EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update.

INTRODUCTION: Hip and knee osteoarthritis (OA) are increasingly common with a significant impact on individuals and society. Non-pharmacological treatments are considered essential to reduce pain and improve function and quality of life. EULAR recommendations for the non-pharmacological core management of hip and knee OA were published in 2013. Given the large number of subsequent studies, an update is needed. METHODS: The Standardised Operating Procedures for EULAR recommendations were followed. A multidisciplinary Task Force with 25 members representing 14 European countries was established. The Task Force agreed on an updated search strategy of 11 research questions. The systematic literature review encompassed dates from 1 January 2012 to 27 May 2022. Retrieved evidence was discussed, updated recommendations were formulated, and research and educational agendas were developed. RESULTS: The revised recommendations include two overarching principles and eight evidence-based recommendations including (1) an individualised, multicomponent management plan; (2) information, education and self-management; (3) exercise with adequate tailoring of dosage and progression; (4) mode of exercise delivery; (5) maintenance of healthy weight and weight loss; (6) footwear, walking aids and assistive devices; (7) work-related advice and (8) behaviour change techniques to improve lifestyle. The mean level of agreement on the recommendations ranged between 9.2 and 9.8 (0-10 scale, 10=total agreement). The research agenda highlighted areas related to these interventions including adherence, uptake and impact on work. CONCLUSIONS: The 2023 updated recommendations were formulated based on research evidence and expert opinion to guide the optimal management of hip and knee OA.

How do family members experience drug death bereavement? A systematic review of the literature.

Despite high rates of drug-related deaths (DRDs), drug-related bereavement has been sparsely investigated. A systematic literature search for qualitative and quantitative studies was conducted. Studies on bereaved DRD family members and systems influencing bereavement were eligible for inclusion. Eight studies were included. Three themes emerged from the thematic analysis (Emotional Roller Coaster, Lack of Understanding by the Social World, and Meaning Making) describing an emotional and existential overload, stigmatization and lack of understanding and help from support systems. The results also shed light on life after the loss. Directions for further research were subsequently outlined.

Effect of blood-flow restricted vs heavy-load strength training on muscle strength: Systematic review and meta-analysis.

INTRODUCTION: Heavy-load strength training (HLT) is generally considered the Gold Standard exercise modality for inducing gains in skeletal muscle strength. However, use of heavy external exercise loads may be contraindicative in frail individuals. Low-load resistance exercise combined with partial blood-flow restriction (LL-BFR exercise) may offer an effective alternative for increasing mechanical muscle strength and size. The aim of this study was to compare the effect of LL-BFR training to HLT on maximal muscle strength gains. Prospero registration-id (CRD42014013382). MATERIALS AND METHODS: A systematic search in six healthcare science databases and reference lists was conducted. Data selected for primary analysis consisted of post-intervention changes in maximal muscle strength. A random-effects meta-analysis with standardized mean differences (SMD) was used. RESULTS: Of 1413 papers identified through systematic search routines, sixteen papers fulfilled the inclusion criteria, totalling 153 participants completing HLT and 157 completing LL-BFR training. The magnitude of training-induced gains in maximal muscle strength did not differ between LL-BFR training and HLT (SMD of -0.17 (95% CI: -0.40; 0.05)). Low between-study heterogeneity was noted (I2  = 0.0%, Chi2 P = 9.65). CONCLUSION: Low-load blood-flow-restricted training appears equally effective of producing gains in maximal voluntary muscle strength compared to HLT in 20- to 80-year-old healthy and habitually active adults.

Adverse events of exercise therapy in randomised controlled trials: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the relative risk (RR) of serious and non-serious adverse events in patients treated with exercise therapy compared with those in a non-exercising control group. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Primary studies were identified based on The Cochrane Database of Systematic Reviews investigating the effect of exercise therapy. ELIGIBILITY CRITERIA: At least two of the authors independently evaluated all identified reviews and primary studies. Randomised controlled trials were included if they compared any exercise therapy intervention with a non-exercising control. Two authors independently extracted data. The RR of serious and non-serious adverse events was estimated separately. RESULTS: 180 Cochrane reviews were included and from these, 773 primary studies were identified. Of these, 378 studies (n=38 368 participants) reported serious adverse events and 375 studies (n=38 517 participants) reported non-serious adverse events. We found no increase in risk of serious adverse events (RR=0.96 (95%CI 0.90 to 1.02, I2: 0.0%) due to exercise therapy. There was, however, an increase in non-serious adverse events (RR=1.19 (95%CI 1.09 to 1.30, I2: 0.0%). The number needed to treat for an additional harmful outcome for non-serious adverse events was 6 [95%CI 4 to 11). CONCLUSION: Participating in an exercise intervention increased the relative risk of non-serious adverse events, but not of serious adverse events. Exercise therapy may therefore be recommended as a relatively safe intervention.PROSPERO registration numberCRD42014014819.

