Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention.

BACKGROUND: Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care. METHODS: Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation. RESULTS: We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users. CONCLUSIONS: We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework.

Objectives: Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM. Design: We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines. Results: Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences). Conclusions: We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework.

Objectives: Symptomatic knee osteoarthritis (OA) frequently co-occurs in individuals with type 2 diabetes mellitus (T2DM). In the context of T2DM, OA is often underdiagnosed and undertreated. To elucidate strategies to improve OA care in persons with T2DM, we assessed their perceptions of the barriers and enablers to seeking and engaging in OA care. Design: We conducted semi-structured interviews with 18 individuals with T2DM and symptomatic knee OA in Ontario, Canada. Transcripts were deductively coded using the Theoretical Domains Framework (TDF), an implementation science framework that incorporates theoretical domains of behaviour determinants, which can be linked to behaviour change techniques. Within each of the relevant domains, data were thematically analyzed to generate belief statements. Results: Seven of the TDF domains prominently influenced the behaviour to seek and engage in OA care. Participants described insufficient receipt of OA knowledge to fully engage in care (knowledge), feeling incapable of participating in physical activity due to joint pain (beliefs about capabilities), uncertainty about effectiveness of therapies (optimism) and lack of guidance from health care providers and insufficient access to community programs/supports (environmental context and resources). Key enablers were strong social support (social influences), sources of accountability (behavioural regulation) and experiencing benefit from treatment (reinforcement). Participants did not see concomitant T2DM as limiting the desire to seek OA care. Conclusions: Among individuals with symptomatic knee OA and T2DM, we identified behavioural determinants of seeking and engaging in OA care. These will be mapped to behavioural change techniques to inform development of a complex intervention.

Formulating Knee Osteoarthritis Management Plans Taking Type 2 Diabetes Into Account: Qualitative Study of Arthritis Therapists Using Theoretical Domains Framework.

OBJECTIVE: Delivering person-centered care in individuals with knee osteoarthritis (OA) necessitates consideration of other chronic conditions that frequently co-occur. We sought to understand the extent to which arthritis therapists consider type 2 diabetes mellitus (T2DM) when treating persons with knee OA and concomitant T2DM, and barriers to doing so. METHODS: We conducted 18 semistructured telephone interviews with arthritis therapists working within a provincially funded arthritis care program (Arthritis Society Canada) in Ontario, Canada. We first analyzed interviews deductively using the Theoretical Domains Framework (TDF) to comprehensively identify barriers and enablers to health behaviors. Then, within TDF domains, we inductively developed themes. RESULTS: We identified 5 TDF domains as prominently influencing the behavior of arthritis therapists considering concomitant T2DM when developing a knee OA management plan. These were as follows: therapists' perceived lack of specific knowledge around comorbidities including diabetes; the lack of breadth in skills in behavioral change techniques to help patients set and reach their goals, particularly when it came to physical activity; variable intention to factor a patient's comorbidity profile to influence their treatment recommendations; the perception of their professional role and identity as joint focused; and the environmental context with lack of formalized follow-up structure of the current Arthritis Society Canada program that limited sufficient patient monitoring and follow-up. CONCLUSION: Within the context of a Canadian arthritis program, we identified several barriers to arthritis therapists considering T2DM in their management plan for persons with knee OA and T2DM. These results can help inform strategies to improve person-centered OA care and overall health outcomes.

Minimal clinically important difference for improvement in six-minute walk test in persons with knee osteoarthritis after total knee arthroplasty.

