Effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program for hip osteoarthritis - protocol for the Better Hip randomised controlled trial.

BACKGROUND: Hip osteoarthritis (OA) is a leading cause of chronic pain and disability worldwide. Self-management is vital with education, exercise and weight loss core recommended treatments. However, evidence-practice gaps exist, and service models that increase patient accessibility to clinicians who can support lifestyle management are needed. The primary aim of this study is to determine the effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program (Better Hip) on the primary outcomes of hip pain on walking and physical function at 6 months, compared with an information-only control for people with hip OA. METHODS: A two-arm, parallel-design, superiority pragmatic randomised controlled trial. 212 members from a health insurance fund aged 45 years and over, with painful hip OA will be recruited. Participants will be randomly allocated to receive: i) Better Hip; or ii) web-based information only (control). Participants randomised to the Better Hip program will have six videoconferencing physiotherapist consultations for education about OA, prescription of individualised home-based strengthening and physical activity programs, behaviour change support, and facilitation of other self-management strategies. Those with a body mass index > 27 kg/m2, aged < 80 years and no specific health conditions, will also be offered six videoconferencing dietitian consultations to undertake a weight loss program. Participants in the control group will be provided with similar educational information about managing hip OA via a custom website. All participants will be reassessed at 6 and 12 months. Primary outcomes are hip pain on walking and physical function. Secondary outcomes include measures of pain; hip function; weight; health-related quality of life; physical activity levels; global change in hip problem; willingness to undergo hip replacement surgery; rates of hip replacement; and use of oral pain medications. A health economic evaluation at 12 months will be conducted and reported separately. DISCUSSION: Findings will determine whether a telehealth-delivered clinician-supported lifestyle management program including education, exercise/physical activity and, for those with overweight or obesity, weight loss, is more effective than information only in people with hip OA. Results will inform the implementation of such programs to increase access to core recommended treatments. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ACTRN12622000461796).

Effects of Hip Pain Diagnostic Labels and Their Explanations on Beliefs About Hip Pain and How to Manage It: An Online Randomized Controlled Trial.

OBJECTIVES: To compare the effects of diagnostic labels and their explanations on people's beliefs about managing hip pain. DESIGN: Online randomized controlled trial involving 626 participants. METHODS: Participants aged ≥45 years with and without hip pain considered a hypothetical scenario (initial doctor consultation for hip pain). They were randomized to receive a diagnostic label and explanation of (1) hip osteoarthritis, (2) persistent hip pain, or (3) hip degeneration. Primary outcomes were the beliefs (1) exercise would damage the hip and (2) surgery is necessary at some stage (scales, 0 = definitely would not/unnecessary, 10 = definitely would/necessary). Secondary outcomes included beliefs about other treatments and care providers. RESULTS: Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain believed exercise was less damaging (mean difference -1.3 [95% CI: -1.9, -0.7] and -1.8 [-2.3, -1.2], respectively) and surgery less necessary (-1.5 [-2.1, -1.0] and -2.2 [-2.7, -1.6], respectively). Compared to hip osteoarthritis, participants who were allocated to persistent hip pain believed surgery was less necessary (-0.7 [-1.2, -0.1]), but not that exercise was less damaging (-0.5 [-1.1, 0.1]). Compared to hip degeneration, participants who were allocated to hip osteoarthritis and persistent hip pain were less concerned about their hip and believed exercise and care from an exercise and sports physician, rheumatologist, or physiotherapist would be more helpful, and care from an orthopaedic surgeon less helpful. CONCLUSIONS: People who were allocated a diagnostic label and explanation of hip osteoarthritis or persistent hip pain believed exercise was less damaging and surgery less necessary for a hip problem than hip degeneration. J Orthop Sports Phys Ther 2023;53(11):673-684. Epub 5 October 2023. doi:10.2519/jospt.2023.11984.

How Does Exercise, With and Without Diet, Improve Pain and Function in Knee Osteoarthritis? A Secondary Analysis of a Randomized Controlled Trial Exploring Potential Mediators of Effects.

