Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative.

OBJECTIVE: To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA). DESIGN: We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7. RESULTS: A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics. CONCLUSION: The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial.

OBJECTIVE: To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice. METHOD: Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. PARTICIPANTS: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression. RESULTS: 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3). CONCLUSION: Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months. TRIAL REGISTRATION: ISRCTN06984617.

Effect of a model consultation informed by guidelines on recorded quality of care of osteoarthritis (MOSAICS): a cluster randomised controlled trial in primary care.

OBJECTIVE: To determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice. DESIGN: Two-arm cluster randomised controlled trial. SETTING: Eight general practices in Cheshire, Shropshire, or Staffordshire UK. PARTICIPANTS: General practitioners and nurses with patients consulting with clinical OA. INTERVENTION: Following six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators. OUTCOMES: Quality of OA care over six months recorded in the medical record. RESULTS: 1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4-28%), exercise (4-22%) and weight loss (1-15%) in intervention practices but not controls (1-3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38). CONCLUSIONS: The intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care. TRIAL REGISTRATION NUMBER: ISRCTN06984617.

Impact of ankylosing spondylitis on work in patients across the UK.

OBJECTIVES: To examine the impact of ankylosing spondylitis (AS) on patients across the UK and to identify factors associated with unemployment, absenteeism, and presenteeism. METHODS: One thousand patients with AS from 10 specialist rheumatology centres across the UK were invited to participate in a study evaluating a new outcome measure. Patients completed a questionnaire, which included questions relating to their work, sociodemographic and clinical characteristics. RESULTS: The questionnaire was completed by 612 patients (438 males; 72%). The mean age of the participants was 50.8 (SD 12.2) years, mean disease duration was 17.3 (SD 11.7) years, and mean symptom duration 22.4 (SD 12.4) years. A total of 206 (40%) patients of working age were not employed. Factors associated with not being employed were social deprivation [odds ratio (OR) 3.52, 95% confidence interval (CI) 2.14-5.80], poor function (OR 3.42, 95% CI 1.90-6.13), depression (OR 2.05, 95% CI 1.12-3.78), increasing age (OR 1.05 per year, 95% CI 1.02-1.08), and longer disease duration (OR 1.03 per year, 95% CI 1.01-1.06). Disease activity (OR 3.24, 95% CI 1.11-9.48) and depression (OR 3.22, 95% CI 1.22-8.48) were associated with absenteeism, while depression (OR 5.69, 95% CI 1.77-18.27, disease activity (OR 3.97, 95% CI 1.76-8.98), anxiety (OR 3.90, 95% CI 1.83-8.31), self-efficacy (OR 0.71, 95% CI 0.58-0.86), and increasing age (OR 1.04 per year, 95% CI 1.00-1.08) were associated with presenteeism. CONCLUSION: Psychological, sociodemographic, and disease-related factors were all found to be related to work status. These factors should be taken into account when considering early treatment and management. Depression, in particular, appears to be associated with employment, absenteeism, and presenteeism, and should therefore be prioritized in clinical practice.

Evaluation of a modified arthritis self-efficacy scale for an ankylosing spondylitis UK population.