BACKGROUND: The interpretability of the six-minute walk test (6MWT) in individuals with knee osteoarthritis (OA) is unclear. We aimed to determine the minimal clinically important difference (MCID) for improvement in 6MWT in persons with knee OA at 12 months after total knee arthroplasty (TKA), and if it differed by baseline walking ability. METHODS: Participants with knee OA were assessed 1 month pre- and 12 months post-TKA, including completion of 6MWT. At 12 months, participant-perceived change in walking ability was assessed on an 8-point Likert scale ranging from "extremely worse" to "extremely better". Using logistic regression, ROC curves examined the ability of change in 6MWT distance to discriminate those who perceived walking was improved. MCID was selected overall and then by quartile of baseline 6MWT distance using the Youden method. RESULTS: Two hundred seventy-eight participants were included: mean age 67 years (SD 8.5), 65.5% female, mean pre-TKA 6MWT distance 323.1 (SD 104.7) m, and mean 12-mo 6MWT distance 396.0 (SD 111.9) m. The overall MCID was 74.3 m (AUC 0.65). Acceptable model discrimination (AUC > 0.70) was achieved for individuals in the lowest quartiles of baseline 6MWT distance: Quartile 1: MCID 88.63 m (AUC 0.73); Quartile 2: MCID 84.47 m (AUC 0.72). CONCLUSIONS: In persons with knee OA 12 months post-TKA, 6MWT MCID is dependent on baseline walking ability. Poor model discrimination for those in the highest (best) quartiles of baseline walking ability raise questions about 6MWT use across the full spectrum of walking ability. Further research is needed to better understand use of 6MWT as a performance-based measure of physical function for persons with knee OA.

Comorbidities do not limit improvement in pain and physical function after total knee arthroplasty in patients with knee osteoarthritis: the BEST-Knee prospective cohort study.

OBJECTIVE: To assess the relationship between comorbidities and amount of improvement in pain and physical function in recipients of total knee arthroplasty (TKA) for knee osteoarthritis (OA). DESIGN: Prospective cohort study. SETTING: Two provincial central intake hip and knee centres in Alberta, Canada. PARTICIPANTS: 1051 participants (278 in 6-minute walk test (6MWT) subset), ≥30 years of age with primary knee OA referred for consultation regarding elective primary TKA; assessed 1 month prior and 12 months after TKA. PRIMARY AND SECONDARY OUTCOME MEASURES: Pre-post TKA change in knee OA pain (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)), physical function (Knee injury and Osteoarthritis Outcome Score (KOOS) Physical Function Short-Form) and 6MWT walking distance; and the reporting of an acceptable symptom state (Patient Acceptable Symptom State (PASS)) at 12 months after TKA. RESULTS: Mean participant age was 67 years (SD 8.8), 59% were female and 85% reported at least one comorbidity. Individuals with a higher number of comorbidities had worse pre-TKA and post-TKA scores for pain, physical function and 6MWT distance. At 12-month follow-up, mean changes in pain, function and 6MWT distance, and proportion reporting a PASS, were similar for those with and without comorbidities. In multivariable regression analysis, adjusted for potential confounders and clustering by surgeon, no specific comorbidities nor total number of comorbidities were associated with less improvement in pain, physical function or 6MWT distance at 12 months after TKA. Patients with diabetes (OR 0.64, 95% CI 0.44 to 0.94) and a higher number of lower extremity troublesome joints (OR 0.85, 95% CI 0.76 to 0.96) had lower odds of reporting a PASS. CONCLUSION: For individuals with knee OA, comorbid conditions do not limit improvement in pain, physical function or walking ability after TKA, and most conditions do not impact achieving an acceptable symptom state.

Impact of Osteoarthritis on Difficulty Walking: A Population-Based Study.

OBJECTIVE: To assess the relationship of hip and knee osteoarthritis (OA) to walking difficulty. METHODS: A population cohort ages ≤55 years recruited from 1996 to 1998 (n = 28,451) completed a standardized questionnaire assessing demographics, health conditions, joint symptoms, and functional limitations, including difficulty walking in the past 3 months. Survey data were linked to health administrative databases; self-report and administrative data were used to identify health conditions. Hip/knee OA was defined as self-reported swelling, pain, or stiffness in a hip or knee lasting ≥6 weeks in the past 3 months without an inflammatory arthritis diagnosis. Using multivariable logistic regression, we examined the determinants of walking difficulty and constructed a clinical nomogram. RESULTS: A total of 18,490 cohort participants were eligible (mean age 68 years, 60% women), and 25% reported difficulty walking. Difficulty walking was significantly and independently associated with older age, female sex, body mass index, and several health conditions. Of the conditions examined, the likelihood of walking difficulty was greatest with hip and knee OA and increased with the number of hip/knee joints affected. The predicted probability of difficulty walking for a 60-year-old middle-income, normal-weight woman was 5-10% with no health conditions, 10-20% with diabetes mellitus and cardiovascular (CV) disease, 40% with OA in 2 hips/knees, 60-70% with diabetes mellitus, CV disease, and OA in 2 hips/knees, and 80% with diabetes mellitus, CV disease, and OA in all hips/knees. CONCLUSION: In a population cohort, symptomatic hip/knee OA was the strongest contributor to walking difficulty. Given the importance of walking to engagement in physical activity for chronic disease management, greater attention to OA is warranted.

