The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: a randomized study

Demographic, health, physical activity, and workplace factors are associated with lower healthy working life expectancy and life expectancy at age 50

Although retirement ages are rising in the United Kingdom and other countries, the average number of years people in England can expect to spend both healthy and work from age 50 (Healthy Working Life Expectancy; HWLE) is less than the number of years to the State Pension age. This study aimed to estimate HWLE with the presence and absence of selected health, socio-demographic, physical activity, and workplace factors relevant to stakeholders focusing on improving work participation. Data from 11,540 adults in the English Longitudinal Study of Ageing were analysed using a continuous time 3-state multi-state model. Age-adjusted hazard rate ratios (aHRR) were estimated for transitions between health and work states associated with individual and combinations of health, socio-demographic, and workplace factors. HWLE from age 50 was 3.3 years fewer on average for people with pain interference (6.54 years with 95% confidence interval [6.07, 7.01]) compared to those without (9.79 [9.50, 10.08]). Osteoarthritis and mental health problems were associated with 2.2 and 2.9 fewer healthy working years respectively (HWLE for people without osteoarthritis: 9.50 years [9.22, 9.79]; HWLE with osteoarthritis: 7.29 years [6.20, 8.39]; HWLE without mental health problems: 9.76 years [9.48, 10.05]; HWLE with mental health problems: 6.87 years [1.58, 12.15]). Obesity and physical inactivity were associated with 0.9 and 2.0 fewer healthy working years respectively (HWLE without obesity: 9.31 years [9.01, 9.62]; HWLE with obesity: 8.44 years [8.02, 8.86]; HWLE without physical inactivity: 9.62 years [9.32, 9.91]; HWLE with physical inactivity: 7.67 years [7.23, 8.12]). Workers without autonomy at work or with inadequate support at work were expected to lose 1.8 and 1.7 years respectively in work with good health from age 50 (HWLE for workers with autonomy: 9.50 years [9.20, 9.79]; HWLE for workers lacking autonomy: 7.67 years [7.22, 8.12]; HWLE for workers with support: 9.52 years [9.22, 9.82]; HWLE for workers with inadequate support: 7.86 years [7.22, 8.12]). This study identified demographic, health, physical activity, and workplace factors associated with lower HWLE and life expectancy at age 50. Identifying the extent of the impact on healthy working life highlights these factors as targets and the potential to mitigate against premature work exit is encouraging to policy-makers seeking to extend working life as well as people with musculoskeletal and mental health conditions and their employers. The HWLE gaps suggest that interventions are needed to promote the health, wellbeing and work outcomes of subpopulations with long-term health conditions.

Physical functioning in patients with end-stage knee osteoarthritis: A cross-sectional study in Jordan using self-reported questionnaire and performance-based tests

BACKGROUND

Knee osteoarthritis (OA) is a debilitating condition that leads to functional limitations. Self-reported questionnaires and performance-based tests are tools commonly used for measuring physical function.

OBJECTIVES

(1) To evaluate the impact of end-stage knee OA on functional outcomes and examine the association between self-reported and performance-based measures of function in patients with end-stage knee osteoarthritis awaiting total knee arthroplasty (2) To explore the interrelationships among pain, strength, and overall physical function in this patient population.

METHODS

In this cross-sectional analysis, 33 patients with end-stage knee OA were recruited and completed the knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and executed performance-based tests including the Timed Up and Go, the 30-second chair stand test, and the Stair Climbing Test. Knee pain, and isometric hip and knee strength were evaluated.

RESULTS

Patients perceived deficits in their physical functionwith a score of 35/100 on the KOS-ADLS and demonstrated functional limitations in all performed tasks. KOS-ADLs was weakly associated with TUG and 30s-CST (r=-0.301, p= 0.047, and r= 0.39, p= 0.014. respectively). Knee pain was linked with the KOS-ADL score and GRS score (r=-0.406, p= 0.010; r=-0.343, p= 0.027; respectively), while the strength of the affected side was correlated with the performed (p=< 0.001) and reported function outcomes (p= 0.007).

CONCLUSION

Participants exhibit declines in both perceived and executed functional abilities. Self-reported and performance-based functional measures are weakly correlated within our study group, highlighting the importance of incorporating both measures in clinical practice for a comprehensive evaluation of physical function. Pain was linked to subjective aspect of physical function, while strength was connected to perceived and performed functional capacity. Implementing a tailored rehabilitation program targeting muscle weakness and pain holds the potential to mitigate functional decline in individuals awaiting total knee arthroplasty (TKA).

The impact of waiting time for orthopaedic consultation on pain levels in individuals with osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

Time spent waiting for access to orthopaedic specialist health services has been suggested to result in increased pain in individuals with osteoarthritis (OA). We assessed whether time spent on an orthopaedic waiting list resulted in a detrimental effect on pain levels in patients with knee or hip OA.

METHODS

We searched Ovid MEDLINE, EMBASE and EBSCOhost databases from inception until September 2021. Eligible articles included individuals with OA on an orthopaedic waitlist and not receiving active treatment, and reported pain measures at two or more time points. Random-effects meta-analysis was used to estimate the pooled effect of waiting time on pain levels. Meta-regression was used to determine predictors of effect size.

RESULTS

Thirty-three articles were included (n = 2,490 participants, 67 ± 3 years and 62% female). The range of waiting time was 2 weeks to 2 years (20.8 ± 18.8 weeks). There was no significant change in pain over time (effect size = 0.082, 95% CI = -0.009, 0.172), nor was the length of time associated with longitudinal changes in pain over time (β = 0.004, 95% CI = -0.005, 0.012). Body mass index was a significant predictor of pain (β = -0.043, 95% CI = -0.079, 0.006), whereas age and sex were not.

CONCLUSIONS

Pain remained stable for up to 1 year in patients with OA on an orthopaedic waitlist. Future research is required to understand whether pain increases in patients waiting longer than 1 year.

Self-care behaviors in older adults suffering from knee osteoarthritis: Application of theory of planned behavior

Background

Osteoarthritis is one of the main reasons causing disablement. Educational intervention for self-care behaviors of patients suffering from knee osteoarthritis is important because its effect on quality of patient life decreases the economic burden of disorder on society and family. This study aimed to investigate the effect of educational intervention based on the theory of planned behavior (TPB) on promoting self-care behaviors in elderly patients suffering from knee osteoarthritis.

Methods

This quasi-experimental study was performed on 200 elderlies suffering from knee osteoarthritis in the rheumatology clinics of Shiraz, Iran, in 2019. The subjects were divided into two groups (100 experimental and 100 control). Before and after 4 months, both experimental and control groups filled a questionnaire. After administering a pre-test to both groups, only the experimental group was trained based on the TPB constructs on self-care behaviors in elderly people suffering from knee osteoarthritis in eight sessions by presenting educational films and images, power points, and group discussions for solving problems.

Results

The mean age of the experimental group was 67.25 ± 3.64, and the mean age of the control group was 66.12 ± 3.50. The average scores of attitudes, subjective norms, perceived behavioral control, intention, and behavior before the educational intervention did not have significant differences in experimental and control groups, however, 4 months after the educational intervention, the paired t-test indicated significant enhancement in every construct in the experimental group, but no significant changes in the control group.

Conclusion

According to the results, the educational intervention increased the self-care behaviors of patients suffering from knee osteoarthritis based on the theory of planned behavior. Therefore, the results of this study can be used in theory-based intervention strategies for self-care behaviors of patients suffering from knee osteoarthritis.

Identifying and Understanding the Non-Clinical Impacts of Delayed or Cancelled Surgery in Order to Inform Prioritisation Processes: A Scoping Review

The COVID-19 pandemic has resulted in significant delays to non-urgent elective surgery. Decision making regarding prioritisation for surgery is currently informed primarily by clinical urgency. The ways in which decision making should also consider potential social and economic harm arising from surgical delay are currently unclear. This scoping review aimed to identify evidence related to (i) the nature and prevalence of social and economic harm experienced by patients associated with delayed surgery, and (ii) any patient assessment tools that could measure the extent of, or predict, such social and economic harm. A rapid scoping review was undertaken following JBI methodological guidance. The following databases were searched in October 2020: AMED; BNI; CINAHL; EMBASE; EMCARE; HMIC; Medline; PsychINFO, Cochrane, and the JBI. A total of 21 publications were included. The findings were categorised into five themes: (i) employment, (ii) social function and leisure, (iii) finances, (iv) patients’ experiences of waiting, and (v) assessment tools that could inform decision making. The findings suggest that, for some patients, waiting for surgery can include significant social, economic, and emotional hardship. Few validated assessment tools exist. There is an urgent need for more research on patients’ experiences of surgical delay in order to inform a more holistic process of prioritising people on surgical waiting lists in the COVID-19 pandemic recovery stages.

