis with a cross-validated classification accuracy of 85.4%. Lower patient-reported function in daily living (ADL) scores and hip frontal plane kinematics during the loading response were most important in classifying High-Responders from other sub-groups, while a combination of hip, knee, ankle kinematics were used to classify Non-Responders from Low-Responders.

Conclusion

Patient-reported outcome measures and objective biomechanical gait data can be an effective method of predicting individual treatment success to an exercise intervention. Measuring gait kinematics, along with patient-reported outcome measures in a clinical setting can be useful in helping make evidence-based decisions regarding optimal treatment for patients with knee OA.

Thrust joint manipulation curricula in first-professional physical therapy education: 2012 update

STUDY DESIGN

Descriptive online observational survey.

OBJECTIVES

To identify the extent of thrust joint manipulation (TJM) integration into first-professional physical therapy program curricula.

BACKGROUND

The most recent survey of TJM curricula was published in 2004, with a wide variation in faculty responses noted. Since that time, faculty resources have been developed and TJM language in "A Normative Model of Physical Therapist Professional Education" from the American Physical Therapy Association has been updated, leaving the current status of TJM education in curricula unknown.

METHODS

Faculty from 205 accredited physical therapy programs were invited to participate in an anonymous 35-item electronic survey during the summer of 2012.

RESULTS

Seventy-two percent of programs responded to the survey, with 99% of programs teaching TJM and 97% of faculty believing TJM to be an entry-level skill. Cervical spine TJM is still being taught at a lower rate than techniques for other body regions. Faculty deemed 91% and 77% of students, respectively, at or above entry-level competency for implementing TJM in their clinical practice upon graduation. Most respondents indicated that increased utilization of TJM during clinical affiliations (78%) and lab hours (78%) would be beneficial to the student's knowledge/application of TJM.

CONCLUSION

The utilization of TJM and faculty perceptions in first-professional physical therapy programs in the United States have evolved over the past decade. With TJM content more fully integrated into educational curricula, programs can now look to refine teaching strategies that enhance learning outcomes.

Does clinical presentation predict response to a nonsurgical chronic disease management program for endstage hip and knee osteoarthritis?

OBJECTIVE

To identify baseline characteristics of participants who will respond favorably following 6 months of participation in a chronic disease management program for hip and knee osteoarthritis (OA).

METHODS

This prospective cohort study assessed 559 participants at baseline and following 6 months of participation in the Osteoarthritis Chronic Care Program. Response was defined as the minimal clinically important difference of an 18% and 9-point absolute improvement in the Western Ontario and McMaster Universities Arthritis Index global score. Multivariate logistic regression modeling was used to identify predictors of response.

RESULTS

Complete data were available for 308 participants. Those who withdrew within the study period were imputed as nonresponders. Three variables were independently associated with response: signal joint (knee vs hip), sex, and high level of comorbidity. Index joint and sex were significant in the multivariate model, but the model was not a sensitive predictor of response.

CONCLUSION

Strong predictors of response to a chronic disease management program for hip and knee OA were not identified. The significant predictors that were found should be considered in future studies.

Predictors of short-term outcome to exercise and manual therapy for people with hip osteoarthritis

BACKGROUND

Physical therapy for hip osteoarthritis (OA) has shown short-term effects but limited long-term benefit. There has been limited research, with inconsistent results, in identifying prognostic factors associated with a positive response to physical therapy.

OBJECTIVES

The purpose of this study was to identify potential predictors of response to physical therapy (exercise therapy [ET] with or without adjunctive manual therapy [MT]) for hip OA based on baseline patient-specific and clinical characteristics.

DESIGN

A prognostic study was conducted.

METHODS

Secondary analysis of data from a multicenter randomized controlled trial (RCT) (N=131) that evaluated the effectiveness of ET and ET+MT for hip OA was undertaken. Treatment response was defined using OMERACT/OARSI responder criteria. Ten baseline measures were used as predictor variables. Regression analyses were undertaken to identify predictors of outcome. Discriminative ability (sensitivity, specificity, and likelihood ratios) of significant variables was calculated.