OBJECTIVE: To explore the mediators of effects of two 6-month telehealth-delivered exercise programs, including exercise with and without weight-loss diet, on pain and function improvements in knee osteoarthritis (OA). METHODS: Secondary analysis of 345 participants from a 3-arm randomized controlled trial of exercise (Exercise program) and exercise plus diet (Diet + Exercise program) versus information (Control program) was conducted. Outcomes were changes in pain (11-point numeric rating scale) and function (Western Ontario and McMaster Universities Osteoarthritis Index [score range 0-68]) at 12 months. Potential mediators were change at 6 months in attitudes toward self-management, fear of movement, arthritis self-efficacy, weight, physical activity, and willingness for knee surgery. For the Diet + Exercise program versus the Exercise program, only change in weight was evaluated. RESULTS: Possible mediators of the Exercise program versus the Control program included reduced fear of movement (accounting for -1.11 units [95% confidence interval (95% CI) -2.15, -0.07] improvement in function) and increased arthritis self-efficacy (-0.40 units [95% CI -0.75, -0.06] reduction in pain, -1.66 units [95% CI -3.04, -0.28] improvement in function). The Diet + Exercise program versus the Control program mediators included reduced fear of movement (-1.13 units [95% CI -2.17, -0.08] improvement in function), increased arthritis self-efficacy (-0.77 units [95% CI -1.26, -0.28] reduction in pain, -5.15 units [95% CI -7.34, -2.96] improvement in function), and weight loss (-1.20 units [95% CI -1.73, -0.68] reduction in pain, -5.79 units [95% CI -7.96, -3.63] improvement in function). Weight loss mediated the Diet + Exercise program versus the Exercise program (-0.89 units [95% CI -1.31, -0.47] reduction in pain, -4.02 units [95% CI -5.77, -2.26] improvement in function). CONCLUSION: Increased arthritis self-efficacy, reduced fear of movement, and weight loss may partially mediate telehealth-delivered exercise program effects, with and without diet, on pain and/or function in knee OA. Weight loss may partially mediate the effect of diet and exercise compared to exercise alone.

Effect of Information Content and General Practitioner Recommendation to Exercise on Treatment Beliefs and Intentions for Knee Osteoarthritis: An Online Multi-Arm Randomized Controlled Trial.

OBJECTIVE: To evaluate effects of general osteoarthritis (OA) information in addition to a treatment option grid and general practitioner (GP) recommendation to exercise on treatment beliefs and intentions. METHODS: An online randomized trial of 735 people 45 years old or older without OA who were recruited from a consumer survey network. Participants read a hypothetical scenario about visiting their GP for knee problems and were randomized to the following: i) 'general information', ii) 'option grid' (general information plus option grid), or iii) 'option grid plus recommendation' (general information plus option grid plus GP exercise recommendation). The primary outcome was an agreement that exercise is the best management option (0-10 numeric rating scale; higher scores indicating higher agreement that exercise is best). The secondary outcomes were beliefs about other management options and management intentions. Linear regression models estimated the mean (95% confidence interval [CI]) between-group difference in postintervention scores, adjusted for baseline. RESULTS: Option grid plus recommendation led to higher agreement that exercise is the best management by a mean of 0.4 units (95% CI: 0.1-0.6) compared with general information. There were no other between-group differences for the primary outcome. Option grid led to higher agreement that surgery was best, and x-rays were necessary, compared with general information (mean between-group differences: 0.7 [CI: 0.2-1.1] and 0.5 [CI: 0.1-1.0], respectively) and option grid plus recommendation (0.5 [CI: 0.1-0.9] and 0.9 [CI: 0.4-1.3]). CONCLUSION: Addition of an option grid and GP exercise recommendation to general OA information led to more favorable views that exercise was best for the hypothetical knee problem. However, differences were small and of unclear clinical importance.

Removing Pathoanatomical Content From Information Pamphlets About Knee Osteoarthritis Did Not Affect Beliefs About Imaging or Surgery, but Led to Lower Perceptions That Exercise Is Damaging and Better Osteoarthritis Knowledge: An Online Randomised Controlled Trial.