Disease-specific pain and function predict future pain impact in hip and knee osteoarthritis.

The objective of this study is to determine if osteoarthritis (OA) pain and function, persistent low back pain (LBP) and psychosocial factors predict future pain impact (PI) in people with hip and knee OA. In a population-based cohort with hip/knee OA, a standardized telephone questionnaire was used to assess baseline sociodemographics, baseline PI, patient-reported OA severity (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) summary score), psychosocial factors (fatigue, pain catastrophizing (PC), anxiety, social network, and depression), and self-reported persistent LBP. Two years post-baseline, PI was assessed using the Pain Impact Questionnaire. The association of key independent variables with PI was evaluated through multivariable linear regression, adjusting for covariates (e.g., age, sex, baseline PI, etc.) In 462 participants, the mean age was 76 years (range 58 to 96), 78 % were female and 35 % reported LBP at baseline. Mean scores for PC (9.4), and anxiety (3.7) were low and social network (20.1) high. In multivariable regression analyses, only the WOMAC summary score (unstandardized ß 0.181 95% CI (0.12, 0.24) p < 0.001) was independently associated with greater PI at follow-up. In a population-based cohort with hip/knee OA, only the baseline WOMAC summary score was an independent predictor of future PI. This suggests that treatment needs to be focused on limiting pain severity and functional limitations in individuals with hip and knee OA. However, scores for the psychosocial factors are indicative of a healthy cohort and therefore results may not be generalizable to those with poorer psychosocial health.

Effects of exercise on bone mass in young women with anorexia nervosa.

PURPOSE: The response of bone to exercise in women with anorexia nervosa (AN) is unclear. We investigated the associations between bone mineral density (BMD) and exercise performed while ill and while recovered in women with a history of AN. METHODS: A cross-sectional study was conducted with 141 women with AN (85 ill; 56 recovered), aged 17-40 yr. BMD at the lumbar spine (LS), femoral neck (FN), and total body (TB) was measured by dual-energy x-ray absorptiometry. Life History Calendar and Minnesota Leisure Time Physical Activity interviews were used to collect lifetime illness and exercise histories (amount and bone loading type). Average hours per week of each of moderate (MOD) and high (HI) bone loading exercise were determined for three illness phases: "before ill," "while ill," and "while recovered." Participants were categorized into four exercise groups for each phase: MOD-ONLY, HI-ONLY, BOTH, and NEITHER (reference group). Weight-adjusted BMD z-scores were compared in the exercise groups by multivariable linear regression, adjusting for illness duration and severity, and exercise during the other illness phases. RESULTS: In ill participants, MOD-ONLY "while ill" had lower BMD at LS (ß = -0.69, 95% confidence interval (CI) = -1.02 to -0.05) and TB (ß = -0.73, 95% CI = -1.31 to -0.15) than the NEITHER group. In recovered participants, HI-ONLY "while recovered" had higher BMD at FN (ß = 0.95, 95% CI = 0.15-1.75) and TB (ß = 0.79, 95% CI = 0.07-1.51) than the NEITHER group. CONCLUSIONS: The effect of exercise on bone in AN patients is dependent on both the type of mechanical loading and the phase of illness during which it was performed. Excessive moderate loading exercise while ill may put patients at higher risk of low bone mass, but high bone loading activities may provoke bone accrual during recovery.

A prospective investigation of the relations among cognitive dietary restraint, subclinical ovulatory disturbances, physical activity, and bone mass in healthy young women.

