"It's the single best thing I've done in the last 10 years": a qualitative study exploring patient and dietitian experiences with, and perceptions of, a multi-component dietary weight loss program for knee osteoarthritis.

OBJECTIVE: Explore patient and dietitian experiences with a multi-component dietary weight loss program for knee osteoarthritis to understand enablers and challenges to success at 6-months. DESIGN: Qualitative study embedded within a randomised controlled trial. Semi-structured individual interviews with 24 patients with knee osteoarthritis who undertook, and five dietitians who supervised, a weight management program (involving a ketogenic very low calorie diet (VLCD), video consultations, educational resources) over 6 months. Data were thematically analysed. RESULTS: Five themes were developed: (1) ease and convenience of program facilitated adherence (structure and simplicity of the meal replacements; not feeling hungry on diet; convenience of consulting via video) (2) social and professional support crucial for success (encouragement from partner, family, and friends; guidance from, and accountability to, dietitian; anxiety around going at it alone) (3) program was engaging and motivating (determination to stick to program; rapid weight loss helped motivation) (4) holistic nature of program was important (suite of high-quality educational resources; exercise important to compliment weight loss) (5) rewarding experience and lifelong impact (improved knee pain and function; positive lifestyle change). CONCLUSIONS: Patients and dietitians described positive experiences with the weight management program, valuing its simplicity, effectiveness, and convenience. Support from dietitians and a comprehensive suite of educational resources, incorporated with an exercise program, were considered crucial for success. Findings suggest this multi-component dietary program is an acceptable weight loss method in people with knee osteoarthritis that may benefit symptoms. Strategies for supporting long-term independent weight management should be a focus of future research.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

Osteoarthritis year in review 2015: rehabilitation and outcomes.

OBJECTIVE: The purpose of this narrative review was to highlight recent research in the rehabilitation of people with osteoarthritis (OA) by summarizing findings from selected key systematic reviews and randomized controlled trials (RCTs). METHODS: A systematic search was conducted using the PubMed, Physiotherapy Evidence Database (PEDro) and Cochrane databases from April 1st 2014 to March 31st 2015. A selection of these is discussed based on study quality, relevance, contribution to new knowledge or controversial findings. Methodological quality of RCTs was assessed using guidelines from PEDro. RESULTS: From 274 articles, 74 were deemed to meet the eligibility criteria including 24 systematic reviews and 50 studies reporting on findings from RCTs. Overall the methodological quality of the RCTs was moderate. The studies were grouped into several themes covering; evidence of rehabilitation outcomes in less studied joints including the hand and hip; new insights into exercise in knee OA; effects of biomechanical treatments on symptoms and structure in knee OA; and effects of acupuncture. CONCLUSIONS: Exercise was the most common treatment evaluated. Although little evidence supported benefit of exercise for hand OA, exercise has positive effects for hip and knee OA symptoms and these benefits may depend upon patient phenotypes. The first evidence that a brace can influence knee joint structure emerged. The latest evidence suggests that acupuncture has, at best, small treatment effects on knee OA pain of unlikely clinical relevance.

Effect of vitamin D supplementation on muscle strength: a systematic review and meta-analysis.

UNLABELLED: This systematic review demonstrates that vitamin D supplementation does not have a significant effect on muscle strength in vitamin D replete adults. However, a limited number of studies demonstrate an increase in proximal muscle strength in adults with vitamin D deficiency. INTRODUCTION: The purpose of this study is to systematically review the evidence on the effect of vitamin D supplementation on muscle strength in adults. METHODS: A comprehensive systematic database search was performed. Inclusion criteria included randomised controlled trials (RCTs) involving adult human participants. All forms and doses of vitamin D supplementation with or without calcium supplementation were included compared with placebo or standard care. Outcome measures included evaluation of strength. Outcomes were compared by calculating standardised mean difference (SMD) and 95% confidence intervals. RESULTS: Of 52 identified studies, 17 RCTs involving 5,072 participants met the inclusion criteria. Meta-analysis showed no significant effect of vitamin D supplementation on grip strength (SMD -0.02, 95%CI -0.15,0.11) or proximal lower limb strength (SMD 0.1, 95%CI -0.01,0.22) in adults with 25(OH)D levels > 25 nmol/L. Pooled data from two studies in vitamin D deficient participants (25(OH)D <25 nmol/L) demonstrated a large effect of vitamin D supplementation on hip muscle strength (SMD 3.52, 95%CI 2.18, 4.85). CONCLUSION: Based on studies included in this systematic review, vitamin D supplementation does not have a significant effect on muscle strength in adults with baseline 25(OH)D >25 nmol/L. However, a limited number of studies demonstrate an increase in proximal muscle strength in adults with vitamin D deficiency.

Rye grass is associated with fewer non-contact anterior cruciate ligament injuries than bermuda grass.

