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Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial.
OBJECTIVE: To compare the effects of a programme of load management education plus exercise, corticosteroid injection use, and no treatment on pain and global improvement in individuals with gluteal tendinopathy. DESIGN: Prospective, three arm, single blinded, randomised clinical trial. SETTING: Brisbane and Melbourne, Australia. PARTICIPANTS: Individuals aged 35-70 years, with lateral hip pain for more than three months, at least 4/10 on the pain numerical rating scale, and gluteal tendinopathy confirmed by clinical diagnosis and magnetic resonance imaging; and with no corticosteroid injection use in previous 12 months, current physiotherapy, total hip replacement, or neurological conditions. INTERVENTIONS: A physiotherapy led education and exercise programme of 14 sessions over eight weeks (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69). MAIN OUTCOMES: Primary outcomes were patient reported global rating of change in hip condition (on an 11 point scale, dichotomised to success and non-success) and pain intensity in the past week (0=no pain, 10=worst pain) at eight weeks, with longer term follow-up at 52 weeks. RESULTS: Of 204 randomised participants (including 167 women; mean age 54.8 years (standard deviation 8.8)), 189 (92.6%) completed 52 week follow-up. Success on the global rating of change was reported at eight weeks by 51/66 EDX, 38/65 CSI, and 20/68 WS participants. EDX and CSI had better global improvement scores than WS (risk difference 49.1% (95% confidence interval 34.6% to 63.5%), number needed to treat 2.0 (95% confidence interval 1.6 to 2.9); 29.2% (13.2% to 45.2%), 3.4 (2.2 to 7.6); respectively). EDX had better global improvement scores than CSI (19.9% (4.7% to 35.0%); 5.0 (2.9 to 21.1)). At eight weeks, reported pain on the numerical rating scale was mean score 1.5 (standard deviation 1.5) for EDX, 2.7 (2.4) for CSI, and 3.8 (2.0) for WS. EDX and CSI participants reported less pain than WS (mean difference -2.2 (95% confidence interval -2.89 to -1.54); -1.2 (-1.85 to -0.50); respectively), and EDX participants reported less pain than CSI (-1.04 (-1.72 to -0.37)). Success on the global rating of change was reported at 52 weeks by 51/65 EDX, 36/63 CSI, and 31/60 WS participants; EDX was better than CSI (20.4% (4.9% to 35.9%); 4.9 (2.8 to 20.6)) and WS (26.8% (11.3% to 42.3%); 3.7 (2.4 to 8.8)). Reported pain at 52 weeks was 2.1 (2.2) for EDX, 2.3 (1.9) for CSI, and 3.2 (2.6) for WS; EDX did not differ from CSI (-0.26 (-1.06 to 0.55)), but both treatments did better than WS (1.13 (-1.93 to -0.33); 0.87 (-1.68 to -0.07); respectively). CONCLUSIONS: For gluteal tendinopathy, education plus exercise and corticosteroid injection use resulted in higher rates of patient reported global improvement and lower pain intensity than no treatment at eight weeks. Education plus exercise performed better than corticosteroid injection use. At 52 week follow-up, education plus exercise led to better global improvement than corticosteroid injection use, but no difference in pain intensity. These results support EDX as an effective management approach for gluteal tendinopathy. TRIAL REGISTRATION: Prospectively registered at the Australian New Zealand Clinical Trials Registry (ACTRN12612001126808).
Predictors and Measures of Adherence to Core Treatments for Osteoarthritis.
Adherence has been proposed as a major barrier to implementing and maintaining the benefits of osteoarthritis (OA) core treatments and is influenced by many factors. Although there are reasonable data to support factors influencing adherence to exercise/physical activity in knee/hip OA populations, there is less research examining alternative interventions, or in the hand OA population. This problem is complicated by the lack of gold-standard measurement of adherence for core osteoarthritis treatments. The predictors of treatment adherence are not well understood, and findings are contradictory. Strategies incorporating behavior change techniques should be implemented to improve and maintain long-term adherence.
PARTNER: a service delivery model to implement optimal primary care management of people with knee osteoarthritis: description of development.
