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High baseline pain is associated with treatment adherence in persons diagnosed with thumb base osteoarthritis: An observational study.
BACKGROUND: Thumb osteoarthritis (OA) is a common and disabling condition. Adherence to prescribed conservative interventions may affect outcomes of thumb OA trials. PURPOSE: The aim of the study was to determine whether baseline pain and hand function is associated with treatment adherence over 12 weeks in participants with thumb base OA. STUDY DESIGN: Observational cohort study nested within a randomized-controlled trial. METHODS: Ninety-four participants from the intervention group were included in the analysis. Baseline pain and function were assessed using a 100 mm Visual Analogue Scale and the Functional Index for Hand Osteoarthritis questionnaire (0-30), respectively. Participants received a combination of treatments including education, orthosis, hand exercises, and topical anti-inflammatory gel. Adherence was measured using a daily self-reported diary. Participants were classified as non-adherent, partially adherent or fully adherent if they completed none, 1 and/or 2 or all 3 of the interventions as prescribed. Ordinal logistic regression modelling was performed. RESULTS: At 12-week follow-up, half of the participants were fully adherent to the treatments (n = 46, 48.9%), 30.9% of participants were partially adherent (n = 29) and 20.2% were non-adherent (n = 19, 20.2%). High baseline pain was a significantly associated with better adherence in the unadjusted model [OR = 3.15, 95% CI (1.18, 8.42)] and adjusted model [OR = 3.20, 95% CI (1.13, 8.20)]. Baseline function was not associated with adherence [OR = 1.03, 95% CI (0.47, 2.23)]. CONCLUSION: High baseline pain was associated with better adherence in participants with thumb base OA. Higher baseline functional impairment was not associated with better adherence.
The experience of surgeons treating unexplained pain after knee arthroplasty : a reflexive thematic analysis.
AIMS: The aim of the present study was to understand the experience of surgeons treating patients with unexplained pain after knee arthroplasty and the role they considered revision surgery to have in the management of this condition. METHODS: Semi-structured interviews were performed with seven consultant knee surgeons in the NHS. Interviews were audio-recorded, transcribed verbatim, and de-identified before analysis using reflexive thematic analysis. RESULTS: Six themes were developed: 1) I need to understand a patient's journey and their expectations; 2) A difficult consultation; 3) I'm the 'fixer'; 4) It's complicated asking for help; 5) I'm uncomfortable operating for truly unexplained pain; and 6) It's a wound I carry with me. CONCLUSION: This study has improved our understanding of the important considerations for surgeons when managing patients with unexplained pain after knee arthroplasty. Our study calls for a holistic approach to care that considers patients' experiences, embraces modern pain theory, and fosters collaboration among healthcare providers.
Psychological factors not strength deficits are associated with severity of gluteal tendinopathy: A cross-sectional study.
BACKGROUND: Gluteal tendinopathy is the most common lower limb tendinopathy presenting to general practice. It has a high prevalence amongst middle-aged women and impacts on daily activities, work participation and quality of life. The aim was to compare physical and psychological characteristics between subgroups of severity of pain and disability. METHODS: A multicentre cross-sectional cohort of 204 participants (mean age 55 years, 82% female) who had a clinical diagnosis of gluteal tendinopathy with magnetic resonance imaging confirmation were assessed. A range of physical and psychosocial characteristics were recorded. Pain and disability were measured with the VISA-G questionnaire. A cluster analysis was used to identify mild, moderate and severe subgroups based on total VISA-G scores. Between-group differences were then evaluated with a MANCOVA, including sex and study site as covariates, followed by a Bonferroni post hoc test. Significance was set at 0.05. RESULTS: There were significantly higher pain catastrophizing and depression scores in the more severe subgroups. Lower pain self-efficacy scores were found in the severe group compared to the moderate and mild groups. Greater waist girth and body mass index (BMI), lower activity levels and poorer quality of life were reported in the severe group compared to the mild group. Hip abductor muscle strength and hip circumference did not differ between subgroups of severity. CONCLUSIONS: Individuals with severe gluteal tendinopathy present with psychological distress, poorer quality of life, greater BMI and waist girth. Given these features, the consideration of psychological factors in more severe patients may be important to optimize patient outcomes and reduce healthcare utilization. SIGNIFICANCE: Patients with severe gluteal tendinopathy exhibit greater psychological distress, poorer quality of life and greater waist girth and BMI when compared to less severe cases. This implies that clinicians ought to consider psychological factors in the management of more severe gluteal tendinopathy.