Participatory learning and action (PLA) to improve health outcomes in high-income settings: a systematic review protocol

INTRODUCTION

Participatory learning and action (PLA) is a form of group reflection and learning with documented efficacy in low-income countries to improve social and health outcomes. PLA represents both a learning philosophy and a practical framework that could be applied to a variety of contexts. To date, PLA has not been widely implemented within high-income countries (HICs) to improve health and health-related outcomes. We aim to synthesise the literature currently available by means of a systematic review to form a foundation for future applications of PLA methodology in HICs.

METHODS AND ANALYSIS

Two reviewers will independently search predefined terms in the following electronic bibliographic databases: MEDLINE, EMBASE, CINAHL and Cochrane Library. The search terms will encompass PLA and PDSA (Plan-Do-Study-Act) projects, as well as studies using the Triple/Quadruple Aim model. We will include randomised controlled trials that incorporate online or face-to-face components using the PLA/PDSA methodology. Our data will be extracted into a standardised prepiloted form with subsequent narrative review according to the SWiM (Synthesis Without Meta-Analysis) guidelines.

ETHICS AND DISSEMINATION

No ethics approval is required for this study. The results of this study will be submitted for publication in a leading peer-reviewed academic journal in this field. Additionally, a report will be produced for the funders of this review, which can be viewed for free on their website.

PROSPERO REGISTRATION NUMBER

CRD42020187978.

Monthly Disposable Income Is a Crucial Factor Affecting the Quality of Life in Patients with Knee Osteoarthritis

Knee osteoarthritis (OA) affects the quality of life (QOL) of elderly people; this study examines the demographic characteristics and QOL of patients with knee OA and identifies demographic characteristics that affect the QOL of these patients. In this cross-sectional study, 30 healthy controls and 60 patients with mild-to-moderate bilateral knee OA aged between 55 and 75 years were enrolled. All participants completed a questionnaire containing questions on 10 demographic characteristics and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36), and their QOL scores in the eight dimensions of the SF-36 were evaluated. In the OA group, significant correlations were observed between monthly disposable income and physical and mental health components. Monthly disposable income was found to considerably affect the QOL of patients with bilateral knee OA (i.e., it is a crucial factor affecting these patients). The findings of this study may provide a reference for formulating preventive strategies for healthy individuals and for future confirmatory research.

The Effectiveness of Client-Centered Intervention With Telerehabilitation Method After Total Knee Arthroplasty

There is known to be a decrease in quality of life and perceived occupational performance and satisfaction following total knee arthroplasty (TKA). This study was planned to examine the effectiveness of a client-centered (CC) intervention with the telerehabilitation (TR) method on the quality of life, perceived occupational performance, and satisfaction after TKA. A total of 38 patients who had undergone TKA were randomly assigned to the CC and control groups. A 12-day intervention program was applied to the CC group. The Nottingham Health Profile (NHP) and Canadian Occupational Performance Measure (COPM) were applied before and after intervention. The 12-day intervention showed a strong effect on all parameters in the CC group (p<.001). In the postintervention comparisons, a significant difference was found in favor of the CC group (p < .001). CC interventions with the TR method can be used in post-TKA interventions.

Efficacy of Specified Manual Therapies in Combination with a Supervised Exercise Protocol for Managing Pain Intensity and Functional Disability in Patients with Knee Osteoarthritis

Purpose

The current study aimed to determine the efficacy of specified manual therapies in combination with a supervised exercise protocol for managing pain intensity and functional disability in patients with knee osteoarthritis.

Methods

The study was based on a two-arm parallel-group randomized controlled trial design, including a total of 32 participants with knee osteoarthritis randomly divided into groups A and B. Group A received a supervised exercise protocol; however, group B received specified manual therapies in combination with a supervised exercise protocol. Pain and functional disability were measured with the numeric pain rating scale (NPRS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), respectively. Data were collected at baseline (pre-intervention), 2 weeks, and 4 weeks post-intervention. To evaluate the efficacy of specific manual therapies with supervised exercise compared to supervised exercise alone, an unpaired t-test and repeated measures ANOVA were used to analyze the data, keeping the level of significance at p<0.05.

Results

A significant (p<0.05) mean difference (∆MD) was found within group A and group B for both outcomes when we compared their baseline scores with 2-week (group A, NPRS: ∆MD=−1.56 and WOMAC: ∆MD=14.94; group B, NPRS: ∆MD=2.06 and WOMAC: ∆MD=22.19) and 4-week post-intervention scores (group A, NPRS: ∆MD=0.62 and WOMAC: ∆MD=6.75; group B, NPRS: ∆MD=0.75 and WOMAC: ∆MD=11.12). In addition, significant mean differences (p<0.05) reported for both outcomes when we compared their scores between groups A and B at 2 weeks (∆MD: NPRS=0.69; WOMAC=10.87) and 4 weeks post-intervention (∆MD: NPRS=0.31; WOMAC=8.00). Furthermore, a post hoc Scheffe analysis for the outcomes NPRS and WOMAC revealed the superiority of group B over group A.

Conclusion

The specified manual therapies, in combination with a supervised exercise protocol, were found to be more effective than a supervised exercise protocol alone for improving pain and functional disability in patients with knee osteoarthritis.

The feasibility and effectiveness of internet-based rehabilitation for patients with knee osteoarthritis: A study protocol of randomized controlled trial in the community setting

BACKGROUND

Internet-based rehabilitation can ease the progression of chronic diseases. There had been studies on internet-based rehabilitation of knee osteoarthritis (OA), but them were conducted at home and ignored the potential benefits in the community setting. This study will explore the feasibility and effectiveness of internet-based rehabilitation accompanies wearable devices in the community setting for the patients with knee OA.

METHODS

An assessor-blinded randomized controlled feasibility trial will be performed to study the feasibility and effectiveness of internet-based rehabilitation program for the patients with knee OA in the community setting. Forty participants with knee OA will be recruited and randomly allocated into internet-based rehabilitation group (IRG) or control group (CG). The interventions of IRG will be performed in the community setting via web-based platform and wearable devices. The outcome measures will be conducted at baseline, and post-intervention 6 weeks, 12 weeks during the study. The feasibility will be tested by the proportion of participants who will complete the internet-based rehabilitation program within 12 weeks in IRG as well as the compliance and satisfaction. Additionally, the effectiveness of internet-based rehabilitation will be assessed by the Western Ontario and McMaster Universities Osteoarthritis Index, 11-point Numerical Rating Scale and Short Form-36 quality-of-life questionnaire.

CONCLUSION

The internet-based rehabilitation program and community-based interventions is feasible and efficacy to ameliorate the osteoarthritic pain and promote the physical function and quality of life for the patients with knee OA in the community setting.

TRIAL REGISTRATION NUMBER

The study was registered in the clinical trial registry ChiCTR2000033397.

Self-reported physical activity is related to knee muscle strength on the unaffected side and walking ability in patients with knee osteoarthritis awaiting total knee arthroplasty: a cross-sectional study

Background: Additional evidence regarding the effectiveness of self-management programs for patients awaiting total knee arthroplasty is required.Objective: The study aimed to determine if self-reported physical activity was related to muscle strength and walking ability in patients with knee osteoarthritis awaiting total knee arthroplasty.Methods: The study included subjects with knee osteoarthritis awaiting total knee arthroplasty (n = 767). Walking ability and bilateral knee muscle strength were measured as dependent variables. Self-report physical activity was assessed based on the guidelines from the Japanese Ministry of Health, Labor and Welfare. Multiple regression models determined if self-reported physical activity was significantly related to dependent variables, after accounting for other related factors.Results: Physical activity was associated with both higher knee flexion (β = -0.09, p = .013) and higher extension (β = -0.09, p = .007) muscle strength on the unaffected side only. In addition, physical inactivity was associated with a lower walking ability level (TUG: β = 0.08, p = .015; 5mWT: β = 0.10, p = .005).Conclusions: These results can help health-services providers develop educational and/or self-management programs to maintain muscle strength on the unaffected side and walking ability in patients awaiting total knee arthroplasty.

Occupational Therapy Interventions for Adults With Musculoskeletal Conditions

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association's (AOTA's) Evidence-Based Practice Project. In this Evidence Connection article, we describe a case report of a person who underwent a total knee replacement due to severe osteoarthritis of his left knee. The occupational therapy assessment and intervention process both before and after surgery in the home setting is described. Findings from the systematic review (Dorsey & Bradshaw, 2017) on this topic were published in the January/February 2017 issue of the American Journal of Occupational Therapy and in AOTA's Occupational Therapy Practice Guidelines for Adults With Musculoskeletal Conditions. Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical reasoning.