OBJECTIVE: Implementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service delivery to implement recommended care for people with knee osteoarthritis (OA) in a primary care setting. METHODS: Three development stages occurred concurrently and iteratively. Each stage considered the healthcare context and was informed by stakeholder input. Stage 1 involved the design of a new model of service delivery (PARTNER). Stage 2 developed a behavioural change intervention targeting general practitioners (GPs) using the behavioural change wheel framework. In stage 3, the 'Care Support Team' component of the service delivery model was operationalised. RESULTS: The focus of PARTNER is to provide patients with education, exercise and/or weight loss advice, and facilitate effective self-management through behavioural change support. Stage 1 model design: based on clinical practice guidelines, known evidence practice gaps in current care, chronic disease management frameworks, input from stakeholders and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER service-delivery model. The key components are: (1) an effective GP consultation and (2) follow-up and ongoing care provided remotely (telephone/email/online resources) by a 'Care Support Team'. Stage 2 GP behavioural change intervention: a multimodal behavioural change intervention was developed comprising a self-audit/feedback activity, online professional development and desktop software to provide decision support, patient information resources and a referral mechanism to the 'Care Support Team'. Stage 3 operationalising the 'care support team'-staff recruited and trained in evidence-based knee OA management and behavioural change methodology. CONCLUSION: The PARTNER model is the result of a comprehensive implementation strategy development process using evidence, behavioural change theory and intervention development guidelines. Technologies for scalable delivery were harnessed and new primary evidence was generated as part of the process.Trial registration number ACTRN12617001595303 (UTN U1111-1197-4809).
Risk Factors for Mobility Decline in Community-Dwelling Older Adults: A Systematic Literature Review.
Mobility is essential to maintaining independence for older adults. This systematic review aimed to summarize evidence about self-reported risk factors for self-reported mobility decline; and to provide an overview of published prognostic models for self-reported mobility decline among community-dwelling older adults. Databases were searched from inception to June 2, 2020. Studies were screened by two independent reviewers who extracted data and assessed study quality. Sixty-one studies (45,187 participants) were included, providing information on 107 risk factors. High-quality evidence and moderate/large effect sizes for the association with mobility decline were found for older age beyond 75 years, the presence of widespread pain, and mobility modifications. Moderate-high quality evidence and small effect sizes were found for a further 21 factors. Three model development studies demonstrated acceptable model performance, limited by high risk of bias. These findings should be considered in intervention development, and in developing a prediction instrument for practical application.
Essential key messages about diagnosis, imaging, and self-care for people with low back pain: a modified Delphi study of consumer and expert opinions.
People with back pain regularly search for information online; however, the quality of this online information is often poor. We established a list of the most important messages about diagnosis, imaging, and self-care for people with low back pain, based on consensus opinion and prioritised in order of importance. A list of key messages was derived from clinical practice guidelines for back pain. During 2 survey rounds, a Delphi panel of consumers with back pain and experts rated the importance of each item and suggested additional statements. Messages were retained that were rated as important by more than 70% of the panel. Retained messages were reviewed by consumer focus groups. A priority pairwise ranking activity determined the rank order of the important messages. A final online survey determined the robustness and currency of the final list of statements. The Delphi process and consumer focus groups resulted in 30 unique messages. Experts considered that the most important messages for patients are (1) remain active and (2) reassurance that back pain is a normal experience and not necessarily related to serious harm. This differed from the preferences of people with back pain who prioritised messages related to (1) identification of more serious pathology and (2) principles of management. This list of important key messages about diagnosis, imaging, and general self-care for people with back pain can be used to inform the development of education resources, including new web sites, as well as to direct clinicians in the information they provide to patients.
Synergistic effects of hip/knee osteoarthritis and comorbidities on mobility and self-care limitations among older adults: Cross-sectional analysis of the Oxford pain, Activity and Lifestyle study.
OBJECTIVE: To estimate synergistic effects of hip/knee osteoarthritis (OA) and comorbidities on mobility or self-care limitations among older adults. METHODS: We used baseline, cross-sectional data from the Oxford Pain, Activity and Lifestyle (OPAL) study. Participants were community-dwelling adults aged 65 years or older who completed a postal questionnaire. Participants reported demographic information, hip/knee OA, comorbidities and mobility and self-care limitations. We used modified Poisson regression models to estimate the independent and combined relative risks (RR) of mobility or self-care limitations, the relative excess risk due to interaction (RERI) between hip/knee OA and comorbidities, attributable proportion of the risk due to the interaction and the ratio of the combined effect and the sum of the individual effects, known as the synergy index. RESULTS: Of the 4,972 participants included, 1,532 (30.8%) had hip/knee OA, and of them 42.9% reported mobility limitations and 8.4% reported self-care limitations. Synergistic effects impacting self-care limitations were observed between hip/knee OA and anxiety (RR: 3.09, 95% Confidence Interval (CI): 2.00 to 4.78; RERI: 0.93, 95% CI: 0.01 to 1.90), and between hip/knee OA and depressive symptoms (RR: 2.71, 95% CI: 1.75 to 4.20; RERI: 0.58, 95% CI: 0.03 to 1.48). The portion of the total RR attributable to this synergism was 30% and 22% respectively. CONCLUSIONS: This study demonstrates that synergism between hip/knee OA and anxiety or depressive symptoms contribute to self-care limitations. These findings highlight the importance of assessing and addressing anxiety or depressive symptoms when managing older adults with hip/knee OA to minimize self-care limitations.
