The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

The OARSI Joint Effort Initiative: Priorities for osteoarthritis management program implementation and research 2024-2028

Objective

The Joint Effort Initiative (JEI) is an international collaboration of clinicians, researchers, and consumer organisations with a shared vision of improving the implementation of osteoarthritis management programs (OAMPs). This study aimed to identify JEI's future priorities and guide direction.

Design

A two-part international survey to prioritise topics of importance to our membership and research stakeholders. Survey one presented a list of 40 topics under 5 themes. Consenting participants were asked to choose their top three topics in each theme. A short list of 25 topics was presented in survey two. Participants were asked to rank the importance (100-point NRS scale, 100 ​= ​highest priority). Response frequency (median, IQR) was used to rank the top priorities by theme.

Results

Ninety-five participants completed survey one (61% female, 48% clinicians) and 57 completed survey two. The top ranked topic/s were:i. Promotion and advocacy: support training for health professionals (median 85, IQR 24).ii. Education and training: incorporating behaviour change into OAMPs (80, 16), advanced OA skills (80, 30), and integration of OA education into clinical training (80, 36).iii. Improving OAMPs delivery: regular updates on changes to best-evidence OA care (84, 24).iv. Future research: improve uptake of exercise, physical activity, and weight-loss (89, 16).v. Enhancing relationships, alliances, and shared knowledge: promote research collaborations (81, 30), share challenges and opportunities for OAMP implementation (80, 23).

Conclusions

These topics will set the JEI's research and collaboration agenda for the next 5 years and stimulate ideas for others working in the field.

Advanced Practice Physiotherapists and the implementation of the JIGSAW-E model for the management of osteoarthritis in Scottish primary care settings: a qualitative case study

OBJECTIVE

To explore the acceptability, barriers and enablers of NICE guidelines for osteoarthritis in the Scottish primary care setting using the Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model and investigate the role of Advanced Physiotherapy Practitioners (APPs) in providing evidence-based care.

DESIGN

A qualitative case study comprised of semi-structured interviews followed by a workshop with participants.

SETTING

10 Scottish primary care practices.

PARTICIPANTS

Six general practitioners (GPs) and eight APPs were interviewed. Twenty-three practitioners attended the workshop including 22 physiotherapists and one GP.

RESULTS

While both GPs and APPs recognised the need to improve and standardise osteoarthritis care delivery, this study found that APPs were better situated to implement the evidence-based model. Barriers to implementation included lack of time for training, limited appointment time for GPs to consult and discuss medication use with patients, limitation of disease specific guidelines for patients with complex multimorbidity, and system-based barriers such as electronic data collection and high staff turnover. The key enabler was practitioners' motivation to provide optimal, standardised quality care for osteoarthritis. To increase acceptance, ownership and usability for both practitioners and patients, the JIGSAW-E model materials required adaptation to the local context.

CONCLUSION

This study provides evidence that the JIGSAW-E model is acceptable in Scottish primary care. Furthermore, the evolving roles of GPs and APPs within multidisciplinary primary care teams provides a platform to implement the JIGSAW-E model, where APPs are well placed to provide leadership and training in the delivery of evidence-based care for osteoarthritis.

POS1106 MEDIATORS OF THE EFFECT OF THERAPEUTIC EXERCISE ON PAIN AND FUNCTION IN PATIENTS WITH KNEE AND HIP OSTEOARTHRITIS; AN INDIVIDUAL PATIENT DATA MEDIATION STUDY FROM THE OA TRIAL BANK

Background

Currently, there is no cure for osteoarthritis (OA). Therapeutic exercise is recommended in all international guidelines to improve pain and function (1). However, randomised controlled trials (RCTs) investigating therapeutic exercise showed that, on average, effect sizes are small to moderate compared to non-exercise controls (2-3). Better knowledge about how therapeutic exercise works to improve pain and function could help improve the design and delivery of future therapeutic exercise interventions and potentially improve patient outcomes.

Objectives

To evaluate the mediating effects of 1) muscle strength, proprioception, and range of motion (ROM) among patients with knee OA, and 2) muscle strength among patients with hip OA, using the procedures established for Individual Participant Data (IPD) analyses by the OA Trial Bank.

Methods

Relevant IPD were sought from all published RCTs comparing therapeutic exercise to a non-exercise control group among people with knee and/or hip OA, using previously published methods (4). For each potential mediator separately, the effect of exercise on the absolute change in pain/function directly after the intervention was determined, controlling for the relative change in mediator under investigation and potential mediator-outcome confounders, using the ‘counterfactual framework’ (5). Next, the effect of exercise on the relative change in the mediator was determined. The percentage mediated was calculated by dividing the natural indirect effect by the total effect.

Results

We obtained IPD from 12 RCTs and 1407 participants (knee OA = 1113; hip OA n=294) that were eligible for inclusion in one or more mediation analyses. Therapeutic exercise showed a significant effect on the relative change in muscle strength in knee OA, but not for proprioception or ROM in knee OA, nor for muscle strength in hip OA. Of all mediators, only the change in muscle strength had a significant effect on the change in pain in knee OA, and on function in knee OA and in hip OA. The percentage mediated for each mediator and each outcome was small (5.3% or less, see Table 1).

