Implementing good life with osteoArthritis from Denmark (GLA:D®) in Australian public hospitals. Part 2: Service providers' perceptions.

BACKGROUND: Previous literature has reported the successful implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program into predominantly private practice settings. There may be unique challenges present within the public hospital setting that influence GLA:D® implementation in public health. OBJECTIVE: Explore the attitudes and experiences of service providers directly involved in implementing GLA:D® in Australian public tertiary hospitals. DESIGN: Qualitative descriptive study design. METHOD: Service providers (n = 14) from three participating hospitals took part in semi-structured focus groups at the completion of the 6-month implementation period. Inductive thematic analysis was employed to identify primary domains across all facilities. RESULTS: Four broad domains were identified. Factors that influenced uptake included GLA:D® being a recognisable, evidence-based product requiring minimal development or adaptation. The fidelity of the GLA:D® Australia program was challenged by referral of patients with multiple/complex medical comorbidities, and patient preference to complete registry data via paper rather than online. Several operational considerations are required when delivering GLA:D® in a public hospital setting, including adequate numbers of GLA:D®-trained staff, additional screening requirements, obtaining appropriate clinical space, and persisting patient barriers to attending the service. GLA:D® provided benefits beyond improvement in pain and function, including social interactivity, high attendance and promotion of long-term self-management, while also maximising service efficiencies. CONCLUSIONS: Implementing GLA:D® in Australian public hospitals was supported by service providers. Specific operational and administrative factors, including staff training, patient complexity, and registry requirements should be considered when attempting to embed and sustain GLA:D® in large Australian public tertiary hospitals.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in australian public hospitals. Part 1: Feasibility.

BACKGROUND: Literature reporting positive outcomes from the Good Life with osteoArthritis in Denmark (GLA:D®) program in Australia mainly involves patients attending private physiotherapy services. OBJECTIVE: Evaluate the feasibility of implementing GLA:D® in Australian public hospitals. DESIGN: Implementation study in three metropolitan tertiary public hospitals over six months. METHOD: Patients aged ≥18 years with knee or hip joint-related problems deemed appropriate for non-surgical care were invited to participate in GLA:D®. Feasibility was evaluated using RE-AIM framework components (Implementation, Effectiveness, Maintenance) using service-level metrics, patient-level data, and program fidelity assessment. Findings of qualitative interviews with service providers are presented in Part 2. RESULTS: Implementation: 70 patients (69 with knee osteoarthritis) participated (13 cohorts). 55 (79%) patients attended both education sessions, and 49 patients (70%) attended 10-12 exercises sessions. Fidelity was met based on environmental, therapist, participant- and program-related criteria. EFFECTIVENESS: At 3 months, patients reported lower average pain (visual analogue scale [0-100 mm]: effect size -0.56, 95% CI -0.88 to -0.23) and disability (HOOS/KOOS-12 [100-0]: 0.67, 0.28 to 1.05), and improved quality of life (EQ-5D overall score: 0.46, 0.11 to 0.80). No adverse events were reported. All patients who completed 3-month assessment (n = 52) would recommend GLA:D®. Maintenance: All participating services elected to continue delivering GLA:D® beyond the study. CONCLUSIONS: Implementing GLA:D® in Australian public hospitals is feasible, safe, and acceptable to patients with knee osteoarthritis. Public hospital patients with knee osteoarthritis reported improvements in pain, disability, and quality of life similar to previous GLA:D® cohorts.

Recruitment and baseline characteristics of young adults at risk of early-onset knee osteoarthritis after ACL reconstruction in the SUPER-Knee trial.