RESULTS

The RCT results showed no significant difference in most outcomes between ET and ET+MT at 9 and 18 weeks posttreatment. Forty-six patients were classified as responders at 9 weeks, and 36 patients were classified as responders at 18 weeks. Four baseline variables were predictive of a positive outcome at 9 weeks: male sex, pain with activity (<6/10), Western Ontario and McMaster Universities Osteoarthritis Index physical function subscale score (<34/68), and psychological health (Hospital Anxiety and Depression Scale score <9/42). No predictor variables were identified at the 18-week follow-up. Prognostic accuracy was fair for all 4 variables (sensitivity=0.5-0.58, specificity=0.57-0.72, likelihood ratios=1.25-1.77), indicating fair discriminative ability at predicting treatment response.

LIMITATIONS

The short-term follow-up limits the interpretation of results, and the low number of identified responders may have resulted in possible overfitting of the predictor model.

CONCLUSIONS

The authors were unable to identify baseline variables in patients with hip OA that indicate those most likely to respond to treatment due to low discriminative ability. Further validation studies are needed to definitively define the best predictors of response to physical therapy in people with hip OA.

Immediate effects of hip mobilization on pain and baropodometric variables--a case report

Manual therapy is an important tool for the treatment of musculoskeletal disorders of mechanical origin. Since the hip is an important structure for weight bearing as well as static and dynamic balance, it is suggested that hip impairments may affect weight distribution. Both static and dynamic balance are dependent on adequate joint mobility which in the presence of any kind of alteration can lead to modifications of plantar pressure distribution patterns which, in turn, can be detected by computerized baropodometry. The aim of this study was to verify clinical and baropodometric immediate effects of a single session of hip mobilization in a patient with chronic anterior hip pain. A physically active 21-year old patient underwent a pre-intervention assessment which included pain rating, active and passive range of movement, passive accessory movement as well as static and dynamic barodometry. The intervention consisted of an anteroposterior grade III + mobilization of the right hip, which was conducted with patient in left side-lying with the right hip flexed at approximately 45°. After the intervention, the patient's pain was reduced and there was an improvement in the active movement related to the pain generation. Baropodometric assessment showed plantar peak pressures shift on both feet, from forefoot to rear foot, and there was also reduction in anteroposterior center of pressure displacement on static recording.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial

OBJECTIVE

To evaluate the cost effectiveness of manual physiotherapy, exercise physiotherapy, and a combination of these therapies for patients with osteoarthritis of the hip or knee.

METHODS

206 Adults who met the American College of Rheumatology criteria for hip or knee osteoarthritis were included in an economic evaluation from the perspectives of the New Zealand health system and society alongside a randomized controlled trial. Resource use was collected using the Osteoarthritis Costs and Consequences Questionnaire. Quality-adjusted life years (QALYs) were calculated using the Short Form 6D. Willingness-to-pay threshold values were based on one to three times New Zealand's gross domestic product (GDP) per capita of NZ$ 29,149 (in 2009).

RESULTS

All three treatment programmes resulted in incremental QALY gains relative to usual care. From the perspective of the New Zealand health system, exercise therapy was the only treatment to result in an incremental cost utility ratio under one time GDP per capita at NZ$ 26,400 (-$34,081 to $103,899). From the societal perspective manual therapy was cost saving relative to usual care for most scenarios studied. Exercise therapy resulted in incremental cost utility ratios regarded as cost effective but was not cost saving. For most scenarios combined therapy was not as cost effective as the two therapies alone.

CONCLUSIONS

In this study, exercise therapy and manual therapy were more cost effective than usual care at policy relevant values of willingness-to-pay from both the perspective of the health system and society. Trial registration number Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee: a randomized controlled trial. 1: clinical effectiveness

OBJECTIVE

To evaluate the clinical effectiveness of manual physiotherapy and/or exercise physiotherapy in addition to usual care for patients with osteoarthritis (OA) of the hip or knee.