OBJECTIVES: To evaluate an Ankylosing Spondylitis-specific Arthritis Self-Efficacy Scale (ASES-AS) United Kingdom (UK) secondary care population. METHODS: The ASES-AS is based on the 8-item ASES with minor alterations in phraseology. Patients from ten secondary care rheumatology centres across England were asked to complete a postal questionnaire concerning sociodemographic and clinical characteristics: Bath AS Functional Index (BASFI), Bath AS Disease Activity Index (BASDAI), numerical pain rating scale (NRS), Hospital Anxiety and Depression Scale (HADS), Short Form 36 (SF-36), Evaluation of AS Quality of Life questionnaire (EASi-QoL) and ASES-AS. Respondents received repeat questionnaires at 2 weeks and 6 months including health transition questions assessing change in AS-specific and general health. The ASES-AS was assessed for data quality, reliability, validity, and responsiveness. RESULTS: Response rate was 64% (n=612), 72% (n=438) were male, mean age 50.8yrs (SD 12.2 yrs), mean disease duration 17.3 yrs (SD 11.7 yrs) and mean symptom duration 22.4 yrs (SD 12.4 yrs). Missing data for each item/total score range was 0.7%-3.1%. Item-total correlations range was 0.66 to 0.83. Cronbach's alpha was 0.93 and test-retest reliability (intraclass correlation coefficient) 0.77. A priori hypothesised associations between ASAS-AS and disease status measures were supported. Social variables potentially related to self-efficacy demonstrated evidence of convergent validity (employment p<0.001, educational level p<0.005). A Modified Standard Response Mean (MSRM) of 0.44 and 0.26 in AS-specific and general health respectively at 6 months indicates moderate responsiveness. CONCLUSIONS: ASES-AS has good evidence supporting its application as an AS-specific self-efficacy measure in research including clinical trials at a group level.

Comparison of reliability, construct validity and responsiveness of the IPAQ-SF and PASE in adults with osteoarthritis.

BACKGROUND: This study assessed the measurement properties of two commonly used self-report physical activity (PA) measures: the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and the Physical Activity Scale for the elderly (PASE) in adults with osteoarthritis. METHODS: Secondary analysis of the MOSAICS cluster randomised controlled trial baseline and 3-month follow-up questionnaires, total scores and subdomains of the IPAQ-SF and PASE were compared. Intra-class correlations (ICC) were used to assess test-retest reliability, measurement error was assessed using standard error of measurement (SEM), smallest detectable change (SDC) and 95% limits of agreement (LoA). Responsiveness was assessed using effect size (ES), standard responsive measurement (SRM) and response ratio (RR). RESULTS: There was moderate correlation (r = 0.56) between the total IPAQ-SF scores (score ranges 0-16,398) and the total PASE scores (score ranges 0-400). Subdomain correlations were also moderate (ranges 0.39-0.57). The PASE showed greater reliability compared to the IPAQ-SF (ICC = 0.68; 0.61-0.74 95% CI and ICC = 0.64; 0.55-0.72, respectively). Measurement errors in both measures were large: PASE SEM = 46.7, SDC = 129.6 and 95% LoA ranges = -117 to 136, the IPAQ-SF SEM = 3532.2 METS-1 min-1 week , SDC = 9790.8 and 95% LoA ranges = -5222 to 5597. Responsiveness was poor: ES -0.14 and -0.16, SRM -0.21 and -0.21, and RR 0.12 and 0.09 for the IPAQ-SF and PASE, respectively. DISCUSSION: The IPAQ-SF and PASE appear limited in reliability, measurement error and responsiveness. Researchers and clinicians should be aware of these limitations, particularly when comparing different levels of PA and monitoring PA levels changes over time in those with osteoarthritis.

Moderators of the effects of therapeutic exercise for people with knee and hip osteoarthritis: A systematic review of sub-group analyses from randomised controlled trials.

Objective: 1) To identify potential moderators of the effect of therapeutic exercise explored in randomised controlled trials (RCTs) of knee and hip osteoarthritis (OA); 2) summarise the extent, strength and quality of evidence reported for moderators. Design: Systematic review (PROSPERO CRD42019148074). Inclusion criteria: a) RCTs with sub-group analyses investigating potential moderator variables; b) participants with knee and/or hip OA; c) therapeutic exercise interventions compared to either no exercise control or alternative exercise intervention(s), and; d) measuring pain or physical function outcomes. Included RCTs' risk of bias and sub-group analysis quality were assessed. Data were extracted on sub-group analyses (methods and potential moderators), outcomes (pain and function) and sub-group findings (associated statistics of potential moderator∗intervention effects). Findings were analysed using narrative synthesis. Results: 14 RCTs were included; 13 knee OA RCTs (n = 2743 participants) explored 23 potential moderators and 1 hip OA RCT (n = 203) explored 6 potential moderators. Sub-group analysis quality was mixed. Knee varus malalignment was the only moderator of therapeutic exercise compared to non-exercise control in 1 RCT (WOMAC-pain adjusted difference 12.7 in the neutral alignment sub-group and 1.8 in the malaligned sub-group, interaction term: p = 0.02). Varus thrust, knee laxity/instability, obesity and cardiac problems all moderated the effect of therapeutic exercise on pain or function compared to different comparison exercise. Conclusions: Therapeutic exercise may be effective for reducing pain in people with knee OA and neutral alignment but not for those with varus malalignment. The exercise moderator literature is limited. More robust evidence is required to inform sub-group exercise selection.