Objectives: The study aims to (1) report the process of recruiting young adults into a secondary knee osteoarthritis prevention randomised controlled trial (RCT) after anterior cruciate ligament reconstruction (ACLR); (2) determine the number of individuals needed to be screened to include one participant (NNS) and (3) report baseline characteristics of randomised participants. Methods: The SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER)-Knee RCT compares SUPER and minimal intervention for young adults (aged 18-40 years) with ongoing symptoms (ie, mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4)) 9-36 months post-ACLR. The NNS was calculated as the number of prospective participants screened to enrol one person. At baseline, participants provided medical history, completed questionnaires (demographic, injury/surgery, rehabilitation characteristics) and underwent physical examination. Results: 1044 individuals were screened to identify 567 eligible people, from which 184 participants (63% male) enrolled. The sample of enrolled participants was multicultural (29% born outside Australia; 2% Indigenous Australians). The NNS was 5.7. For randomised participants, mean±SD age was 30±6 years. The mean body mass index was 27.3±5.2 kg/m2, with overweight (43%) and obesity (21%) common. Participants were, on average, 2.3 years post-ACLR. Over half completed <8 months of postoperative rehabilitation, with 56% having concurrent injury/surgery to meniscus and/or cartilage. The most affected KOOS (0=worst, 100=best) subscale was quality of life (mean 43.7±19.1). Conclusion: Young adults post-ACLR were willing to participate in a secondary osteoarthritis prevention trial. Sample size calculations should be multiplied by at least 5.7 to provide an estimate of the NNS. The SUPER-Knee cohort is ideally positioned to monitor and intervene in the early development and trajectory of osteoarthritis. Trial registration number: ACTRN12620001164987.

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review.

OBJECTIVE: Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA. METHOD: Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored. RESULTS: We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations. CONCLUSION: There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Injury prevention for women and girls playing Australian Football: programme cocreation, dissemination and early adopter coach feedback.

Background: Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play). Methods: We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women's/girls' teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied. Results: Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1-4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points). Conclusions: Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

Co-development and evaluation of the Musculoskeletal Telehealth Toolkit for physiotherapists.

INTRODUCTION: In-person physiotherapy services are not readily available to all individuals with musculoskeletal conditions, especially those in rural regions or with time-intensive responsibilities. The COVID-19 pandemic highlighted that telehealth may facilitate access to, and continuity of care, yet many physiotherapists lack telehealth confidence and training. This project co-developed and evaluated a web-based professional development toolkit supporting physiotherapists to provide telehealth services for musculoskeletal conditions. METHODS: A mixed-methods exploratory sequential design applied modified experience-based co-design methods (physiotherapists [n = 13], clinic administrators [n = 2], and people with musculoskeletal conditions [n = 7]) to develop an evidence-informed toolkit. Semi-structured workshops were conducted, recorded, transcribed, and thematically analysed, refining the toolkit prototype. Subsequently, the toolkit was promoted via webinars and social media. The usability of the toolkit was examined with pre-post surveys examining changes in confidence, knowledge, and perceived telehealth competence (19 statements modelled from the theoretical domains framework) between toolkit users (>30 min) and non-users (0 min) using chi-squared tests for independence. Website analytics were summarised. RESULTS: Twenty-two participants engaged in co-design workshops. Feedback led to the inclusion of more patient-facing resources, increased assessment-related visual content, streamlined toolkit organisation, and simplified, downloadable infographics. Three hundred and twenty-nine physiotherapists from 21 countries completed the baseline survey, with 172 (52%) completing the 3-month survey. Toolkit users had greater improvement in knowledge, confidence, and competence than non-users in 42% of statements. Seventy-two percentage of toolkit users said it changed their practice, and 95% would recommend the toolkit to colleagues. During the evaluation period, the toolkit received 5486 total views. DISCUSSION: The co-designed web-based Musculoskeletal Telehealth Toolkit is a professional development resource that may increase physiotherapist's confidence, knowledge, and competence in telehealth.

Using SUpported Motivational InTerviewing (SUMIT) to increase physical activity for people with knee osteoarthritis: a pilot, feasibility randomised controlled trial.