Interventions to increase adherence to therapeutic exercise in older adults with low back pain and/or hip/knee osteoarthritis: a systematic review and meta-analysis.
OBJECTIVE: To evaluate whether interventions aimed at increasing adherence to therapeutic exercise increase adherence greater than a contextually equivalent control among older adults with chronic low back pain and/or hip/knee osteoarthritis. DESIGN: A systematic review and meta-analysis. DATA SOURCES: Five databases (MEDLINE (PubMed), CINAHL, SportDISCUS (EBSCO), Embase (Ovid) and Cochrane Library) were searched until 1 August 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials that isolated the effects of interventions aiming to improve adherence to therapeutic exercise among adults ≥45 years of age with chronic low back pain and/or hip/knee osteoarthritis were included. RESULTS: Of 3899 studies identified, nine studies (1045 participants) were eligible. Four studies, evaluating strategies that aimed to increase motivation or using behavioural graded exercise, reported significantly better exercise adherence (d=0.26-1.23). In contrast, behavioural counselling, action coping plans and/or audio/video exercise cues did not improve adherence significantly. Meta-analysis using a random effects model with the two studies evaluating booster sessions with a physiotherapist for people with osteoarthritis revealed a small to medium significant pooled effect in favour of booster sessions (standardised mean difference (SMD) 0.39, 95% CI 0.05 to 0.72, z=2.26, p=0.02, I2=35%). CONCLUSIONS: Meta-analysis provides moderate-quality evidence that booster sessions with a physiotherapist assisted people with hip/knee osteoarthritis to better adhere to therapeutic exercise. Individual high-quality trials supported the use of motivational strategies in people with chronic low back pain and behavioural graded exercise in people with osteoarthritis to improve adherence to exercise.
Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis: Synthesis of the Literature Using Behavior Change Theory.
Exercise is recommended for hip and knee osteoarthritis (OA). Patient initiation of, and adherence to, exercise is key to the success of managing symptoms. This study aimed to (1) identify modifiable barriers and facilitators to participation in intentional exercise in hip and/or knee OA, and (2) synthesize findings using behavior change theory. A scoping review with systematic searches was conducted through March 2015. Two reviewers screened studies for eligibility. Barriers and facilitators were extracted and synthesized according to the Theoretical Domains Framework (TDF) by two independent reviewers. Twenty-three studies (total of 4633 participants) were included. The greatest number of unique barriers and facilitators mapped to the Environmental Context and Resources domain. Many barriers were related to Beliefs about Consequences and Beliefs about Capabilities, whereas many facilitators were related to Reinforcement. Clinicians should take a proactive role in facilitating exercise uptake and adherence, rather than trusting patients to independently overcome barriers to exercise. Strategies that may be useful include a personalized approach to exercise prescription, considering environmental context and available resources, personalized education about beneficial consequences of exercise and reassurance about exercise capability, and use of reinforcement strategies. Future research should investigate the effectiveness of behavior change interventions that specifically target these factors.
What do people with knee or hip osteoarthritis need to know? An international consensus list of essential statements for osteoarthritis.
OBJECTIVE: To establish priority key messages for patients with osteoarthritis (OA). METHODS: A Delphi survey and priority pairwise ranking activity was conducted. Participants included 51 OA experts from 13 countries and 9 patients (consumers) living with hip and/or knee OA. During 3 Delphi rounds, the panel of experts and consumers rated recommendations extracted from clinical guidelines and provided additional statements they considered important. When ≥70% of panel members agreed a statement was "essential," it was retained for the next Delphi round. The final list of essential statements was reviewed by a consumer focus group and statements were modified for clarity if required. Finally, a priority pairwise ranking activity determined the rank order of the list of essential messages. RESULTS: Eighty-five experts and 15 consumers were invited to participate; 51 experts and 9 consumers completed round 1 of the Delphi survey, and 43 experts and 8 consumers completed the final priority ranking activity. From an original list of 114 statements, 21 statements were rated as essential. Most statements (n = 17) related to nondrug treatment approaches for OA. Study limitations included that >50% of the panel comprised of physical therapists lead to high rankings of exercise and physical activity statements and also that only English-language statements were considered. CONCLUSION: OA experts and consumers have identified and prioritized 21 key patient messages about OA. These messages may be used to inform the content of consumer educational materials to ensure patients are educated about the most important aspects of OA and its management.
