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Baumbach L, Feddern W, Kretzler B, Hajek A, König HH. Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations. SPORTS MEDICINE - OPEN 2024; 10:38. [PMID: 38613739 PMCID: PMC11016054 DOI: 10.1186/s40798-024-00713-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/02/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists. METHODS We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist. RESULTS We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons. CONCLUSIONS High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.
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Affiliation(s)
- Linda Baumbach
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Wiebke Feddern
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Benedikt Kretzler
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Gómez-Redondo P, Valenzuela PL, Martínez-de-Quel Ó, Sánchez-Martín C, Cerezo-Arroyo M, Moreno-Manzanaro D, Alegre LM, Guadalupe-Grau A, Ara I, Mañas A. The role of supervision and motivation during exercise on physical and mental health in older adults: a study protocol for a randomized controlled trial (PRO-Training project). BMC Geriatr 2024; 24:274. [PMID: 38509514 PMCID: PMC10953175 DOI: 10.1186/s12877-024-04868-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/04/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Although supervised exercise is frequently recommended for older adults, its superiority over unsupervised exercise remains uncertain. Furthermore, whether motivational techniques could help to enhance the effectiveness of the latter remains to be elucidated. The present randomized controlled trial aims to determine the role of supervision and motivational strategies on the safety, adherence, efficacy, and cost-effectiveness of different exercise programs for improving physical and mental health in older adults. METHODS Participants (n = 120, aged 60-75 years) will be randomly allocated into five groups: 1-Control (CON), 2-Supervised exercise without motivational intervention (SUP), 3- Supervised exercise with motivational intervention (SUP +), 4- Unsupervised exercise without motivational intervention (UNSUP) and 5- Unsupervised exercise with motivational intervention (UNSUP +). Over 24 weeks, all exercise groups will participate in a multicomponent exercise program three times/week (performed in group classes at a center for SUP and SUP + , or home without supervision but with the help of a mobile app for UNSUP and UNSUP +), while the CON group will maintain their usual lifestyle. The motivational intervention (for SUP + and UNSUP + groups) will be based on the self-determination theory, including strategies such as phone calls, interactive workshops, motivational messages, informative infographics and videos. Primary outcomes will include safety, adherence, costs, and lower-body muscular function using a leg press machine. Secondary outcomes will include upper-body muscular function, physical and cardiorespiratory function, blood pressure and heart rate, body composition, health-related quality of life, cognitive performance, anxiety, depression, physical activity levels, sleep and sedentarism, biochemical markers, motivators and barriers to exercise. Assessments will be conducted at baseline, mid-intervention (i.e., week 13), at the end of the intervention (i.e., week 25), and 24 weeks later (i.e., week 49). DISCUSSION The findings of this trial might provide valuable insights into the role of supervision and motivational strategies on the effectiveness of exercise programs for older adults. Additionally, the study could contribute to developing cost-effective interventions, supporting the design of future public policies for healthy aging. TRIAL REGISTRATION NCT05619250. Registered 16 November 2022.
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Affiliation(s)
- Paola Gómez-Redondo
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Pedro L Valenzuela
- Physical Activity and Health Research Group (PaHerg), Research Institute of Hospital, 12 de Octubre (imas12), Madrid, Spain
- Department of Systems Biology, University of Alcalá, Madrid, Spain
| | - Óscar Martínez-de-Quel
- Didactics of Languages, Arts and Physical Education Department, Faculty of Education, Complutense University of Madrid, 28040, Madrid, Spain
- Faculty of Sciences for Physical Activity and Sport (INEF), Polytechnic University of Madrid, 28040, Madrid, Spain
| | - Coral Sánchez-Martín
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Mónica Cerezo-Arroyo
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - David Moreno-Manzanaro
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Luis M Alegre
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Amelia Guadalupe-Grau
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Ignacio Ara
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain
| | - Asier Mañas
- GENUD Toledo Research Group, Faculty of Sports Sciences, University of Castilla-La Mancha, Avda. Carlos III S/N, 45071, Toledo, Spain.
- CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Madrid, Spain.
- Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Junta de Comunidades de Castilla-La Mancha (JCCM), Toledo, Spain.
- Didactics of Languages, Arts and Physical Education Department, Faculty of Education, Complutense University of Madrid, 28040, Madrid, Spain.
- Center UCM-ISCIII for Human Evolution and Behavior, 28029, Madrid, Spain.
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Abbott JH, Wilson R, Pryymachenko Y, Sharma S, Pathak A, Chua JYY. Economic evaluation: a reader's guide to studies of cost-effectiveness. Arch Physiother 2022; 12:28. [PMID: 36517825 PMCID: PMC9753355 DOI: 10.1186/s40945-022-00154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Understanding what an economic evaluation is, how to interpret it, and what it means for making choices in a health delivery context is necessary to contribute to decisions about healthcare resource allocation. The aim of this paper to demystify the working parts of a health economic evaluation, and explain to clinicians and clinical researchers how to read and interpret cost-effectiveness research. MAIN BODY This primer distils key content and constructs of economic evaluation studies, and explains health economic evaluation in plain language. We use the PICOT (participant, intervention, comparison, outcome, timeframe) clinical trial framework familiar to clinicians, clinical decision-makers, and clinical researchers, who may be unfamiliar with economics, as an aide to reading and interpreting cost-effectiveness research. We provide examples, primarily of physiotherapy interventions for osteoarthritis. CONCLUSIONS Economic evaluation studies are essential to improve decisions about allocating resources, whether those resources be your time, the capacity of your service, or the available funding across the entire healthcare system. The PICOT framework can be used to understand and interpret cost-effectiveness research.
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Affiliation(s)
- J. Haxby Abbott
- grid.29980.3a0000 0004 1936 7830Centre for Musculoskeletal Outcomes Research, Otago Medical School, University of Otago, Dunedin, New Zealand
| | - Ross Wilson
- grid.29980.3a0000 0004 1936 7830Health Economist & Research Fellow, Otago Medical School, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Yana Pryymachenko
- grid.29980.3a0000 0004 1936 7830Health Economist & Postdoctoral Fellow, Otago Medical School, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Saurab Sharma
- grid.29980.3a0000 0004 1936 7830Otago Medical School, Postdoctoral Fellow, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Anupa Pathak
- grid.29980.3a0000 0004 1936 7830Graduate Research Student, Otago Medical School, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
| | - Jason Y. Y. Chua
- grid.29980.3a0000 0004 1936 7830Graduate Research Student, Otago Medical School, Centre for Musculoskeletal Outcomes Research, University of Otago, Dunedin, New Zealand
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Møller S, Riel H, Wester J, Simony A, Viberg B, Jensen C. Surgical or non-surgical treatment of plantar fasciopathy (SOFT): study protocol for a randomized controlled trial. Trials 2022; 23:845. [PMID: 36195936 PMCID: PMC9531425 DOI: 10.1186/s13063-022-06785-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy. Methods In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert (n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert (n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment. Discussion By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy. Trial registration ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06785-w.
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Affiliation(s)
- Stefan Møller
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Sygehusvej 24, 6000, Kolding, Denmark.
| | - Henrik Riel
- Center for General Practice at Aalborg University, Fyrkildevej 7, 9220, Aalborg, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.,Department of Physiotherapy, University College of Northern Denmark, Aalborg, Denmark
| | - Jens Wester
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Sygehusvej 24, 6000, Kolding, Denmark
| | - Ane Simony
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Sygehusvej 24, 6000, Kolding, Denmark
| | - Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Sygehusvej 24, 6000, Kolding, Denmark
| | - Carsten Jensen
- Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital - University Hospital of Southern Denmark, Sygehusvej 24, 6000, Kolding, Denmark
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It Hurts to Move! Intervention Effects and Assessment Methods for Movement-Evoked Pain in Patients With Musculoskeletal Pain: A Systematic Review with Meta-analysis. J Orthop Sports Phys Ther 2022; 52:345-374. [PMID: 35128943 DOI: 10.2519/jospt.2022.10527] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To estimate the effects of musculoskeletal rehabilitation interventions on movementevoked pain and to explore the assessment methods/protocols used to evaluate movement-evoked pain in adults with musculoskeletal pain. DESIGN Systematic review with meta-analysis. LITERATURE SEARCH Three electronic databases (PubMed, Web of Science, and Scopus) were searched. STUDY SELECTION CRITERIA Randomized controlled trials investigating musculoskeletal rehabilitation interventions for movement-evoked pain in adults with musculoskeletal pain were included. DATA SYNTHESIS Meta-analysis was conducted for outcomes with homogeneous data from at least 2 trials. The mean change in movementevoked pain was the primary outcome measure. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS Thirty-eight trials were included, and 60 different interventions were assessed. There was moderate-certainty evidence of a beneficial effect of exercise therapy compared to no treatment (standardized mean difference [SMD], -0.65; 95% confidence interval [CI]: -0.83, -0.47; P<.001) on movement-evoked pain in adults with musculoskeletal pain. There was low-certainty evidence of a beneficial effect of transcutaneous electrical nerve stimulation compared to no treatment (SMD, -0.46; 95% CI: -0.71, -0.21; P = .0004). There was no benefit of transcutaneous electrical nerve stimulation when compared to sham transcutaneous electrical nerve stimulation (SMD, -0.28; 95% CI: -0.60, 0.05; P = .09; moderate-certainty evidence). CONCLUSION There was moderate-certainty evidence that exercise therapy is effective for reducing movement-evoked pain in patients with musculoskeletal pain compared to no treatment. Consider exercise therapy as the first-choice treatment for movement-evoked pain in clinical practice. J Orthop Sports Phys Ther 2022;52(6):345-374. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10527.