Modes of e-Health delivery in secondary prevention programmes for patients with coronary artery disease: a systematic review.

BACKGROUND: Electronic health (e-Health) interventions are emerging as an effective alternative model for improving secondary prevention of coronary artery disease (CAD). The aim of this study was to describe the effectiveness of different modes of delivery and components in e-Health secondary prevention programmes on adherence to treatment, modifiable CAD risk factors and psychosocial outcomes for patients with CAD. METHOD: A systematic review was carried out based on articles found in MEDLINE, CINAHL, and Embase. Studies evaluating secondary prevention e-Health programmes provided through mobile-Health (m-Health), web-based technology or a combination of m-Health and web-based technology were eligible. The main outcomes measured were adherence to treatment, modifiable CAD risk factors and psychosocial outcomes. The quality appraisal of the studies included was conducted using the Joanna Briggs Institute critical appraisal tool for RCT. The results were synthesised narratively. RESULT: A total of 4834 titles were identified and 1350 were screened for eligibility. After reviewing 123 articles in full, 24 RCTs including 3654 participants with CAD were included. Eight studies delivered secondary prevention programmes through m-Health, nine through web-based technology, and seven studies used a combination of m-Health and web-based technology. The majority of studies employed two or three secondary prevention components, of which health education was employed in 21 studies. The m-Health programmes reported positive effects on adherence to medication. Most studies evaluating web-based technology programmes alone or in combination with m-Health also utilised traditional CR, and reported improved modifiable CAD risk factors. The quality appraisal showed a moderate methodological quality of the studies. CONCLUSION: Evidence exists that supports the use of e-Health interventions for improving secondary prevention of CAD. However, a comparison across studies highlighted a wide variability of components and outcomes within the different modes of delivery. High quality trials are needed to define the most efficient mode of delivery and components capable of addressing a favourable outcome for patients. TRIAL REGISTRATION: Not applicable.

Effect of Soft Braces on Pain and Physical Function in Patients With Knee Osteoarthritis: Systematic Review With Meta-Analyses.

OBJECTIVES: To systematically review and synthesize the effects of soft braces on pain and on self-reported and performance-based physical function in patients with knee osteoarthritis. DATA SOURCES: The following electronic databases were searched from inception to April 20, 2016: The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, CINAHL, SPORTDiscus, Web of Science, and PEDro. STUDY SELECTION: Randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs), such as controlled clinical trials, crossover studies, and case-control studies, were included. Two reviewers independently screened articles and determined inclusion through predefined criteria. DATA EXTRACTION: Data related to participant demographics, study design and methods, interventions, and outcomes, including numerical means and SDs, were extracted by 1 reviewer. Methodological quality assessment was independently performed by 2 reviewers. DATA SYNTHESIS: Eleven studies were identified, including 6 RCTs and 5 non-RCTs. The methodological quality of included RCTs was low. There was a moderate improvement in pain (standardized mean difference [SMD]=.52; 95% confidence interval [CI], .14-.89; P=.007; 284 participants) in favor of wearing a brace compared with not wearing a brace for the immediate, within-group comparison. There was a moderate improvement in pain (SMD=.61; 95% CI, .33-.89; P<.001; 206 participants) and a small to moderate improvement in self-reported physical function (SMD=.39; 95% CI, .11-.67; P=.006; 206 participants) in favor of patients receiving a soft brace versus standard care for the prolonged effect, between-group comparison. CONCLUSIONS: Currently available evidence indicates that soft braces have moderate effects on pain and small to moderate effects on self-reported physical function in knee osteoarthritis. These findings highlight the importance of soft braces as a technique to improve pain and physical function in both the short- and long-term. Additional high-quality studies are warranted to improve confidence in the findings.

Association of malalignment, muscular dysfunction, proprioception, laxity and abnormal joint loading with tibiofemoral knee osteoarthritis - a systematic review and meta-analysis.