Stature loss and recovery following a period of loading: effect of time of day and presence or absence of low back pain.

BACKGROUND: Stature reductions in asymptomatic individuals, caused by a set load, are lower later in the day when stature is in the trough of diurnal variation; hence most stature reduction investigations are conducted in the morning. Recent evidence suggests that it is not the reductions in stature, but the recovery of stature, that is of greatest importance. The aim of this investigation was to establish whether stature recovery is also affected by time of day and to determine if any differences exist between a chronic low back pain and asymptomatic group. METHODS: Eleven chronic low back pain participants (age=32.8 SD 7.9 yrs, mass=74.4 SD 14.2 kg and height=1.73 SD 0.07 m) and 11 asymptomatic participants (age=31.0 SD 6.3 yrs, body mass=72.6 SD 11.5 kg and height=1.76 SD 0.09 m) underwent two 20 min loaded walking tasks (10% body mass), one in the morning (09:00) and one in the afternoon (14:00), followed by a 20 min unloaded recovery period. Measurements of stature were obtained throughout. FINDINGS: The asymptomatic group experienced significantly less stature reduction (P=0.05; ES=1.1) and greater stature recovery (P=0.02; ES=0.9) in the afternoon compared to the morning. The chronic low back pain group experienced a similar pattern to the asymptomatic group, however no significant difference between sessions for changes in stature was evident P=0.07. INTERPRETATION: Further investigations of stature recovery should be restricted to the morning when comparing individuals with and without chronic low back pain, as time of day appeared to have effect on stature recovery, particularly in the asymptomatic group. Time dependent differences in stature change between these two populations warrants further investigation.

The feasibility and acceptability of a physical activity intervention for older people with chronic musculoskeletal pain: The iPOPP pilot trial protocol.

INTRODUCTION: This pilot trial will inform the design and methods of a future full-scale randomized controlled trial (RCT) and examine the feasibility, acceptability and fidelity of the Increasing Physical activity in Older People with chronic Pain (iPOPP) intervention, a healthcare assistant (HCA)-supported intervention to promote walking in older adults with chronic musculoskeletal pain in a primary care setting. METHODS AND ANALYSIS: The iPOPP study is an individually randomized, multicentre, three-parallel-arm pilot RCT. A total of 150 participants aged ≥65 years with chronic pain in one or more index sites will be recruited and randomized using random permuted blocks, stratified by general practice, to: (i) usual care plus written information; (ii) pedometer plus usual care and written information; or (iii) the iPOPP intervention. A theoretically informed mixed-methods approach will be employed using semi-structured interviews, audio recordings of the HCA consultations, self-reported questionnaires, case report forms and objective physical activity data collection (accelerometry). Follow-up will be conducted 12 weeks post-randomization. Collection of the quantitative data and statistical analysis will be performed blinded to treatment allocation, and analysis will be exploratory to inform the design and methods of a future RCT. Analysis of the HCA consultation recordings will focus on the use of a checklist to determine the fidelity of the iPOPP intervention delivery, and the interview data will be analysed using a constant comparison approach in order to generate conceptual themes focused around the acceptability and feasibility of the trial, and then mapped to the Theoretical Domains Framework to understand barriers and facilitators to behaviour change. A triangulation protocol will be used to integrate quantitative and qualitative data and findings.

The influence of different unloading positions upon stature recovery and paraspinal muscle activity.

