A multidisciplinary lifestyle program for metabolic syndrome-associated osteoarthritis: the "Plants for Joints" randomized controlled trial.

OBJECTIVE: To determine the effectiveness of the "Plants for Joints" multidisciplinary lifestyle program in patients with metabolic syndrome-associated osteoarthritis (MSOA). DESIGN: Patients with hip or knee MSOA were randomized to the intervention or control group. The intervention group followed a 16-week program in addition to usual care based on a whole food plant-based diet, physical activity, and stress management. The control group received usual care. The patient-reported Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) total score (range 0-96) was the primary outcome. Secondary outcomes included other patient-reported, anthropometric, and metabolic measures. An intention-to-treat analysis with a linear-mixed model adjusted for baseline values was used to analyze between-group differences. RESULTS: Of the 66 people randomized, 64 completed the study. Participants (84% female) had a mean (SD) age of 63 (6) years and body mass index of 33 (5) kg/m2. After 16 weeks, the intervention group (n = 32) had a mean 11-point larger improvement in WOMAC-score (95% CI 6-16; p = 0.0001) compared to the control group. The intervention group also lost more weight (-5 kg), fat mass (-4 kg), and waist circumference (-6 cm) compared to the control group. Patient-Reported Outcomes Measurement Information System (PROMIS) fatigue, pain interference, C-reactive protein, hemoglobin A1c, fasting glucose, and low-density lipoproteins improved in the intervention versus the control group, while other PROMIS measures, blood pressure, high-density lipoproteins, and triglycerides did not differ significantly between the groups. CONCLUSION: The "Plants for Joints" lifestyle program reduced stiffness, relieved pain, and improved physical function in people with hip or knee MSOA compared to usual care.

High-intensity versus low-intensity resistance training in patients with knee osteoarthritis: A randomized controlled trial.

OBJECTIVES: To assess whether (i) high-intensity resistance training (RT) leads to increased muscle strength compared to low-intensity RT in patients with knee osteoarthritis (OA); and (ii) RT with vitamin D supplementation leads to increased muscle strength compared to placebo in a subgroup with vitamin D deficiency. DESIGN: Randomized controlled trial. SETTING: Outpatient rehabilitation centre. SUBJECTS: Patients with knee OA. INTERVENTIONS: 12 weeks of RT at high-intensity RT (70-80% of 1-repetition maximum (1-RM)) or low-intensity RT (40-50% of 1-RM) and 24 weeks of vitamin D (1200 International units vitamin D3 per day) or placebo supplementation. MAIN MEASURES: Primary outcome measure was isokinetic muscle strength. Other outcome measure for muscle strength was the estimated 1-RM. Secondary outcome measures were knee pain and physical functioning. RESULTS: 177 participants with a mean age of 67.6 ± 5.8 years were included, of whom 50 had vitamin D deficiency. Isokinetic muscle strength (in Newton metre per kilogram bodyweight) at start, end and 24 weeks after the RT was 0.98 ± 0.40, 1.11 ± 0.40, 1.09 ± 0.42 in the high-intensity group and 1.02 ± 0.41, 1.15 ± 0.42, 1.12 ± 0.40 in the low-intensity group, respectively. No differences were found between the groups, except for the estimated 1-RM in favour of the high-intensity group. In the subgroup with vitamin D deficiency, no difference on isokinetic muscle strength was found between the vitamin D and placebo group. CONCLUSIONS: High-intensity RT did not result in greater improvements in isokinetic muscle strength, pain and physical functioning compared to low-intensity RT in knee OA, but was well tolerated. Therefore these results suggest that either intensity of resistance training could be utilised in exercise programmes for patients with knee osteoarthritis. No synergistic effect of vitamin D supplementation and RT was found, but this finding was based on underpowered data.

Muscle weakness is associated with non-contractile muscle tissue of the vastus medialis muscle in knee osteoarthritis.