Self-reported home exercise adherence – fact or fiction? A validity and reliability study using concealed accelerometry among people with knee osteoarthritis
Purpose: To determine if sleep interventions improve pain and sleep in people with osteoarthritis and/or spinal pain. Methods: An electronic database search was conducted in Medline,Embase, AMED, PsycINFO, CENTRAL, CINAHL and PEDro from theirinception date to April 2016. Keywords relating to “sleep”, “osteoarthritis”, “spinal pain”, and “randomized control trial” were combined. Eligible studies were randomized control trials (RCT) from peer reviewed journals which investigated the use of sleep interventions for people with osteoarthritis and/or spinal pain. Sleep interventions were defined as interventions which aim to directly improve sleep related outcomes, including both non-pharmacological and pharmacological methods. Two investigators independently screened the literature search (title and abstract, followed by full text), extracted data and assessed methodological quality of included studies. Meta-analyses were performed to pool effect sizes for pain and sleep quality. Sensitivity analyses were performed with the following criteria: osteoarthritis or spinal pain, any sleep intervention, compared to a control/placebo group, 10 participants per group and PEDro Score6/10. The review protocol was registered with the International Prospective Register of Systematic Reviews (CRD42016036315). Results: Of 1199 unique records, 97 underwent full text screening and 22 studies were included. 14 studies examined spinal pain, six for osteoarthritis, and two were mixed. Sleep interventions were cognitive behavioural therapy (CBT) (n ¼ 8), pillows (n ¼ 4), sleep medication (n ¼ 3), exercise (n ¼ 2), massage (n ¼ 2), music (n ¼ 1), acupuncture (n ¼ 1), and mattresses (n ¼ 1). Intervention periods ranged from four to ten weeks. Seven studies combined sleep and pain interventions, however none combined CBT for sleep with exercise or physiotherapy. Overall pooled post-treatment results (mean age ¼ 33-73 years, n ¼ 1339) had high heterogeneity scores ranging from 62-95%. Random effects estimates showed that sleep interventions led to significant improvements in pain (standardized mean difference 4.94, 95% confidence interval [1.47-8.42], P ¼ 0.005) and sleep quality (9.13, [4.36-13.90], P<0.001). After sensitivity analyses, 7 RCTs were incorporated into the meta-analysis (mean age ¼ 42 to 72 years, n ¼ 354), with heterogeneity scores ranging from 10-45%. The pooled fixed effect estimates showed significant improvements in pain (10.78, [6.84- 14.72]; P<0.001) and sleep quality (8.21, [4.83-11.58]; P<0.001). Conclusions: Sleep interventions alone are likely to improve pain and sleep quality for people with osteoarthritis and/or spinal pain. Although the magnitude of change may not be clinically significant, further highquality studies using CBT for sleep in conjunction with other interventions for people with osteoarthritis and/or spinal pain should be conducted
Trajectories of adherence to home-based exercise programs among people with knee osteoarthritis
Purpose: Exercise is the cornerstone of optimal non-surgical management of knee osteoarthritis (OA). However, for exercise interventions to be successful adherence is crucial. Given that adherence to exercise among people with knee OA is influenced by a vast array of factors, it is unsurprising that exercise adherence varies across individuals. Identifying distinct exercise adherence trajectories among people with knee OA allows a better understanding of how adherence to exercise typically changes over time, and may facilitate identification of individuals most at risk of poor or declining exercise adherence, who may benefit from interventions specifically designed to boost exercise adherence at particular time points. The aim of this study was to investigate the presence of groups showing different trajectories of self-reported adherence to home exercise programs among people with knee OA, and to compare baseline characteristics across identified groups. Methods: We performed a pooled analysis of data from three randomised controlled trials involving exercise interventions for people aged ≥50 years with clinical knee OA (n = 331) in Australia. Exercise adherence was self-reported on an 11-point numerical rating scale (NRS, 0 = not at all, 10 = completely as instructed) reflecting on the previous 12 week period from 12 weeks up to 78 weeks from baseline. Latent class growth analysis was used to identify groups of participants with distinct trajectories of adherence. The optimal model was identified by initially fitting a single-group model, then successively increasing the number of groups until model estimation failed. The model with the lowest Bayesian information criterion (BIC) was selected as the optimal model. Baseline characteristics of these groups were compared using chi-squared tests, one-way ANOVA and Kruskal Wallis tests where appropriate. Results: The optimal model identified three groups of participants with distinct trajectories of home exercise adherence over time: one whose adherence rapidly declined and then remained poor (Group 1 termed “Rapidly declining adherence”, n = 157, 47.4% of the cohort), a second group whose adherence started high and declined gradually over time (Group 2 termed “Gradually declining adherence”, n = 153, 45.1% of the cohort), and a small third group whose adherence was poor throughout (Group 3 termed “Low adherence”, n = 21, 6.3% of the cohort). Mean adherence was higher in the “Gradually declining adherence” group compared to the “Rapidly declining adherence” and “Low adherence” groups at all time points. At baseline the “Rapidly declining adherence” group reported significantly lower WOMAC pain (mean difference (95%CI) −0.8 (−1.4, −0.2)) and better WOMAC function (−3.1 (−5.2, −1.1) compared to the “Gradually declining adherence” group. In addition the “Low adherence” group reported borderline significantly poorer self-efficacy in managing their OA symptoms compared to the “Rapidly declining adherence” group (mean difference (95%CI) 1.9 (0.0, 3.8)). Conclusions: Three distinct trajectories of self-reported adherence to prescribed home exercise among people with knee OA were found. Few baseline characteristics differed between these groups, and in this cohort these differences between groups were small. Our results highlight the need for close monitoring of adherence from initiation of a home exercise program in order to identify and intervene with participants following a low or rapidly declining adherence trajectory.