BACKGROUND: To investigate (1) the association of specific biomechanical factors with knee osteoarthritis and knee osteoarthritis development, and (2) the impact of other relevant risk factors on this association. METHODS: MEDLINE, EMBASE, CINAHL and SPORTDiscus were searched up until April 2017. Studies were included if they fulfilled the following criteria: the study 1) assessed the association of a biomechanical factor with knee osteoarthritis, or knee osteoarthritis development; 2) reported on skeletal malalignment, muscular dysfunction, impaired proprioception, laxity and abnormal loading during gait; 3) was a cohort study with participants developing knee osteoarthritis and participants not developing knee osteoarthritis, or a case-control or cross-sectional study with participants with knee osteoarthritis and without knee osteoarthritis. Risk of bias was assessed with the QUIPS tool and meta-analyses were performed using random effects models. RESULTS: Of 6413 unique studies identified, 59 cross-sectional studies were eligible for meta-analyses (9825 participants, 5328 with knee osteoarthritis). No cohort studies fulfilled the inclusion criteria. Compared with healthy controls, patients with knee osteoarthritis have higher odds of having lower muscle strength, proprioception deficits, more medial varus-valgus laxity and less lateral varus-valgus laxity. Patients with medial knee osteoarthritis have higher odds of having a higher knee adduction moment than healthy controls. Level of evidence was graded as 'very low' to 'moderate' quality. Due to large between study differences moderation of other risk factors on biomechanical risk factors could not be evaluated. CONCLUSIONS: Patients with knee osteoarthritis are more likely to display a number of biomechanical characteristics. The causal relationship between specific biomechanical factors and the development of knee osteoarthritis could not be determined as no longitudinal studies were included. There is an urgent need for high quality, longitudinal studies to evaluate the impact of specific biomechanical factors on the development of knee osteoarthritis. TRIAL REGISTRATION: (PROSPERO ID: CRD42015025092 ).

Measurement properties of clinical assessment methods for classifying generalized joint hypermobility-A systematic review.

The purpose was to perform a systematic review of clinical assessment methods for classifying Generalized Joint Hypermobility (GJH), evaluate their clinimetric properties, and perform the best evidence synthesis of these methods. Four test assessment methods (Beighton Score [BS], Carter and Wilkinson, Hospital del Mar, Rotes-Querol) and two questionnaire assessment methods (Five-part questionnaire [5PQ], Beighton Score-self reported [BS-self]) were identified on children or adults. Using the Consensus-based Standards for selection of health Measurement Instrument (COSMIN) checklist for evaluating the methodological quality of the identified studies, all included studies were rated "fair" or "poor." Most studies were using BS, and for BS the reliability most of the studies showed limited positive to conflicting evidence, with some shortcomings on studies for the validity. The three other test assessment methods lack satisfactory information on both reliability and validity. For the questionnaire assessment methods, 5PQ was the most frequently used, and reliability showed conflicting evidence, while the validity had limited positive to conflicting evidence compared with test assessment methods. For BS-self, the validity showed unknown evidence compared with test assessment methods. In conclusion, following recommended uniformity of testing procedures, the recommendation for clinical use in adults is BS with cut-point of 5 of 9 including historical information, while in children it is BS with cut-point of at least 6 of 9. However, more studies are needed to conclude on the validity properties of these assessment methods, and before evidence-based recommendations can be made for clinical use on the "best" assessment method for classifying GJH. © 2017 Wiley Periodicals, Inc.

Optimizing literature search in systematic reviews - are MEDLINE, EMBASE and CENTRAL enough for identifying effect studies within the area of musculoskeletal disorders?

BACKGROUND: When conducting systematic reviews, it is essential to perform a comprehensive literature search to identify all published studies relevant to the specific research question. The Cochrane Collaborations Methodological Expectations of Cochrane Intervention Reviews (MECIR) guidelines state that searching MEDLINE, EMBASE and CENTRAL should be considered mandatory. The aim of this study was to evaluate the MECIR recommendations to use MEDLINE, EMBASE and CENTRAL combined, and examine the yield of using these to find randomized controlled trials (RCTs) within the area of musculoskeletal disorders. METHODS: Data sources were systematic reviews published by the Cochrane Musculoskeletal Review Group, including at least five RCTs, reporting a search history, searching MEDLINE, EMBASE, CENTRAL, and adding reference- and hand-searching. Additional databases were deemed eligible if they indexed RCTs, were in English and used in more than three of the systematic reviews. Relative recall was calculated as the number of studies identified by the literature search divided by the number of eligible studies i.e. included studies in the individual systematic reviews. Finally, cumulative median recall was calculated for MEDLINE, EMBASE and CENTRAL combined followed by the databases yielding additional studies. RESULTS: Deemed eligible was twenty-three systematic reviews and the databases included other than MEDLINE, EMBASE and CENTRAL was AMED, CINAHL, HealthSTAR, MANTIS, OT-Seeker, PEDro, PsychINFO, SCOPUS, SportDISCUS and Web of Science. Cumulative median recall for combined searching in MEDLINE, EMBASE and CENTRAL was 88.9% and increased to 90.9% when adding 10 additional databases. CONCLUSION: Searching MEDLINE, EMBASE and CENTRAL was not sufficient for identifying all effect studies on musculoskeletal disorders, but additional ten databases did only increase the median recall by 2%. It is possible that searching databases is not sufficient to identify all relevant references, and that reviewers must rely upon additional sources in their literature search. However further research is needed.