BACKGROUND: Quadriceps weakness is assumed to be associated with compositional properties of the vastus medialis muscle in patients with knee osteoarthritis (OA). METHODS: The aim was to determine the association of non-contractile muscle tissue in the vastus medialis muscle, measured with routine MRI, with muscle extensor strength in patients with knee OA. Sagittal T1-weighted 3T MRI of 94 patients with knee OA, routinely acquired in clinical practice were used for analysis. Using the MRI's, the amount of non-contractile muscle tissue in the vastus medialis muscle was measured, expressed as a percentage of (non)-contractile tissue, dichotomized into a low and a high non-contractile percentage group. Muscle strength was assessed by isokinetic measurement of knee extensors and by conduction of the Get-Up and Go (GUG) test. In regression analyses, associations of percentage of non-contractile muscle tissue with muscle strength and GUG time were determined and controlled for sex, age, BMI and radiographic severity. RESULTS: A high percentage of non-contractile muscle tissue (> 11.2%) was associated with lower muscle strength (B = -0.25, P = 0.006) and with longer GUG time (B = 1.09, P = 0.021). These associations were specifically confounded by sex and BMI, because these two variables decreased the regression coefficient (B) with > 10%. CONCLUSIONS: A high percentage of non-contractile muscle tissue in the vastus medialis muscle measured by clinical T1-weighted 3T MRI is associated with muscle weakness. The association is confounded by sex and BMI. Non-contractile muscle tissue seems to be an important compositional property of the vastus medialis muscle underlying quadriceps weakness.

Health promotion and disease prevention in the education of health professionals: a mapping of European educational programmes from 2019.

BACKGROUND: Health professionals face barriers in carrying out effective health promotion and disease prevention. To indicate what are the needs for curriculum development in educational programmes, this study aims to provide an overview of how various health professionals are currently trained in health promotion and disease prevention at different educational levels. METHODS: In 2019, a descriptive mapping exercise was performed focusing on European programmes for different health and healthcare professionals at the three levels of education (undergraduate, postgraduate, and continuous professional development [CPD]). Data were collected by a self-developed online survey that was distributed using a modified snowball method. RESULTS: A total of 186 educational programmes of 17 different health professionals were analysed, implemented in 31 countries (60% were undergraduate, 30% postgraduate and 10% CPD programmes). Nearly all programmes indicated that expected outcomes were defined on knowledge (99%), skills (94%) and behaviours/attitudes (89%) regarding health promotion and disease prevention. A multidisciplinary approach was reported to be applied by 81% of the programmes. Traditional teaching methods such as lectures (97%) and assignments (81%) were dominant, while e-learning was less frequently used (46%). Digitalization in health promotion and digital health coaching were the least addressed topics in most programmes. CONCLUSIONS: Health promotion and disease prevention are reported at all surveyed levels of education for a broad spectrum of health professionals. Educational programmes cover contents on knowledge, skills, and behaviours. There is a need for capacity building and joint development in health promotion education. Specifically, there is a need to include digitalisation and novel teaching in the educational programmes of health promotion and disease prevention.

Construct validity of the OCTOPuS stratification algorithm for allocating patients with knee osteoarthritis into subgroups.

BACKGROUND: We recently developed a model of stratified exercise therapy, consisting of (i) a stratification algorithm allocating patients with knee osteoarthritis (OA) into one of the three subgroups ('high muscle strength subgroup' representing a post-traumatic phenotype, 'low muscle strength subgroup' representing an age-induced phenotype, and 'obesity subgroup' representing a metabolic phenotype) and (ii) subgroup-specific exercise therapy. In the present study, we aimed to test the construct validity of this algorithm. METHODS: Data from five studies (four exercise therapy trial cohorts and one cross-sectional cohort) were used to test the construct validity of our algorithm by 63 a priori formulated hypotheses regarding three research questions: (i) are the proportions of patients in each subgroup similar across cohorts? (15 hypotheses); (ii) are the characteristics of each of the subgroups in line with their proposed underlying phenotypes? (30 hypotheses); (iii) are the effects of usual exercise therapy in the 3 subgroups in line with the proposed effect sizes? (18 hypotheses). RESULTS: Baseline data from a total of 1211 patients with knee OA were analyzed for the first and second research question, and follow-up data from 584 patients who were part of an exercise therapy arm within a trial for the third research question. In total, the vast majority (73%) of the hypotheses were confirmed. Regarding our first research question, we found similar proportions in each of the three subgroups across cohorts, especially for three cohorts. Regarding our second research question, subgroup characteristics were almost completely in line with the proposed underlying phenotypes. Regarding our third research question, usual exercise therapy resulted in similar, medium to large effect sizes for knee pain and physical function for all three subgroups. CONCLUSION: We found mixed results regarding the construct validity of our stratification algorithm. On the one hand, it is a valid instrument to consistently allocate patients into subgroups that aligned our hypotheses. On the other hand, in contrast to our hypotheses, subgroups did not differ substantially in effects of usual exercise therapy. An ongoing trial will assess whether this algorithm accompanied by subgroup-specific exercise therapy improves clinical and economic outcomes.