Pain Coping Skills Training for Patients Who Catastrophize About Pain Prior to Knee Arthroplasty: A Multisite Randomized Clinical Trial

BACKGROUND

Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education.

METHODS

A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure.

RESULTS

Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12-month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), -0.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, -0.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups.

CONCLUSIONS

Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The effect of a 12 week prehabilitation program on pain and function for patients undergoing total knee arthroplasty: A prospective controlled study

BACKGROUND

The concept of preparing the body before a stressful event, such as surgery, has been termed "prehabilitation" (preoperative physiotherapy and exercise programs). Prehabilitation programs for people awaiting total knee arthroplasty (TKA) have positive effects on patients health status and may also lead to better postoperative outcomes.

AIM

The purpose of this study was to examine effect of a prehabilitation program on knee pain, functional ability among patients with knee osteoarthritis after TKA surgery.

STUDY DESIGN

A Prospective Controlled Study.

PATIENTS AND METHODS

Subjects enrolled in this prospective controlled study who referred to our Orthopedics and Traumatology outpatient clinic between 2014 April-2015 May, had severe OA with pain not responsive to conservative treatment and scheduled for unilateral TKA. Subjects were assigned to a control or prehabilitation group. Patients of prehabilitation group were recruited from the orthopaedic waiting lists for primary unilateral TKA. Partipicants in the prehabilitation group were prescribed a training program that consisted of education and home-based exercise 12 weeks before the operation. After the TKA, all subjects partipicated in the same postoperative rehabilitation protocol. Evaluations were made before the surgery, with follow-up assessments at 3 and 6 months after surgery. Knee pain was assessed by the use of a 10-cm Visual Analog Scale (VAS) and function assesed by Knee injury and Osteoarthritis Outcome Score (KOOS) scale.

RESULTS

A statistically significant improvement was observed in the values of VAS and all subsclaes of KOOS in both groups at third and sixth month compared to baseline. The intergroup comparison of the improvement (pre-post scores at sixth month) did not show any statistically significant diffeferences in VAS and KOOS scores.

CONCLUSION

Our results show that prehabilitation before TKA is not superior to surgical treatment alone but about 20% of the patients changed their operation decision. So it is important to be able to postpone this process especially in the early period.

A theory of planned behavior-based intervention to improve quality of life in patients with knee/hip osteoarthritis: a randomized controlled trial

Osteoarthritis (OA) is a common chronic disorder among elderly people that affects joints such as the knee and hip in particular. The objective of the current study was to examine the efficacy of an intervention based on a theory of planned behavior (TPB) in improving health-related quality of life in middle-age and older adults with this condition. One hundred twenty patients diagnosed with knee/hip OA were recruited from a general hospital. Measures administered at baseline were the SF-12, EuroQol (EQ-5D), Osteoarthritis Knee and Hip Quality of Life (OAKHQoL), and TPB questionnaire. Also assessed were body mass index (BMI), Kellgren-Lawrence Scale, six-minute walk test (SMWT), muscle strength, range of motion (ROM), and joint tenderness and swelling. Participants were randomly assigned to either the intervention (n = 60) or the control group (n = 60). The intervention group received an educational program based on TPB that was administered over 1 month. The control group did not receive this treatment. Three months after the intervention, both groups were reevaluated and comparisons made. Compared to the no-treatment control group, those in the intervention group scored higher on HRQoL, both general and specific, at 3-month follow-up (p < 0.01). The only exception was the vitality domain. Significant differences were also found on the TPB questionnaire, the SMWT, and muscle strength in the expected direction (p < 0.05). While those in the intervention group improved significantly on all clinical measures from pre-test to post-test, those in the control group showed improvement only on BMI and joint tenderness. This TPB-based intervention was found to be efficacious in improving HRQoL and several clinical parameters in patients with knee/hip OA. Studies are needed to examine the effectiveness of this intervention in patients with other chronic medical conditions.

What is the current evidence of the impact on quality of life whilst waiting for management/treatment of orthopaedic/musculoskeletal complaints? A systematic scoping review

PURPOSE

To describe quality of life (QoL) outcome measures that are reported in the literature in patients waiting for outpatient orthopaedic/musculoskeletal specialist care and how waiting impacts on QoL in these terms.

METHODS

A subset of studies reporting on QoL outcome measures were extracted from literature identified in a recent scoping search of Medline, Embase, Pubmed, NHS Economic Evaluation Database (Prospero registration CRD42016047332). The systematic scoping search examined impacts on patients waiting for orthopaedic specialist care. Two independent reviewers ranked study design using the National Health and Medical Research Council aetiology evidence hierarchy, and appraised study quality using Critical Appraisal Skills Programme tools. QoL measures were mapped against waiting period timepoints.

RESULTS

The scoping search yielded 142 articles, of which 18 reported on impact on QoL. These studies reported only on patients waiting for hip and/or knee replacement surgery. The most recent study reported on data collected in 2006/7. The Western Ontario and McMaster Universities Arthritis Index and the SF-36 were the most commonly reported QoL measures. QoL was measured at variable timepoints in the waiting period (from a few weeks to greater than 12 months). The impact of waiting on QoL was inconsistent.

CONCLUSION

The evidence base was over 10 years old, reported only on patients with hip and knee problems, and on limited QoL outcome measures, and with inconsistent findings. A better understanding of the impact on QoL for patients waiting for specialist care could be gained by using standard timepoints in the waiting period, patients with other orthopaedic conditions, comprehensive QoL measures, as well as expectations, choices and perspectives of patients waiting for specialist care.

Randomized blinded trial of standardized written patient information before total knee arthroplasty

Background

The effect of patient education before total knee arthroplasty (TKA) is controversial. No consensus exists about the optimal content of educational interventions. In a previous study, we developed and validated an educational booklet on the peri-TKA management of knee osteoarthritis.

Purposes

Our primary purpose was to evaluate the impact of the educational booklet on knowledge among patients awaiting TKA.

Patients and methods

This randomized controlled single-blind trial evaluated standard information by the surgeon with or without delivery of the educational booklet 4–6 weeks before primary noncomplex TKA in patients aged 55–75 years with incapacitating knee osteoarthritis. Patients were enrolled at a French surgical center between June 2011 and January 2012. A patient knowledge score was determined at baseline, on the day before TKA, and 3–6 weeks after TKA, using a self-administered questionnaire developed for our previous study. The assessor was blinded to group assignment.

Results

Of 44 eligible patients, 42 were randomized, 22 to the intervention and 20 to the control group, all of whom were included in the analysis. The groups were comparable at baseline. The intervention was associated with significantly better patient knowledge scores.

Conclusions

An educational booklet improves knowledge among patients awaiting TKA. A study assessing the impact of the booklet combined with a exercise program would be helpful.

Level of evidence

Level I, randomized controlled double-blind trial; see S1 CONSORT Checklist.

Trial registration

clinicaltrials.gov #NCT01747759

Effectiveness of Occupational Therapy Interventions for Lower-Extremity Musculoskeletal Disorders: A Systematic Review

Lower-extremity (LE) musculoskeletal disorders (MSDs) can have a major impact on the ability to carry out daily activities. The effectiveness of interventions must be examined to enable occupational therapy practitioners to deliver the most appropriate services. This systematic review examined the literature published between 1995 and July 2014 that investigated the effectiveness of occupational therapy interventions for LE MSDs. Forty-three articles met the criteria and were reviewed. Occupational therapy interventions varied on the basis of population subgroup: hip fracture, LE joint replacement, LE amputation or limb loss, and nonsurgical osteoarthritis and pain. The results indicate an overall strong role for occupational therapy in treating clients with LE MSDs. Activity pacing is an effective intervention for nonsurgical LE MSDs, and multidisciplinary rehabilitation is effective for LE joint replacement and amputation. Further research on specific occupational therapy interventions in this important area is needed.

Effects of a tele-prehabilitation program or an in-person prehabilitation program in surgical candidates awaiting total hip or knee arthroplasty: Protocol of a pilot single blind randomized controlled trial

Background

The accessibility for total joint arthroplasty often comes up against long wait lists, and may lead to deleterious effects for the awaiting patients. This pilot single blind randomized controlled trial aims to evaluate the impact of a telerehabilitation prehabilitation program before a hip or knee arthroplasty compared to in-person prehabilitation or to usual wait for surgery.