Aquatic exercise for the treatment of knee and hip osteoarthritis.

BACKGROUND: Osteoarthritis is a chronic disease characterized by joint pain, tenderness, and limitation of movement. At present, no cure is available. Thus only treatment of the person's symptoms and treatment to prevent further development of the disease are possible. Clinical trials indicate that aquatic exercise may have advantages for people with osteoarthritis. This is an update of a published Cochrane review. OBJECTIVES: To evaluate the effects of aquatic exercise for people with knee or hip osteoarthritis, or both, compared to no intervention. SEARCH METHODS: We searched the following databases up to 28 April 2015: the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library Issue 1, 2014), MEDLINE (from 1949), EMBASE (from 1980), CINAHL (from 1982), PEDro (Physiotherapy Evidence Database), and Web of Science (from 1945). There was no language restriction. SELECTION CRITERIA: Randomized controlled clinical trials of aquatic exercise compared to a control group (e.g. usual care, education, social attention, telephone call, waiting list for surgery) of participants with knee or hip osteoarthritis. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included trials. We analysed the pooled results using standardized mean difference (SMD) values. MAIN RESULTS: Nine new trials met the inclusion criteria and we excluded two earlier included trials. Thus the number of participants increased from 800 to 1190 and the number of included trials increased from six to 13. Most participants were female (75%), with an average age of 68 years and a body mass index (BMI) of 29.4. Osteoarthritis duration was 6.7 years, with a great variation of the included participants. The mean aquatic exercise duration was 12 weeks. We found 12 trials at low to unclear risk of bias for all domains except blinding of participants and personnel. They showed that aquatic exercise caused a small short term improvement compared to control in pain (SMD -0.31, 95% CI -0.47 to -0.15; 12 trials, 1076 participants) and disability (SMD -0.32, 95% CI -0.47 to -0.17; 12 trials, 1059 participants). Ten trials showed a small effect on quality of life (QoL) (SMD -0.25, 95% CI -0.49 to -0.01; 10 trials, 971 participants). These effects on pain and disability correspond to a five point lower (95% CI three to eight points lower) score on mean pain and mean disability compared to the control group (scale 0 to 100), and a seven point higher (95% CI 0 to 13 points higher) score on mean QoL compared with control group (scale 0 to 100). No included trials performed a radiographic evaluation. No serious adverse events were reported in the included trials with relation to aquatic exercise. AUTHORS' CONCLUSIONS: There is moderate quality evidence that aquatic exercise may have small, short-term, and clinically relevant effects on patient-reported pain, disability, and QoL in people with knee and hip OA. The conclusions of this review update does not change those of the previous published version of this Cochrane review.

Implementing guidelines in nursing homes: a systematic review.

BACKGROUND: Research on guideline implementation strategies has mostly been conducted in settings which differ significantly from a nursing home setting and its transferability to the nursing home setting is therefore limited. The objective of this study was to systematically review the effects of interventions to improve the implementation of guidelines in nursing homes. METHODS: A systematic literature search was conducted in the Cochrane Library, CINAHL, Embase, MEDLINE, DARE, HTA, CENTRAL, SveMed + and ISI Web of Science from their inception until August 2015. Reference screening and a citation search were performed. Studies were eligible if they evaluated any type of guideline implementation strategy in a nursing home setting. Eligible study designs were systematic reviews, randomised controlled trials, non-randomised controlled trials, controlled before-after studies and interrupted-time-series studies. The EPOC risk of bias tool was used to evaluate the risk of bias in the included studies. The overall quality of the evidence was rated using GRADE. RESULTS: Five cluster-randomised controlled trials met the inclusion criteria, evaluating a total of six different multifaceted implementation strategies. One study reported a small statistically significant effect on professional practice, and two studies demonstrated small to moderate statistically significant effects on patient outcome. The overall quality of the evidence for all comparisons was low or very low using GRADE. CONCLUSIONS: Little is known about how to improve the implementation of guidelines in nursing homes, and the evidence to support or discourage particular interventions is inconclusive. More implementation research is needed to ensure high quality of care in nursing homes. PROTOCOL REGISTRATION: PROSPERO 2014: CRD42014007664.