Motivational factors mediate the association of general self-efficacy and performance outcomes in acutely hospitalised older patients.

OBJECTIVES: To study (i) the association of general self-efficacy (GSE) on the course of subjective (i.e. basic and instrumental activities of daily living (ADLs and IADLs) and objective physical performance outcomes (short physical performance battery (SPPB)) among older persons from discharge up to 3 months post-discharge and (ii) the extent to whether motivational factors such as depressive symptoms, apathy and fatigue mediate this association. METHODS: Prospective multi-centre cohort of acutely hospitalised patients aged ≥70 (Hospital-ADL study). Structural equation modelling was used to analyse the structural relationships. RESULTS: The analytic sample included 236 acutely hospitalised patients. GSE had a significant total effect on the course of subjective and objective performance outcomes (ADLs: ß = -0.21, P < 0.001, IADLs: ß = -0.24, P < 0.001 and SPPB: ß = 0.17, P < 0.001). However, when motivational factors as mediator were included into the same model, motivational factors (IADLs: ß = 0.51, P < 0.001; SPPB: ß = 0.49, P < 0.001) but not GSE remained significantly associated with IADLs (ß = -0.06, P = 0.16) and SPPB (ß = 0.002, P = 0.97). Motivational factors partially mediated the relationship between GSE and ADLs (ß = -0.09, P = 0.04). The percentage of mediation was 55, 74 and 99% for ADLs, IADLs and SPPB, respectively. CONCLUSIONS: Motivational factors and GSE are both associated with subjective and objective performance outcomes. However, the relationship between GSE and subjective and objective performance outcomes was highly mediated by motivational factors. Taken together, this suggests that GSE is important to being physically active but not sufficient to becoming more physical active in acutely hospitalised older patients; motivation is important to improving both subjective and objective performance.

Priorities for the effective implementation of osteoarthritis management programs: an OARSI international consensus exercise.

OBJECTIVE: The Joint Effort Initiative was endorsed by Osteoarthritis Research Society International (OARSI) in 2018 as a collaboration between international researchers and clinicians with an interest in the implementation of osteoarthritis management programs (OAMPs). This study aimed to identify and prioritise activities for future work of the Joint Effort Initiative. DESIGN: A survey was emailed to delegates of the 2018 OARSI World Congress attending a pre-conference workshop or with a known interest in OAMPs (n = 115). Delegates were asked about the most important issues regarding OAMP implementation. The top 20 issues were synthesised into 17 action statements, and respondents were invited to participate in a priority ranking exercise to determine the order of importance of the statements. RESULTS: Survey respondents (n = 51, 44%) were most commonly female (71%), with an allied health background (57%), affiliated with universities (73%) from Oceania (37%), and Europe/UK (45%). The five highest ranked action statements were: CONCLUSION: Prioritising statements will bring focus to the future work of the Joint Effort Initiative in the future and provide a basis for longer-term actions.

Hopelessness and Other Depressive Symptoms in Adults 70 Years and Older as Predictors of All-Cause Mortality Within 3 Months After Acute Hospitalization: The Hospital-ADL Study.

OBJECTIVE: Depression among older adults predicts mortality after acute hospitalization. Depression is highly heterogeneous in its presentation of symptoms, whereas individual symptoms may differ in predictive value. This study aimed to investigate the prevalence of individual cognitive-affective depressive symptoms during acute hospitalization and investigate the predictive value of both overall and individual cognitive-affective depressive symptoms for mortality between admission up to 3-month postdischarge among older patients. METHODS: A prospective multicenter cohort study enrolled 401 acutely hospitalized patients 70 years and older (Hospitalization-Associated Disability and impact on daily Life Study). The predictive value of depressive symptoms, assessed using the Geriatric Depression Scale 15, during acute hospitalization on mortality was analyzed with multiple logistic regression. RESULTS: The analytic sample included 398 patients (M (SD) = 79.6 (6.6) years; 51% men). Results showed that 9.3% of participants died within 3 months, with symptoms of apathy being most frequently reported. The depression total score during hospitalization was associated with increased mortality risk (admission: odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.2-1.3; discharge: OR = 1.2, 95% CI = 1.2-1.4). Stepwise multiple logistic regression analyses yielded the finding that feelings of hopelessness during acute hospitalization were a strong unique predictor of mortality (admission: OR = 3.6, 95% CI = 1.8-7.4; discharge: OR = 5.7, 95% CI = 2.5-13.1). These associations were robust to adjustment for demographic factors, somatic symptoms, and medical comorbidities. CONCLUSIONS: Symptoms of apathy were most frequently reported in response to acute hospitalization. However, feelings of hopelessness about their situation were the strongest cognitive-affective predictor of mortality. These results imply that this item is important in identifying patients who are in the last phase of their lives and for whom palliative care may be important.