OBJECTIVE: The objective of this study was to determine the feasibility and effectiveness of using SUpported Motivational InTerviewing (SUMIT) to increase physical activity in people with knee osteoarthritis (KOA). DESIGN: Randomised controlled trial. SETTING: We recruited people who had completed Good Life with osteoArthritis Denmark (GLA:D) from private, public and community settings in Victoria, Australia. INTERVENTIONS: Participants were randomised participants to receive SUMIT or usual care. SUMIT comprised five motivational interviewing sessions targeting physical activity over 10 weeks, and access to a multimedia web-based platform. PARTICIPANTS: Thirty-two participants were recruited (17 SUMIT, 15 control) including 22 females (69%). OUTCOME MEASURES: Feasibility outcomes included recruitment rate, adherence to motivational interviewing, ActivPAL wear and drop-out rate. Effect sizes (ESs) were calculated for daily steps, stepping time, time with cadence >100 steps per minute, time in bouts >1 min; 6 min walk distance, Knee Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, function, sport and recreation, and quality of life (QoL)), Euroqual, systolic blood pressure, body mass index, waist circumference, 30 s chair stand test and walking speed during 40 m walk test. RESULTS: All feasibility criteria were achieved, with 32/63 eligible participants recruited over seven months; with all participants adhering to all motivational interviewing calls and achieving sufficient ActivPAL wear time, and only two drop-outs (6%).12/15 outcome measures showed at least a small effect (ES>0.2) favouring the SUMIT group, including daily time with cadence >100 steps per minute (ES=0.43). Two outcomes, walking speed (ES= 0.97) and KOOS QoL (ES=0.81), showed a large effect (ES>0.8). CONCLUSION: SUMIT is feasible in people with knee osteoarthritis. Potential benefits included more time spent walking at moderate intensity, faster walking speeds and better QoL. TRIAL REGISTRATION NUMBER: ACTRN12621000267853.

Association of baseline physical activity participation with participant characteristics and outcomes following education and exercise-therapy in people with knee osteoarthritis: A GLA:D® Australia prospective cohort study.

OBJECTIVES: To investigate whether participants with knee osteoarthritis classified as 'more' or 'less' physically active at baseline differ in characteristics and/or outcomes at baseline and at 3 and 12 months following the commencement of an education and exercise-therapy program. METHODS: Prospective cohort study using the GLA:D® Australia registry. The University of California, Los Angeles Physical Activity Scale (UCLA) participant data dichotomised as 'more' (≥7) or 'less' active (≤6). Groups were compared using chi-square (obesity [baseline only], comorbidity prevalence, medication consumption, fear of damage from physical activity); and linear mixed model regression (12-item Injury Osteoarthritis Outcome Score [KOOS-12], pain [visual analogue scale], health-related quality of life [QoL] [EQ-5D-5L]) statistics, adjusted for age, sex and baseline physical activity at 3 and 12 months. RESULTS: We included 1059 participants (70% female). At baseline, 267 (25%) were classified as 'more' active, increasing to 29% and 30% at 3 and 12 months, respectively. At baseline, compared to the 'less' active group, the 'more' active group had a lower proportion of participants who were obese ('more' = 21% vs. 'less' = 44%), had comorbidities (58% vs. 74%) and consumed medications (71% vs. 85%); lower pain intensity (37 vs. 47); and higher KOOS-12 (59 vs. 50), and health-related QoL (0.738 vs. 0.665) scores. When accounting for age, sex and baseline physical activity, improvements seen in knee-related burden and health-related QoL were not different between groups at 3 or 12 months. Compared to the 'less' active group, the proportion of participants not consuming medication remained higher in the 'more' active group at 3 ('more' 45% vs. 'less' 28%) and 12 months (43% vs. 32%). CONCLUSION: 'More' active people with knee osteoarthritis were less likely to be obese, had fewer comorbidities, lower medication consumption, knee-related burden and pain intensity, and higher health-related QoL than 'less' active participants at all timepoints.

Does the one-leg rise test reflect quadriceps strength in individuals following anterior cruciate ligament reconstruction?