Table 1.

Percentage mediated for all potential mediators, by outcome and joint.

Knee OAPainKnee OAFunctionHip OAPainHip OAFunctionMuscle strength2.4%2.3%absentabsentProprioceptionabsent0.2%--Range of motion1.8%5.3%--

‘absent’: no percentage mediated calculated, since direct and indirect effect had opposite directions.

‘-‘: factors not considered a potential mediator for therapeutic exercise in hip OA.

Conclusion

In the first IPD mediation analysis to our knowledge of this scale, muscle strength, proprioception and ROM did mediate the effect of therapeutic exercise for pain and function in knee OA, but only to a very small degree. We observed no such mediating effect of muscle strength for therapeutic exercise in patients with hip OA. The challenge remains to better understand the key mechanisms of action of therapeutic exercise for knee and hip OA, so that exercise interventions can be designed and delivered to target these and therewith optimise the effects for patients.

References

[1]Bierma-Zeinstra S, et al. Nonpharmacological and nonsurgical approaches in OA. Best Pract Res Clin Rheumatol. 2020 Apr;34(2):101564.

[2]Fransen M, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015 Jan 9;1:CD004376.

[3]Fransen M, et al. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22(4):CD007912.

[4]Holden MA, et al. Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA): a systematic review update and individual participant data meta-analysis protocol. BMJ Open. 2017 Dec 22;7(12):e018971.

[5]VanderWeele TJ, Vansteelandt S. Mediation Analysis with Multiple Mediators. Epidemiol Methods. 2014 Jan;2(1):95-115.

Acknowledgements

We thank all members of the OA Trial Bank Exercise Collaborative, who shared IPD with the OA Trial Bank/STEER OA for making this study possible.

Disclosure of Interests

Jos Runhaar Grant/research support from: Fellowship from the Foundation for Research in Rheumatology (FOREUM), Melanie Holden Grant/research support from: Grant from the Chartered Society of Physiotherapy Charitable Trust (grant no PRF/16/A07), and the National Institute for Health Research (NIHR) School of Primary Care Research (grant no 531), Miriam Hattle: None declared, Johny Quicke Grant/research support from: JQ is part-funded by an NIHR CRN West Midlands Research Scholarship and part funded by the Haywood Foundation, Richard Riley: None declared, Emma Healey Grant/research support from: part funded by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) West Midlands., Danielle van der Windt: None declared, Krysia Dziedzic: None declared, Marienke Van Middelkoop: None declared, S.M.A. Bierma-Zeinstra Grant/research support from: OA Trial Bank received long-term funding by the Dutch Arthritis Association, Nadine Foster: None declared

OP0191 CONCEPTUALISING PATIENT AND PUBLIC INVOLVEMENT IN MUSCULOSKELETAL GUIDELINES IMPLEMENTATION: THE ALLIANCE FRAMEWORK

Background

Patient and Public Involvement (PPI), have supported high quality Rheumatology research which have now been successfully curated into widely endorsed evidence-based recommendations and guidelines. However, uptake and applicability of guidelines is less than optimal, significant variation exist in care, and health and socio-economic burdens attributed to rheumatic conditions continues to rise, suggesting an implementation challenge.

Objectives

We conducted a rapid review to investigate the role of PPI in guideline implementation.

Methods

A comprehensive search for relevant literature was undertaken (three databases - Medline, Embase, Cinahl, and two large repositories -WHO, G-IN). A priori eligibility criteria and systematic review-based methods were used to identify primary studies with explicit reference to PPI involvement in a rheumatic/musculoskeletal - MSK guideline implementation activity. Extracted data from included studies was interrogated for details regarding activities, contexts, outcomes, and impact of PPI in guidelines implementation and further discussed in review project meetings. Findings were brought together in a narrative synthesis. Recommendations for future research and practice, and a conceptual framework for PPI in Rheumatic and MSK guidelines implementation were co-developed with a public contributor.

Results

Ten papers were included, only 1 from the global south. A prevalence of consultative PPI activities in guidelines dissemination (e.g., language translations, patient versions) was found. Few studies explicitly report high-level PPI engagement in relation to care pathway adjustments, care commissioning, institutional operations and policy with a view to MSK guideline implementation. Training, development, and practice of PPI in MSK guideline implementations were not evidenced to have spread much beyond Europe and are also not well reported in literature nor rightly accrued as PPI activities in guideline implementation. The alliance framework (Figure 1) highlighting an iterative process of “creative thinking/co-production” and “strategic doing” helps to conceptualise PPI in MSK guideline implementation. The framework guides knowledge translation from guidelines to real world practice and aims to drive quality improvement for MSK care with patients, for patients, across and within care settings globally.

Figure 1.

The Alliance framework for conceptualising Patient and Public Involvement in Rheumatic and Musculoskeletal guidelines implementation.