The immediate effect of a soft knee brace on dynamic knee instability in persons with knee osteoarthritis.

Objectives: Wearing a soft knee brace has been shown to reduce self-reported knee instability in persons with knee OA. There is a need to assess whether a soft knee brace has a beneficial effect on objectively assessed dynamic knee instability as well. The aims of the study were to evaluate the effect of a soft knee brace on objectively assessed dynamic knee instability and to assess the difference in effect between a non-tight and a tight soft knee brace in persons with knee OA. Methods: Thirty-eight persons with knee OA and self-reported knee instability participated in a laboratory study. A within-subject design was used comparing no brace vs brace and comparing a non-tight vs a tight brace. The primary outcome measure was dynamic knee instability, expressed by the perturbation response (PR). The PR reflects deviation in the mean knee varus-valgus angle during level walking after a controlled mechanical perturbation. Linear mixed-effect model analysis was used to evaluate the effect of a brace on dynamic knee instability. Results: Wearing a brace significantly reduced the PR compared with not wearing a brace (B = -0.16, P = 0.01). There was no difference between a non-tight and a tight brace (B = -0.03, P = 0.60). Conclusion: This study is the first to report that wearing a soft knee brace reduces objectively assessed dynamic knee instability in persons with knee OA. Wearing a soft brace results in an objective improvement of knee instability beyond subjectively reported improvement. Trial registration: Nederlands Trial register (trialregister.nl) NTR6363.

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.

Analgesic use in patients with knee and/or hip osteoarthritis referred to an outpatient center: a cross-sectional study within the Amsterdam Osteoarthritis Cohort.

Although analgesics are widely recommended in current guidelines, underuse and inadequate prescription of analgesics seem to result in suboptimal treatment effects in patients with knee and/or hip osteoarthritis (OA). This study aimed (i) to describe the use of analgesics; and (ii) to determine factors that are related to analgesic use in patients with knee and/or hip OA referred to an outpatient center. A cross-sectional study with data from 656 patients with knee and/or hip OA referred to an outpatient center (Amsterdam Osteoarthritis (AMS-OA) cohort) was conducted. Self-reported use of analgesic (yes/no) was administered and subdivided into acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs, including coxibs) and opioids. Logistic regression analyses were performed to analyze the association between analgesic use and disease-related, predisposing and enabling factors. Analgesic use was reported by 63% of the patients, with acetaminophen, NSAIDs and opioid use reported by 50, 30 and 12%, respectively. Factors related to analgesic use were higher pain severity, longer duration of symptoms, higher radiographic hip OA severity, overweight/obesity and psychological distress. These factors explained 21% of the variance of analgesic use. More than one-third of patients with established knee and/or hip OA referred to an outpatient center did not use any analgesics. Although multiple, mostly disease-related associated factors were found, analgesic use remained predominantly unexplained. Our study seems to indicate that prescription of analgesics should be guided more dominantly by clinical symptoms and needs, and preceded by a thorough shared decision-making process between patient and physician.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs.

OBJECTIVE: To identify effective mind-body exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning non-traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with mind-body exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement). RESULTS: The four high-quality studies identified demonstrated that various mind-body exercise programs are promising for improving the management of knee osteoarthritis. Hatha Yoga demonstrated significant improvement for pain relief (Grade B) and physical function (Grade C+). Tai Chi Qigong demonstrated significant improvement for quality of life (Grade B), pain relief (Grade C+) and physical function (Grade C+). Sun style Tai Chi gave significant improvement for pain relief (Grade B) and physical function (Grade B). CONCLUSION: Mind-body exercises are promising approaches to reduce pain, as well as to improve physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part three: aerobic exercise programs.