Methods/design

Thirty-six patients on a wait list for a total hip or knee arthroplasty will be recruited and randomly assigned to one of three groups. The in-person prehabilitation group (n = 12) will receive a 12-week rehabilitation program (2 sessions/week) including education, exercises of the lower limb and cardiovascular training. Patients in the tele-prehabilitation group (n = 12) will receive the same intervention using a telecommunication software. The control group (n = 12) will be provided with the hospital's usual documentation before surgery. The Lower Extremity Functional Scale (LEFS) will be the primary outcome measure taken at baseline and at 12 weeks. Secondary measures will include self-reported function and quality of life as well as performance tests. A mixed-model, 2-way repeated-measure ANOVA will be used to analyse the effects of the rehabilitation programs.

Discussion

This pilot study is the first to evaluate the feasibility and the impact of a telerehabilitation prehabilitation program for patients awaiting a total joint arthroplasty. The results of this pilot-RCT will set the foundations for further research in the fields of rehabilitation and tele-medicine for patients suffering from lower limb osteoarthritis.

Trial registration

ClinicalTrials.gov: NCT02636751.

Improving the self-management of chronic pain: COping with persistent Pain, Effectiveness Research in Self-management (COPERS)

Background

Chronic musculoskeletal pain is a common problem that is difficult to treat. Self-management support interventions may help people to manage this condition better; however, there is limited evidence showing that they improve clinical outcomes. Our overarching research question was ‘Does a self-management support programme improve outcomes for people living with chronic musculoskeletal pain?’.

Aim

To develop, evaluate and test the clinical effectiveness and cost-effectiveness of a theoretically grounded self-management support intervention for people living with chronic musculoskeletal pain.

Methods

In phase 1 we carried out two systematic reviews to synthesise the evidence base for self-management course content and delivery styles likely to help those with chronic pain. We also considered the psychological theories that might underpin behaviour change and pain management principles. Informed by these data we developed the Coping with persistent Pain, Evaluation Research in Self-management (COPERS) intervention, a group intervention delivered over 3 days with a top-up session after 2 weeks. It was led by two trained facilitators: a health-care professional and a layperson with experience of chronic pain. To ensure that we measured the most appropriate outcomes we reviewed the literature on potential outcome domains and measures and consulted widely with patients, tutors and experts. In a feasibility study we demonstrated that we could deliver the COPERS intervention in English and, to increase the generalisability of our findings, also in Sylheti for the Bangladeshi community. In phase 2 we ran a randomised controlled trial to test the clinical effectiveness and cost-effectiveness of adding the COPERS intervention to a best usual care package (usual care plus a relaxation CD and a pain toolkit leaflet). We recruited adults with chronic musculoskeletal pain largely from primary care and musculoskeletal physiotherapy services in two localities: east London and Coventry/Warwickshire. We collected follow-up data at 12 weeks (self-efficacy only) and 6 and 12 months. Our primary outcome was pain-related disability (Chronic Pain Grade disability subscale) at 12 months. We also measured costs, health utility (European Quality of Life-5 Dimensions), anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], coping, pain acceptance and social integration. Data on the use of NHS services by participants were extracted from NHS electronic records.

Results

We recruited 703 participants with a mean age of 60 years (range 19–94 years); 81% were white and 67% were female. Depression and anxiety symptoms were common, with mean HADS depression and anxiety scores of 7.4 [standard deviation (SD) 4.1] and 9.2 (SD 4.6), respectively. Intervention participants received 85% of the course content. At 12 months there was no difference between treatment groups in our primary outcome of pain-related disability [difference –1.0 intervention vs. control, 95% confidence interval (CI) –4.9 to 3.0]. However, self-efficacy, anxiety, depression, pain acceptance and social integration all improved more in the intervention group at 6 months. At 1 year these differences remained for depression (–0.7, 95% CI –1.2 to –0.2) and social integration (0.8, 95% CI, 0.4 to 1.2). The COPERS intervention had a high probability (87%) of being cost-effective compared with usual care at a threshold of £30,000 per quality-adjusted life-year.

Conclusions

Although the COPERS intervention did not affect our primary outcome of pain-related disability, it improved psychological well-being and is likely to be cost-effective according to current National Institute for Health and Care Excellence criteria. The COPERS intervention could be used as a substitute for less well-evidenced (and more expensive) pain self-management programmes. Effective interventions to improve hard outcomes in chronic pain patients, such as disability, are still needed.

Trial registration

Current Controlled Trials ISRCTN22714229.

Funding

The project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 14. See the NIHR Journals Library website for further project information.

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

The PLE(2)NO self-management and exercise program for knee osteoarthritis: Study Protocol for a Randomized Controlled Trial

Background

International recommendations suggest exercise and self-management programs, including non-pharmacological treatments, for knee osteoarthritis (KOA) because they can benefit pain relief and improve function and exercise adherence. The implementation of a combined self-management and exercise program termed PLE²NO may be a good method for controlling KOA symptoms because it encourages the development of self-efficacy to manage the pathology. This study will assess the effects of a self-management and exercise program in comparison to an educational intervention (control program) on symptoms, physical fitness, health-related quality of life, self-management behaviors, self-efficacy, physical activity level and coping strategies.

Methods/Design

This PLE²NO study is a single-blinded, randomized controlled trial of elderly (aged above 60 yrs old) patients with clinical and radiographic KOA. The patients will be allocated into either an educational group (control) or a self-management and exercise group (experimental). All participants will receive a supplement of chondroitin and glucosamine sulfates. This paper describes the protocol that will be used in the PLE²NO program.

Discussion

This program has several strengths. First, it involves a combination of self-management and exercise approaches, is available in close proximity to the patients and occurs over a short period of time. The latter two characteristics are crucial for maintaining participant adherence. Exercise components will be implemented using low-cost resources that permit their widespread application. Moreover, the program will provide guidance regarding the effectiveness of using a self-management and exercise program to control KOA symptoms and improve self-efficacy and health-related quality of life.

Trial registration

NCT02562833 (09/23/2015)

Obesity, knee osteoarthritis, and polypathology: factors favoring weight loss in older people

AIM

We aimed to explore the meaning of obesity in elderly persons with knee osteoarthritis (KO) and to determine the factors that encourage or discourage weight loss.

BACKGROUND

Various studies have demonstrated that body mass index is related to KO and that weight loss improves symptoms and functional capacity. However, dietary habits are difficult to modify and most education programs are ineffective.

DESIGN

A phenomenological qualitative study was conducted. Intentional sampling was performed in ten older persons with KO who had lost weight and improved their health-related quality of life after participating in a health education program. A thematic content analysis was conducted following the stages proposed by Miles and Huberman.

FINDINGS

Participants understood obesity as a risk factor for health problems and stigma. They believed that the cause of obesity was multifactorial and criticized health professionals for labeling them as "obese" and for assigning a moral value to slimness and diet. The factors identified as contributing to the effectiveness of the program were a tolerant attitude among health professionals, group education that encouraged motivation, quantitative dietary recommendations, and a meaningful learning model based on social learning theories.

CONCLUSION

Dietary self-management without prohibitions helped participants to make changes in the quantity and timing of some food intake and to lose weight without sacrificing some foods that were deeply rooted in their culture and preferences. Dietary education programs should focus on health-related quality of life and include scientific knowledge but should also consider affective factors and the problems perceived as priorities by patients.

Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials

OBJECTIVES

The clinical impact of preoperative physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement.

DESIGN

We searched PubMed, Embase and Cochrane CENTRAL up to November 2015 for randomised controlled trials comparing prehabilitation versus no prehabilitation before joint replacement surgery. Postoperative pain and function scores were converted to Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales (0-100, high scores indicate worse outcome). Random effects meta-analysis was performed to calculate weighted mean differences (WMD, 95% CI), subgrouped by hip and knee surgery.

PRIMARY AND SECONDARY OUTCOMES

Postoperative pain and function scores, time to resume activities of daily living, quality of life, length of hospital stay, total cost, patient satisfaction, postoperative complications, any adverse events and discontinuations.

RESULTS

Of 22 studies (1492 patients), 18 had high risk of bias. Prehabilitation slightly reduced pain scores within 4 weeks postoperatively (WMD -6.1 points, 95% CI -10.6 to -1.6 points, on a scale of 0-100), but differences did not remain beyond 4 weeks. Prehabilitation slightly improved WOMAC function score at 6-8 and 12 weeks (WMD -4.0, 95% CI -7.5 to -0.5), and time to climbing stairs (WMD -1.4 days, 95% CI -1.9 to -0.8 days), toilet use (-0.9 days, 95% CI -1.3 to -0.5 days) and chair use (WMD -1.2 days, 95% CI -1.7 to -0.8 days). Effects were similar for knee and hip surgery. Differences were not found for SF-36 scores, length of stay and total cost. Other outcomes of interest were inadequately reported.