OBJECTIVE: To explore if one-leg rise test performance is associated with quadriceps strength following anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional. PARTICIPANTS: 100 individuals (50 females, 50 males) aged 18-40 years, 9-36 months post-ACLR with ongoing knee symptoms (KOOS4 <80/100). MAIN OUTCOME MEASURES: Number of one-leg rise repetitions (using an adjustable-height plinth) and isometric quadriceps strength using isokinetic dynamometry (60° flexion, normalised to body mass). Multivariable fractional polynomial regression models adjusted for sex explored relationships between one-leg rise performance (repetitions) and quadriceps strength (Nm/kg) for each limb. RESULTS: A non-linear, increasing association between one-leg rise performance and quadriceps strength was observed, with the rate of increase attenuating at higher values of one-leg rise performance. Similar relationships were observed in the ACLR (ß = 0.15, 95%CI 0.10 to 0.20; adjusted r2 = 0.51) and contralateral limb (ß = 0.14, 95%CI 0.08 to 0.19; r2 = 0.42). CONCLUSION: The one-leg rise test can be an indicator of quadriceps strength in individuals after ACLR, enabling clinicians to easily monitor quadriceps strength recovery without specialised equipment. With the relationship between one-leg rise performance and quadriceps strength attenuating with a larger number of one-leg rises achieved, other factors (e.g., motivation, endurance) likely contribute to one-leg rise performance at higher values.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines.

OBJECTIVES: Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines. METHODS: Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154). RESULTS: Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty. CONCLUSION: Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Co-design of the web-based 'My Knee' education and self-management toolkit for people with knee osteoarthritis.

Objective: Describe the co-design process and learnings related to developing the web-based Translating Research Evidence and Knowledge (TREK) 'My Knee' education and self-management toolkit for people with knee osteoarthritis. Co-design process: Stage (i): Understand and define; systematically reviewed education interventions in published trials; appraised web-based information about knee osteoarthritis; and used concept mapping to identify education priorities of people with knee osteoarthritis and physiotherapists. Stage (ii): Prototype; created a theory-, guideline- and evidence-informed toolkit. Stage (iii): Test and iterate; completed three co-design workshops with end-users (i.e., people with knee osteoarthritis and health professionals); plus an expert review. Results: The toolkit is available at myknee.trekeducation.org. Stage (i) identified the need for more accurate and co-designed resources to address broad education needs generated during concept mapping, including guidance on surgery, dispelling common misconceptions and facilitating engagement with exercise therapy and weight management. A theory- and research-informed prototype was created in Stage (ii) to address broad learning and education needs. Stage (iii) co-design workshops (n = 15 people with osteoarthritis and n = 9 health professionals) informed further content creation and refinement, alongside improvements to optimise usability. Expert opinion review (n = 8) further refined accuracy and usability. Conclusions: The novel co-design methodology employed to create the TREK 'My Knee' toolkit facilitated the alignment of the content and usability to meet the broad education needs of people with knee osteoarthritis and health professionals. This toolkit aims to improve and facilitate engagement with guideline-recommended first-line care for people with knee osteoarthritis. Future work will determine its effectiveness in improving clinical outcomes in this population.

Self-reported effects of warm seasonal temperatures in persons with spinal cord injury.

OBJECTIVE: Spinal cord injury (SCI) interrupts motor, sensory, and autonomic pathways, impairing mobility and increasing heat storage during warm seasonal temperatures due to compromised autonomic control of vasodilation and sweating and recognition of body temperature. Thus, persons with SCI are more vulnerable to hyperthermia and its adverse effects. However, information regarding how persons with SCI perceive warmer seasons and whether thermal discomfort during warmer seasons restricts routine activities remains anecdotal. DESIGN: Cross-sectional, self-report surveys. SETTING: VA Medical Center and Kessler Institute for Rehabilitation. PARTICIPANTS: Three groups of 50 participants each: tetraplegia, paraplegia, and matched non-SCI controls. OUTCOME MEASURES: Tetraplegia, paraplegia, and control groups responded "yes" or "no" when asked whether warm seasonal temperatures adversely affected comfort or participation in routine activities. RESULTS: The percentage of responses differed among tetraplegia, paraplegia, and control groups when asked if they required ≥20 min to cool down once overheated (44 vs. 20 vs. 12%; X2 = 14.7, P < 0.001), whether heat-related discomfort limited their ability to go outside (62 vs. 34 vs. 32%; X2 = 11.5, P = 0.003), if they needed to use a water-mister because of the heat (70 vs. 44 vs. 42%; X2 = 9.8, P = 0.008), and if heat-related discomfort limited participation in social activities (40 vs. 20 vs. 16%; X2 = 8.7, P = 0.01). CONCLUSION: Warmer seasonal temperatures had a greater negative impact on reported comfort and daily activities of persons with SCI than non-SCI controls. Those with tetraplegia were most adversely affected. Our findings warrant increasing awareness and identifying interventions to address the vulnerability of persons with SCI to hyperthermia.