OBJECTIVES: To identify effective aerobic exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) was used, based on statistical significance ( P < 0.5) and clinical importance (⩾15% improvement). RESULTS: The five high-quality studies included demonstrated that various aerobic training exercises are generally effective for improving knee osteoarthritis within a 12-week period. An aerobic exercise program demonstrated significant improvement for pain relief (Grade B), physical function (Grade B) and quality of life (Grade C+). Aerobic exercise in combination with strengthening exercises showed significant improvement for pain relief (3 Grade A) and physical function (2 Grade A, 2 Grade B). CONCLUSION: A short-term aerobic exercise program with/without muscle strengthening exercises is promising for reducing pain, improving physical function and quality of life for individuals with knee osteoarthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs.

OBJECTIVE: To identify effective strengthening exercise programs and provide rehabilitation teams and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. METHODS: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+ or D-) was based on statistical significance ( p < 0.5) and clinical importance (⩾15% improvement). RESULTS: The 26 high-quality studies identified demonstrated that various strengthening exercise programs with/without other types of therapeutic exercises are generally effective for improving knee osteoarthritis management within a six-month period. Strengthening exercise programs demonstrated a significant improvement for pain relief (four Grade A, ten Grade B, two Grade C+), physical function (four Grade A, eight Grade B) and quality of life (three Grade B). Strengthening in combination with other types of exercises (coordination, balance, functional) showed a significant improvement in pain relief (three Grade A, 11 Grade B, eight Grade C+), physical function (two Grade A, four Grade B, three Grade C+) and quality of life (one Grade A, one Grade C+). CONCLUSION: There are a variety of choices for strengthening exercise programs with positive recommendations for healthcare professionals and knee osteoarthritis patients. There is a need to develop combined behavioral and muscle-strengthening strategies to improve long-term maintenance of regular strengthening exercise programs.

Exercise for osteoarthritis of the knee.

BACKGROUND: Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines. OBJECTIVES: To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life. SEARCH METHODS: Five electronic databases were searched, up until May 2013. SELECTION CRITERIA: All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group. DATA COLLECTION AND ANALYSIS: Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months). MAIN RESULTS: In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup. AUTHORS' CONCLUSIONS: High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.

Exercise for osteoarthritis of the knee: a Cochrane systematic review.

OBJECTIVE: To determine whether land-based therapeutic exercise is beneficial for people with knee osteoarthritis (OA) in terms of reduced joint pain or improved physical function and quality of life. METHODS: Five electronic databases were searched, up until May 2013. Randomised clinical trials comparing some form of land-based therapeutic exercise with a non-exercise control were selected. Three teams of two review authors independently extracted data and assessed risk of bias for each study. Standardised mean differences immediately after treatment and 2-6 months after cessation of formal treatment were separately pooled using a random effects model. RESULTS: In total, 54 studies were identified. Overall, 19 (35%) studies reported adequate random sequence generation, allocation concealment and adequately accounted for incomplete outcome data. However, research results may be vulnerable to selection, attrition and detection bias. Pooled results from 44 trials indicated that exercise significantly reduced pain (12 points/100; 95% CI 10 to 15) and improved physical function (10 points/100; 95% CI 8 to 13) to a moderate degree immediately after treatment, while evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect (4 points/100; 95% CI 2 to 5). In addition, 12 studies provided 2-month to 6-month post-treatment sustainability data which showed significantly reduced knee pain (6 points/100; 95% CI 3 to 9) and 10 studies which showed improved physical function (3 points/100; 95% CI 1 to 5). CONCLUSIONS: Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2-6 months after cessation of formal treatment.

Osteoarthritis of the knee: multicompartmental or compartmental disease?

OBJECTIVE: Knee OA has been conceptualized as a multicompartmental disease, as a compartmental disease or as a combination of these two disease processes. The aim of this study was to determine the associations between four radiographic features (joint space narrowing, osteophyte formation, sclerosis and cysts) across and within the three knee compartments (medial tibiofemoral, lateral tibiofemoral and patellofemoral compartment) in knee OA. METHODS: Data from the Amsterdam OA Cohort were used. In 298 patients diagnosed with knee OA, radiographic features were examined in three knee joint compartments. Radiographic features were scored according to standardized scoring methods. Factor analysis was used to examine associations between the four radiographic features across and within compartments. RESULTS: A bifactor model showed a general multicompartmental factor: 10 of 12 radiographic features across the entire joint were associated with the general factor. The bifactor model also showed three compartmental factors-one for each compartment: joint space narrowing, sclerosis and to a lesser extent osteophyte formation were associated with these compartmental factors. CONCLUSION: These findings suggest a multicompartmental disease process in the knee, characterized by associations among features across the entire joint, as well as compartmental disease processes in each knee compartment, characterized by associations among features within specific compartments. Longitudinal studies are needed to explore the possibility of the development from a compartmental disease to a multicompartmental disease and the impact of contributing factors on the development.