CONCLUSIONS

Existing evidence suggests that prehabilitation may slightly improve early postoperative pain and function among patients undergoing joint replacement; however, effects remain too small and short-term to be considered clinically-important, and did not affect key outcomes of interest (ie, length of stay, quality of life, costs).

Current Concepts in Hip Preservation Surgery: Part II--Rehabilitation

CONTEXT

Successful treatment of nonarthritic hip pain in young athletic individuals remains a challenge. A growing fund of clinical knowledge has paralleled technical innovations that have enabled hip preservation surgeons to address a multitude of structural variations of the proximal femur and acetabulum and concomitant intra-articular joint pathology. Often, a combination of open and arthroscopic techniques are necessary to treat more complex pathomorphologies. Peri- and postoperative recovery after such procedures can pose a substantial challenge to the patient, and a dedicated, thoughtful approach may reduce setbacks, limit morbidity, and help optimize functional outcomes.

EVIDENCE ACQUISITION

PubMed and CINAHL databases were searched to identify relevant scientific and review articles through December 2014 using the search terms hip preservation, labrum, surgical dislocation, femoroacetabular impingement, postoperative rehabilitation, peri-acetabular osteotomy, and rotational osteotomy. Reference lists of included articles were reviewed to locate additional references of interest.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Hip preservation procedures and appropriate rehabilitation have allowed individuals to return to a physically active lifestyle.

CONCLUSION

Effective postoperative rehabilitation must consider modifications and precautions specific to the particular surgical techniques used. Proper postoperative rehabilitation after hip preservation surgery may help optimize functional recovery and maximize clinical success and patient satisfaction.

The clinical effectiveness of self-care interventions with an exercise component to manage knee conditions: A systematic review

OBJECTIVE

Treatment of knee conditions should include approaches to support self-care and exercise based interventions. The most effective way to combine self-care and exercise has however not been determined sufficiently. Therefore the aim was to evaluate the clinical effectiveness of self-care programmes with an exercise component for individuals with any type of knee conditions.

METHODS

A keyword search of Medline, CINAHL, Amed, PsycInfo, Web of Science, and Cochrane databases was conducted up until January 2015. Two reviewers independently assessed manuscript eligibility against inclusion/exclusion criteria. Study quality was assessed using the Downs and Black quality assessment tool and the Cochrane Risk of Bias Tool. Data were extracted about self-care and exercise intervention type, control intervention, participants, length of follow-up, outcome measures, and main findings.

RESULTS

From the 7392 studies identified through the keyword search the title and abstract of 5498 were screened. The full text manuscripts of 106 studies were retrieved to evaluate their eligibility. Twenty-one manuscripts met the inclusion/exclusion criteria.

CONCLUSION

The treatment potential of combined self-care and exercise interventions has not been maximised because of limitations in study design and failure to adequately define intervention content. Potentially the most beneficial self-care treatment components are training self-management skills, information delivery, and goal setting. Exercise treatment components could be strengthened by better attention to dose and progression. Modern technology to streamline delivery and support self-care should be considered. More emphasis is required on using self-care and exercise programmes for chronic condition prevention in addition to chronic condition management.

Effect of preoperative neuromuscular training (NEMEX-TJR) on functional outcome after total knee replacement: an assessor-blinded randomized controlled trial

Background

Improving functional status preoperatively through exercise may improve postoperative outcome. Previous knowledge on preoperative exercise in knee osteoarthritis is insufficient. The aim of the study was to compare the difference in change between groups in lower extremity function from baseline to 3 months after Total Knee Replacement (TKR) following a neuromuscular exercise programme (NEMEX-TJR) plus a knee school educational package (KS) or KS alone.

Methods

45 patients (55–83 years, 53% male, waiting for TKR) were randomized to receive a minimum of 8 sessions of NEMEXTJR plus 3 sessions of KS or 3 sessions of KS alone. Function was assessed with the Chair Stand Test (CST, primary endpoint) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales focusing on daily living function (ADL) and pain (secondary endpoints). Assessments were performed immediately before and after the intervention, and at 6 weeks, 3 months and 12 months after surgery by a physiotherapist, blinded to group allocation.

Results

After intervention before surgery we observed a small improvement for primary and secondary endpoints in both groups, which did not differ significantly between groups: comparing the exercise to the control group the treatment effect for the CST was −1.5 seconds (95% CI: −5.3, 2.2), for KOOS ADL and KOOS pain the treatment effect was 1.3 points (−10.1, 12.8) and −2.3 (−12.4, 7.9) respectively. At 3 months after surgery we observed a small improvement in the primary endpoint in the control group and a significant improvement in the secondary endpoints in both exercise and control groups, which did not differ significantly between groups: comparing the exercise group to the control group the treatment effect in the CST was 2.0 seconds (−1.8, 5.8), for KOOS ADL and KOOS pain the treatment effect was −4.9 points (−16.3, 6.5) and −3.3 points (−13.5, 6.8) respectively.

Conclusions

A median (IQR) of 10 (8, 14) exercise sessions before surgery showed an additional small but non-significant improvement in all functional assessments compared to patient education alone. These benefits were not sustained after TKR. Our trial doesn’t give a conclusive answer to whether additional preoperative exercise on postoperative functional outcomes is beneficial.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0556-8) contains supplementary material, which is available to authorized users.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Preoperative education for hip or knee replacement

BACKGROUND

Hip or knee replacement is a major surgical procedure that can be physically and psychologically stressful for patients. It is hypothesised that education before surgery reduces anxiety and enhances clinically important postoperative outcomes.

OBJECTIVES

To determine whether preoperative education in people undergoing total hip replacement or total knee replacement improves postoperative outcomes with respect to pain, function, health-related quality of life, anxiety, length of hospital stay and the incidence of adverse events (e.g. deep vein thrombosis).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2013, Issue 5), MEDLINE (1966 to May 2013), EMBASE (1980 to May 2013), CINAHL (1982 to May 2013), PsycINFO (1872 to May 2013) and PEDro to July 2010. We handsearched the Australian Journal of Physiotherapy (1954 to 2009) and reviewed the reference lists of included trials and other relevant reviews.

SELECTION CRITERIA

Randomised or quasi-randomised trials of preoperative education (verbal, written or audiovisual) delivered by a health professional within six weeks of surgery to people undergoing hip or knee replacement compared with usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We analysed dichotomous outcomes using risk ratios. We combined continuous outcomes using mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). Where possible, we pooled data using a random-effects meta-analysis.

MAIN RESULTS

We included 18 trials (1463 participants) in the review. Thirteen trials involved people undergoing hip replacement, three involved people undergoing knee replacement and two included both people with hip and knee replacements. Only six trials reported using an adequate method of allocation concealment, and only two trials blinded participants. Few trials reported sufficient data to analyse the major outcomes of the review (pain, function, health-related quality of life, global assessment, postoperative anxiety, total adverse events and re-operation rate). There did not appear to be an effect of time on any outcome, so we chose to include only the latest time point available per outcome in the review.In people undergoing hip replacement, preoperative education may not offer additional benefits over usual care. The mean postoperative anxiety score at six weeks with usual care was 32.16 on a 60-point scale (lower score represents less anxiety) and was 2.28 points lower with preoperative education (95% confidence interval (CI) -5.68 to 1.12; 3 RCTs, 264 participants, low-quality evidence), an absolute risk difference of -4% (95% CI -10% to 2%). The mean pain score up to three months postoperatively with usual care was 3.1 on a 10-point scale (lower score represents less pain) and was 0.34 points lower with preoperative education (95% CI -0.94 to 0.26; 3 RCTs, 227 participants; low-quality evidence), an absolute risk difference of -3% (95% CI -9% to 3%). The mean function score at 3 to 24 months postoperatively with usual care was 18.4 on a 68-point scale (lower score represents better function) and was 4.84 points lower with preoperative education (95% CI -10.23 to 0.66; 4 RCTs, 177 participants; low-quality evidence), an absolute risk difference of -7% (95% CI -15% to 1%). The number of people reporting adverse events, such as infection and deep vein thrombosis, did not differ between groups, but the effect estimates are uncertain due to very low quality evidence (23% (17/75) reported events with usual care versus 18% (14/75) with preoperative education; risk ratio (RR) 0.79; 95% CI 0.19 to 3.21; 2 RCTs, 150 participants). Health-related quality of life, global assessment of treatment success and re-operation rates were not reported.In people undergoing knee replacement, preoperative education may not offer additional benefits over usual care. The mean pain score at 12 months postoperatively with usual care was 80 on a 100-point scale (lower score represents less pain) and was 2 points lower with preoperative education (95% CI -3.45 to 7.45; 1 RCT, 109 participants), an absolute risk difference of -2% (95% CI -4% to 8%). The mean function score at 12 months postoperatively with usual care was 77 on a 100-point scale (lower score represents better function) and was no different with preoperative education (0; 95% CI -5.63 to 5.63; 1 RCT, 109 participants), an absolute risk difference of 0% (95% CI -6% to 6%). The mean health-related quality of life score at 12 months postoperatively with usual care was 41 on a 100-point scale (lower score represents worse quality of life) and was 3 points lower with preoperative education (95% CI -6.38 to 0.38; 1 RCT, 109 participants), an absolute risk difference of -3% (95% CI -6% to 1%). The number of people reporting adverse events, such as infection and deep vein thrombosis, did not differ between groups (18% (11/60) reported events with usual care versus 13% (7/55) with preoperative education; RR 0.69; 95% CI 0.29 to 1.66; 1 RCT, 115 participants), an absolute risk difference of -6% (-19% to 8%). Global assessment of treatment success, postoperative anxiety and re-operation rates were not reported.