Trajectories of adherence to home-based exercise programs among people with knee osteoarthritis.
OBJECTIVE: To investigate the presence of different trajectories of self-reported adherence to home exercise programs among people with knee osteoarthritis (OA), and to compare baseline characteristics across identified groups. DESIGN: Pooled analysis of data from three randomised controlled trials involving exercise interventions for people aged ≥50 years with clinical knee OA (n = 341). Exercise adherence was self-reported on an 11-point numerical rating scale (NRS; 0 = not at all-10 = completely as instructed). Latent class growth analysis was used to identify distinct trajectories of adherence, at intervals from 12 to 78 weeks from baseline. Baseline characteristics of these groups were compared using chi-squared tests, one-way analysis of variance (ANOVA) and Kruskal Wallis tests where appropriate. RESULTS: Three distinct adherence trajectories were identified: a "Rapidly declining adherence" group (n = 157, 47.4%) whose adherence was 7.7 ± 1.6 (/10) at 12 weeks, declined to 4.2 ± 2.2 by 22 weeks and remained low thereafter; a "Gradually declining adherence" group (n = 153, 45.1%) whose adherence declined from 8.5 ± 1.5 to 7.8 ± 1.5 over the same period, and continued to decline slowly, and a "Low adherence" group (n = 21, 6.3%) whose adherence was 2.2 ± 1.4 at 12 weeks and remained low. At baseline the "Rapidly declining adherence" group reported significantly lower Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain (mean difference (95% Confidence Interval (CI)) -0.8 (-1.4, -0.2)) and better WOMAC function compared to the "Gradually declining adherence" group (-3.1 (-5.2, -1.1)). CONCLUSION: Three trajectories of self-reported adherence to home exercises were found among people with knee OA. Findings highlight the need for close monitoring of adherence from initiation of a home exercise program in order to identify and intervene when low or rapidly declining adherence is identified.
Improving Adherence to Exercise: Do People With Knee Osteoarthritis and Physical Therapists Agree on the Behavioral Approaches Likely to Succeed?
OBJECTIVE: To describe which behavior change techniques (BCTs) to promote adherence to exercise have been experienced by people with knee osteoarthritis (OA) or used by physical therapists, and to describe patient- and physical therapist-perceived effectiveness of a range of BCTs derived from behavioral theory. METHODS: Two versions of a custom-designed survey were administered in Australia and New Zealand, one completed by adults with symptomatic knee OA and the second by physical therapists who had treated people with knee OA in the past 6 months. Survey questions ascertained the frequency of receiving/prescribing exercise for knee OA, BCTs received/used targeting adherence to exercise, and perceived effectiveness of 36 BCTs to improve adherence to prescribed exercise. RESULTS: A total of 230 people with knee OA and 143 physical therapists completed the survey. Education about the benefits of exercise was the most commonly received/used technique by both groups. People with knee OA rated the perceived effectiveness of all BCTs significantly lower than the physical therapists (mean difference 1.9 [95% confidence interval 1.8-2.0]). When ranked by group mean agreement score, 2 BCTs were among the top 5 for both groups: development of specific goals related to knee pain and function; and review, supervision, and correction of exercise technique at subsequent treatment sessions. CONCLUSION: Goal-setting techniques related to outcomes were considered to be effective by both respondent groups, and testing of interventions incorporating these strategies should be a research priority.