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Center based versus home based geriatric rehabilitation on sarcopenia components: a systematic review and meta-analysis. Arch Phys Med Rehabil 2022; 103:1663-1675.e3. [DOI: 10.1016/j.apmr.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 11/09/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022]
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Oh SL, Kim DY, Bae JH, Lim JY. Effects of rural community-based integrated exercise and health education programs on the mobility function of older adults with knee osteoarthritis. Aging Clin Exp Res 2021; 33:3005-3014. [PMID: 32020485 DOI: 10.1007/s40520-020-01474-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022]
Abstract
AIM To examine the effects of a rural community-based program integrating health education and self-directed home-based resistance training on the mobility function of older women with knee osteoarthritis (OA). METHODS Participants were assigned to the control (CON) or intervention (INT) group. Participants completed a mobility function assessment and questionnaire evaluation. The CON group received only the health education program and the INT group also participated in resistance training for 5 months. Primary outcomes were mobility function measured using a timed chair stand (TCS), timed up & go (TUG), gait speed (GS), and knee extensor strength (KES). We evaluated body composition and questionnaire results (WOMAC score, SARC-F scale, and SOF index) as secondary outcomes. RESULTS There were significant differences in the interactions of group-by-time effects for TCS (p < 0.001), TUG (p = 0.006), GS (p = 0.020), and knee strength (p = 0.010). In the CON group, TCS (p = 0.003) and TUG (p = 0.005) increased compared with baseline, while in the INT group, TCS decreased significantly (p < 0.001) and TUG tended to decrease after the intervention. The INT group showed improvement in GS (p < 0.001) and KES (p = 0.003) after the intervention. By contrast, the CON group showed decreasing GS (p = 0.021) and KES (p = 0.011) compared with baseline. The SARC-F scale differed significantly in the interaction of group-by-time effects (p = 0.030), while the body composition, SOF index, and WOMAC score did not differ. CONCLUSION These results suggest that an integrated intervention program combining self-directed home-based resistance training with health education effectively improves the mobility function of older adults with knee OA dwelling in rural areas.
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Affiliation(s)
- Seung-Lyul Oh
- Aging & Mobility Biophysics Laboratory, Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Day-Young Kim
- Aging & Mobility Biophysics Laboratory, Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jun-Hyun Bae
- Aging & Mobility Biophysics Laboratory, Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae-Young Lim
- Aging & Mobility Biophysics Laboratory, Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.
- Institute on Aging, Seoul National University, Seoul, South Korea.
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Epskamp S, Dibley H, Ray E, Bond N, White J, Wilkinson A, Chapple CM. Range of motion as an outcome measure for knee osteoarthritis interventions in clinical trials: an integrated review. PHYSICAL THERAPY REVIEWS 2021. [DOI: 10.1080/10833196.2020.1867393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Samantha Epskamp
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Hayley Dibley
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Elizabeth Ray
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Nicole Bond
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Joshua White
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Amanda Wilkinson
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Cathy M. Chapple
- School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Ritschl V, Stamm TA, Aletaha D, Bijlsma JWJ, Böhm P, Dragoi R, Dures E, Estévez-López F, Gossec L, Iagnocco A, Negrón JB, Nudel M, Marques A, Moholt E, Skrubbeltrang C, Van den Bemt B, Viktil K, Voshaar M, Carmona L, de Thurah A. Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider. RMD Open 2020; 6:e001432. [PMID: 33161377 PMCID: PMC7856118 DOI: 10.1136/rmdopen-2020-001432] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs). METHODS An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews. RESULTS After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise. CONCLUSIONS The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.
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Affiliation(s)
- Valentin Ritschl
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | - Peter Böhm
- Deutsche Rheuma-Liga Bundesverband e.V., Bonn, Germany
| | - Razvan Dragoi
- University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Emma Dures
- University of the West of England Bristol, Bristol, UK
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | | | - Laure Gossec
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
- APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - José B Negrón
- Instituto de Investigación Social y Sanitaria, Puerto Rico
| | | | - Andréa Marques
- Centro Hospitalar e Universitário de Coimbra, Health Sciences Research Unit: Nursing, UICISA-E, Coimbra, Portugal
| | - Ellen Moholt
- Diakonhjemmet Hospital, Division of Rheumatology and Research, Oslo, Norway
| | | | - Bart Van den Bemt
- Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands
- Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kirsten Viktil
- University of Oslo, Oslo, Norway
- Diakonhjemmet Hospital Pharmacy, Oslo, Norway
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (Inmusc), Madrid, Spain
| | - Annette de Thurah
- Rheumatology, Aarhus University Hospital, Århus N, Denmark
- Clinical Medicine, Aarhus University, Aarhus, Denmark
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Warwick H, O'Donnell J, Mather RC, Jiranek W. Disparity of health services in patients with knee osteoarthritis before total knee arthroplasty. Arthroplast Today 2020; 6:81-87. [PMID: 32211481 PMCID: PMC7083741 DOI: 10.1016/j.artd.2019.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/19/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022] Open
Abstract
Background Recent evidence describes which interventions are driving insurance payments in the management of osteoarthritis (OA) before total knee arthroplasty (TKA); however, relatively little is known about how these costs are distributed among patients. Methods We reviewed the Humana claims database for patients who underwent primary TKA from 2009 to 2016. Insurance payments for treatment, imaging, and evaluation and management were calculated from OA diagnosis to TKA, the distribution of payments was determined, and a high-payment group was identified by determining the point at which patients began to account for a disproportionate percentage of payments. This group of high-payment patients was compared with remaining patients (low-payment patients) based on demographic factors and nonarthroplasty payments and utilization. Results The top 30% of patients accounted for more than 70% of nonarthroplasty payments. High-payment patients were more likely to be younger, female, and more comorbid. Median time from diagnosis to TKA for high-payment patients was 3 times longer than that for low-payment patients (654 days [320-1191] vs 204 days [68-582], P < .001), and median payment per patient was more than 5 times higher ($1891 [1405-2782] vs $362 [198-613], P < .001). Conclusions Identification of high-payment patients in the management of knee OA may allow for targeted care pathways and cost-reduction strategies in the nonarthroplasty period, although additional studies are necessary to further characterize this population and efficiently recognize appropriate TKA candidates and timing.
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Affiliation(s)
- Hunter Warwick
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan O'Donnell
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - William Jiranek
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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11
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Barlow T, Rhodes-Jones T, Ballinger S, Metcalfe A, Wright D, Thompson P. Decreasing the number of arthroscopies in knee osteoarthritis - a service evaluation of a de-implementation strategy. BMC Musculoskelet Disord 2020; 21:140. [PMID: 32126992 PMCID: PMC7055049 DOI: 10.1186/s12891-020-3125-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Personalised Knee Improvement Programme (P-KIP) was developed based on previously published work, with the hypothesis that surgeons would refer patients to a well-structured conservative management intervention instead of for arthroscopy (de-implementation of arthroscopy by substitution with P-KIP). This meets NICE guidelines and international recommendations but such programmes are not widely used in the UK. Our aim was to determine whether P-KIP would reduce the number of arthroscopies performed for knee osteoarthritis. METHODS P-KIP is a conservative care pathway including a group education session followed by individually tailored one-to-one dietician and physiotherapy sessions. Virtual clinic follow-up is conducted three to 6 months after completion of the programme. The service began in July 2015. The number of arthroscopies saved, measured from hospital level coding data, is the primary outcome measure. Interrupted time series analysis of coding data was conducted. As a quality assurance process, patient reported outcome measures (Oxford Knee Score; Euroqol 5D) were collected at baseline and at follow up. RESULTS Time series analysis demonstrates that the programme saved 15.4 arthroscopies a month (95% confidence interval 9-21; p < 0.001), equating to 184 arthroscopies a year in a single hospital. The PROMs data demonstrated improvements in patient reported outcome scores consistent with previous published reports of conservative interventions in similar patient populations. CONCLUSIONS Results suggest that P-KIP reduces the number of arthroscopies performed, and patients who took part in P-KIP had an improvement in their knee and general health outcomes. P-KIP has the potential to deliver efficiency savings and relive pressure on operative lists, however replication in other sites is required.
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Affiliation(s)
- Timothy Barlow
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
- Clinical Sciences Research Laboratories, Warwick University UHCW, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Timothy Rhodes-Jones
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Sue Ballinger
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Andrew Metcalfe
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
- Clinical Sciences Research Laboratories, Warwick University UHCW, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - David Wright
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Peter Thompson
- University Hospitals of Coventry and Warwickshire, Clifford Bridge Road, Coventry, CV2 2DX UK
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12
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Shahabi S, Rezapour A, Arabloo J. Economic evaluations of physical rehabilitation interventions in older adults with hip and/or knee osteoarthritis: a systematic review. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2019. [DOI: 10.1080/21679169.2019.1672785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Saeed Shahabi
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jalal Arabloo
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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13
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Goodwin VA, Hill JJ, Fullam JA, Finning K, Pentecost C, Richards DA. Intervention development and treatment success in UK health technology assessment funded trials of physical rehabilitation: a mixed methods analysis. BMJ Open 2019; 9:e026289. [PMID: 31467046 PMCID: PMC6720467 DOI: 10.1136/bmjopen-2018-026289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Physical rehabilitation is a complex process, and trials of rehabilitation interventions are increasing in number but often report null results. This study aimed to establish treatment success rates in physical rehabilitation trials funded by the National Institute of Health Research Health Technology Assessment (NIHR HTA) programme and examine any relationship between treatment success and the quality of intervention development work undertaken. DESIGN This is a mixed methods study. SETTING This study was conducted in the UK. METHODS The NIHR HTA portfolio was searched for all completed definitive randomised controlled trials of physical rehabilitation interventions from inception to July 2016. Treatment success was categorised according to criteria developed by Djulbegovic and colleagues. Detailed textual data regarding any intervention development work were extracted from trial reports and supporting publications and informed the development of quality ratings. Mixed methods integrative analysis was undertaken to explore the relationship between quantitative and qualitative data using joint displays. RESULTS Fifteen trials were included in the review. Five reported a definitive finding, four of which were in favour of the 'new' intervention. Eight trials reported a true negative (no difference) outcome. Integrative analysis indicated those with lower quality intervention development work were less likely to report treatment success. CONCLUSIONS Despite much effort and funding, most physical rehabilitation trials report equivocal findings. Greater focus on high quality intervention development may reduce the likelihood of a null result in the definitive trial, alongside high quality trial methods and conduct.