Musculoskeletal pain and loneliness, social support and social engagement among older adults: Analysis of the Oxford Pain, Activity and Lifestyle cohort.
BACKGROUND: Musculoskeletal (MSK) pain is common in older adults. Physical and psychological consequences of MSK pain have been established, but it is also important to consider the social impact. We aimed to estimate the association between MSK pain and loneliness, social support and social engagement. METHODS: We used baseline data from the Oxford Pain, Activity and Lifestyle study. Participants were community-dwelling adults aged 65 years or older from across England. Participants reported demographic information, MSK pain by body site, loneliness, social support and social engagement. We categorised pain by body regions affected (upper limb, lower limb and spinal). Widespread pain was defined as pain in all three regions. We used logistic regression models to estimate associations between distribution of pain and social factors, controlling for covariates. RESULTS: Of the 4977 participants analysed, 4193 (84.2%) reported any MSK pain, and one-quarter (n = 1298) reported widespread pain. Individuals reporting any pain were more likely to report loneliness (OR [odds ratio]: 1.62; 95% CI [confidence interval]: 1.32-1.97) or insufficient social support (OR: 1.54; 95% CI: 1.08-2.19) compared to those reporting no pain. Widespread pain had the strongest association with loneliness (OR: 1.94; 95% CI: 1.53-2.46) and insufficient social support (OR: 1.71; 95% CI: 1.14-2.54). Pain was not associated with social engagement. CONCLUSIONS: Older adults commonly report MSK pain, which is associated with loneliness and perceived insufficiency of social support. This finding highlights to clinicians and researchers the need to consider social implications of MSK pain in addition to physical and psychological consequences.
Measuring adherence to unsupervised, conservative treatment for knee osteoarthritis: A systematic review.
OBJECTIVE: To describe the measurement of adherence to unsupervised, conservative treatments for knee osteoarthritis (OA), including the methods of adherence measurement, parameters for assessing adherence and any values used to quantify adherence. METHODS: A systematic review with search terms related to knee OA, conservative treatments and adherence was conducted. The protocol was registered with the International Prospective Register of Systematic Reviews (registration number CRD42020158188). Seven electronic databases (MEDLINE, AMED, EMBASE, CINAHL, SportDiscus, PsychINFO, PEDro) were searched from inception to February 02, 2021. Studies that included unsupervised, conservative treatment(s) for knee OA measuring adherence were eligible. Studies were independently screened for inclusion by two researchers. Data was extracted by one researcher and verified by a second researcher. Extracted data included: study type, population, type of treatment, adherence measurement methods, time-points, recall, parameters and values used to quantify adherence. RESULTS: Of 5033 references identified, 242 studies comprising of 261 treatments were included in the review. The majority of studies were randomised controlled trials investigating therapeutic exercise (n = 107, 41.0%). The most common adherence measurement across all treatments was through self-reported diary (n = 137, 52.5%) and the most common parameter was assessing the frequency of the treatment (n = 79, 30.3%). Only a small number of studies provided values for quantifying satisfactory adherence (n = 26, 9.3%). CONCLUSION: There is a wide variety in the reporting of adherence to conservative treatments for knee OA and standardised methods for measuring and reporting adherence are needed. Developing a tool to measure adherence to conservative treatments for knee OA is a priority.