Conclusion

Despite success of PPI in rheumatology/MSK research, oversight or ineffective PPI in guideline implementation may hamper translation of novel advances in MSK care into real world practice and patient benefit. The Alliance framework prioritises effective PPI in MSK guideline implementation design, delivery, and evaluation, ideally applied in parallel with the development of evidence-based guidance recommendations. It highlights continuous application of innovative thinking, dynamic, and impactful collaborations for bridging the evidence-practice gap and improving quality of care for MSK patients globally through novel partnerships.

Disclosure of Interests

None declared

OP0198-HPR A STRUCTURED MODEL FOR OA CARE IN PRIMARY HEALTHCARE IS A COST-EFFECTIVE ALTERNATIVE COMPARED TO USUAL CARE FOR PEOPLE WITH HIP AND KNEE OA

Background:

To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international treatment recommendations. A previous analysis of a cluster RCT (cRCT) showed that compared to usual care, the intervention group reported higher quality of care and greater satisfaction with care. Also, more patients were treated according to international guidelines and fulfilled recommendations for physical activity at the 6-month follow-up.

Objectives:

To assess the cost-utility of a structured model for hip or knee OA care.

Methods:

A cRCT with stepped-wedge cohort design was conducted in 6 Norwegian municipalities (clusters) in 2015-17. The OA care model was implemented in one cluster at the time by switching from “usual care” to the structured model. The implementation of the model was facilitated by interactive workshops for general practitioners (GPs) and physiotherapists (PTs) with an update on OA treatment recommendations. The GPs explained the OA diagnosis and treatment alternatives, provided pharmacological treatment when appropriate, and suggested referral to physiotherapy. The PT-led patient OA education programme was group-based and lasted 3 hours followed by an 8–12-week individually tailored resistance exercise programme with twice weekly 1-hour supervised group sessions (5–10 patients per PT). An optional 10-hours Healthy Eating Program was available. Participants were ≥45 years with symptomatic hip or knee OA.

Costs were measured from the healthcare perspective and collected from several sources. Patients self-reported visits in primary healthcare at 3, 6, 9 and 12 months. Secondary healthcare visits and joint surgery data were extracted from the Norwegian Patient Register. The health outcome, quality-adjusted life-year (QALY), was estimated based on the EQ-5D-5L scores at baseline, 3, 6, 9 and 12 months. The result of the cost-utility analysis was reported using the incremental cost-effectiveness ratio (ICER), defined as the incremental costs relative to incremental QALYs (QALYs gained). Based on Norwegian guidelines, the threshold is €27500. Sensitivity analyses were performed using bootstrapping to assess the robustness of reported results and presented in a cost-effectiveness plane (Figure 1).

Results:

The 393 patients’ mean age was 63 years (SD 9.6) and 74% were women. 109 patients were recruited during control periods (control group), and 284 patients were recruited during interventions periods (intervention group). Only the intervention group had a significant increase in EQ-5D-5L utility scores from baseline to 12 months follow-up (mean change 0.03; 95% CI 0.01, 0.05) with QALYs gained: 0.02 (95% CI -0.08, 0.12). The structured OA model cost approx. €301 p.p. with an additional €50 for the Healthy Eating Program. Total 12 months healthcare cost p.p. was €1281 in the intervention and €3147 in the control group, resulting in an incremental cost of -€1866 (95% CI -3147, -584) p.p. Costs related to surgical procedures had the largest impact on total healthcare costs in both groups. During the 12-months follow-up period, 5% (n=14) in the intervention compared to 12% (n=13) in the control group underwent joint surgery; resulting in a mean surgical procedure cost of €553 p.p. in the intervention as compared to €1624 p.p. in the control group. The ICER was -€93300, indicating that the OA care model resulted in QALYs gained and cost-savings. At a threshold of €27500, it is 99% likely that the OA care model is a cost-effective alternative.

Conclusion:

The results of the cost-utility analysis show that implementing a structured model for OA care in primary healthcare based on international guidelines is highly likely a cost-effective alternative compared to usual care for people with hip and knee OA. More studies are needed to confirm this finding, but this study results indicate that implementing structured OA care models in primary healthcare may be beneficial for the individual as well as for the society.

Disclosure of Interests:

None declared

OP0321-HPR HIGHER QUALITY OF CARE AND LESS SURGERY AFTER IMPLEMENTING OSTEOARTHRITIS GUIDELINES IN PRIMARY CARE– LONG-TERM RESULTS FROM A CLUSTER RANDOMIZED CONTROLLED TRIAL

Background:

To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed and implemented among general practitioners (GPs) and physiotherapists (PTs) in primary care. The model was developed based on international treatment recommendations. After 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeon, and more patients fulfilled physical activity criteria among OA patients receiving the new model of care compared to the usual care control group1.

Objectives:

To assess the long-term effects 12 months after implementing the model in primary care.