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Affiliation(s)
- Victoria A Goodwin
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Jacqueline J Hill
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - James A Fullam
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Katie Finning
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Claire Pentecost
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - David A Richards
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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14
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Fenocchi L, Riskowski JL, Mason H, Hendry GJ. A systematic review of economic evaluations of conservative treatments for chronic lower extremity musculoskeletal complaints. Rheumatol Adv Pract 2019; 2:rky030. [PMID: 31431975 PMCID: PMC6649923 DOI: 10.1093/rap/rky030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/19/2018] [Indexed: 11/12/2022] Open
Abstract
Objective The aim was to appraise and synthesize studies evaluating the clinical and cost effectiveness of conservative interventions for chronic lower extremity musculoskeletal (MSK) conditions and describe their characteristics, including the type of economic evaluation, primary outcomes and which conditions. Methods The search strategy related to economic evaluations of lower limb MSK conditions that used conservative therapies. Eight electronic databases were searched (CENTRAL, MEDLINE, PubMed, EMBASE, CINAHL, PEDro, NHSEED and Proquest), as were the reference lists from included articles. The quality of articles was appraised using a modified version of the economic evaluations’ reporting checklist (economic) and The Cochrane Collaboration’s tool for assessing risk of bias (clinical). Results Twenty-six studies were eligible and included in the review. Economic evaluations of conservative interventions for OA or pain affecting the knee/hip (n = 25; 93%) were most common. The main approaches adopted were cost–utility analysis (n = 17; 68%) or cost–effectiveness analysis (n = 5; 19%). Two studies involved interventions including footwear/foot orthoses; for heel pain (n = 1; 4%) and overuse injuries (n = 1; 4%). Fifty per cent of economic evaluations adopted the EQ-5D-3L as the primary outcome measure for quality of life and quality-adjusted life year calculations. Conclusion Economic evaluations have been conducted largely for exercise-based interventions for MSK conditions of the hip and knee. Few economic evaluations have been conducted for other clinically important lower limb MSK conditions. A matrix presentation of costs mapped with outcomes indicated increasing costs with either no difference or improvements in clinical effectiveness. The majority of economic evaluations were of good reporting quality, as were the accompanying clinical studies.
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Affiliation(s)
- Linda Fenocchi
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University.,Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - Jody L Riskowski
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University
| | - Helen Mason
- Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - Gordon J Hendry
- Musculoskeletal Health Research Group, School of Health and Life Sciences, Glasgow Caledonian University
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15
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Lewis R, Gómez Álvarez CB, Rayman M, Lanham-New S, Woolf A, Mobasheri A. Strategies for optimising musculoskeletal health in the 21 st century. BMC Musculoskelet Disord 2019; 20:164. [PMID: 30971232 PMCID: PMC6458786 DOI: 10.1186/s12891-019-2510-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/17/2019] [Indexed: 12/19/2022] Open
Abstract
We live in a world with an ever-increasing ageing population. Studying healthy ageing and reducing the socioeconomic impact of age-related diseases is a key research priority for the industrialised and developing countries, along with a better mechanistic understanding of the physiology and pathophysiology of ageing that occurs in a number of age-related musculoskeletal disorders. Arthritis and musculoskeletal disorders constitute a major cause of disability and morbidity globally and result in enormous costs for our health and social-care systems.By gaining a better understanding of healthy musculoskeletal ageing and the risk factors associated with premature ageing and senescence, we can provide better care and develop new and better-targeted therapies for common musculoskeletal disorders. This review is the outcome of a two-day multidisciplinary, international workshop sponsored by the Institute of Advanced Studies entitled "Musculoskeletal Health in the 21st Century" and held at the University of Surrey from 30th June-1st July 2015.The aim of this narrative review is to summarise current knowledge of musculoskeletal health, ageing and disease and highlight strategies for prevention and reducing the impact of common musculoskeletal diseases.
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Affiliation(s)
- Rebecca Lewis
- School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Constanza B Gómez Álvarez
- School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Margaret Rayman
- School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Susan Lanham-New
- School of Biosciences and Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Anthony Woolf
- Department of Rheumatology, Royal Cornwall Hospital, Truro, UK
| | - Ali Mobasheri
- School of Veterinary Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK. .,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Queen's Medical Centre, Nottingham, UK. .,Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania. .,The D-BOARD FP7 Consortium, . .,The APPROACH IMI Consortium, .
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16
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Poget F, Blackburn T, Descloux F, Fiddler H. Participating in an exercise group after anterior cruciate ligament reconstruction (ACLR) is perceived to influence psychosocial factors and successful recovery: a focus group qualitative study. Physiotherapy 2019; 105:492-500. [PMID: 30717882 DOI: 10.1016/j.physio.2018.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 12/01/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To explore the patients' experiences of participating in an exercise group following anterior cruciate ligament reconstruction (ACLR). DESIGN Hermaneutic phenomenological qualitative study of two focus groups. SETTING Outpatient care, private rehabilitation centre. PARTICIPANTS Nine adults who had participated in an exercise group led by a physiotherapist following ACLR. RESULTS Three major themes emerged from the data: psychosocial factors, physical outcomes and identity of the exercise group. The most significant perception of engaging in an exercise group following ACLR was its influence on psychosocial factors, especially motivation, self-confidence and social support. The group influenced the participants' motivation, enjoyment and commitment to exercise during their rehabilitation. Social support, self-confidence and reassurance were mostly gained. The participants taking part in sport experienced the ACLR group as a substitute for sport trainings. The group was perceived to help enhance speed of recovery and facilitate the return to normal life, especially for participants with lower reported motivation and adherence to home-exercises. The authors interpreted that the subjective physical outcomes' improvements described by all the participants was potentially an increased level of self-efficacy. The challenging role of the physiotherapist was highlighted as well as the promotion of shared accountability between patients and the group's leader. The exercise group's identity was questioned within the rehabilitation process, and the need for more knowledge of its existence in order to promote exercise group therapy was suggested. CONCLUSION Participating in an exercise group therapy influences psychosocial factors such as motivation, self-confidence, social support, potentially self-efficacy and helps enhance a faster successful recovery following ACLR. Our findings indicate that participants with a lower reported adherence to home-exercises may especially benefit from it.
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Affiliation(s)
- Fanny Poget
- School of Health Sciences (HESAV), University of Applied Sciences and Arts Western Switzerland (HES-SO), 1011 Lausanne, Switzerland.
| | - Tiffany Blackburn
- School of Health Sciences, University of Brighton, Darley Road, Eastbourne BN20 7UR, United Kingdom.
| | - Fanny Descloux
- Physio Grancy 47, Boulevard de Grancy 47, 1006 Lausanne, Switzerland.
| | - Helen Fiddler
- School of Health Sciences, University of Brighton, Darley Road, Eastbourne BN20 7UR, United Kingdom.
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17
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Bartholdy C, Nielsen SM, Warming S, Hunter DJ, Christensen R, Henriksen M. Poor replicability of recommended exercise interventions for knee osteoarthritis: a descriptive analysis of evidence informing current guidelines and recommendations. Osteoarthritis Cartilage 2019; 27:3-22. [PMID: 30248500 DOI: 10.1016/j.joca.2018.06.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/28/2018] [Accepted: 06/21/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the reporting completeness of exercise-based interventions for knee osteoarthritis (OA) in studies that form the basis of current clinical guidelines, and examine if the clinical benefit (pain and disability) from exercise is associated with the intervention reporting completeness. DESIGN Review of clinical OA guidelines METHODS: We searched MEDLINE and EMBASE for guidelines published between 2006 and 2016 including recommendations about exercise for knee OA. The studies used to inform a recommendation were reviewed for exercise reporting completeness. Reporting completeness was evaluated using a 12-item checklist; a combination of the Template for Intervention Description and Replication (TIDieR) and Consensus on Exercise Reporting Template (CERT). Each item was scored 'YES' or 'NO' and summarized as a proportion of interventions with complete descriptions and each intervention's completeness was summarized as the percentage of completely described items. The association between intervention description completeness score and clinical benefits was analyzed with a multilevel meta-regression. RESULTS From 10 clinical guidelines, we identified 103 original studies of which 100 were retrievable (including 133 interventions with 6,926 patients). No interventions were completely described on all 12 items (median 33% of items complete; range 17-75%). The meta-regression analysis indicated that poorer reporting was associated with greater effects on pain and no association with effects on disability. CONCLUSION The inadequate description of recommended interventions for knee OA is a serious problem that precludes replication of effective interventions in clinical practice. By consequence, the relevance and usability of clinical guideline documents and original study reports are diminished. PROSPERO CRD42016039742.
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Affiliation(s)
- C Bartholdy
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2000 Copenhagen, Denmark; Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark.
| | - S M Nielsen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2000 Copenhagen, Denmark.
| | - S Warming
- Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark.
| | - D J Hunter
- Rheumatology Department, Royal North Shore Hospital and Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, NSW, Australia.
| | - R Christensen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2000 Copenhagen, Denmark; Department of Rheumatology, Odense University Hospital, Denmark.
| | - M Henriksen
- The Parker Institute, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2000 Copenhagen, Denmark; Department of Physical and Occupational Therapy, Copenhagen University Hospital Bispebjerg and Frederiksberg, 2400 Copenhagen, Denmark.