History taking & physical assessment
History taking and physical assessment are essential first steps in any clinical encounter. Comprehensive and accurate history taking and physical assessment allow the “complete picture” of an individual presenting with possible osteoarthritis to be established. A person-centered approach is key, with active, open communication. Using techniques such as active listening, empathy, building rapport, open-ended questions, closed-ended probing questions, avoiding leading and “why” questions, allowing silence, and using nonverbal communication enable rich information to be elicited. A holistic approach to history taking ensures that all aspects of the individual are considered. Key components include systematically reviewing symptoms, participation, previous history, comorbidities, psychological factors, sleep and fatigue, support, attitudes and beliefs, red flag screening, using person-reported outcome measures, and setting goals. The physical assessment should be viewed as an extension of history taking. Adopting a systematic approach to physical assessment focusing on the four components: look (general and local observation), feel (palpation), move (range of movement), and measure (range of movement assessment, muscle strength and length, function, neurological features, and special tests) ensures comprehensive information is gained. Together, history taking and physical assessment form the foundation on which a personalized management plan can be built and to optimize engagement and adherence with management in long term.
Dysfunctional mitochondria in ageing T cells: a perspective on mitochondrial quality control mechanisms.
Dysfunctional mitochondria are a hallmark of T cell ageing and contribute to organismal ageing. This arises from the accumulation of reactive oxygen species (ROS), impaired mitochondrial dynamics, and inefficient removal of dysfunctional mitochondria. Both cell-intrinsic and cell-extrinsic mechanisms for removing mitochondria and their byproducts have been identified in T cells. In this review, we explore how T cells manage mitochondrial damage through changes in mitochondrial metabolism, mitophagy, asymmetric mitochondrial inheritance, and mitochondrial transfer, highlighting the impact of these mechanisms on T cell ageing and overall organismal ageing. We also discuss current therapeutic strategies aimed at removing dysfunctional mitochondria and their byproducts and propose potential new therapeutic targets that may reverse immune ageing or organismal ageing.
High-Dose vs. Standard-Dose Influenza Vaccine in Heart Failure: A Prespecified Analysis of the DANFLU-2 Trial
<jats:p> <jats:bold>Background:</jats:bold> Influenza contributes substantially to disease burden in individuals with heart failure (HF) and is an established trigger of cardiovascular (CV) and HF events. Standard-dose inactivated influenza vaccine (SD-IIV) is recommended for HF, though immune responses may be attenuated. High-dose IIV (HD-IIV) was developed to enhance immunogenicity, but its effectiveness compared with SD-IIV against hospitalization for influenza and CV disease by HF status remains uncertain. </jats:p> <jats:p> <jats:bold>Methods:</jats:bold> This was a prespecified analysis of a pragmatic, prospective, individually randomized, open-label trial with registry-based endpoint-evaluation conducted in Denmark across the 2022/2023 to 2024/2025 influenza seasons. Citizens ≥65 years were randomized 1:1 to HD-IIV or SD-IIV. Outcomes included hospitalization for influenza-related illness, laboratory-confirmed influenza (LCI), any CV disease, cardio-respiratory disease, and HF, assessed by HF status. Effect of HD-IIV vs. SD-IIV in reducing risk of outcomes assessed was expressed as risk ratios (RR). </jats:p> <jats:p> <jats:bold>Results:</jats:bold> The trial randomized 332,438 participants (48.6% female, mean age 73.7±5.8 years), including 10,410 with HF at baseline (27.4% female, mean age 76.0±6.3 years). Overall, HD-IIV was associated with a statistically significant lower incidence of hospitalization for influenza-related illness, LCI, cardio-respiratory disease, CV disease, and HF compared with SD-IIV. In participants with HF, effect estimates were similar: RR for influenza-related hospitalization was 0.48 (95%CI, 0.20-1.06; p <jats:sub>interaction</jats:sub> =0.64), for LCI hospitalization 0.55 (95%CI, 0.29-1.02; p <jats:sub>interaction</jats:sub> =0.59), for cardio-respiratory hospitalization 0.89 (95%CI, 0.77-1.02; p <jats:sub>interaction</jats:sub> =0.34), for CV hospitalization 0.86 (95%CI, 0.72-1.02; p <jats:sub>interaction</jats:sub> =0.34), and for HF hospitalization 0.82 (95%CI, 0.61-1.11; p <jats:sub>interaction</jats:sub> =0.83). Findings were consistent across HF subgroups by disease duration, recency of hospitalization, most recent N-terminal pro-B-type natriuretic peptide, and presence of device therapy. </jats:p> <jats:p> <jats:bold>Conclusions:</jats:bold> In this prespecified exploratory analysis of the largest individually randomized influenza vaccine trial ever conducted, HD-IIV was associated with lower rates of influenza and CV hospitalizations compared with SD-IIV, with effect estimates similar across HF status at baseline and HF subgroups. </jats:p>