Evidence for key individual characteristics associated with outcomes following combined first-line interventions for knee osteoarthritis: A systematic review.

OBJECTIVE: To identify individual characteristics associated with outcomes following combined first-line interventions for knee osteoarthritis. METHODS: MEDLINE, CINAHL, Scopus, Web of Science Core Collection and the Cochrane library were searched. Studies were included if they reported an association between baseline factors and change in pain or function following combined exercise therapy, osteoarthritis education, or weight management interventions for knee osteoarthritis. Risk of bias was assessed using Quality in Prognostic Factor Studies. Data was visualised and a narrative synthesis was conducted for key factors (age, sex, BMI, comorbidity, depression, and imaging severity). RESULTS: 32 studies were included. Being female compared to male was associated with 2-3 times the odds of a positive response. Older age was associated with reduced odds of a positive response. The effect size (less than 10% reduction) is unlikely to be clinically relevant. It was difficult to conclude whether BMI, comorbidity, depression and imaging severity were associated with pain and function outcomes following a combined first-line intervention for knee osteoarthritis. Low to very low certainty evidence was found for sex, BMI, depression, comorbidity and imaging severity and moderate certainty evidence for age. Varying study methods contributed to some difficulty in drawing clear conclusions. CONCLUSIONS: This systematic review found no clear evidence to suggest factors such as age, sex, BMI, OA severity and presence of depression or comorbidities are associated with the response to first-line interventions for knee OA. Current evidence indicates that some groups of people may respond equally to first-line interventions, such as those with or without comorbidities. First-line interventions consisting of exercise therapy, education, and weight loss for people with knee OA should be recommended irrespective of sex, age, obesity, comorbidity, depression and imaging findings.

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia: A mixed-methods program evaluation.

INTRODUCTION: We aimed to evaluate the implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia using Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation framework. METHODS: Using a convergent mixed-methods design, semi-structured one-on-one interviews with physiotherapist adopters and nonadopters of GLA:D® via telehealth were analyzed thematically alongside the examination of registry data (1 March 2020-10 February 2022) from patients with hip or knee osteoarthritis completing GLA:D® via telehealth (telehealth-only) or combined with in-person care (hybrid). Effectiveness was determined as changes from baseline to 3-month follow-up (mean differences, 95% confidence intervals, effect size) for Knee injury and Osteoarthritis Outcome Score (KOOS-12)/Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12), and chair stand test. Group- and individual-level changes were compared to published minimally clinically important change scores. RESULTS: Twenty-three interviews (12 adopters, 11 nonadopters) found key barriers/facilitators to reach and adoption, high perceived effectiveness, and strategies to support sustainability. Of 2612 registered patients, 85 (3%) and 115 (4%) completed GLA:D® via telehealth-only or hybrid model, respectively. Most effectiveness outcomes were associated with moderate-large improvements. Group-level changes exceeded minimally clinically important change values for KOOS/HOOS-quality of life and chair stand test. Nearly two out of three patients reached a minimally clinically important change for KOOS/HOOS-quality of life. With telehealth-only and hybrid delivery, 99% (n = 82) and 85% (n = 97) were satisfied/very satisfied. Physiotherapist adoption was limited (n = 128, 6%). DISCUSSION: GLA:D® delivered via telehealth is effective, had high patient satisfaction, and was perceived positively by physiotherapist adopters. Addressing low reach and adoption requires further implementation strategies to facilitate greater telehealth opportunities for patients and physiotherapists.