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18
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Kigozi J, Jowett S, Nicholls E, Tooth S, Hay EM, Foster NE. Cost-utility analysis of interventions to improve effectiveness of exercise therapy for adults with knee osteoarthritis: the BEEP trial. Rheumatol Adv Pract 2018; 2:rky018. [PMID: 30506022 PMCID: PMC6251481 DOI: 10.1093/rap/rky018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 05/15/2018] [Indexed: 11/24/2022] Open
Abstract
Objectives Evidence regarding the cost-effectiveness of enhancing physical therapy exercise programmes in order to improve outcomes for patients with knee OA remains unclear. This study investigates the cost-effectiveness of two enhanced physical therapy interventions compared with usual physical therapy care (UC) for adults with knee OA. Methods A trial-based cost–utility analysis of individually tailored exercise (ITE) or targeted exercise adherence (TEA) compared with UC was undertaken over a period of 18 months. Patient-level costs were obtained, and effectiveness was measured in terms of quality-adjusted life years (QALYs), allowing the calculation of cost per QALY gained from a base-case UK health-care perspective. Results The UC group was associated with lower National Health Service (NHS) costs [ITE-UC: £273.30, 95% CI: £−62.10 to £562.60; TEA-UC: £141.80, 95% CI: £−135.60 to £408.10)] and slightly higher QALY gains (ITE-UC: −0.015, 95% CI: −0.057 to 0.026; TEA-UC: −0.003, 95% CI: −0.045 to 0.038). In the base case, UC was the most likely cost-effective option (probability <40% of ITE or TEA cost-effective at £20 000/QALY). Differences in total costs were attributable to intervention costs, number of visits to NHS consultants and knee surgery, which were higher in both ITE and TEA groups. Conclusion This is the first economic evaluation comparing usual physical therapy care vs enhanced exercise interventions for knee OA that involves greater exercise individualization, supervision and progression or that focuses on exercise and physical activity adherence over the longer term. Our findings show that UC is likely to be the most cost-effective option. Trial registration Current Controlled Trials ISRCTN 93634563. Trial protocol Full details of the trial protocol can be found in the Supplementary Appendix, available with the full text of this article at http://www.biomedcentral.com/1471-2474/15/254 doi: 10.1186/1471-2474-15-254
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Affiliation(s)
- Jesse Kigozi
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.,Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.,Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.,Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
| | - Stephanie Tooth
- Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK.,Keele Clinical Trials Unit, David Weatherall Building, Keele University, Staffordshire, UK
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19
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Briani RV, Ferreira AS, Pazzinatto MF, Pappas E, De Oliveira Silva D, Azevedo FMD. What interventions can improve quality of life or psychosocial factors of individuals with knee osteoarthritis? A systematic review with meta-analysis of primary outcomes from randomised controlled trials. Br J Sports Med 2018; 52:1031-1038. [PMID: 29549150 DOI: 10.1136/bjsports-2017-098099] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To systematically review evidence of primary outcomes from randomised controlled trials (RCTs) examining the effect of treatment strategies on quality of life (QoL) or psychosocial factors in individuals with knee osteoarthritis (OA). DESIGN Systematic review with meta-analysis. DATA SOURCES Medline, Embase, SPORTDiscus, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science were searched from inception to November 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We included RCTs investigating the effect of conservative interventions on QoL or psychosocial factors in individuals with knee OA. Only RCTs considering these outcomes as primary were included. RESULTS Pooled data supported the use of exercise therapy compared with controls for improving health-related and knee-related QoL. There was limited evidence that a combined treatment of yoga, transcutaneous electrical stimulation and ultrasound may be effective in improving QoL. Limited evidence supported the use of cognitive behavioural therapies (with or without being combined with exercise therapy) for improving psychosocial factors such as self-efficacy, depression and psychological distress. SUMMARY/CONCLUSION Exercise therapy (with or without being combined with other interventions) seems to be effective in improving health-related and knee-related QoL or psychosocial factors of individuals with knee OA. In addition, evidence supports the use of cognitive behavioural therapies (with or without exercise therapy) for improving psychosocial factors such as self-efficacy, depression and psychological distress in individuals with knee OA. PROSPERO REGISTRATION NUMBER CRD42016047602.
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Affiliation(s)
- Ronaldo Valdir Briani
- School of Science and Technology, Laboratory of Biomechanics and Motor Control (LABCOM), São Paulo State University, Presidente Prudente, Brazil
| | - Amanda Schenatto Ferreira
- School of Science and Technology, Laboratory of Biomechanics and Motor Control (LABCOM), São Paulo State University, Presidente Prudente, Brazil
| | - Marcella Ferraz Pazzinatto
- School of Science and Technology, Laboratory of Biomechanics and Motor Control (LABCOM), São Paulo State University, Presidente Prudente, Brazil
| | - Evangelos Pappas
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Danilo De Oliveira Silva
- La Trobe Sports and Exercise Medicine Research Centre (LASEM), La Trobe University, School of Allied Health, Melbourne, Victoria, Australia
| | - Fábio Mícolis de Azevedo
- School of Science and Technology, Laboratory of Biomechanics and Motor Control (LABCOM), São Paulo State University, Presidente Prudente, Brazil
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METHODOLOGICAL QUALITY OF ECONOMIC EVALUATIONS ALONGSIDE TRIALS OF KNEE PHYSIOTHERAPY. Int J Technol Assess Health Care 2017; 33:454-462. [PMID: 28857017 DOI: 10.1017/s0266462317000757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The methodological quality of an economic evaluation performed alongside a clinical trial can be underestimated if the paper does not report key methodological features. This study discusses methodological assessment issues on the example of a systematic review on cost-effectiveness of physiotherapy for knee osteoarthritis. METHODS Six economic evaluation studies included in the systematic review and related clinical trials were assessed using the 10-question check-list by Drummond and the Physiotherapy Evidence Database (PEDro) scale. RESULTS All economic evaluations were performed alongside a clinical trial but the studied interventions were too heterogeneous to be synthesized. Methodological quality of the economic evaluations reported in the papers was not free of drawbacks, and in some cases, it improved when information from the related clinical trial was taken into account. CONCLUSIONS Economic evaluation papers dedicate little space to methodological features of related clinical trials; therefore, the methodological quality can be underestimated if evaluated separately from the trials. Future economic evaluations should follow more strictly the recommendations about methodology and the authors should pay special attention to the quality of reporting.
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21
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Curtis GL, Chughtai M, Khlopas A, Newman JM, Khan R, Shaffiy S, Nadhim A, Bhave A, Mont MA. Impact of Physical Activity in Cardiovascular and Musculoskeletal Health: Can Motion Be Medicine? J Clin Med Res 2017; 9:375-381. [PMID: 28392856 PMCID: PMC5380169 DOI: 10.14740/jocmr3001w] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/12/2022] Open
Abstract
Physical activity is a well-known therapeutic tool for various types of medical conditions, including vasculopathic diseases such as coronary artery disease, stroke, type 2 diabetes, and obesity. Additionally, increased physical activity has been proposed as a therapy to improve musculoskeletal health; however, there are conflicting reports about physical activity potentially leading to degenerative musculoskeletal disease, especially osteoarthritis (OA). Additionally, although physical activity is known to have its benefits, it is unclear as to what amount of physical activity is the most advantageous. Too much, as well as not enough exercise can have negative consequences. This could impact how physicians advise their patients about exercise intensity. Multiple studies have evaluated the effect of physical activity on various aspects of health. However, there is a paucity of systematic studies which review cardiovascular and musculoskeletal health as outcomes. Therefore, the purpose of this review was to assess how physical activity impacts these aspects of health. Specifically, we evaluated the effect of various levels of physical activity on: 1) cardiovascular and 2) musculoskeletal health. The review revealed that physical activity may decrease cardiovascular disease and improve OA symptoms, and therefore, motion can be considered a “medicine”. However, because heavy activity can potentially lead to increased OA risk, physicians should advise their patients that excessive activity can also potentially impact their health negatively, and should be done in moderation, until further study.
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Affiliation(s)
- Gannon L Curtis
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jared M Newman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rafay Khan
- Raritan Bay Medical Center, Perth Amboy, NJ, USA
| | - Shervin Shaffiy
- St. Georges University School of Medicine, True Blue, Grenada, West Indies
| | - Ali Nadhim
- Raritan Bay Medical Center, Perth Amboy, NJ, USA
| | - Anil Bhave
- Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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MacPherson H, Vickers A, Bland M, Torgerson D, Corbett M, Spackman E, Saramago P, Woods B, Weatherly H, Sculpher M, Manca A, Richmond S, Hopton A, Eldred J, Watt I. Acupuncture for chronic pain and depression in primary care: a programme of research. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05030] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundThere has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money.AimOur aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression.Methods and resultsWe synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective.ConclusionWe have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence.Trial registrationCurrent Controlled Trials ISRCTN63787732.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin Bland
- Department of Health Sciences, University of York, York, UK
| | | | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Eldon Spackman
- Centre for Health Economics, University of York, York, UK
| | - Pedro Saramago
- Centre for Health Economics, University of York, York, UK
| | - Beth Woods
- Centre for Health Economics, University of York, York, UK
| | | | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | | | - Ann Hopton
- Department of Health Sciences, University of York, York, UK
| | - Janet Eldred
- Department of Health Sciences, University of York, York, UK
| | - Ian Watt
- Department of Health Sciences/Hull York Medical School, University of York, York, UK
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Hagberg LA, Lindholm L. Review Article: Cost-effectiveness of healthcare-based interventions aimed at improving physical activity. Scand J Public Health 2016; 34:641-53. [PMID: 17132598 DOI: 10.1080/14034940600627853] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Aim: This article aims to review current knowledge concerning the cost-effectiveness of healthcare-based interventions aimed at improving physical activity. Method: A search was performed for economic evaluations containing the terms ``physical activity'', ``exercise'', or ``fitness''. Cost-effectiveness for the articles found was described based on a model for evaluating interventions intended to promote physical activity. Results: A total of 26 articles were found in the search. Nine of them concern a general population, 7 evaluated older people, and 10 studied disease-specific populations. A preventive perspective is most common, but some have a treatment perspective. Around 20 of the interventions studied were cost-effective according to their authors, but all analyses had some shortcomings in their evaluation methods. Conclusion: This review found many examples of cost-effective interventions. There is a lack of evidence for the cost-effectiveness of interventions aimed at those whose only risk factor for illness is a sedentary lifestyle. There is more evidence, although it is limited, for the cost-effectiveness of interventions aimed at high-risk groups or those who manifest poor health related to physical inactivity. Most of the evidence for cost-effectiveness is for older people and those with heart failure. Promotion of physical activity can be cost-effective with different methods and in different settings, but there remains a lack of evidence for specific methods in specific populations.