OBJECTIVE: Compare the effects of osteoarthritis information, with or without pathoanatomical content, on people's beliefs about managing osteoarthritis. DESIGN: Online randomized controlled trial involving 556 participants. METHODS: Participants considered a hypothetical scenario where their doctor informed them that they had knee osteoarthritis. Participants were randomized to a control condition, where they received currently available osteoarthritis information with pathoanatomical content or an experimental condition, where they received the same osteoarthritis information but without pathoanatomical content. Primary outcomes were participants' beliefs about the need for x-ray to confirm diagnosis and joint replacement surgery in the future. RESULTS: There were no between-group differences in primary outcomes for x-ray (mean difference [MD], -0.3; 95% confidence interval [CI]: -0.9, 0.4) and surgery (MD, -0.2; 95% CI: -0.7, 0.2), each rated on an 11-point numeric rating scale. Participants in the experimental group had lower perceptions that exercise would damage the knee (MD, -0.4; 95% CI: -0.8, 0.0; rated on an 11-point numeric rating scale) and better osteoarthritis knowledge (MD, 0.9; 95% CI: 0.0, 1.9; rated on a scale ranging from 11 to 55). Among those without tertiary education, participants in the experimental group had lower perceptions that x-ray was necessary than control (MD, -0.8; 95% CI: -1.5, -0.1). Among those who had never sought care for knee pain, participants in the experimental group had lower perceptions about the need for surgery (MD, -0.7; 95% CI: -1.2, -0.2). CONCLUSIONS: Removing pathoanatomical content may not change beliefs about imaging and surgery but may lead to lower perceptions that exercise is damaging and may improve osteoarthritis knowledge. However, effects were small and of unclear clinical relevance. Tertiary education or a history of care seeking for knee pain may moderate effects on primary outcomes. J Orthop Sports Phys Ther 2023;53(4):1-15. Epub: 12 December 2022. doi:10.2519/jospt.2022.11618.

Comparing Video-Based, Telehealth-Delivered Exercise and Weight Loss Programs With Online Education on Outcomes of Knee Osteoarthritis : A Randomized Trial.

BACKGROUND: Scalable knee osteoarthritis programs are needed to deliver recommended education, exercise, and weight loss interventions. OBJECTIVE: To evaluate two 6-month, telehealth-delivered exercise programs, 1 with and 1 without dietary intervention. DESIGN: 3-group, parallel randomized (5:5:2) trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000930280). SETTING: Australian private health insurance members. PARTICIPANTS: 415 persons with symptomatic knee osteoarthritis and a body mass index between 28 and 40 kg/m2 who were aged 45 to 80 years. INTERVENTION: All groups received access to electronic osteoarthritis information (control). The exercise program comprised 6 physiotherapist consultations via videoconference for exercise, self-management advice, and behavioral counseling, plus exercise equipment and resources. The diet and exercise program included an additional 6 dietitian consultations for a ketogenic very-low-calorie diet (2 formulated meal replacements and a low-carbohydrate meal daily) followed by a transition to healthy eating, as well as nutrition and behavioral resources. MEASUREMENTS: Primary outcomes were changes in knee pain (numerical rating scale [NRS] of 0 to 10, higher indicating worse) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; scale, 0 to 68, higher indicating worse) at 6 months (primary time point) and 12 months. Secondary outcomes were weight, physical activity, quality of life, mental health, global change, satisfaction, willingness to have surgery, orthopedic appointments, and knee surgery. RESULTS: A total of 379 participants (91%) provided 6-month primary outcomes, and 372 (90%) provided 12-month primary outcomes. At 6 months, both programs were superior to control for pain (between-group mean difference in change on NRS: diet and exercise, -1.5 [95% CI, -2.1 to -0.8]; exercise, -0.8 [CI, -1.5 to -0.2]) and function (between-group mean difference in change on WOMAC: diet and exercise, -9.8 [CI, -12.5 to -7.0]; exercise, -7.0 [CI, -9.7 to -4.2]). The diet and exercise program was superior to exercise (pain, -0.6 [CI, -1.1 to -0.2]; function, -2.8 [CI, -4.7 to -0.8]). Findings were similar at 12 months. LIMITATION: Participants and clinicians were unblinded. CONCLUSION: Telehealth-delivered exercise and diet programs improved pain and function in people with knee osteoarthritis and overweight or obesity. A dietary intervention conferred modest additional pain and function benefits over exercise. PRIMARY FUNDING SOURCE: Medibank, the Medibank Better Health Foundation Research Fund, and a National Health and Medical Research Council Centre of Research Excellence.