DESIGN

In this 2 × 2 factorial randomized controlled trial, 206 adults (mean age 66 years) who met the American College of Rheumatology criteria for hip or knee OA were randomly allocated to receive manual physiotherapy (n = 54), multi-modal exercise physiotherapy (n = 51), combined exercise and manual physiotherapy (n = 50), or no trial physiotherapy (n = 51). The primary outcome was change in the Western Ontario and McMaster osteoarthritis index (WOMAC) after 1 year. Secondary outcomes included physical performance tests. Outcome assessors were blinded to group allocation.

RESULTS

Of 206 participants recruited, 193 (93.2%) were retained at follow-up. Mean (SD) baseline WOMAC score was 100.8 (53.8) on a scale of 0-240. Intention to treat analysis showed adjusted reductions in WOMAC scores at 1 year compared with the usual care group of 28.5 (95% confidence interval (CI) 9.2-47.8) for usual care plus manual therapy, 16.4 (-3.2 to 35.9) for usual care plus exercise therapy, and 14.5 (-5.2 to 34.1) for usual care plus combined exercise therapy and manual therapy. There was an antagonistic interaction between exercise therapy and manual therapy (P = 0.027). Physical performance test outcomes favoured the exercise therapy group.

CONCLUSIONS

Manual physiotherapy provided benefits over usual care, that were sustained to 1 year. Exercise physiotherapy also provided physical performance benefits over usual care. There was no added benefit from a combination of the two therapies.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ACTRN12608000130369.

Which prognostic factors for low back pain are generic predictors of outcome across a range of recovery domains?

BACKGROUND

Recovery from low back pain (LBP) is multidimensional and requires the use of multiple-response (outcome) measures to fully reflect these many dimensions. Predictive prognostic variables that are present or stable in all or most predictive models that use different outcome measures could be considered "universal" prognostic variables.

OBJECTIVE

The aim of this study was to explore the potential of universal prognostic variables in predictive models for 4 different outcome measures in patients with mechanical LBP.

DESIGN

Predictive modeling was performed using data extracted from a randomized controlled trial. Four prognostic models were created using backward stepwise deletion logistic, Poisson, and linear regression.

METHODS

Data were collected from 16 outpatient physical therapy facilities in 10 states. All 149 patients with LBP were treated with manual therapy and spine strengthening exercises until discharge. Four different measures of response were used: Oswestry Disability Index and Numeric Pain Rating Scale change scores, total visits, and report of rate of recovery.

RESULTS

The set of statistically significant predictors was dependent on the definition of response. All regression models were significant. Within both forms of the 4 models, meeting the clinical prediction rule for manipulation at baseline was present in all 4 models, whereas no irritability at baseline and diagnosis of sprains and strains were present in 2 of 4 of the predictive models.

LIMITATIONS

The primary limitation is that this study evaluated only 4 of the multiple outcome measures that are pertinent for patients with LBP.

CONCLUSIONS

Meeting the clinical prediction rule was prognostic for all outcome measures and should be considered a universal prognostic predictor. Other predictive variables were dependent on the outcomes measure used in the predictive model.

Targeting care: tailoring nonsurgical management according to clinical presentation

International evidence-based guidelines recommend a multitude of nonsurgical treatment options for the management of osteoarthritis. This article summarizes the evidence available for patient characteristics that have been analyzed as potential predictors of response to nonsurgical interventions for patients with hip and knee osteoarthritis. The specific variables targeted for this review include body mass index, psychological factors, muscle strength, tibiofemoral alignment, radiographic changes, and signs of inflammation. Several studies provide moderate to good evidence of potential predictors of response to nonsurgical treatments, and areas for future research are illuminated.