Trajectory of knee health in runners with and without heightened osteoarthritis risk: the TRAIL prospective cohort study protocol.

INTRODUCTION: Running is one of the most popular recreational activities worldwide, due to its low cost and accessibility. However, little is known about the impact of running on knee joint health in runners with and without a history of knee surgery. The primary aim of this longitudinal cohort study is to compare knee joint structural features on MRI and knee symptoms at baseline and 4-year follow-up in runners with and without a history of knee surgery. Secondary aims are to explore the relationships between training load exposures (volume and/or intensity) and changes in knee joint structure and symptoms over 4 years; explore the relationship between baseline running biomechanics, and changes in knee joint structure and symptoms over 4 years. In addition, we will explore whether additional variables confound, modify or mediate these associations, including sex, baseline lower-limb functional performance, knee muscle strength, psychological and sociodemographic factors. METHODS AND ANALYSIS: A convenience sample of at least 200 runners (sex/gender balanced) with (n=100) and without (n=100) a history of knee surgery will be recruited. Primary outcomes will be knee joint health (MRI) and knee symptoms (baseline; 4 years). Exposure variables for secondary outcomes include training load exposure, obtained daily throughout the study from wearable devices and three-dimensional running biomechanics (baseline). Additional variables include lower limb functional performance, knee extensor and flexor muscle strength, biomarkers, psychological and sociodemographic factors (baseline). Knowledge and beliefs about osteoarthritis will be obtained through predefined questions and semi-structured interviews with a subset of participants. Multivariable logistic and linear regression models, adjusting for potential confounding factors, will explore changes in knee joint structural features and symptoms, and the influence of potential modifiers and mediators. ETHICS AND DISSEMINATION: Approved by the La Trobe University Ethics Committee (HEC-19524). Findings will be disseminated to stakeholders, peer-review journals and conferences.

SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) versus minimal intervention for young adults at risk of knee osteoarthritis after ACL reconstruction: SUPER-Knee randomised controlled trial protocol.

INTRODUCTION: Anterior cruciate ligament injury and reconstruction (ACLR) is often associated with pain, functional loss, poor quality of life and accelerated knee osteoarthritis development. The effectiveness of interventions to enhance outcomes for those at high risk of early-onset osteoarthritis is unknown. This study will investigate if SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) is superior to a minimal intervention control for improving pain, function and quality of life in young adults with ongoing symptoms following ACLR. METHODS AND ANALYSIS: The SUPER-Knee Study is a parallel-group, assessor-blinded, randomised controlled trial. Following baseline assessment, 184 participants aged 18-40 years and 9-36 months post-ACLR with ongoing symptoms will be randomly allocated to one of two treatment groups (1:1 ratio). Ongoing symptoms will be defined as a mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sports and recreational activities and knee-related quality of life. Participants randomised to SUPER will receive a 4-month individualised, physiotherapist-supervised strengthening and neuromuscular programme with education. Participants randomised to minimal intervention (ie, control group) will receive a printed best-practice guide for completing neuromuscular and strengthening exercises following ACLR. The primary outcome will be change in the KOOS4 from baseline to 4 months with a secondary endpoint at 12 months. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, kinesiophobia, physical activity, thigh muscle strength, knee function and knee cartilage morphology (ie, lesions, thickness) and composition (T2 mapping) on MRI. Blinded intention-to-treat analyses will be performed. Findings will also inform cost-effectiveness analyses. ETHICS AND DISSEMINATION: This study is approved by the La Trobe University and Alfred Hospital Ethics Committees. Results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER: ACTRN12620001164987.

Kinematic and Kinetic Gait Characteristics in People with Patellofemoral Pain: A Systematic Review and Meta-analysis.