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Affiliation(s)
- Lars A Hagberg
- Orebro County Council, Department of Public Health, Orebro, Sweden.
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Tan SS, Teirlinck CH, Dekker J, Goossens LMA, Bohnen AM, Verhaar JAN, van Es PP, Koes BW, Bierma-Zeinstra SMA, Luijsterburg PAJ, Koopmanschap MA. Cost-utility of exercise therapy in patients with hip osteoarthritis in primary care. Osteoarthritis Cartilage 2016; 24:581-8. [PMID: 26620092 DOI: 10.1016/j.joca.2015.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 10/16/2015] [Accepted: 11/17/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care. METHOD This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data. RESULTS A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group (€ 1233) compared to the control group (€ 1331). The average annual societal costs per patient were lower in the intervention group (€ 2634 vs € 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02). CONCLUSION Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects. TRIAL REGISTRATION NUMBER NTR1462.
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Affiliation(s)
- S S Tan
- Erasmus University Rotterdam, Institute for Medical Technology Assessment & Institute of Health Policy and Management, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands; Erasmus MC University Medical Center, Department of Rehabilitation Medicine, Rotterdam, The Netherlands.
| | - C H Teirlinck
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands.
| | - J Dekker
- VU University Medical Center, Department of Rehabilitation Medicine & EMGO Institute for Health and Care Research, Amsterdam, The Netherlands.
| | - L M A Goossens
- Erasmus University Rotterdam, Institute for Medical Technology Assessment & Institute of Health Policy and Management, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
| | - A M Bohnen
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands.
| | - J A N Verhaar
- Erasmus MC University Medical Center, Department of Orthopaedics, Rotterdam, The Netherlands.
| | - P P van Es
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands.
| | - B W Koes
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands.
| | - S M A Bierma-Zeinstra
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands; Erasmus MC University Medical Center, Department of Orthopaedics, Rotterdam, The Netherlands.
| | - P A J Luijsterburg
- Erasmus MC University Medical Center, Department of General Practice, Rotterdam, The Netherlands.
| | - M A Koopmanschap
- Erasmus University Rotterdam, Institute for Medical Technology Assessment & Institute of Health Policy and Management, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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Wood LRJ, Blagojevic-Bucknall M, Stynes S, D'Cruz D, Mullis R, Whittle R, Peat G, Foster NE. Impairment-targeted exercises for older adults with knee pain: a proof-of-principle study (TargET-Knee-Pain). BMC Musculoskelet Disord 2016; 17:47. [PMID: 26821917 PMCID: PMC4731955 DOI: 10.1186/s12891-016-0899-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 01/22/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Therapeutic exercise is an effective intervention for knee pain and osteoarthritis (OA) and should be individualised. In a preliminary, proof-of-principle study we sought to develop a home exercise programme targeted at specific physical impairments of weak quadriceps, reduced knee flexion range of motion (ROM) and poor balance, and evaluate whether receipt of this was associated with improvements in those impairments and in patient-reported outcomes among older adults with knee pain. METHODS This community-based study used a single group, before-after study design with 12-week follow-up. Participants were 58 adults aged over 56 years with knee pain and evidence of quadriceps weakness, loss of flexion ROM, or poor balance, recruited from an existing population-based, observational cohort. Participants received a 12-week home exercise programme, tailored to their physical impairments. The programme was led, monitored and progressed by a physiotherapist over six home visits, alternating with six telephone calls. Primary outcome measures were maximal isometric quadriceps strength, knee flexion ROM and timed single-leg standing balance, measured at baseline, 6 and 12 weeks by a research nurse blinded to the nature and content of participants' exercise programmes. Secondary outcome measures included the WOMAC. RESULTS At 12 weeks, participants receiving strengthening exercises demonstrated a statistically significant change in quadriceps isometric strength compared to participants not receiving strengthening exercises: 3.9 KgF (95 % CI 0.1, 7.8). Changes in knee flexion ROM (2.1° (-2.3, 6.5)) and single-leg balance time (-2.4 s (-4.5, 6.7)) after stretching and balance retraining exercises respectively, were not found to be statistically significant. There were significant improvements in mean WOMAC Pain and Physical Function scores: -2.2 (-3.1, -1.2) and -5.1 (-7.8, -2.5). CONCLUSIONS A 12-week impairment-targeted, home-based exercise programme for symptomatic knee OA appeared to be associated with modest improvements in self-reported pain and function but no strong evidence of greater improvement in the specific impairments targeted by each exercise package, with the possible exception of quadriceps strengthening. TRIAL REGISTRATION Clinical Trial Registration Number: ISRCTN 61638364 Date of registration: 24 June 2010.
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Affiliation(s)
- Laurence R J Wood
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Milica Blagojevic-Bucknall
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Siobhán Stynes
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Deborah D'Cruz
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Ricky Mullis
- General Practice and Primary Care Research Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, CB1 8RN, UK
| | - Rebecca Whittle
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK.
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Silva A, Mello MTD, Gávea Junior SA, Queiroz SSD, Tufik S, Mattiello SM. Therapeutic modalities and postural balance of patients with knee osteoarthritis: systematic review. FISIOTERAPIA EM MOVIMENTO 2015. [DOI: 10.1590/0103-5150.028.003.ar01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AbstractObjective The objective of this review was to evaluate the evidence of the influence of therapeutic modalities on postural balance in patients with knee osteoarthritis (OA).Methods A search for published papers on therapeutic modalities was conducted using the Pubmed, Medline, Lilacs and SciELO databases. The keywords “knee” and “balance” in combination with “osteoarthritis” were used as the search strategy. Randomized controlled clinical trials published in the last 10 years in either English or Portuguese were selected. The PEDro scale was applied to assess the quality of the selected clinical trials.Results A total of 46 studies of patients with knee OA were found, of which seven were analyzed in full and 39 were excluded because they did not meet the inclusion criteria. Of the seven studies reviewed, six were considered to have a high methodological quality on the PEDro scale. Several therapeutic modalities were found (physical exercise, hydrotherapy, electrotherapy and manual therapy), and postural balance improved in only three studies.Conclusion The studies included in this systematic review had a high methodological quality, so it can be concluded that the therapeutic modalities used in those studies improved postural balance in patients with knee OA.
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Brody LT. Knee osteoarthritis: Clinical connections to articular cartilage structure and function. Phys Ther Sport 2014; 16:301-16. [PMID: 25783021 DOI: 10.1016/j.ptsp.2014.12.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 11/26/2014] [Accepted: 12/03/2014] [Indexed: 12/14/2022]
Abstract
Articular cartilage is a unique biphasic material that supports a lifetime of compressive and shear forces across joints. When articular cartilage deteriorates, whether due to injury, wear and tear or normal aging, osteoarthritis and resultant pain can ensue. Understanding the basic science of the structure and biomechanics of articular cartilage can help clinicians guide their patients to appropriate activity and loading choices. The purpose of this article is to examine how articular cartilage structure and mechanics, may interact with risk factors to contribute to OA and how this interaction provides guidelines for intervention choices This paper will review the microstructure of articular cartilage, its mechanical properties and link this information to clinical decision making.
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Affiliation(s)
- Lori Thein Brody
- University of Wisconsin Hospital and Clinics, Research Park Clinic, 621 Science Drive, Madison, WI 53711, USA; Orthopaedic and Sports Science, Rocky Mountain University of Health Professions, 122 East 1700 South, Bldg. C, Provo, UT 84606, USA.
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Efficacy of rehabilitation programs for improving muscle strength in people with hip or knee osteoarthritis: a systematic review with meta-analysis. Osteoarthritis Cartilage 2014; 22:1752-73. [PMID: 25065642 DOI: 10.1016/j.joca.2014.07.005] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 06/27/2014] [Accepted: 07/10/2014] [Indexed: 02/02/2023]
Abstract
To analyse the effect of exercise-based rehabilitation programs for improving lower limb muscle strength in individuals with hip or knee osteoarthritis (OA). A systematic search utilizing seven databases identified randomized controlled trials (RCTs) evaluating lower limb strength outcomes of exercise-based interventions for participants with hip or knee OA. All studies were screened for eligibility and methodological quality. Quality of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Data were pooled and meta-analyses performed where appropriate. Forty RCTs were included and the majority (77%) involved resistance based exercise programs. For knee OA populations, there was high quality evidence for improved knee extension (standardized mean difference (SMD) = 0.47, 95% confidence intervals (CI) 0.29, 0.66) and flexion strength (SMD = 0.74, 95% CI 0.56, 0.92) with low-intensity resistance program when compared to a control at short term (ST) follow-up. There was moderate quality evidence for a large effect favouring high-intensity resistance programs (SMD = 0.76, 95% CI 0.47, 1.06) when compared to a control. This effect was sustained at intermediate term (IT) follow-up (SMD = 0.80, 95% CI 0.44, 1.17). Few studies reported on outcomes at long term (LT) follow-up. Only one study reported on a population with hip OA. When compared to a control group, high-intensity resistance exercise demonstrated moderate quality of evidence for large and sustained improvements for knee muscle strength in knee OA patients. Further work is needed to compare different modes of exercise at a LT follow-up for knee OA patients and to address the dearth of literature evaluating exercise interventions in people with hip OA.