Physical activity and anomalous bodily experiences in patients with first-episode schizophrenia.

BACKGROUND: Low physical activity is strongly correlated with metabolic syndrome (MetS) and poor physical health. Although the prevalence of MetS is high in patients with first-episode schizophrenia (FES), little is still known about the level of and possible barriers for physical activity in FES. AIM: The purpose of the study was to compare physical activity in patients with FES with healthy controls; to investigate changes in physical activity over 1 year of follow-up; and to explore the correlations of physical activity and anomalous bodily experiences reported by patients with FES. METHODS: Both physical activity and aerobic fitness were measured. Anomalous bodily experiences were measured by selected items from the Examination of Anomalous Self-Experience and The Body Awareness Scale. Psychopathological data comprising negative and positive symptoms and data on psychotropic medication were obtained from medical records of all patients. RESULTS: Physical activity and aerobic fitness was significantly lower in patients with FES compared with healthy controls (p < 0.001). Over 1 year of follow-up patients had lower physical activity and aerobic fitness. Patients with more severe anomalous bodily experiences had significantly lower physical activity compared with patients with fewer such experiences (p = 0.030). In linear regression analyses only negative symptoms were significantly correlated with low physical activity (ß = -0.88; 95% confidence interval = -1.48 to -0.29; p < 0.001). CONCLUSION: Physical activity and aerobic fitness is low in patients with FES. Both anomalous bodily experiences and negative symptoms are significantly correlated with low physical activity.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis.

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

The effect of isometric exercise of the hand on the synovial blood flow in patients with rheumatoid arthritis measured by color Doppler ultrasound.

In 90% of patients with rheumatoid arthritis (RA), the joints of the hand are affected. Studies of grip strength training have not indicated a negative effect on disease activity after training. Introduction of ultrasound Doppler (USD) to measure increased blood flow induced by inflammation has made it possible to investigate the direct effect on blood supply in the synovium after training. In this case-control study, 24 patients with RA with USD activity in the wrist joint participated. The USD activity was measured by the color fraction (CF) (CF = colored pixels/total number of pixels in ROI). Twenty-four patients were assigned to an 8-week grip strength training program. At baseline and after 8 weeks of training, an USD examination of the wrist joint was performed. In the training group, we measured grip strength and pain in the wrist joint. Six patients withdrew from the training because of pain or change in medication. Eighteen patients served as control group. There was a modest, not significant, decrease in the CF in response to training (1.86%; P = 0.08). Grip strength increased 8.8% after training (P = 0.055). Pain in motion deceased after training (P = 0.04). No difference in the CF was seen between the training and control groups, neither at baseline nor at follow-up (P = 0.82 and P = 0.48). Patients withdrawing from training had a significantly higher CF than the other patients (P > 0.001). The results in this study might indicate that the flow in the synovium assessed by USD is not affected by grip strength training.

Low levels of physical activity in patients with severe mental illness.

BACKGROUND: Physical inactivity is an independent risk factor for cardiovascular diseases and Type 2 diabetes, both being highly prevalent in patients with severe mental illness. Though physical activity has become an important issue in psychiatric treatment and rehabilitation in the past decade, systematic evaluations of physical activity level in psychiatric populations could be more disseminated. AIM: The primary aim of the study was to investigate the physical activity level of psychiatric patients in comparison with healthy controls. METHODS: Patients with severe mental illness (n =47) and a group of healthy controls (n =28) matched on sex and age reported their physical activity level using the Physical Activity Scale (PAS). PAS was administered as an interview in relation to patients and as a questionnaire in relation to healthy controls. RESULTS: Patients had statistically significant lower levels of physical activity compared with healthy controls (P <0.0001) and the level of physical activity among patients was hazardously low. CONCLUSION: The study confirmed previous studies and clinical experience that patients with severe mental illness are physically inactive and emphasize the importance of physical activity in psychiatric treatment and rehabilitation. The PAS is an applicable and relevant method for evaluating physical activity levels in psychiatric patients.