AUTHORS' CONCLUSIONS

Although preoperative education is embedded in the consent process, we are unsure if it offers benefits over usual care in terms of reducing anxiety, or in surgical outcomes, such as pain, function and adverse events. Preoperative education may represent a useful adjunct, with low risk of undesirable effects, particularly in certain patients, for example people with depression, anxiety or unrealistic expectations, who may respond well to preoperative education that is stratified according to their physical, psychological and social need.

Quadriceps strengthening exercises are effective in improving pain, function and quality of life in patients with osteoarthritis of the knee

Objective

The purpose of this research was to verify the effectiveness of an eight-week quadriceps strengthening program on pain, function and quality of life of patients with knee osteoarthritis.

Methods

A hundred patients were randomized into two groups: 1- Exercise Group (ExG) and 2- Orientation Group. The Timed Up and Go (TUG) test, the Numerical Rating Scale (NRS) and the Short Form-36 were used for the assessment.

Results

Eighty-one patients completed the survey. According to the intention to treat (ITT) analysis, there was statistically significant difference in ExG compared to OG in all the variables assessed.

Conclusion

The program quadriceps strengthening exercises applied in this randomized clinical trial was effective in improving pain, function and quality of life of patients with knee osteoarthritis. Level of Evidence I, Randomized Clinical Trial.

Self-management education programmes for osteoarthritis

BACKGROUND

Self-management education programmes are complex interventions specifically targeted at patient education and behaviour modification. They are designed to encourage people with chronic disease to take an active self-management role to supplement medical care and improve outcomes.

OBJECTIVES

To assess the effectiveness of self-management education programmes for people with osteoarthritis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PyscINFO, SCOPUS and the World Health Organization (WHO) International Clinical Trial Registry Platform were searched, without language restriction, on 17 January 2013. We checked references of reviews and included trials to identify additional studies.

SELECTION CRITERIA

Randomised controlled trials of self-management education programmes in people with osteoarthritis were included. Studies with participants receiving passive recipients of care and studies comparing one type of programme versus another were excluded.

DATA COLLECTION AND ANALYSIS

In addition to standard methods we extracted components of the self-management interventions using the eight domains of the Health Education Impact Questionnaire (heiQ), and contextual and participant characteristics using PROGRESS-Plus and the Health Literacy Questionnaire (HLQ). Outcomes included self-management of osteoarthritis, participant's positive and active engagement in life, pain, global symptom score, self-reported function, quality of life and withdrawals (including dropouts and those lost to follow-up). We assessed the quality of the body of evidence for these outcomes using the GRADE approach.

MAIN RESULTS

We included twenty-nine studies (6,753 participants) that compared self-management education programmes to attention control (five studies), usual care (17 studies), information alone (four studies) or another intervention (seven studies). Although heterogeneous, most interventions included elements of skill and technique acquisition (94%), health-directed activity (85%) and self-monitoring and insight (79%); social integration and support were addressed in only 12%. Most studies did not provide enough information to assess all PROGRESS-Plus items. Eight studies included predominantly Caucasian, educated female participants, and only four provided any information on participants' health literacy. All studies were at high risk of performance and detection bias for self-reported outcomes; 20 studies were at high risk of selection bias, 16 were at high risk of attrition bias, two were at high risk of reporting bias and 12 were at risk of other biases. We deemed attention control as the most appropriate and thus the main comparator.Compared with attention control, self-management programmes may not result in significant benefits at 12 months. Low-quality evidence from one study (344 people) indicates that self-management skills were similar in active and control groups: 5.8 points on a 10-point self-efficacy scale in the control group, and the mean difference (MD) between groups was 0.4 points (95% confidence interval (CI) -0.39 to 1.19). Low-quality evidence from four studies (575 people) indicates that self-management programmes may lead to a small but clinically unimportant reduction in pain: the standardised mean difference (SMD) between groups was -0.26 (95% CI -0.44 to -0.09); pain was 6 points on a 0 to 10 visual analogue scale (VAS) in the control group, treatment resulted in a mean reduction of 0.8 points (95% CI -0.14 to -0.3) on a 10-point scale, with number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 5 to 23). Low-quality evidence from one study (251 people) indicates that the mean global osteoarthritis score was 4.2 on a 0 to 10-point symptom scale (lower better) in the control group, and treatment reduced symptoms by a mean of 0.14 points (95% CI -0.54 to 0.26). This result does not exclude the possibility of a clinically important benefit in some people (0.5 point reduction included in 95% CI). Low-quality evidence from three studies (574 people) showed no signficant difference in function between groups (SMD -0.19, 95% CI -0.5 to 0.11); mean function was 1.29 points on a 0 to 3-point scale in the control group, and treatment resulted in a mean improvement of 0.04 points with self-management (95% CI -0.10 to 0.02). Low-quality evidence from one study (165 people) showed no between-group difference in quality of life (MD -0.01, 95% CI -0.03 to 0.01) from a control group mean of 0.57 units on 0 to 1 well-being scale. Moderate-quality evidence from five studies (937 people) shows similar withdrawal rates between self-management (13%) and control groups (12%): RR 1.11 (95% CI 0.78 to 1.57). Positive and active engagement in life was not measured.Compared with usual care, moderate-quality evidence from 11 studies (up to 1,706 participants) indicates that self-management programmes probably provide small benefits up to 21 months, in terms of self-management skills, pain, osteoarthritis symptoms and function, although these are of doubtful clinical importance, and no improvement in positive and active engagement in life or quality of life. Withdrawal rates were similar. Low to moderate quality evidence indicates no important differences in self-management , pain, symptoms, function, quality of life or withdrawal rates between self-management programmes and information alone or other interventions (exercise, physiotherapy, social support or acupuncture).

AUTHORS' CONCLUSIONS

Low to moderate quality evidence indicates that self-management education programmes result in no or small benefits in people with osteoarthritis but are unlikely to cause harm.Compared with attention control, these programmes probably do not improve self-management skills, pain, osteoarthritis symptoms, function or quality of life, and have unknown effects on positive and active engagement in life. Compared with usual care, they may slightly improve self-management skills, pain, function and symptoms, although these benefits are of unlikely clinical importance.Further studies investigating the effects of self-management education programmes, as delivered in the trials in this review, are unlikely to change our conclusions substantially, as confounding from biases across studies would have likely favoured self-management. However, trials assessing other models of self-management education programme delivery may be warranted. These should adequately describe the intervention they deliver and consider the expanded PROGRESS-Plus framework and health literacy, to explore issues of health equity for recipients.

Prehabilitation improves physical function of individuals with severe disability from hip or knee osteoarthritis

PURPOSE

To evaluate the effects of prehabilitation (enhancing physical capacity before total hip or knee joint arthroplasty) on pain and physical function of adults with severe hip and knee osteoarthritis (OA).

METHODS

Consecutive patients (n=650) from 2006 to 2008 with hip or knee OA awaiting total joint arthroplasty (TJA) attended a hospital outpatient clinic for a prehabilitation assessment. All participants completed self-report (Lower Extremity Functional Scale [LEFS] and visual analogue scale for pain [VAS]) and functional performance measures (self-paced walk [SPW], timed stair, and timed up-and-go [TUG] tests). A subset of 28 participants with severe disability participated in a structured outpatient prehabilitation programme. Between-group differences were assessed via independent t-tests; paired Student's t-tests and Wilcoxon signed rank tests were used to compare changes in pain and function following the prehabilitation programme.