Methods:

A cluster-randomised controlled trial with a stepped-wedge design was conducted in six Norwegian municipalities (clusters). The intervention included implementation of the model, facilitated by interactive workshops for GPs and PTs. The main components of the model were a PT led, 3 hour patient education programme followed by 8-12 weeks of individually tailored, supervised exercise. Patient participants were ≥45 years with symptomatic hip or knee OA. Primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0–100, 100 = optimal quality). Secondary outcomes included satisfaction with care, referrals to physiotherapy, orthopaedic surgeon and magnetic resonance imaging (MRI), joint replacement surgery, fulfilment of physical activity recommendations, and proportion with overweight (body mass index ≥25 kg/m2). Data was analysed using multilevel mixed models adjusted for age, sex and secular time.

Results:

In all, 40 of 80 GPs and 37 of 64 PTs attended the workshops. A total of 393 patients with hip and knee OA were included, with 284 in the intervention and 109 in the usual care control group. In the intervention group, 92% attended the OA education programme and 64% completed ≥8 weeks of exercise. At 12 months the intervention group reported significantly higher quality of care (score 58 vs. 41, mean difference: 17.6; 95% CI 11.1, 24.0) compared to the control group. The intervention group reported significantly higher satisfaction with care (Odds ratio (OR) 7.8; 95% CI 3.55, 17.27) and a significantly larger proportion (OR: 4.0; 95% CI 1.27, 12.63) met the recommendations for physical activity compared to the control group. A smaller proportion was referred to orthopaedic surgeon (OR 0.5; 95% CI 0.29, 1.00) and a smaller proportion received joint replacement surgery in the intervention (4%) compared to the control group (11%) (OR 0.3; 95% CI 0.14, 0.74). The proportion of patients referred to physiotherapy or MRI and the proportion with overweight were similar between the groups.

Conclusion:

Implementation of a structured model for OA care led to improved quality of care, higher satisfaction with care and higher physical activity levels after 12 months. These results are comparable to the 6 months results, which indicate a long-term persistence in the beneficial effects of the intervention. The lower surgical rate in the intervention compared to the control group suggests that higher uptake of OA recommendations in primary care may reduce or postpone the need for surgery in people with hip or knee OA.

References:

[1]Østerås N, Moseng T, Bodegom-Vos LV, et al. Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial.PLOS Medicine.2019;16(10):e1002949.

Disclosure of Interests:

None declared

FRI0401 IMPLEMENTATION OF NICE GUIDELINES FOR OSTEOARTHRITIS IN PRIMARY CARE. FEASIBILITY STUDY OF JIGSAW-E IN SCOTLAND

Background:

In the UK osteoarthritis (OA) is a common musculoskeletal problem with 8.75 million people seeking treatment in 20151.Evidence-based guidelines are available for the management of OA but implementation into routine daily practice remains complex. The Joint Implementation of Guidelines for Osteoarthritis in Western Europe (JIGSAW-E) model of care was developed and evaluated in England and implemented in Europe with an aim to optimise quality primary care for OA, support self-management and promote use of NICE guidelines2. The intervention includes:

Objectives:

To explore the feasibility of implementing the JIGSAW-E model to support people with OA in Scottish primary care.

Research questions were informed by the Theoretical Domains Framework with an aim of:

Methods:

This qualitative study was comprised of 2 phases:

Phase 1 included semi-structured interviews with health professionals (GPs and Extended Scope Practitioners) working in primary care. A purposeful sampling approach aimed to provide geographical and professional representation across Scotland. Interviews were recorded, transcribed and analysed using a theoretically-informed thematic framework approach.

Phase 2 involved an engagement workshop that allowed for refinement and direct validation of emergent findings.

Results:

90 invitations were sent to practice managers in primary care. 14 participants from 10 practices across 6 Health Boards in Scotland were recruited for interviews, including 6 GPs and 8 Physiotherapy Extended Scope Practitioners (ESPs). 23 participants attended the engagement workshop (ESPs = 22, GPs =1). Thematic analysis indicated four main themes related to the research questions:

Conclusion:

Overall, participants were in favour of the JIGSAW-E model in Scotland. Contextual adaptation of written materials would increase acceptance, ownership and usability by both practitioners and patients. The evolving role of GPs and ESPs is key to implementation, where ESPs provide leadership in the delivery of evidence-based care for patients with osteoarthritis.

References:

[1]Arthritis Research UK. State of Musculoskeletal Health 2017.

[2]Dziedzic KS et al. Implementation of musculoskeletal Models of Care in primary care settings: Theory, practice, evaluation and outcomes for musculoskeletal health in high-income economies. Best practice & research Clinical rheumatology 2016;30(3):375-97.

Acknowledgements:

Thanks are due to the JIGSAW-E team, all participants, SISCC and EIT for funding.

Disclosure of Interests:

None declared

Evidence flowers: An innovative, visual method of presenting "best evidence" summaries to health professional and lay audiences

BACKGROUND & AIMS

Barriers to dissemination and engagement with evidence pose a threat to implementing evidence-based medicine. Understanding, retention, and recall can be enhanced by visual presentation of information. The aim of this exploratory research was to develop and evaluate the accessibility and acceptability of visual summaries for presenting evidence syntheses with multiple exposures or outcomes to professional and lay audiences.