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Abstract
Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.
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Bollen JC, Dean SG, Siegert RJ, Howe TE, Goodwin VA. A systematic review of measures of self-reported adherence to unsupervised home-based rehabilitation exercise programmes, and their psychometric properties. BMJ Open 2014; 4:e005044. [PMID: 24972606 PMCID: PMC4078771 DOI: 10.1136/bmjopen-2014-005044] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Adherence is an important factor contributing to the effectiveness of exercise-based rehabilitation. However, there appears to be a lack of reliable, validated measures to assess self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises. OBJECTIVES A systematic review was conducted to establish what measures were available and to evaluate their psychometric properties. DATA SOURCES MEDLINE, EMBASE, PsycINFO CINAHL (June 2013) and the Cochrane library were searched (September 2013). Reference lists from articles meeting the inclusion criteria were checked to ensure all relevant papers were included. STUDY SELECTION To be included articles had to be available in English; use a self-report measure of adherence in relation to a prescribed but unsupervised home-based exercise or physical rehabilitation programme; involve participants over the age of 18. All health conditions and clinical populations were included. DATA EXTRACTION Descriptive data reported were collated on a data extraction sheet. The measures were evaluated in terms of eight psychometric quality criteria. RESULTS 58 studies were included, reporting 61 different measures including 29 questionnaires, 29 logs, two visual analogue scales and one tally counter. Only two measures scored positively for one psychometric property (content validity). The majority of measures had no reported validity or reliability testing. CONCLUSIONS The results expose a gap in the literature for well-developed measures that capture self-reported adherence to prescribed but unsupervised home-based rehabilitation exercises.
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Affiliation(s)
| | - Sarah G Dean
- PenCLAHRC, University of Exeter Medical School, Exeter, UK
| | - Richard J Siegert
- Department of Psychology, Auckland University of Technology (AUT University), Auckland, New Zealand
| | - Tracey E Howe
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Maetzler W, Nieuwhof F, Hasmann SE, Bloem BR. Emerging therapies for gait disability and balance impairment: promises and pitfalls. Mov Disord 2014; 28:1576-86. [PMID: 24132846 DOI: 10.1002/mds.25682] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/13/2013] [Accepted: 08/13/2013] [Indexed: 12/31/2022] Open
Abstract
Therapeutic management of gait and balance impairment during aging and neurodegeneration has long been a neglected topic. This has changed considerably during recent years, for several reasons: (1) an increasing recognition that gait and balance deficits are among the most relevant determinants of an impaired quality of life and increased mortality for affected individuals; (2) the arrival of new technology, which has allowed for new insights into the anatomy and functional (dis)integrity of gait and balance circuits; and (3) based in part on these improved insights, the development of new, more specific treatment strategies in the field of pharmacotherapy, deep brain surgery, and physiotherapy. The initial experience with these emerging treatments is encouraging, although much work remains to be done. The objective of this narrative review is to discuss several promising developments in the field of gait and balance treatment. We also address several pitfalls that can potentially hinder a fast and efficient continuation of this vital progress. Important issues that should be considered in future research include a clear differentiation between gait and balance as two distinctive targets for treatment and recognition of compensatory mechanisms as a separate target for therapeutic intervention.
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Affiliation(s)
- Walter Maetzler
- Hertie Institute for Clinical Brain Research, Department of Neurodegeneration, Center of Neurology, University of Tübingen, Tübingen, Germany; German Center for Neurodegenerative Diseases (DNZE), Tübingen, Germany
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Matassi F, Duerinckx J, Vandenneucker H, Bellemans J. Range of motion after total knee arthroplasty: the effect of a preoperative home exercise program. Knee Surg Sports Traumatol Arthrosc 2014; 22:703-9. [PMID: 23271039 DOI: 10.1007/s00167-012-2349-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 12/10/2012] [Indexed: 12/30/2022]
Abstract
PURPOSE Preoperative range of motion (ROM) is the most important variable to determine final flexion after total knee arthroplasty (TKA). The purpose of this study was to determine whether a preoperative home exercise program could improve ROM in the arthritic knee and whether this influenced ROM and functional recovery following primary TKA. METHODS During the period between 2005 and 2006, one hundred and twenty-two patients with gonarthrosis were included in a prospective study and randomly allocated to either the control or the treatment group. The sixty-one subjects in the treatment group underwent a 6-week home-based exercise program before TKA surgery. All one hundred and twenty-two patients were assessed before and after this exercise intervention. Postoperative assessments were at 6 weeks, 6 months and 1 year. Each evaluation included knee ROM and the Knee Society Clinical Rating System. Length of hospital stay and postoperative duration before achieving 90° of knee flexion were also recorded. RESULTS Exercise program improves knee motion in the presence of gonarthrosis. After TKA, the patients in the exercise group achieved 90° of knee flexion faster and had a shorter hospital stay. There is no prolonged effect on knee motion or patient function between 6 weeks and 1 year postoperatively. CONCLUSION Preoperative exercise of the arthritic knee facilitates immediate postoperative recovery following primary TKA. LEVELS OF EVIDENCE Therapeutic study, Level I.
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Affiliation(s)
- Fabrizio Matassi
- Orthopedic Clinic, University of Florence, Largo Palagi, 1, 50139, Florence, Italy,
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Bennell K, Hinman RS, Wrigley TV, Creaby MW, Hodges P. Exercise and osteoarthritis: cause and effects. Compr Physiol 2013; 1:1943-2008. [PMID: 23733694 DOI: 10.1002/cphy.c100057] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Osteoarthritis (OA) is a common chronic joint condition predominantly affecting the knee, hip, and hand joints. Exercise plays a role in the development and treatment of OA but most of the literature in this area relates to knee OA. While studies indicate that exercise and physical activity have a generally positive effect on healthy cartilage metrics, depending upon the type of the activity and its intensity, the risk of OA development does appear to be moderately increased with sporting participation. In particular, joint injury associated with sports participation may be largely responsible for this increased risk of OA with sport. Various repetitive occupational tasks are also linked to greater likelihood of OA development. There are a number of physical impairments associated with OA including pain, muscle weakness and altered muscle function, reduced proprioception and postural control, joint instability, restricted range of motion, and lower aerobic fitness. These can result directly from the OA pathological process and/or indirectly as a result of factors such as pain, effusion, and reduced activity levels. These impairments and their underlying physiology are often targeted by exercise interventions and evidence generally shows that many of these can be modified by specific exercise. There is currently little clinical trial evidence to show that exercise can alter mechanical load and structural disease progression in those with established OA, although a number of impairments, that are amenable to change with exercise, appears to be associated with increased mechanical load and/or disease progression in longitudinal studies.
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Affiliation(s)
- Kim Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, University of Melbourne, Australia.
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Boyers D, McNamee P, Clarke A, Jones D, Martin D, Schofield P, Smith BH. Cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population: a systematic review of the literature. Clin J Pain 2013; 29:366-75. [PMID: 23042472 DOI: 10.1097/ajp.0b013e318250f539] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the cost-effectiveness of self-management techniques for older populations (65 and over) with chronic pain and in the absence of such evidence to investigate this question in an aging adult population (average age 60 and over). METHODS Systematic review of randomized controlled trials (RCTs) with cost-effectiveness data and at least 6 months' follow-up, up to December 2010. RESULTS No RCT studies reported cost-effectiveness of self-management exclusively in the over 65 age group. Ten RCTs reported participants with an average age of 60 years or over and met all other inclusion criteria. All of these studies measured cost-effectiveness as cost per improvement in primary outcome, 7 of them using the Western Ontario and McMaster Universities Osteoarthritis Index score, of which 6 reported the pain dimension. Six studies reported cost per quality-adjusted life year (QALY)-gained information, with a further 1 reporting EQ-5D. In 7 studies, relative to usual care, self-management was effective, and in the remaining 3 studies, there was no significant difference. Among those reporting cost per QALY-gained results, self-management did not lead to statistically significant QALY gains relative to usual care (with only one exception). Eight studies suggested that the cost of developing and delivering self-management interventions may be partly offset by savings from reduced subsequent health care resource use. CONCLUSIONS Self-management is effective among an aging adult population (mean age over 60) with chronic pain and may be cost-effective when outcomes are measured using the Western Ontario and McMaster Universities Osteoarthritis Index pain score. Cost-effectiveness is less certain when measured using the QALY metric. Uncertainty over conclusions regarding cost-effectiveness exists partly due to lack of information regarding societal willingness to pay for pain improvement. There is a need for large multicentred high-quality RCTs to confirm the findings of this review exclusively among older aged populations, such as those who have already reached the statutory retirement age.
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Affiliation(s)
- Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Fosterhill Aberdeen AB25 2ZD, UK.
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Bennell KL, Wrigley TV, Hunt MA, Lim BW, Hinman RS. Update on the Role of Muscle in the Genesis and Management of Knee Osteoarthritis. Rheum Dis Clin North Am 2013; 39:145-76. [DOI: 10.1016/j.rdc.2012.11.003] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Gaught AM, Carneiro KA. Evidence for determining the exercise prescription in patients with osteoarthritis. PHYSICIAN SPORTSMED 2013; 41:58-65. [PMID: 23445861 DOI: 10.3810/psm.2013.02.2000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Osteoarthritis (OA) is a chronic joint disease that affects more than one-third of older adults (age > 65 years), most often involving the hip and knee. Osteoarthritis causes pain and limits mobility, thereby reducing patient quality of life. Conservative, nonsurgical, nonpharmacologic treatment strategies include weight reduction, orthotics, physical therapy modalities, acupuncture, massage, and exercise. The breadth of the current literature on OA can make determining the appropriate exercise prescription challenging. Aerobic exercise, strengthening exercise, Tai chi, and aquatic exercise can all alleviate pain and improve function in patients with OA. The choice of the specific type and mode of delivery of the exercise should be individualized and should consider the patient's preferences. Ongoing monitoring and supervision by a health care professional are essential for patients to participate in and benefit from exercise.