BACKGROUND: Cognitive dietary restraint (CDR) may mediate subclinical ovulatory disturbances, which may result in loss of bone mineral density (BMD). CDR is associated with greater physical activity, which may modify the effect of CDR and ovulatory disturbances on bone mass. OBJECTIVE: We aimed to investigate the relations among CDR, ovulatory disturbances, and physical activity and their effect on BMD in healthy premenopausal women over a 2-y period. DESIGN: In this prospective cohort study, key explanatory factors, important covariates, and BMD were measured at baseline and at 12 and 24 mo; 225 women completed the baseline assessment, and 189 completed the study. CDR was measured with the Three-Factor Eating Questionnaire, and physical activity was measured with the Baecke scale. An average of 9.8 menstrual cycles in 2 y were monitored by using salivary progesterone measurements and urinary ovulation detection kits. Ovulatory disturbances included anovulatory cycles or short luteal phase lengths of <10 d. BMD at the lumbar spine, femoral neck, and total body was measured by using dual-energy X-ray absorptiometry. General linear mixed modeling was used to determine predictors of change in BMD over time. RESULTS: CDR was not associated with ovulatory disturbances or changes in BMD. The average annual rate of change in lumbar spine BMD was decreased by 0.01 g/cm(2) in women who had experienced > or =3 monitored cycles with ovulatory disturbances (P = 0.02). CONCLUSIONS: CDR did not predict bone loss, and there was no relation between CDR and ovulatory disturbances. Ovulatory disturbances had a negative effect on the rate of change at the lumbar spine. The cause of these disturbances is unknown.

Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy.

OBJECTIVE: To identify key factors associated with outcomes of patients who underwent 8 weeks of physical therapy (PT) for lateral epicondylitis. DESIGN: Multicenter prospective design with inception cohort of lateral epicondylitis patients commencing PT. Baseline clinical examinations were conducted by 1 physical therapist; self-report outcome measures were completed at baseline and 8 weeks later. SETTING: Nine private sports medicine clinics and 2 hospital outpatient departments in Ontario, Canada. PARTICIPANTS: Eighty-three patients with unilateral lateral epicondylitis identified by the treating physical therapists. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The final scores of the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and a vertical pain visual analog scale (VAS) were used as the dependent variables. RESULTS: The final prognostic model for the 8-week DASH scores included the baseline score (95% confidence interval [CI], 0.34-0.66), sex (female) (95% CI, 3.3-14.5), and self-reported nerve symptoms (95% CI, 0.8-13.8). The model for the 8-week VAS scores included the baseline score (95% CI, 0.01-0.37), sex (female) (95% CI, 0.4-18.2), and self-reported nerve symptoms (95% CI, 4.7-25.5). A subanalysis indicated that women were more likely than men to have work-related onsets, repetitive keyboarding jobs, and cervical joint signs. Among women, these factors were associated with higher final DASH and VAS scores. CONCLUSIONS: Women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after PT management of lateral epicondylitis. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs have a prognostic influence on women.

Computer use associated with poor long-term prognosis of conservatively managed lateral epicondylalgia.

STUDY DESIGN: Multicenter prospective design with a cohort of patients with lateral epicondylalgia commencing physical therapy. OBJECTIVE: To identify key factors associated with long-term prognosis of conservatively managed lateral epicondylalgia. BACKGROUND: The response to conservative management of lateral epicondylalgia is inconsistent and the rate of recovery varies widely among individuals. The reasons for these discrepancies are not understood. The identification of factors associated with prognosis will aid in the prediction of patient outcomes. METHODS AND MEASURES: Sixty patients with lateral epicondylalgia, recruited from 9 sports medicine clinics and 2 hospital outpatient physical therapy departments in Ontario, Canada, were followed for 6 months. A baseline clinical assessment was conducted on each participant using standard physical therapy techniques. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a 100-mm pain visual analog scale (VAS) were completed at baseline and 6 months later. RESULTS: The key factor associated with both 6-month DASH and pain VAS scores was repetitive-work tasks (DASH, 9.8 [P < .011; pain VAS, 13.1 mm [P = .0105]). A subanalysis indicated that women were more likely than men to have cervical joint signs and, among women, positive cervical articular signs were also associated with higher final DASH and pain VAS scores. CONCLUSIONS: Although many of the participants identified sports activities as the cause of their injury, these findings emphasize the importance that a patient's work tasks can have on recovery of lateral epicondylalgia. This would suggest that management should perhaps focus on work stations, postures, and behaviors.