RESULTS

A total of 28 individuals (16 female) with mean age 67 (SD 10) years and BMI 33 (8) kg/m(2) awaiting TJA (10 hips, 18 knees) participated in a prehabilitation programme of 9 (6) weeks' duration. Relative to baseline, there was significant improvement in LEFS score (mean change 7.6; 95% CI, 1.7-13.5; p=0.013), SPW (mean change 0.17 m/s; 95% CI, 0.07-0.26; p=0.001), TUG (mean change 4.2 s; 95% CI, 2.0-6.4; p<0.001), and stair test performance (mean change 3.8 s [SD 14.6]; p=0.005) following prehabilitation.

CONCLUSION

This study presents preliminary evidence that prehabilitation improves physical function even in the most severely compromised patients with OA awaiting TJA.

Evidence-based review for patients undergoing elective hip and knee replacement

BACKGROUND

The objective of this study was to evaluate the evidence for different interventions in the preoperative, perioperative and post-operative care for people undergoing elective total hip (THR) and knee (TKR) replacement surgery.

METHOD

A multidisciplinary working group comprising consumers, managers and clinicians from the areas of orthopaedics, rheumatology, aged care and rehabilitation evaluated randomized controlled trials (RCTs) and systematic reviews/meta-analyses concerning aspects of preoperative, perioperative and post-operative clinical care periods for THR/TKR through systematic searching of Medline, Embase, CENTRAL and the Cochrane Database of Systematic Reviews from May 2007 to April 2011. Multiple reviewers determined study eligibility and one or more members extracted primary study findings. The body of evidence were assessed and specific recommendations made according to NHMRC guidelines.

RESULTS

Twenty-five aspects were identified for review. Recommendations for 16 of 25 areas of care were made: impact of waiting, multidisciplinary preparation, preoperative exercise, smoking cessation, interventions for comorbid conditions, predictors of outcome, clinical pathways, implementation of a blood management programme, antibiotic prophylaxis, regional anaesthesia and analgesia, use of a tourniquet in knee replacement, venous thromboembolism prophylaxis, early post-operative cryotherapy, early mobilization and continuous passive motion. In the post-operative period, study heterogeneity across all aspects of care precluded specific recommendations.

CONCLUSIONS

There was a deficiency in the quality of the evidence supporting key aspects of the continuum of care for primary THR/TKR surgery. Consequently, recommendations were limited. Prioritization and funding for research into areas likely to impact clinical practice and patient outcomes after elective joint replacement surgery are the next important steps.

Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To investigate the preoperative effects of exercise-based interventions on pain and physical function for people awaiting joint replacement surgery of the hip or knee.

DATA SOURCES

Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Reference lists of retrieved articles were also screened.

STUDY SELECTION

Randomized or quasi-randomized studies comparing an exercise-based intervention with a no-intervention group for people awaiting hip or knee joint replacement surgery were included. Outcomes were pain and physical function including self-reported function, walking speed, and muscle strength. One of 2 reviewers determined that 18 studies met the inclusion criteria.

DATA EXTRACTION

The methodologic quality of each study was independently assessed by 2 reviewers using the PEDro scale, and a final PEDro score was determined by discussion and consensus between the reviewers. Participants' characteristics, content and design of the interventions, and data for quantitative synthesis were extracted by 1 reviewer.

DATA SYNTHESIS

For participants awaiting knee replacement surgery, quantitative data synthesis found no significant differences between the exercise and no-intervention groups for pain, self-reported function, walking speed, or muscle strength. For participants awaiting hip replacement surgery, quantitative data synthesis found a significant difference between the groups, with standardized mean differences (SMDs) indicating a medium-sized effect in favor of intervention for both pain (SMD=.45; 95% confidence interval .15-.75) and self-reported function (SMD=.46; 95% confidence interval .20-.72).

CONCLUSIONS

Exercise-based interventions can reduce pain and improve physical function for people awaiting hip replacement surgery but not knee replacement surgery.

A phase III randomized three-arm trial of physical therapist delivered pain coping skills training for patients with total knee arthroplasty: the KASTPain protocol

BACKGROUND

Approximately 20% of patients report persistent and disabling pain following total knee arthroplasty (TKA) despite an apparently normally functioning prosthesis. One potential risk factor for unexplained persistent pain is high levels of pain catastrophizing. We designed a three-arm trial to determine if a pain coping skills training program, delivered prior to TKA, effectively reduces function-limiting pain following the procedure in patients with high levels of pain catastrophizing.

METHODS/DESIGN

The trial will be conducted at four University-based sites in the US. A sample of 402 patients with high levels of pain catastrophizing will be randomly assigned to either a pain coping skills training arm, an arthritis education control arm or usual care. Pain coping skills will be delivered by physical therapists trained and supervised by clinical psychologist experts. Arthritis education will be delivered by nurses trained in the delivery of arthritis-related content. The primary outcome will be change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scale score 12 months following surgery. A variety of secondary clinical and economic outcomes also will be evaluated.

DISCUSSION

The trial will be conducted at four University-based sites in the US. A sample of 402 patients with high levels of pain catastrophizing will be randomly assigned to either a pain coping skills training arm, an arthritis education control arm or usual care. Pain coping skills will be delivered by physical therapists trained and supervised by clinical psychologist experts. Arthritis education will be delivered by nurses trained in the delivery of arthritis-related content. The primary outcome will be change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain scale score 12 months following surgery. A variety of secondary clinical and economic outcomes also will be evaluated.

Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review

OBJECTIVES

The objective of the study was to report the evidence for effectiveness of different self-management course characteristics and components for chronic musculoskeletal pain.

METHODS

We searched 9 relevant electronic databases for randomized, controlled trials (RCTs). Two reviewers selected studies against inclusion criteria and assessed their quality. We classified RCTs according to type of course delivery (group, individual, mixed or remote), tutor (healthcare professional, lay or mixed), setting (medical, community or occupational), duration (more or less than 8 weeks), and the number and type of components (psychological, lifestyle, pain education, mind body therapies, and physical activity). We extracted data on pain intensity, physical function, self-efficacy, global health, and depression and compared these outcomes for self-management and usual care or waiting list control. We used random effects standardized mean difference meta-analysis. We looked for patterns of clinically important and statistically significant beneficial effects for courses with different delivery characteristics and the presence or absence of components across outcomes over 3 follow-up intervals.

RESULTS

We included 46 RCTs (N=8539). Group-delivered courses that had healthcare professional input showed more beneficial effects. Longer courses did not necessarily give better outcomes. There was mixed evidence of effectiveness for components of courses, but data for courses with a psychological component showed slightly more consistent beneficial effects over each follow-up period.

DISCUSSION

Serious consideration should be given to the development of short (<8 weeks) group and healthcare professional-delivered interventions but more research is required to establish the most effective and cost-effective course components.

A hierarchy of patient-reported outcomes for meta-analysis of knee osteoarthritis trials: empirical evidence from a survey of high impact journals

Objectives. To develop a prioritised list based on responsiveness for extracting patient-reported outcomes (PROs) measuring pain and disability for performing meta-analyses in knee osteoarthritis (OA). Methods. A systematic search was conducted in 20 highest impact factor general and rheumatology journals chosen a priori. Eligible studies were randomised controlled trials, using two or more PROs measuring pain and/or disability. Results. A literature search identified 402 publications and 38 trials were included, resulting in 54 randomised comparisons. Thirty-five trials had sufficient data on pain and 15 trials on disability. The WOMAC “pain” and “function” subscales were the most responsive composite scores. The following list was developed. Pain: (1) WOMAC “pain” subscale, (2) pain during activity (VAS), (3) pain during walking (VAS), (4) general knee pain (VAS), (5) pain at rest (VAS), (6) other composite pain scales, and (7) other single item measures. Disability: (1) WOMAC “function” subscale, (2) SF-36 “physical function” subscale, (3) SF-36 (Physical composite score), and (4) Other composite disability scores. Conclusions. As choosing the PRO most favourable for the intervention from individual trials can lead to biased estimates, using a prioritised list as developed in this study is recommended to reduce risk of biased selection of PROs in meta-analyses.

Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review

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.

Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis

OBJECTIVE

To determine if pre-operative interventions for hip and knee osteoarthritis provide benefit before and after joint replacement.

METHOD

Systematic review with meta-analysis of randomised controlled trials (RCTs) of pre-operative interventions for people with hip or knee osteoarthritis awaiting joint replacement surgery. Standardised mean differences (SMD) were calculated for pain, musculoskeletal impairment, activity limitation, quality of life, and health service utilisation (length of stay and discharge destination). The GRADE approach was used to determine the quality of the evidence.