METHODS

"Evidence flowers" were developed as a visual method of presenting data from 4 case scenarios: 2 complex evidence syntheses with multiple outcomes, Cochrane reviews, and clinical guidelines. Petals of evidence flowers were coloured according to the GRADE evidence rating system to display key findings and recommendations from the evidence summaries. Application of evidence flowers was observed during stakeholder workshops. Evaluation and feedback were conducted via questionnaires and informal interviews.

RESULTS

Feedback from stakeholders on the evidence flowers collected from workshops, questionnaires, and interviews was encouraging and helpful for refining the design of the flowers. Comments were made on the content and design of the flowers, as well as the usability and potential for displaying different types of evidence.

CONCLUSIONS

Evidence flowers are a novel and visually stimulating method for presenting research evidence from evidence syntheses with multiple exposures or outcomes, Cochrane reviews, and clinical guidelines. To promote access and engagement with research evidence, evidence flowers may be used in conjunction with other evidence synthesis products, such as (lay) summaries, evidence inventories, rapid reviews, and clinical guidelines. Additional research on potential adaptations and applications of the evidence flowers may further bridge the gap between research evidence and clinical practice.

Self-reported quality care for knee osteoarthritis: comparisons across Denmark, Norway, Portugal and the UK

Objectives

To assess and compare patient perceived quality of osteoarthritis (OA) management in primary healthcare in Denmark, Norway, Portugal and the UK.

Methods

Participants consulting with clinical signs and symptoms of knee OA were identified in 30 general practices and invited to complete a cross-sectional survey including quality indicators (QI) for OA care. A QI was considered as eligible if the participant had checked ‘Yes’ or ‘No’, and as achieved if the participant had checked ‘Yes’ to the indicator. The median percentage (with IQR and range) of eligible QIs achieved by country was determined and compared in negative binominal regression analysis. Achievement of individual QIs by country was determined and compared using logistic regression analyses.

Results

A total of 354 participants self-reported QI achievement. The median percentage of eligible QIs achieved (checked ‘Yes’) was 48% (IQR 28%, 64%; range 0–100%) for the total sample with relatively similar medians across three of four countries. Achievement rates on individual QIs showed a large variation ranging from 11% (referral to services for losing weight) to 67% (information about the importance of exercise) with significant differences in achievement rates between the countries.

Conclusions

The results indicated a potential for improvement in OA care in all four countries, but for somewhat different aspects of OA care. By exploring these differences and comparing healthcare services, ideas may be generated on how the quality might be improved across nations. Larger studies are needed to confirm and further explore the findings.

Subsets of symptomatic hand osteoarthritis in community-dwelling older adults in the United Kingdom: prevalence, inter-relationships, risk factor profiles and clinical characteristics at baseline and 3-years

OBJECTIVE

To compare the population prevalence, inter-relationships, risk factor profiles and clinical characteristics of subsets of symptomatic hand osteoarthritis (OA) with a view to understanding their relative frequency and distinctiveness.

METHOD

1076 community-dwelling adults with hand symptoms (60% women, mean age 64.7 years) were recruited and classified into pre-defined subsets using physical examination and standardised hand radiographs, scored with the Kellgren & Lawrence (K&L) and Verbruggen-Veys grading systems. Detailed information on selected risk factors was obtained from direct measurement (Body Mass Index (BMI)), self-complete questionnaires (excessive use of hands, previous hand injury) and medical record review (hypertension, dyslipidaemia, type 2 diabetes). Hand pain and disability were self-reported at baseline and 3-year follow-up using Australian/Canadian Osteoarthritis Hand Index (AUSCAN).

RESULTS

Crude population prevalence estimates for symptomatic hand OA subsets in the adult population aged 50 years and over were: thumb base OA (22.4%), nodal interphalangeal joint (IPJ) OA (15.5%), generalised hand OA (10.4%), non-nodal IPJ OA (4.9%), erosive OA (1.0%). Apart from thumb base OA, there was considerable overlap between the subsets. Erosive OA appeared the most distinctive with the highest female: male ratio, and the most disability at baseline and 3-years. A higher frequency of obesity, hypertension, dyslipidaemia, and metabolic syndrome was observed in this subset.

CONCLUSION

Overlap in the occurrence of hand OA subsets poses conceptual and practical challenges to the pursuit of distinct phenotypes. Erosive OA may nevertheless provide particular insight into the role of metabolic and cardiovascular risk factors in the pathogenesis of OA.

Radiographic hand osteoarthritis: patterns and associations with hand pain and function in a community-dwelling sample

OBJECTIVE

Patterns of radiographic osteoarthritis (ROA) of the hand are often examined by row, with the four joints of the thumb studied inconsistently. The objectives of this study were to determine relationships of ROA at different hand joints, use the findings to define radiographic sub-groups and investigate their associations with pain and function.

METHODS

Sixteen joints in each hand were scored for the presence of ROA in a community-dwelling cohort of adults, 50-years-and-over, with self-reported hand pain or problems. Principal components analysis (PCA) with varimax rotation was used to study patterns of ROA in the hand joints and identify distinct sub-groups. Differences in pain and function between these sub-groups were assessed using Australian/Canadian Osteoarthritis Index (AUSCAN), Grip Ability Test (GAT) and grip and pinch strength.