BACKGROUND: Patellofemoral pain (PFP) is a prevalent knee condition with many proposed biomechanically orientated etiological factors and treatments. OBJECTIVE: We aimed to systematically review and synthesize the evidence for biomechanical variables (spatiotemporal, kinematic, kinetic) during walking and running in people with PFP compared with pain-free controls, and determine if biomechanical variables contribute to the development of PFP. DESIGN: Systematic review and meta-analysis. DATA SOURCES: We searched Medline, CINAHL, SPORTDiscus, Embase, and Web of Science from inception to October 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: All study designs (prospective, case-control [± interventional component, provided pre-intervention data were reported for both groups], cross-sectional) comparing spatiotemporal, kinematic, and/or kinetic variables during walking and/or running between people with and without PFP. RESULTS: We identified 55 studies involving 1300 people with PFP and 1393 pain-free controls. Overall pooled analysis identified that people with PFP had slower gait velocity [moderate evidence, standardized mean difference (SMD) - 0.50, 95% confidence interval (CI) - 0.72, - 0.27], lower cadence (limited evidence, SMD - 0.43, 95% CI - 0.74, - 0.12), and shorter stride length (limited evidence, SMD - 0.46, 95% CI - 0.80, - 0.12). People with PFP also had greater peak contralateral pelvic drop (moderate evidence, SMD - 0.46, 95% CI - 0.90, - 0.03), smaller peak knee flexion angles (moderate evidence, SMD - 0.30, 95% CI - 0.52, - 0.08), and smaller peak knee extension moments (limited evidence, SMD - 0.41, 95% CI - 0.75, - 0.07) compared with controls. Females with PFP had greater peak hip flexion (moderate evidence, SMD 0.83, 95% CI 0.30, 1.36) and rearfoot eversion (limited evidence, SMD 0.59, 95% CI 0.03, 1.14) angles compared to pain-free females. No significant between-group differences were identified for all other biomechanical variables. Data pooling was not possible for prospective studies. CONCLUSION: A limited number of biomechanical differences exist when comparing people with and without PFP, mostly characterized by small-to-moderate effect sizes. People with PFP ambulate slower, with lower cadence and a shortened stride length, greater contralateral pelvic drop, and lower knee flexion angles and knee extension moments. It is unclear whether these features are present prior to PFP onset or occur as pain-compensatory movement strategies given the lack of prospective data. TRIAL REGISTRATION: PROSPERO # CRD42019080241.

Are Physical Function and Fear of Movement Risk Factors for Patellofemoral Pain? A 2-Year Prospective Study.

CONTEXT: To determine (1) whether physical function and fear of movement are prospectively associated with the risk of females developing patellofemoral pain (PFP) and (2) whether they change following development of PFP. DESIGN: Prospective observational study. METHODS: A total of 114 asymptomatic females (18-22 y old) completed assessment of physical function (forward step-down test and single-leg hop for distance) and fear of movement using the Tampa Scale for Kinesiophobia at baseline and 2-year follow-up. Presence of symptoms of PFP was monitored bimonthly. RESULTS: Ninety participants (retention rate = 79%) completed the 2-year follow-up assessment, with 27 (24% of the cohort) developing PFP. Physical function, including forward step-down test (P = .659) and single-leg hop for distance (P = .825), and fear of movement (P = .479) were not associated with the risk of developing PFP. Females who developed PFP presented with reduced forward step-down repetitions (mean difference = 2.8; 95% confidence interval, 0.2 to 5.3) and single-leg hop for distance (10.2; 95% confidence interval, 2.7 to 17.7 cm) at 2-year follow-up. There was no statistically significant difference between those who did and did not develop PFP for fear of movement (-3.4; 95% confidence interval, -7.0 to 0.2). CONCLUSIONS: Physical function and fear of movement were not associated with the risk of developing PFP in young females. However, the change over time in the step-down and single-leg hop for distance tests may suggest that, even in the early stages of PFP, young females present impaired physical function compared with females who did not develop symptoms. Fear of movement may develop due to persistent PFP, and does not appear to be a risk factor or key feature in females with PFP of short symptoms duration.