OBJECTIVE: To determine whether stature recovery and paraspinal muscle activity can be altered in individuals with and without chronic low-back pain by assuming different unloading positions. DESIGN: A case-control study considering the effects of unloading position on stature recovery in individuals with and without chronic low-back pain. BACKGROUND: Stature recovery has been documented to be lower in individuals with chronic low-back pain. Elevated paraspinal muscle activity subjects the spine to increased compression, which may delay stature recovery. However, the mechanism(s) causing prolonged stature recovery are yet to be explored. METHODS: Eleven chronic low-back pain participants (age 33 yr (SD 12.2), height 1.72 m (SD 0.08), body mass 75.9 kg (SD 10.7)) and eleven asymptomatic participants (age 30.5 yr (SD 9.7), height 1.75 m (SD 0.10), body mass 73.3 kg (SD 11.7)) performed a loaded walking task (10% body mass) and adopted four unloading positions on separate occasions. Measurements of stature and muscle activity were recorded during each position. FINDINGS: Individuals with chronic low-back pain exhibited higher paraspinal EMG and delayed stature recovery in all positions (P<0.05). Both groups experienced greatest stature recovery and least muscle activity during gravity inversion (P<0.05). INTERPRETATION: Elevated muscle activity was found in the chronic low-back pain group supporting the existence of this explanation for delayed stature recovery. The gravity inverted position resulted in the lowest EMG and the greatest stature recovery. Further research is required to determine whether improving stature recovery has clinical implications by reducing pain/disability.

Patients with well-established ankylosing spondylitis show limited deterioration in a ten-year prospective cohort study.

This study aims to describe the deterioration of well-established ankylosing spondylitis (AS) over a 10-year period. Patients with well-established AS under secondary care review were assessed at baseline and re-assessed after a 10-year period. Data on patient characteristics, spinal mobility and self-reported health status (AS Quality of Life, Bath AS Disease Activity Index, EuroQoL, Revised Leeds Disability Questionnaire and Short Form-12) were compared between the two time points. One hundred fifty-nine patients took part in the initial assessment. After 10 years, 69/117 patients still under secondary care follow-up attended a second assessment. At the second assessment, this cohort was predominately male (92.8 %), mean age of 48.7 years (SD 9.7) and mean disease and symptom duration of 14.9 (SD 9.0) and 21.9 years (SD 13.3), respectively. Amongst the physical and patient-reported measures, only tragus to wall (p < 0.001), cervical rotation (p = 0.001) and disability (p = 0.02) had significantly deteriorated over time. The percentage of patients who had withdrawn from the workforce before normal retirement age increased from 37 to 53 % over the 10-year period. Many of the measures used in the assessment of AS do not generally deteriorate over time in those with well-established disease. This suggests that deterioration may plateau in established disease. However, AS has a long-term social impact with levels of employment in this cohort 30 % lower than the general population. Interventions directed at preventing deterioration may be more effective earlier in their disease course, before this plateau is reached.

Repeatability of stature measurements in individuals with and without chronic low-back pain.

Measurements of reduction in stature have been used to compare spinal loading in chronic low-back pain (CLBP) and asymptomatic populations. Whether there are any differences in the repeatability of stature measurements, between those with and without CLBP, is not known. This investigation aimed to determine the repeatability of stature measurements in those with (n = 12) and without (n = 12) CLBP, and to establish if the ability to produce repeatable measurements is retained after a specific timeframe. Stature measurements were taken on two separate sessions that were 2 weeks apart, using a stadiometer accurate to 0.01 mm. All participants attained a mean SD of < or = 0.5 mm by the third measurement set taken on the first session of testing and no significant difference in mean SD was found between those with (0.37 mm) and without (0.40 mm) CLBP (p > 0.05). Intraclass correlation coefficients (ICC) demonstrated good levels of repeatability for all stature measurements obtained from the participants and the values for Standard error of the measurement (SEM) improved as the mean SD decreased with each measurement set. Investigators should have confidence in the ability of those with and without CLBP to produce equally repeatable stature measurements with appropriate prior practice. The second session of testing demonstrated that both groups had retained the ability to achieve the desired level of repeatability (SD < or = 0.5 mm) 2 weeks later without further practice.