Patient experiences with physiotherapy for knee osteoarthritis in Australia-a qualitative study.

OBJECTIVE: Physiotherapists commonly provide non-surgical care for people with knee osteoarthritis (OA). It is unknown if patients are receiving high-quality physiotherapy care for their knee OA. This study aimed to explore the experiences of people who had recently received physiotherapy care for their knee OA in Australia and how these experiences aligned with the national Clinical Care Standard for knee OA. DESIGN: Qualitative study using semistructured individual telephone interviews and thematic analysis, where themes/subthemes were inductively derived. Questions were informed by seven quality statements of the OA of the Knee Clinical Care Standard. Interview data were also deductively analysed according to the Standard. SETTING: Participants were recruited from around Australia via Facebook and our research volunteer database. PARTICIPANTS: Interviews were conducted with 24 people with recent experience receiving physiotherapy care for their knee OA. They were required to be aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee. RESULTS: Six themes emerged: (1) presented with a pre-existing OA diagnosis (prior OA care from other health professionals; perception of adequate OA knowledge); (2) wide variation in access and provision of physiotherapy care (referral pathways; funding models; individual vs group sessions); (3) seeking physiotherapy care for pain and functional limitations (knee symptoms; functional problems); (4) physiotherapy management focused on function and exercise (assessment of function; various types of exercises prescribed; surgery, medications and injections are for doctors; adjunctive treatments); (5) professional and personalised care (trust and/or confidence; personalised care) and (6) physiotherapy to postpone or prepare for surgery. CONCLUSION: Patients' experiences with receiving physiotherapy care for their knee OA were partly aligned with the standard, particularly regarding comprehensive assessment, self-management, and exercise.

Physiotherapists may improve management of knee osteoarthritis through greater psychosocial focus, being proactive with advice, and offering longer-term reviews: a qualitative study.

QUESTIONS: What are the experiences of physiotherapists delivering care for people with knee osteoarthritis? How do these experiences align with the national Clinical Care Standard? DESIGN: A qualitative study using individual interviews. PARTICIPANTS: Twenty-two Australian physiotherapists (mean age 34 years, 50% female) with experience in providing care for people with knee osteoarthritis. METHODS: Physiotherapists participated in semi-structured individual telephone interviews. Questions were informed by seven quality statements from the national Knee Osteoarthritis Clinical Care Standard. Thematic analysis was undertaken, with themes/subthemes inductively derived. Interview data were also deductively analysed according to the Clinical Care Standard. RESULTS: Five themes emerged. First, physiotherapists focused on biomedical assessment with little psychosocial consideration. They managed 'mechanical' aspects of knee osteoarthritis, aiming to restore functional ability. Second, physiotherapists' perceived their role as primarily providing goal-orientated personalised exercise via short-term episodic care. Knee surgery was considered a last option, but physiotherapists 'prepped' patients who decided on surgery. Third, clinical challenges included patient comorbidity, unsatisfactory patient adherence and a patient's desire for a 'quick fix'. The other two themes were: physiotherapists described a mismatch between what they know and what they do regarding imaging, weight management and manual therapy; and physiotherapists viewed weight loss, medication and surgical advice as outside of their professional role. CONCLUSION: Physiotherapists' reported experiences of delivering care for people with knee osteoarthritis were mostly consistent with the quality care standard. Care may be improved by increasing the focus on psychosocial aspects of care, offering longer-term reviews, and being more proactive with advice and/or referral regarding weight loss, pain medications and knee surgery. By describing the potential benefits and harms of common osteoarthritis medications and surgical interventions, physiotherapists will ensure that their patients are fully informed about all their treatment options.

Better Knee, Better Me™: effectiveness of two scalable health care interventions supporting self-management for knee osteoarthritis - protocol for a randomized controlled trial.

BACKGROUND: Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese. METHODS: Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m2 and < 41 kg/m2 and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed. DISCUSSION: This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).