RESULTS

PCA was undertaken on data from 592 participants and identified four components: distal interphalangeal joints (DIPs), proximal interphalangeal joints (PIPs), metacarpophalangeal joints (MCPs), thumb joints. However, the left thumb interphalangeal (IP) joint cross-loaded with the PIP and thumb groups. On this basis, participants were categorised into four radiographic sub-groups: no osteoarthritis (OA), finger only OA, thumb only OA and combined thumb and finger OA. Statistically significant differences were found between the sub-groups for AUSCAN function, and in women alone for grip and pinch strength. Participants with combined thumb and finger OA had the worst scores.

CONCLUSION

Individual thumb joints can be clustered together as a joint group in ROA. Four radiographic sub-groups of hand OA can be distinguished. Pain and functional difficulties were highest in participants with both thumb and finger OA.

EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT

Objectives:

To develop evidence-based recommendations for the diagnosis of hand osteoarthritis (OA).

Methods:

The multidisciplinary guideline development group, representing 15 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched for systematically. Whenever possible, the sensitivity, specificity and likelihood ratio (LR) were calculated; relative risk and odds ratios were estimated for risk factors for hand OA. Quality of evidence was categorised using the European League Against Rheumatism (EULAR) hierarchy, and strength of recommendation was assessed by the EULAR visual analogue scale.

Results:

Diagnostic topics included clinical manifestations, radiographic features, subgroups, differential diagnosis, laboratory tests, risk factors and comorbidities. The sensitivity, specificity and LR varied between tests depending upon the cut-off level, gold standard and controls. Overall, no single test could be used to define hand OA on its own (LR <10) but a composite of the tests greatly increased the chance of the diagnosis. The probability of a subject having hand OA was 20% when Heberden nodes alone were present, but this increased to 88% when in addition the subject was over 40 years old, had a family history of nodes and had joint space narrowing in any finger joint.

Conclusion:

Ten key recommendations for diagnosis of hand OA were developed using research evidence and expert consensus. Diagnosis of hand OA should be based on assessment of a composite of features.

An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial

OBJECTIVES

Cost-effectiveness and cost-utility analyses were conducted to compare advice and exercise plus manual therapy (MT) and advice and exercise plus pulsed shortwave diathermy (PSWD) with advice and exercise alone (A&E) in the treatment of non-specific neck disorders by experienced physiotherapists.

METHODS

Between July 2000 and June 2002, 350 participants with neck disorders from 15 physiotherapy departments were randomized to: A&E (n = 115); MT (n = 114) and PSWD (n = 121). Outcome and resource-use data were collected using physiotherapist case report forms and participant self-complete questionnaires. Outcome measures were the Northwick Park Neck Pain Questionnaire (NPQ) and EuroQoL EQ-5D [used to derive quality-adjusted-life-year (QALY) utility scores]. Two economic viewpoints were considered (health care and societal). Cost-effectiveness acceptability curves were used to assess the probabilities of the interventions being cost-effective at different willingness-to-pay threshold values.

RESULTS

Mean improvement in NPQ at 6 months was 11.5 in the A&E group, 10.2 in the MT group and 10.3 in the PSWD group; mean QALY scores were 0.362, 0.342 and 0.360, respectively. Mean health care costs were pound sterling105, pound sterling119 and pound sterling123 in the A&E, MT and PSWD groups, respectively. Mean societal costs were pound sterling373, pound sterling303 and pound sterling 338 in each group, respectively. Depending on the viewpoint and the outcome measure, A&E or MT were most likely to be the cost-effective interventions. PSWD was consistently the least cost-effective intervention.

CONCLUSIONS

The cost-effective intervention is likely to be A&E or MT, depending on the economic perspective and preferred outcome, but not PSWD.

A prospective double blind placebo-controlled randomized trial of ultrasound in the physiotherapy treatment of shoulder pain

OBJECTIVE

To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy.

METHODS

In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat.

RESULTS

A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points.

CONCLUSIONS

The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.

EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVES

To develop evidence based recommendations for the management of hand osteoarthritis (OA).

METHODS

The multidisciplinary guideline development group comprised 16 rheumatologists, one physiatrist, one orthopaedic surgeon, two allied health professionals, and one evidence based medicine expert, representing 15 different European countries. Each participant contributed up to 10 propositions describing key clinical points for management of hand OA. Final recommendations were agreed using a Delphi consensus approach. A systematic search of Medline, Embase, CINAHL, Science Citation Index, AMED, Cochrane Library, HTA, and NICE reports was used to identify the best available research evidence to support each proposition. Where possible, the effect size and number needed to treat were calculated for efficacy. Relative risk or odds ratio was estimated for safety, and incremental cost effectiveness ratio was used for cost effectiveness. The strength of recommendation was provided according to research evidence, clinical expertise, and perceived patient preference.