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Affiliation(s)
- Amber M Gaught
- Department of Physical Medicine and Rehabilitation, University of North Carolina, Chapel Hill, NC, USA
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Golightly YM, Allen KD, Caine DJ. A comprehensive review of the effectiveness of different exercise programs for patients with osteoarthritis. PHYSICIAN SPORTSMED 2012; 40:52-65. [PMID: 23306415 PMCID: PMC4077018 DOI: 10.3810/psm.2012.11.1988] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Exercise is recommended as a first-line conservative intervention approach for osteoarthritis (OA). A wide range of exercise programs are available and scientific evidence is necessary for choosing the optimal strategy of treatment for each patient. The purpose of this review is to discuss the effectiveness of different types of exercise programs for OA based on trials, systematic reviews, and meta-analyses in the literature. Publications from January 1997 to July 2012 were searched in 4 electronic databases using the terms osteoarthritis, exercise, exercise program, effectiveness, and treatment outcome. Strong evidence supports that aerobic and strengthening exercise programs, both land- and water-based, are beneficial for improving pain and physical function in adults with mild-to-moderate knee and hip OA. Areas that require further research include examination of the long-term effects of exercise programs for OA, balance training for OA, exercise programs for severe OA, the effect of exercise programs on progression of OA, the effectiveness of exercise for joint sites other than the knee or hip, and the effectiveness of exercise for OA by such factors as age, sex, and obesity. Efforts to improve adherence to evidence-based exercise programs for OA and to promote the dissemination and implementation of these programs are crucial.
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Affiliation(s)
- Yvonne M. Golightly
- Research Assistant Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, NC,Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC,Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC
| | - Kelli D. Allen
- Associate Research Professor, Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC,Research Health Scientist, Health Services Research and Development Service, Durham Veterans Affairs Medical Center, Durham, NC
| | - Dennis J. Caine
- Professor, Department of Physical Education, Exercise Science and Wellness, University of North Dakota, Grand Forks, ND
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Ängeby Möller K, Kinert S, Størkson R, Berge OG. Gait analysis in rats with single joint inflammation: influence of experimental factors. PLoS One 2012; 7:e46129. [PMID: 23071540 PMCID: PMC3465303 DOI: 10.1371/journal.pone.0046129] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/28/2012] [Indexed: 01/18/2023] Open
Abstract
Disability and movement-related pain are major symptoms of joint disease, motivating the development of methods to quantify motor behaviour in rodent joint pain models. We used observational scoring and automated methods to compare weight bearing during locomotion and during standing after single joint inflammation induced by Freund's complete adjuvant (0.12–8.0 mg/mL) or carrageenan (0.47–30 mg/mL). Automated gait analysis was based on video capture of prints generated by light projected into the long edge of the floor of a walkway, producing an illuminated image of the contact area of each paw with light intensity reflecting the contact pressure. Weight bearing was calculated as an area-integrated paw pressure, that is, the light intensity of all pixels activated during the contact phase of a paw placement. Automated static weight bearing was measured with the Incapacitance tester. Pharmacological sensitivity of weight-bearing during locomotion was tested in carrageenan-induced monoarthritis by administration of the commonly used analgesics diclofenac, ibuprofen, and naproxen, as well as oxycodone and paracetamol. Observational scoring and automated quantification yielded similar results. We found that the window between control rats and monoarthritic rats was greater during locomotion. The response was more pronounced for inflammation in the ankle as compared to the knee, suggesting a methodological advantage of using this injection site. The effects of both Freund's complete adjuvant and carrageenan were concentration related, but Freund's incomplete adjuvant was found to be as effective as lower, commonly used concentrations of the complete adjuvant. The results show that gait analysis can be an effective method to quantify behavioural effects of single joint inflammation in the rat, sensitive to analgesic treatment.
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Pinto D, Robertson MC, Hansen P, Abbott JH. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:1-12. [PMID: 22264966 DOI: 10.1016/j.jval.2011.09.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 08/29/2011] [Accepted: 09/12/2011] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. METHODS We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars. RESULTS Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving. CONCLUSIONS There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice.
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Affiliation(s)
- Daniel Pinto
- Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
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Matthews GA, Dumville JC, Hewitt CE, Torgerson DJ. Retrospective cohort study highlighted outcome reporting bias in UK publicly funded trials. J Clin Epidemiol 2011; 64:1317-24. [PMID: 21889307 DOI: 10.1016/j.jclinepi.2011.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 02/25/2011] [Accepted: 03/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess outcome reporting bias and dissemination bias in trials funded by the National Health System (NHS) Health Technology Assessment (HTA) program. STUDY DESIGN AND SETTING A retrospective cohort study of HTA monographs and corresponding journal publications including all clinical effectiveness randomized controlled trials published as HTA monographs between 1999 and 2005 by the NHS HTA program. RESULTS There was a higher median P-value (P=0.33, interquartile range [IQR]: 0.02-0.54) among trials without a journal publication compared with those with a journal publication (P=0.14, IQR: 0.007-0.43), although the difference was not statistically significant (Mann-Whitney U test, z=-0.70; P=0.48). A higher proportion of statistically significant findings were reported in journal articles when compared with the outcomes reported in the HTA monographs. Trials published in general medical journals tended to have smaller P-values (median: 0.05, IQR: 0.001-0.22) than those published in more specialist journals (median: 0.33 IQR: 0.008-0.58), although this result was not significant (Mann-Whitney U test, z=-1.63; P=0.10). CONCLUSIONS Among journal-published trials, there were a greater proportion of statistically significant findings included in the journal reports compared with those in the HTA monographs.
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Abstract
Osteoarthritis is a leading cause of disability with incidence and prevalence rising in most nations. Management to address the degenerative joint is stratified according to degree of severity of involvement and always begins with non-surgical modalities before progressing through a range of surgeries, including arthroscopy, osteotomy, unicompartmental and total knee replacement. Predictability of results depends on the type of procedure with total joint replacement giving the most sustainable relief from symptoms, improvement of function and longevity of construct. Obesity is a health priority in developed countries where it is overrepresented in patients presenting for joint replacement. Complications, poor patient satisfaction and joint function can be directly attributable to obesity. Efforts to address obesity should be considered as part of the approach to managing osteoarthritis.
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Affiliation(s)
- Peter F M Choong
- Department of Orthopaedics Surgery, University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia.
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Dziedzic KS, Hill S, Nicholls E, Hammond A, Myers H, Whitehurst T, Bailey J, Clements C, Whitehurst DGT, Jowett S, Handy J, Hughes RW, Thomas E, Hay EM. Self management, joint protection and exercises in hand osteoarthritis: a randomised controlled trial with cost effectiveness analyses. BMC Musculoskelet Disord 2011; 12:156. [PMID: 21745357 PMCID: PMC3146911 DOI: 10.1186/1471-2474-12-156] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 07/11/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited evidence for the clinical and cost effectiveness of occupational therapy (OT) approaches in the management of hand osteoarthritis (OA). Joint protection and hand exercises have been proposed by European guidelines, however the clinical and cost effectiveness of each intervention is unknown.This multicentre two-by-two factorial randomised controlled trial aims to address the following questions:• Is joint protection delivered by an OT more effective in reducing hand pain and disability than no joint protection in people with hand OA in primary care?• Are hand exercises delivered by an OT more effective in reducing hand pain and disability than no hand exercises in people with hand OA in primary care?• Which of the four management approaches explored within the study (leaflet and advice, joint protection, hand exercise, or joint protection and hand exercise combined) provides the most cost-effective use of health care resources METHODS/DESIGN Participants aged 50 years and over registered at three general practices in North Staffordshire and Cheshire will be mailed a health survey questionnaire (estimated mailing sample n = 9,500). Those fulfilling the eligibility criteria on the health survey questionnaire will be invited to attend a clinical assessment to assess for the presence of hand or thumb base OA using the ACR criteria. Eligible participants will be randomised to one of four groups: leaflet and advice; joint protection (looking after your joints); hand exercises; or joint protection and hand exercises combined (estimated n = 252). The primary outcome measure will be the OARSI/OMERACT responder criteria combining hand pain and disability (measured using the AUSCAN) and global improvement, 6 months post-randomisation. Secondary outcomes will also be collected for example pain, functional limitation and quality of life. Outcomes will be collected at baseline and 3, 6 and 12 months post-randomisation. The main analysis will be on an intention to treat basis and will assess the clinical and cost effectiveness of joint protection and hand exercises for managing hand OA. DISCUSSION The findings will improve the cost-effective evidence based management of hand OA. TRIAL REGISTRATION identifier: ISRCTN33870549.