OBJECTIVE: To assess the contribution of ground variables including grass type to the rate of anterior cruciate ligament (ACL) injury in the Australian Football League (AFL), specifically which factors are primarily responsible for previously observed warm season and early season biases for ACL injuries. METHODS: Grass types used at the major AFL venues from 1992 to 2004 were established by consultation with ground managers, and ground hardness and other weather variables were measured prospectively. RESULTS: There were 115 ACL injuries occurring in matches during the survey time period, 88 with a non-contact mechanism. In multivariate analysis, use of bermuda (couch) grass as opposed to rye grass, higher grade of match, and earlier stage of the season were independent risk factors for non-contact ACL injury. Ground hardness readings did not show a significant association with ACL injury risk, whereas weather variables of high evaporation and low prior rainfall showed univariate association with injury risk but could not be entered into a logistic regression equation. DISCUSSION: Rye grass appears to offer protection against ACL injury compared with bermuda (couch) grass fields. The likely mechanism is reduced "trapping" of football boots by less thatch. Grass species as a single consideration cannot fully explain the ACL early season bias, but is probably responsible for the warm season bias seen in the AFL. Weather variables previously identified as predictors are probably markers for predominance of bermuda over rye grass in mixed fields.

Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial.

OBJECTIVES: To use a randomised, double blind, placebo controlled trial to establish the effect on straight leg raise, hip internal rotation, and muscle pain of dry needling treatment to the gluteal muscles in athletes with posterior thigh pain referred from gluteal trigger points. METHODS: A randomised, double blind, placebo controlled trial of 59 male runners was performed during the 2002 Australian Rules football season. Subjects were thoroughly screened and had magnetic resonance imaging of their hamstring muscles to exclude local pathology. The inclusion criterion was reproduction of recognisable posterior thigh pain with the application of digital pressure to the gluteal trigger points. Subjects randomly received either therapeutic or placebo needle treatment on one occasion at their gluteal trigger points. Range of motion and visual analogue scale data were collected immediately before, immediately after, 24 hours after, and 72 hours after the intervention. Range of motion was measured with passive straight leg raise and hip internal rotation. Visual analogue scales were completed for hamstring and gluteal pain and tightness at rest and during a running task. RESULTS: Magnetic resonance imaging scans revealed normal hamstring musculature in most subjects. Straight leg raise and hip internal rotation remained unchanged in both groups at all times. Visual analogue scale assessment of hamstring pain and tightness and gluteal tightness after running showed improvements immediately after the intervention in both groups (p = 0.001), which were maintained at 24 and 72 hours. The magnitude of this improvement was the same for therapeutic and placebo interventions. Resting muscle pain and tightness were unaffected. CONCLUSIONS: Neither dry needling nor placebo needling of the gluteal muscles resulted in any change in straight leg raise or hip internal rotation. Both interventions resulted in subjective improvement in activity related muscle pain and tightness. Despite being commonly used clinical tests in this situation, straight leg raise and hip internal rotation are not likely to help the therapist assess response to treatment. Patient reports of response to such treatment are better indicators of its success. The mechanisms by which these responses occur and the reasons for the success of the placebo needling treatment are areas for further investigation.

A systematic review of physical interventions for patellofemoral pain syndrome.

OBJECTIVE: Physical interventions (nonpharmacological and nonsurgical) are the mainstay of treatment for patellofemoral pain syndrome (PFPS). Physiotherapy is the most common of all physical interventions and includes specific vastus medialis obliquus or general quadriceps strengthening and/or realignment procedures (tape, brace, stretching). These treatments appear to be based on sound theoretical rationale and have attained widespread acceptance, but evidence for the efficacy of these interventions is not well established. This review will present the available evidence for physical interventions for PFPS. DATA SOURCES: Computerized bibliographic databases (MEDLINE, Current Contents, CINAHL) were searched, including the keywords "patellofemoral," "patella," and "anterior knee pain," combined with "treatment," "rehabilitation," and limited to clinical trials through October 2000. STUDY SELECTION: The critical eligibility criteria used for inclusion were that the study be a controlled trial, that outcome assessments were adequately described, and that the treatment was a nonpharmacological, nonsurgical physical intervention. RESULTS: Of the 89 potentially relevant titles, 16 studies were reviewed and none of these fulfilled all of the requirements for a randomized, controlled trial. Physiotherapy interventions were evaluated in eight trials, and the remaining eight trials examined different physical interventions. Significant reductions in PFPS symptoms were found with a corrective foot orthosis and a progressive resistance brace, but there is no evidence to support the use of patellofemoral orthoses, acupuncture, low-level laser, chiropractic patellar mobilization, or patellar taping. Overall the physiotherapy interventions had significant beneficial effects but these interventions were not compared with a placebo control. There is inconclusive evidence to support the superiority of one physiotherapy intervention compared with others. CONCLUSIONS: The evidence to support the use of physical interventions in the management of PFPS is limited. There appears to be a consistent improvement in short-term pain and function due to physiotherapy treatment, but comparison with a placebo group is required to determine efficacy, and further trials are warranted for the other interventions.