RESULTS

Eleven key propositions involving 17 treatment modalities were generated through three Delphi rounds. Treatment topics included general considerations (for example, clinical features, risk factors, comorbidities), non-pharmacological (for example, education plus exercise, local heat, and splint), pharmacological (for example, paracetamol, NSAIDs, NSAIDs plus gastroprotective agents, COX-2 inhibitors, systemic slow acting disease modifying drugs, intra-articular corticosteroids), and surgery. Of 17 treatment modalities, only six were supported by research evidence (education plus exercise, NSAIDs, COX-2 inhibitors, topical NSAIDs, topical capsaicin, and chondroitin sulphate). Others were supported either by evidence extrapolated from studies of OA affecting other joint sites or by expert opinion. Strength of recommendation varied according to level of evidence, benefits and harms/costs of the treatment, and clinical expertise.

CONCLUSION

Eleven key recommendations for treatment of hand OA were developed using a combination of research based evidence and expert consensus. The evidence was evaluated and the strength of recommendation was provided.

The impact of musculoskeletal hand problems in older adults: findings from the North Staffordshire Osteoarthritis Project (NorStOP)

OBJECTIVES

Hand problems are common in older people, but their impact on everyday life is not clear. The aim of this study was to investigate the impact of hand problems in community-dwelling older adults and how this varies with age and gender.

METHODS

Analysis was performed in 7878 subjects who responded to a baseline questionnaire. Participants defined as having hand problems were sent a second questionnaire, which included questions about hand pain and disability. Severe disability was defined as a score of 4 or more points on a validated hand and finger function scale. Estimates of 1-month period prevalence of hand pain and severe disability were calculated for the total responder population, by age and gender.

RESULTS

2113 persons with hand problems completed Stage 2 (78.6% response). One-year period prevalence of hand problems was 47% and estimated 1-month period prevalence of hand pain was 30.8%. These figures varied little with age. Severe hand-related disability affected 12.3% (95% confidence interval 11.3-13.3%) of this sample, was significantly more common in females than males, and increased in prevalence to the oldest age-groups.

CONCLUSIONS

Musculoskeletal hand problems are common in the population aged over 50 yrs. Most are painful, and have a significant impact on everyday life. Women and the very old appear especially vulnerable to the effect of hand problems on their daily activities.

The illness perceptions associated with health and behavioural outcomes in people with musculoskeletal hand problems: findings from the North Staffordshire Osteoarthritis Project (NorStOP)

OBJECTIVE

Illness perceptions may influence health outcomes, including pain. The objective of the study was to investigate the illness perceptions associated with health and behaviour in a population of older adults with musculoskeletal hand problems.

METHODS

A two-stage cross-sectional postal survey was sent to individuals aged 50 yrs and over, registered with three general practices in North Staffordshire. Stage 1, a Health Survey questionnaire, was sent to 11,230 individuals and enquired about general health status, including anxiety and depression. Individuals reporting hand problems at Stage 1 were sent Stage 2, a detailed hand questionnaire. The hand questionnaire included: the Arthritis Impact Measurement Scales 2 (AIMS2) (hand and finger function, pain and medication scales), and questions on self-reported diagnoses and general practitioner (GP) consultation. Perceptions were measured by the Illness Perceptions Questionnaire-Revised (IPQ-R), and an item on perceived frustration with their hand problems. Of the 7878 responders to the Health Survey questionnaire 3749 (47.6%) reported 'hand problems' and 2695 (71.9%) gave permission to be re-contacted. The hand questionnaire was completed by 2113 (adjusted response rate 78.6%).

RESULTS

A belief that their hand problem had a profound impact on life, caused a range of symptoms and made them frustrated were the perceptions most strongly and consistently associated with health and behaviour. There was little difference between individuals who did and those who did not report their hand problem to be osteoarthritis with respect to perceptions or between perceptions associated with health and behaviour.

CONCLUSIONS

The results suggest that older people who consider their musculoskeletal hand problem to have negative effects on their life will be more likely to encounter difficulties that may lead them to consult, take medication or both. Understanding the illness perceptions of these individuals may identify opportunities for intervention.

Conservative hand therapy treatments in rheumatoid arthritis--a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of three different physiotherapeutic approaches in the management of the rheumatoid hand.

METHODS

In a randomized controlled trial, participants with rheumatoid arthritis (RA) recruited from a rheumatology department in Mid-Staffordshire, UK (February 1999 to January 2001) were randomized to three groups. All received joint protection (JP) information delivered by a therapist at baseline. Group 1 participants received a set of additional hand-strengthening and mobilizing home exercises, group 2 a different set of additional hand-stretching exercises and group 3 the JP information alone. The primary outcome was the Arthritis Impact Measurement Scales II (AIMS II) (upper limb; hand and finger function subscales). Outcomes were assessed at baseline and 1, 3 and 6 months. Analysis was by intention to treat.

RESULTS

Sixty-seven participants (mean age 59.6 yr) were recruited: group 1 n = 21, group 2 n = 24 and group 3 n = 22. A 78% follow-up was achieved at 6 months. There was a mean fall (SD) in AIMS II upper limb function 0-6 month change scores in group 1 of 1.00 (1.07). In groups 2 and 3 there was a mean increase in AIMS II scores of 0.18 (1.54) and 0.30 (1.22), respectively. The differences in AIMS change scores between group 1 and groups 2 and 3 were statistically significant (P = 0.007) and remained so after adjustment for multiple testing (P = 0.012).