Comprehensiveness, accuracy, quality, credibility and readability of online information about knee osteoarthritis.

BACKGROUND: People are increasingly using the Internet to retrieve health information about chronic musculoskeletal conditions, yet content can be inaccurate and of variable quality. OBJECTIVE: To summarise (i) comprehensiveness, (ii) accuracy and clarity, iii) quality of information about treatment choices, (iv) credibility and (v) readability of online information about knee osteoarthritis. METHOD: Systematic appraisal of website content. Searches for "knee osteoarthritis" and "knee arthritis" were performed using Google and Bing (October 2020). The top 20 URLs of each search were screened for eligibility. Comprehensiveness, accuracy and clarity of content were matched against 14 pre-defined topic descriptors. DISCERN and HONcode were used to measure quality of information about treatment choices and website credibility, respectively. Flesch Reading Ease and Flesch-Kincaid Grade Level tests were used to assess readability. RESULTS: Thirty-five websites were included. Websites were generally comprehensive (median, range = 12, 0-14/14) with descriptors available for 67% (n = 330/490) of topics across all websites, but only 35% (n = 116/330) were accurate and clear. Quality of information about treatment choices was generally low (median DISCERN score, range = 40, 16-56/80). Credibility descriptors were present for 65% (n = 181/280) of items, with 81% (n = 146/181) of descriptors being clear. Median Flesch reading ease was 53 (range = 21-74), and Flesch-Kincaid grade level was 8 (range = 5-11). CONCLUSION: Few websites provide accurate and clear content aligned to key research evidence. Quality of information about treatment choices was poor, with large variation in comprehensiveness, credibility and readability. IMPLICATIONS: Careful consideration is required by clinicians to identify what online information people with knee osteoarthritis have accessed and to address misinformed beliefs.

A survey of patient and medical professional perspectives on implementing osteoarthritis management programs for hip and knee osteoarthritis.

BACKGROUND: Strategies are needed to improve referral into, and uptake of, osteoarthritis (OA) management programs. This survey investigated and compared patients' and medical professionals' views around hip and knee OA management and factors impacting implementation of an osteoarthritis management program. METHODS: As part of a mixed-methods program of research, patients with hip or knee OA and medical professionals routinely involved in the management of OA, were invited to complete a comprehensive online survey. All data were analysed descriptively or using chi squared tests. Survey findings for factors perceived to impact implementation of an OA management programme were triangulated with previously reported qualitative data. RESULTS: Fifty-three patients (38 females, 15 males) and 32 medical professionals (orthopaedic surgeons, sports physicians, rehabilitation physicians, rheumatologists and general practitioners) completed the survey. Twenty-eight patients (53%) had prior participation in the OA management programme (GLA:D® ) and 19 medical professionals (59%) had previously referred patients to the programme. Of the participants with prior exposure, 21 patients (75%) and 15 medical professionals (79%) agreed the programme was beneficial. A higher proportion of medical professionals, compared to patients, believed weight loss (100% vs. 67%), injection therapy (50% vs. 21%), hip replacement (100% vs. 62%) and knee replacement (97% vs. 62%) were effective treatments, with no differences for all other treatments. The barriers and enablers identified for referral into, and participation in, an OA management programme mostly aligned to factors identified in previous related qualitative research. Divergent factors in the survey included patients concerns about doing exercise-therapy with 81% (higher than expected) not reporting any concerns about exercising, and 19% (lower than expected) concerned about their OA joint, such as making their pain worse. CONCLUSIONS: This study has extended our understanding of barriers and enablers for referral into, and participation in, an OA management programme with a lower than expected number of patients being concerned about exercising due to their OA joint. Patients and medical professionals had positive views relating to the quality of the programme delivery, patient satisfaction and programme effectiveness. Medical professionals were more likely than patients to consider weight loss, injections and joint replacement as effective treatment options.