RESULTS

Twenty-three RCTs involving 1461 participants awaiting hip or knee replacement surgery were identified. Meta-analysis provided moderate quality evidence that pre-operative exercise interventions for knee osteoarthritis reduced pain prior to knee replacement surgery (SMD (95% CI)=0.43 [0.13, 0.73]). None of the other meta-analyses investigating pre-operative interventions for knee osteoarthritis demonstrated any effect. Meta-analyses provided low to moderate quality evidence that exercise interventions for hip osteoarthritis reduced pain (SMD (95% CI)=0.52 [0.04, 1.01]) and improved activity (SMD (95% CI)=0.47 [0.11, 0.83]) prior to hip replacement surgery. Meta-analyses provided low quality evidence that exercise with education programs improved activity after hip replacement with reduced time to reach functional milestones during hospital stay (e.g., SMD (95% CI)=0.50 [0.10, 0.90] for first day walking).

CONCLUSION

Low to moderate evidence from mostly small RCTs demonstrated that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement.

Factors influencing health-related quality of life after TKA in patients who are obese

BACKGROUND

Although the health-related quality of life (HRQL) for patients who are obese seems to improve after TKA, the magnitude of improvement and the associated factors remain controversial. We previously found body mass index was not associated with changes in HRQL after TKA.

QUESTIONS/PURPOSES

The purposes of this secondary analysis were to determine which patient characteristics and surgical factors were associated with worse health status after TKA in patients who are severe or morbidly obese.

METHODS

We assessed 60 patients (53 females; mean age, 70 years) 12 months after surgery. The mean number of comorbidities was 2.5. Mean lower limb anthropometric index scores were: suprapatellar, 1.6; infrapatellar, 2; and suprapatellar/infrapatellar, 1.2. Intraoperative difficulty (IOD) was Grade 0, 40%; Grade 1, 48%; and Grade 2, 12%. Ten patients (17%) had complications. We measured HRQL using the disease-specific WOMAC questionnaire. Patient characteristics (sociodemographic variables, BMI, comorbidity, lower limb anthropometry) and surgical factors (IOD, complications, postoperative medical data) were collected. Associations between WOMAC dimension scores at 12 months and patient characteristics and surgical factors were analyzed using linear regression models.

RESULTS

Factors associated with worse WOMAC dimension scores in patients who were obese included the number of comorbidities, an infrapatellar index percentile less than 75, IOD Grade 2, and the number of complications after discharge.

CONCLUSIONS

For patients with knee osteoarthritis who were severe or morbidly obese, various lower limb anthropometric features, degree of IOD, and postoperative complications negatively influenced postoperative WOMAC scores.

LEVEL OF EVIDENCE

Level II Prognostic Study. See Guidelines for a complete description of levels of evidence.

Effect of an education programme for patients with osteoarthritis in primary care--a randomized controlled trial

BACKGROUND

Osteoarthritis (OA) is a degenerative disease, considered to be one of the major public health problems. Research suggests that patient education is feasible and valuable for achieving improvements in quality of life, in function, well-being and improved coping. Since 1994, Primary Health Care in Malmö has used a patient education programme directed towards OA. The aim of this study was to evaluate the effects of this education programme for patients with OA in primary health care in terms of self-efficacy, function and self-perceived health.

METHOD

The study was a single-blind, randomized controlled trial (RCT) in which the EuroQol-5D and Arthritis self-efficacy scale were used to measure self-perceived health and self-efficacy and function was measured with Grip Ability Test for the upper extremity and five different functional tests for the lower extremity.

RESULTS

We found differences between the intervention group and the control group, comparing the results at baseline and after 6 months in EuroQol-5D (p < 0.001) and in standing one leg eyes closed (p = 0.02) in favour of the intervention group. No other differences between the groups were found.

CONCLUSION

This study has shown that patient education for patients with osteoarthritis is feasible in a primary health care setting and can improve self-perceived health as well as function in some degree, but not self-efficacy. Further research to investigate the effect of exercise performance on function, as well as self-efficacy is warranted.

TRIAL REGISTRATION

The trial is registered with ClinicalTrials.gov.

REGISTRATION NUMBER

NCT00979914.

Total knee replacement and health-related quality of life: factors influencing long-term outcomes

OBJECTIVE

To evaluate health-related quality of life (HRQOL) in patients with osteoarthritis undergoing total knee replacement (TKR); identify the influence of sociodemographic, clinical, intraoperative, and postoperative variables on HRQOL; and determine patient perceptions at 7 years.

METHODS

We conducted a prospective study with 7 years of followup. HRQOL measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and Short Form 36 [SF-36]); sociodemographic, clinical, intraoperative, inpatient, and postoperative data; patient perceptions of TKR outcomes; and physical activity at 7 years were determined. Associations were analyzed using linear regression models.

RESULTS

Of 146 eligible patients, 112 (86 women, mean age 67.3 years) completed followup data. There were significant differences between pre- and postoperative WOMAC pain, stiffness, and function scores (P < 0.001). Variables retained in each of the models explained 14-32% (adjusted R(2)) of variability of the WOMAC dimensions. Obesity and postdischarge complications were associated with worse scores in all WOMAC dimensions (P < 0.05). Eighty-six percent of patients were satisfied with TKR, 80% would undergo the operation again, and 56% did regular physical activity and had better WOMAC scores (P < 0.05, except for stiffness [not significant]). Mean +/- SD SF-36 scores for men and women at 7 years were 55.1 +/- 27.1 and 39.5 +/- 22.9 for physical function, 71.2 +/- 36.5 and 51.5 +/- 42.7 for physical role, 66.2 +/- 26 and 55.6 +/- 28.9 for bodily pain, and 60.7 +/- 17.1 and 50.7 +/- 21.2 for general health, respectively.

CONCLUSION

WOMAC dimension scores, especially pain, significantly improved at 7 years and were negatively influenced by obesity and postdischarge complications. HRQOL measures may help identify an increased risk of negative outcomes after TKR.

Waiting for total knee replacement surgery: factors associated with pain, stiffness, function and quality of life

Background

Recent evidences show that education and rehabilitation while waiting for knee replacement have positive effects on the patients' health status. Identification of factors associated with worse pain, function and health-related quality of life (HRQoL) while waiting for surgery could help develop pre-surgery rehabilitation interventions that target specifically these factors and prioritize patients that may benefit the most from them. The objectives of this study were to measure pain, stiffness, function and HRQoL in patients at enrolment on waiting lists for knee replacement and to identify demographic, clinical, socioeconomic and psychosocial characteristics associated with these outcomes.

Methods

This study is part of a broader study measuring the effects of pre-surgery wait in patients scheduled for knee replacement. From 02/2006 to 09/2007, 197 patients newly scheduled for total knee replacement were recruited from the waiting lists of three university hospitals in Quebec City, Canada. Pain, stiffness and function were measured with the Western Ontario and McMaster Osteoarthritis Index (WOMAC) and HRQoL was measured with the SF-36 Health Survey. Stepwise multiple regression analysis was used to assess the strength of the associations between the independent variables and the WOMAC and SF-36 scores.

Results

The scores of all eight HRQoL physical and mental domains of the SF-36 were significantly lower than aged matched Canadian normative data (p < 0.05). Contralateral knee pain, higher psychological distress, higher body mass index (BMI) and the use of a walking aid were significantly associated with worse function (p < 0.05) and contributed to 22% of the variance of the WOMAC function score (multiple r = 0.47). A higher BMI, the use of a walking aid, contralateral knee pain and advanced age were significantly associated with worse physical function (p < 0.05) and contributed to 17% of the variance of the SF-36 HRQoL physical functioning score (multiple r = 0.41).

Conclusion

Patients waiting for knee replacement have poor function and HRQoL. Characteristics that were found to be associated with these outcomes could help develop pre-surgery rehabilitation program and prioritize patients that may benefit the most from them. Such programs could include interventions to reduce psychological distress, therapeutic exercises targeting both knees and weight loss management.

Experimental Study of COX-2 Selective and Traditional Non-steroidal Anti-inflammatory Drugs in Total Hip Replacement

This study investigated the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on peri-operative blood loss during elective total hip replacement. Patients were randomized to receive enteric-coated diclofenac 50 mg ( n = 18), rofecoxib 12.5 mg ( n = 17) or placebo ( n = 16) administered orally three times daily for 2 weeks prior to surgery. Severe adverse effects resulting in discontinuation of trial participation occurred in six patients in the diclofenac group, five patients in the rofecoxib group and two patients in the placebo group; all drop-outs occurred at various times after surgery. Compared with placebo, peri-operative blood loss increased by 32% in the diclofenac group and by 7% in the rofecoxib group. Total mean ± SD blood loss was 1040 ± 136 ml in the diclofenac group, 844 ± 83 ml in the rofecoxib group and 789 ± 82 ml in the placebo group. Thus, administering a non-selective NSAID 2 weeks prior to elective total hip replacement significantly increases peri-operative blood loss.