Decrease of muscle strength is associated with increase of activity limitations in early knee osteoarthritis: 3-year results from the cohort hip and cohort knee study.

OBJECTIVE: To determine whether a decrease in muscle strength over 3 years is associated with an increase in activity limitations in persons with early symptomatic knee osteoarthritis (OA), and to examine whether the longitudinal association between muscle strength and activity limitations is moderated by knee joint proprioception and laxity. DESIGN: A longitudinal cohort study with 3-year follow-up. Measurements were performed at the second (t0) and fifth (t1) year of the Cohort Hip and Cohort Knee (CHECK) study. Statistical analyses included paired t tests, chi-square tests, and regression analyses. In regression analyses, the association between muscle strength and activity limitations was adjusted for confounders. SETTING: A rehabilitation and rheumatology center. PARTICIPANTS: Subjects (N=146) with early symptomatic knee OA from the CHECK study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Muscle strength, proprioception, and laxity were assessed using specifically designed measurement devices. Self-reported and performance-based activity limitations were measured with the Western Ontario and McMaster Universities Osteoarthritis Index, the Get Up and Go test, the walk test, and the stair-climb test. RESULTS: A total of 116 women (79.5%) and 30 men (20.5%), with a mean age ± SD of 58.4±4.9 years and a mean body mass index ± SD of 25.5±3.6, were included in the study. Overall, small 3-year changes in muscle strength and activity limitations were observed. At the group level, the average muscle strength increased by 10% (1.0±0.3 to 1.1±0.3Nm/kg) over the 3 years. The 3-year decrease in muscle strength was independently associated with an increase in performance-based activity limitations on all 3 measures (B=-1.12, B=-5.83, and B=-1.25, respectively). Proprioception and laxity did not moderate this association. CONCLUSIONS: In patients with early knee OA, decreased muscle strength is associated with an increase in activity limitations. Our results are a step toward understanding the role of muscle weakness in the development of activity limitations in knee OA. Further well-designed experimental studies are indicated to establish the causal role of muscle weakness in activity limitations.

Long-term effectiveness of a lifestyle intervention for rheumatoid arthritis and osteoarthritis: 1-year follow-up of the 'Plants for Joints' randomised clinical trial.

OBJECTIVES: In two randomised controlled trials, the Plants for Joints (PFJ) multidisciplinary lifestyle intervention reduced signs and symptoms of rheumatoid arthritis (RA), or metabolic syndrome-associated hip or knee osteoarthritis (MSOA) compared with usual care. The current study investigated long-term outcomes. METHODS: After completion of two 16-week trials in people with (1) RA or (2) MSOA, control groups switched to the active PFJ intervention. At the end of the intervention, all participants were followed up in a 1-year observational extension study. Primary outcomes were 28-joint Disease Activity Score (DAS28) (RA) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (MSOA). Secondary outcomes included body composition, metabolic outcomes, medication changes and intervention adherence. An intention-to-treat analysis with a linear mixed model was used to analyse within-group changes. RESULTS: 65 (84%) of 77 RA participants and 49 (77%) of 64 MSOA participants completed the extension study. The effects of the PFJ intervention were replicated in the original control groups and sustained within the RA group a year after intervention completion (mean DAS28 -0.9 points; p<0.001), while in the MSOA group mean WOMAC increased towards but remained well under the starting value (-7.8 points, p<0.001). Improvements in C-reactive protein, waist circumference (RA and MSOA); low-density lipoprotein cholesterol (RA); and weight, haemoglobin A1c, blood pressure (MSOA) were also sustained. Participants had a net decrease of medication, and intervention adherence was largely sustained. CONCLUSIONS: A year after the PFJ lifestyle intervention, improvements of disease activity and metabolic outcomes within RA and MSOA groups were largely sustained and related to sustained adherence, with a net decrease of medication. TRIAL REGISTRATION NUMBERS: NL7800, NL7801.