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Affiliation(s)
- Krysia S Dziedzic
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Susan Hill
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Elaine Nicholls
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Alison Hammond
- Centre for Health, Sport & Rehabilitation Research, University of Salford, Frederick Road, Salford, Greater Manchester, M6 6PU, UK
| | - Helen Myers
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Tracy Whitehurst
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Jo Bailey
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Charlotte Clements
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - David GT Whitehurst
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
- School of Population and Public Health, University of British Columbia, Vancouver, BCV5ZIM9, Canada
| | - Sue Jowett
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
- School of Health and Population Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - June Handy
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Rhian W Hughes
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Elaine Thomas
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Elaine M Hay
- Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG, UK
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Bossmann T, Kirchberger I, Glaessel A, Stucki G, Cieza A. Validation of the Comprehensive ICF Core Set for Osteoarthritis: the perspective of physical therapists. Physiotherapy 2011; 97:3-16. [DOI: 10.1016/j.physio.2009.11.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 11/11/2009] [Indexed: 10/19/2022]
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Bennell KL, Hinman RS. A review of the clinical evidence for exercise in osteoarthritis of the hip and knee. J Sci Med Sport 2010; 14:4-9. [PMID: 20851051 DOI: 10.1016/j.jsams.2010.08.002] [Citation(s) in RCA: 250] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 08/03/2010] [Accepted: 08/06/2010] [Indexed: 02/06/2023]
Abstract
Osteoarthritis (OA) is a chronic joint disease with the hip and knee being commonly affected lower limb sites. Osteoarthritis causes pain, stiffness, swelling, joint instability and muscle weakness, all of which can lead to impaired physical function and reduced quality of life. This review of evidence provides recommendations for exercise prescription in those with hip or knee OA. A narrative review was performed. Conservative non-pharmacological strategies, particularly exercise, are recommended by all clinical guidelines for the management of OA and meta-analyses support these exercise recommendations. Aerobic, strengthening, aquatic and Tai chi exercise are beneficial for improving pain and function in people with OA with benefits seen across the range of disease severities. The optimal exercise dosage is yet to be determined and an individualized approach to exercise prescription is required based on an assessment of impairments, patient preference, co-morbidities and accessibility. Maximising adherence is a key element dictating success of exercise therapy. This can be enhanced by the use of supervised exercise sessions (possibly in class format) in the initial exercise period followed by home exercises. Bringing patients back for intermittent consultations with the exercise practitioner, or attendance at "refresher" group exercise classes may also assist long-term adherence and improved patient outcomes. Few studies have evaluated the effects of exercise on structural disease progression and there is currently no evidence to show that exercise can be disease modifying. Exercise plays an important role in managing symptoms in those with hip and knee OA.
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Affiliation(s)
- Kim L Bennell
- Centre for Health Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Australia.
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Abstract
Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there is considerable controversy regarding how best to treat the younger, athletic patient with advanced arthritis. Treatment options range from nonsurgical management with exercise and nonsteroidal anti-inflammatory drugs, to joint arthroplasty with activity modification. When properly indicated, arthroscopic débridement, high tibial osteotomy, unicondylar knee arthroplasty, and total knee arthroplasty allow younger patients with arthritis to maintain an active, healthy lifestyle.
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Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010; 18:476-99. [PMID: 20170770 DOI: 10.1016/j.joca.2010.01.013] [Citation(s) in RCA: 1036] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update evidence for available therapies in the treatment of hip and knee osteoarthritis (OA) and to examine whether research evidence has changed from 31 January 2006 to 31 January 2009. METHODS A systematic literature search was undertaken using MEDLINE, EMBASE, CINAHL, AMED, Science Citation Index and the Cochrane Library. The quality of studies was assessed. Effect sizes (ESs) and numbers needed to treat were calculated for efficacy. Relative risks, hazard ratios (HRs) or odds ratios were estimated for side effects. Publication bias and heterogeneity were examined. Sensitivity analysis was undertaken to compare the evidence pooled in different years and different qualities. Cumulative meta-analysis was used to examine the stability of evidence. RESULTS Sixty-four systematic reviews, 266 randomised controlled trials (RCTs) and 21 new economic evaluations (EEs) were published between 2006 and 2009. Of 51 treatment modalities, new data on efficacy have been published for more than half (26/39, 67%) of those for which research evidence was available in 2006. Among non-pharmacological therapies, ES for pain relief was unchanged for self-management, education, exercise and acupuncture. However, with new evidence the ES for pain relief for weight reduction reached statistical significance, increasing from 0.13 [95% confidence interval (CI) -0.12, 0.36] in 2006 to 0.20 (95% CI 0.00, 0.39) in 2009. By contrast, the ES for electromagnetic therapy which was large in 2006 (ES=0.77, 95% CI 0.36, 1.17) was no longer significant (ES=0.16, 95% CI -0.08, 0.39). Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed. The ES for pain relief with acetaminophen diminished numerically, but not significantly, from 0.21 (0.02, 0.41) to 0.14 (0.05, 0.22) and was no longer significant when analysis was restricted to high quality trials (ES=0.10, 95% CI -0.0, 0.23). New evidence for increased risks of hospitalisation due to perforation, peptic ulceration and bleeding with acetaminophen >3g/day have been published (HR=1.20, 95% CI 1.03, 1.40). ES for pain relief from IA hyaluronic acid, glucosamine sulphate, chondroitin sulphate and avocado soybean unsponifiables also diminished and there was greater heterogeneity of outcomes and more evidence of publication bias. Among surgical treatments further negative RCTs of lavage/debridement were published and the pooled results demonstrated that benefits from this modality of therapy were no greater than those obtained from placebo. CONCLUSION Publication of a large amount of new research evidence has resulted in changes in the calculated risk-benefit ratio for some treatments for OA. Regular updating of research evidence can help to guide best clinical practice.
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Affiliation(s)
- W Zhang
- Nottingham City Hospital, University of Nottingham, Nottingham, UK.
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Jordan JL, Holden MA, Mason EEJ, Foster NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010; 2010:CD005956. [PMID: 20091582 PMCID: PMC6769154 DOI: 10.1002/14651858.cd005956.pub2] [Citation(s) in RCA: 203] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness. OBJECTIVES To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain. SEARCH STRATEGY We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials. SELECTION CRITERIA Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints. DATA COLLECTION AND ANALYSIS Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information. MAIN RESULTS We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting. AUTHORS' CONCLUSIONS Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.
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Affiliation(s)
- Joanne L Jordan
- Keele UniversityArthritis Research Campaign National Primary Care Centre Primary Care SciencesKeeleStaffordshireUKST5 5BG
| | - Melanie A Holden
- Keele UniversityPrimary Care Sciences Research CentreKeeleStaffordshireUKST5 5BG
| | - Elizabeth EJ Mason
- Keele UniversityPrimary Care Sciences Research CentreKeeleStaffordshireUKST5 5BG
| | - Nadine E Foster
- Keele UniversityPrimary Care Sciences Research CentreKeeleStaffordshireUKST5 5BG
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Abstract
Musculoskeletal problems are the most common cause of restriction in daily life in most countries. Most health care for musculoskeletal problems is provided in primary care settings, and back pain and joint problems together represent the largest workload of cases of chronic disease seen and managed there. This article reflects on aspects of the occurrence, natural history, prognosis, and management of common joint problems in primary care. Although the biomedical model has contributed to major advances, a model that embraces chronic pain management and its psychological and social components is needed. In particular, primary care is the ideal arena to achieve high-impact secondary prevention of pain and disability in people with osteoarthritis. Physical therapists are in a crucial position in primary care to provide support for self-management of this condition, especially for interventions related to exercise and behavioral change.
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Cost-effectiveness of interventions based on physical exercise in the treatment of various diseases: A systematic literature review. Int J Technol Assess Health Care 2009; 25:427-54. [DOI: 10.1017/s0266462309990353] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objectives:The aim of this study was to review studies reporting cost-effectiveness of exercise-based interventions in treatment of various diseases.Methods:Systematic literature search using several databases. Abstracts initially screened independently by two authors, full-text articles again evaluated by two authors, who decided whether an article should be included. Included were scientifically valid articles describing controlled studies that included an exercise-based intervention in the treatment of an established medical condition, and also reported on the cost-effectiveness of the intervention, or its effect on the utilization of health services. Quality was assessed with an established approach.Results:A total of 914 articles were identified, of them 151 were obtained for closer review. Sixty-five articles describing sixty-one studies were included. Most (82 percent) were randomized trials. Twenty-eight studies dealt with musculoskeletal disorders, fifteen with cardiology, four with rheumatic diseases, four with pulmonary diseases, three with urinary incontinence, and two with vascular disorders. There was one study each in the fields of oncology, chronic fatigue, endocrinology, psychiatry, and neurology. Exercise interventions in musculoskeletal disorders were deemed to be cost-effective in 54 percent, in cardiology in 60 percent, and in rheumatic diseases in 75 percent of the cases. There was some evidence that exercise might be cost-effective in intermittent claudication, breast cancer patients, diabetes, and schizophrenia.Conclusions:The number of studies assessing cost-effectiveness of exercise interventions in various diseases is still limited. The results show large variation but suggest that some exercise interventions can be cost-effective. Most convincing evidence was found for rehabilitation of cardiac and back pain patients; however, even in these cases, the evidence was partly contradictory.
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Improvement in aerobic capacity after an exercise program in sporadic inclusion body myositis. J Clin Neuromuscul Dis 2009; 10:178-84. [PMID: 19494728 DOI: 10.1097/cnd.0b013e3181a23c86] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The study aimed to investigate the effects of a combined functional and aerobic exercise program on aerobic capacity, muscle strength, and functional mobility in a group of patients with sporadic inclusion body myositis (IBM). METHODS Aerobic capacity, muscle strength, and functional capacity assessments were conducted on 7 participants with sporadic IBM before and after a 12-week exercise program, which included resistance exercises and aerobic stationary cycling 3 times per week on alternative days. RESULTS Aerobic capacity of the group increased significantly by 38%, and significant strength improvements were observed in 4 of the muscle groups tested (P < 0.05). The exercise program was well tolerated, and there was no significant change in the serum creatine kinase level after the exercise period. CONCLUSIONS An aerobic exercise program can be safely tolerated by patients with sporadic IBM and can improve aerobic capacity and muscle strength when combined with resistance training. These findings indicate that aerobic and functional muscle strengthening exercise should be considered in the management of patients with IBM.
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