CONCLUSION

Statistically significant improvements in arm function have been demonstrated following a programme of home-strengthening hand exercises in RA patients compared with simple stretches or advice alone.

A cost consequences analysis of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care

OBJECTIVE

Local steroid injections and community-based physiotherapy have been shown to be of similar benefit for treating shoulder pain presenting to primary care. This paper presents a cost consequences analysis of a prospective economic evaluation, conducted alongside a randomized clinical trial (RCT) of corticosteroid injections versus physiotherapy for new episodes of unilateral shoulder pain, to determine the economic implications of injection versus physiotherapy.

METHODS

A pragmatic RCT with 207 patients randomized to either physiotherapy (n = 103) or local steroid injection (n = 104) was conducted. The resource inputs required were identified for each treatment arm in terms of capital, staff and consumables. These were measured for the period up to 6 months post-randomization. Outcome measures included shoulder disability, shoulder pain, global assessment of health change and the EQ5D, all at 6 months. A sensitivity analysis was performed around the general practitioner minor surgical fee.

RESULTS

Analysis is presented on the 199 patients for which the general practice record review (101 physiotherapy, 98 injection) was available. The total mean costs, per patient, were 71.28 pound sterling for the injection group and 114.60 pound sterling for the physiotherapy group. The difference in average total cost per patient was 43.32 pound sterling (95% bootstrap confidence interval: 16.21 pound sterling, 68.03 pound sterling ). This is a statistically significant difference in cost. Outcome was similar in both groups across all measures following intervention. Smaller mean differences in cost were observed between the treatment groups in the sensitivity analysis, but the difference remained in favour of injection over physiotherapy.

CONCLUSIONS

This study has shown, given similar clinical outcomes across the treatment groups, that corticosteroid injections were the cost-effective option for patients presenting with new episodes of unilateral shoulder pain in primary care.

Two pragmatic trials of treatment for shoulder disorders in primary care: generalisability, course, and prognostic indicators

OBJECTIVE

To investigate predictors of long term prognosis in patients treated for shoulder pain in primary care.

METHODS

Data were taken from two pragmatic randomised clinical trials investigating the effectiveness of conservative treatments for shoulder pain presenting to primary care. Shoulder pain severity, disability, and perceived recovery measured in the long term (UK, 18 months; Netherlands, 12 months) were considered as outcome measures. Prognostic indicators measured before randomisation were determined by linear regression (pain severity and disability) and logistic regression (perceived recovery).

RESULTS

316 adults with a new episode of shoulder pain were recruited (UK, n = 207; Netherlands, n = 109). In multivariate analysis, greater shoulder disability at follow up was associated with higher baseline disability score, concomitant neck pain, and a gradual onset and longer duration of shoulder symptoms. Pain scores at follow up were higher in women and in those with longer baseline duration of symptoms and higher baseline pain or disability scores. Being female, reporting gradual onset of symptoms, and a higher baseline disability score each independently reduced the likelihood of perceived recovery.

CONCLUSIONS

The results suggest that there is no long term difference in outcome between patients with shoulder pain treated with different clinical interventions in different clinical settings, or having different clinical diagnoses. Baseline clinical characteristics of this consulting population, rather than the randomised treatments which they received, were the most powerful predictors of outcome. Whether this highlights the need for earlier intervention or reflects different natural histories of shoulder pain is a topic for further research.

Spinal mobility in ankylosing spondylitis: reliability, validity and responsiveness

OBJECTIVE

To evaluate the measurement properties of an evidence-based selection of measures of spinal mobility in patients with ankylosing spondylitis (AS).

METHODS

Measurements of spinal mobility were taken by trained observers within a UK rheumatology centre. Inter-observer reliability was assessed. Intra-observer reliability was assessed in patients reporting no change in AS-specific health at 2 weeks. Validity was assessed and scores were correlated with responses to health transition questions. Responsiveness was evaluated for patients reporting change in health at 6 months.

RESULTS

Reliability estimates support the use of all measures in individual evaluation (intraclass correlation>0.90). Correlations between measures of spinal mobility were in the hypothesized direction; the largest was between the modified Schober index (15 cm) (MSI) and the other measures. As hypothesized, small to moderate levels of correlation were found between mobility measures and patient-assessed health status. There was no significant linear relationship between mobility measures and self-reported health transition. Fingertip-to-floor distance following trunk forward flexion (FFD) was the most responsive mobility measure but was not as responsive as two AS-specific patient-assessed instruments, the Ankylosing Spondylitis Quality of Life Questionnaire (ASQoL) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). The MSI and cervical rotation (Crot) also had evidence of responsiveness. Low levels of responsiveness were found for the remaining measures.

CONCLUSION

All mobility measures had adequate levels of reliability and validity. The MSI had a strong relationship with all mobility measures, and the FFD and Crot were the most responsive to self-perceived changes in health at 6 months. The MSI, FFD and Crot are recommended for clinical practice and research.