Physical therapy in persons with osteoarthritis

Osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability. According to a study by Lawrence et al, an estimated 27 million Americans were living with OA in 2008. This number will continue to increase as the population of persons older than 65 years grows. Because of the increasing number of persons who have this chronic condition that causes pain and decreases function, the prevalence of this diagnosis in primary care and musculoskeletal clinics likely will increase. The reduction of pain and improvement in function should be goals of providers who treat these patients. Physical therapy (PT) is a commonly used treatment modality for persons with OA. Many treatment modalities are available within the scope of PT, including strength training, manual therapy, aquatic therapy, electrical stimulation, and balance and perturbation training. A review of the most recent and highest-quality literature regarding these modalities found that strength training, aquatic therapy, and balance and perturbation therapy were the most beneficial with respect to reducing pain and improving function. Evidence clearly indicates that electrical stimulation likely has very little impact on these variables, and evidence regarding manual therapy is equivocal. Literature reviewing prognostic indicators for persons with OA who will likely respond to PT reveal that persons with milder disease (ie, unilateral OA, symptoms for less than 1 year, and a 40-m self-paced walking test of less than 25.9 seconds) and those who have pain of 6 or greater on the numerical pain rating scale are likely to have better outcomes with PT, which suggests that earlier referral is preferable. Barriers to the acceptance of PT as a therapeutic treatment for OA include fatalistic patient and provider perspectives, inadequate analgesia, and a fear among some patients and providers that increased activity will lead to progression of their OA.

Preliminary state of development of prediction models for primary care physical therapy: a systematic review

OBJECTIVE

To summarize the methodological quality and developmental stage of prediction models for musculoskeletal complaints that are relevant for physical therapists in primary care.

STUDY DESIGN AND SETTING

A systematic literature search was carried out in the databases of Medline, Embase, and Cinahl. Studies on prediction models for musculoskeletal complaints that can be used by primary care physical therapists were included. Methodological quality of the studies was assessed and relevant study characteristics were extracted.

RESULTS

The search retrieved 4,702 references of which 29 studies were included in this review. The study quality of the included studies showed substantial variation. The studied populations consisted mostly of back (n=10) and neck pain (n=6) patients, and patients with knee complaints (n=4). Most studies (n=22) used "perceived recovery" as primary outcome. Most prediction models (n=18) were at the derivation level of development.

CONCLUSIONS

Many prediction models are available for a wide range of patient populations. The developmental stage of most models is preliminary and the study quality is often moderate. We do not recommend physiotherapist to use these models yet. All models reviewed here are in the developmental stage and need validation and impact evaluation before using them in daily practice.

Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis

BACKGROUND

Our aim was to develop a rating scale to assess the therapeutic validity of therapeutic exercise programmes. By use of this rating scale we investigated the therapeutic validity of therapeutic exercise in patients awaiting primary total joint replacement (TJR). Finally, we studied the association between therapeutic validity of preoperative therapeutic exercise and its effectiveness in terms of postoperative functional recovery.

METHODS

(Quasi) randomised clinical trials on preoperative therapeutic exercise in adults awaiting TJR on postoperative recovery of functioning within three months after surgery were identified through database and reference screening. Two reviewers extracted data and assessed the risk of bias and therapeutic validity. Therapeutic validity of the interventions was assessed with a nine-itemed, expert-based rating scale (scores range from 0 to 9; score ≥6 reflecting therapeutic validity), developed in a four-round Delphi study. Effects were pooled using a random-effects model and meta-regression was used to study the influence of therapeutic validity.

RESULTS

Of the 7,492 articles retrieved, 12 studies (737 patients) were included. None of the included studies demonstrated therapeutic validity and two demonstrated low risk of bias. Therapeutic exercise was not associated with 1) observed functional recovery during the hospital stay (Standardised Mean Difference [SMD]: -1.19; 95%-confidence interval [CI], -2.46 to 0.08); 2) observed recovery within three months of surgery (SMD: -0.15; 95%-CI, -0.42 to 0.12); and 3) self-reported recovery within three months of surgery (SMD -0.07; 95%-CI, -0.35 to 0.21) compared with control participants. Meta-regression showed no statistically significant relationship between therapeutic validity and pooled-effects.

CONCLUSION

Preoperative therapeutic exercise for TJR did not demonstrate beneficial effects on postoperative functional recovery. However, poor therapeutic validity of the therapeutic exercise programmes may have hampered potentially beneficial effects, since none of the studies met the predetermined quality criteria. Future review studies on therapeutic exercise should address therapeutic validity.