Utility of clinical tests to diagnose MRI-confirmed gluteal tendinopathy in patients presenting with lateral hip pain.
PURPOSE: Gluteal tendinopathy (GT) is a source of lateral hip pain, yet common clinical diagnostic tests have limited validity. Patients with GT are often misdiagnosed, resulting in inappropriate management, including surgery. This study determined the diagnostic utility of clinical tests for GT, using MRI as the reference standard. METHODS: 65 participants with lateral hip pain were examined to evaluate the ability of clinical tests to detect MRI-determined GT (an increase in intratendinous signal intensity on T2-weighted images). Palpation of the greater trochanter and several clinical pain provocation tests applying compressive and tensile loads on the gluteal tendons were investigated. MRI of the painful hip was examined by a radiologist, blind to clinical findings. RESULTS: Pain reported within 30 s of standing on the affected limb conclusively moves a (nominal) 50% pretest probability of GT presence on MRI to a post-test probability of 98% (specificity 100%, positive likelihood ratio ∼12), whereas no pain on palpation (80% sensitivity) would rule out its presence. 20 participants (31%) had GT on MRI but clinically negative (ie, not positive on palpation and another test). CONCLUSIONS: Keeping in mind that the sample size was small (ie, possibly underpowered for indices of diagnostic utility with low precision), the results of this study indicate that a patient who reports lateral hip pain within 30 s of single-leg-standing is very likely to have GT. Patients with lateral hip pain who are not palpably tender over the greater trochanter are unlikely to have MRI-detected GT.
Use of nondrug, nonoperative interventions by community-dwelling people with hip and knee osteoarthritis.
OBJECTIVE: Guidelines recommend nondrug, nonoperative treatments as the first-line approach for hip and knee osteoarthritis (OA), yet there is limited data regarding use of these treatments in OA. This study describes the use of nondrug, nonoperative interventions in people with hip and knee OA. METHODS: A convenience sample of 591 people with hip or knee OA completed a questionnaire indicating their past and/or current use of 17 nondrug, nonoperative interventions each for their hip or knee OA. Descriptive analyses, based on frequency counts and proportions, and chi-square tests described the use of each intervention in the total cohort, and within subgroups of knee and hip OA. RESULTS: Participants were currently using a mean ± SD of 0.8 ± 0.9 of the strongly recommended interventions. Making efforts to lose weight (50%, n = 294) and shoe orthoses (30%, n = 175) were the most common currently used interventions. Strengthening (26%, n = 152) and stretching exercises (23%, n = 133) were the most common interventions that participants had tried in the past but were no longer utilizing. Of note, 12% (n = 71) had never used any of the interventions. Use of 5 treatments (shoe orthoses, heat and/or cold, muscle strengthening exercises, walking aids, and transcutaneous electrical nerve stimulation) was significantly different between the hip and knee cohorts (P < 0.05). CONCLUSION: Use of nondrug, nonoperative interventions was low among people with hip and knee OA. Our findings show evidence–practice gaps, particularly with respect to the interventions most strongly recommended in clinical guidelines for hip and knee OA (weight loss and exercise).
Self-reported Home Exercise Adherence: A Validity and Reliability Study Using Concealed Accelerometers.
BACKGROUND: Accurate measurement of adherence to prescribed exercise programs is essential. Diaries and self-report rating scales are commonly used, yet little evidence exists to demonstrate their validity and reliability. OBJECTIVES: To examine the concurrent validity of adherence to home strengthening exercises measured by (1) exercise diaries and (2) a self-report rating scale, compared to adherence measured using an accelerometer concealed in an ankle cuff weight. Test-retest reliability of the self-report rating scale was also assessed. METHODS: In this clinical measurement study, 54 adults aged 45 years or older with self-reported chronic knee pain were prescribed a home quadriceps-strengthening program. Over 12 weeks, participants completed paper exercise diaries and, at appointments every 2 weeks, rated their adherence on an 11-point numeric rating scale. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises. Self-reported adherence rating scale data over each 2-week period were analyzed using descriptive statistics, the Wilcoxon signed-rank test, and a Bland-Altman plot to assess agreement, Spearman correlations for validity, and intraclass correlation coefficients for test-retest reliability. RESULTS: Exercise adherence was significantly overestimated in diaries during the 12 weeks (diary median, 220 exercises; accelerometer, 176; P