Self-management approaches for osteoarthritis in the hand: a 2×2 factorial randomised trial.

BACKGROUND: Osteoarthritis is the leading cause of disability in older adults. Evidence of effectiveness for self-management of hand osteoarthritis is lacking. METHODS: In this randomised, factorial trial, we evaluated the effectiveness of joint protection versus no joint protection, and hand exercise versus no hand exercise in adults, 50 years of age or older, with hand osteoarthritis. Following a population survey (n=12 297), eligible individuals were randomly assigned (1:1:1:1) to: leaflet and advice; joint protection; hand exercise; joint protection plus hand exercise. Joint protection and hand exercises were delivered by nine occupational therapists, over four group sessions. The primary outcome was the OARSI/OMERACT responder criteria at 6 months. Outcomes were collected blind to allocation (3, 6, 12 m). Analysis was by intention to treat. RESULTS: Of 257 participants randomised (65:62:65:65) (mean age (SD) 66 years (9.1); female 66%) follow-up was 85% at 6 m (n=212). Baseline characteristics and loss to follow-up were similar between groups. There were no reported treatment side effects. At 6 m 33% assigned joint protection were responders compared with 21% with no joint protection (p=0.03). Of those assigned hand exercises, 28% were responders compared with 25% with no exercises (n.s.). Differences in secondary outcomes were not statistically significant, except for improvement in pain self-efficacy with joint protection (3 m p=0.002; 6 m p=0.001; 12 m p=0.03). CONCLUSIONS: These findings show that occupational therapists can support self-management in older adults with hand osteoarthritis, and that joint protection provides an effective intervention for medium term outcome. (Funded by the Arthritis Research UK ISRCTN 33870549).

Implementing the NICE osteoarthritis guidelines: a mixed methods study and cluster randomised trial of a model osteoarthritis consultation in primary care--the Management of OsteoArthritis In Consultations (MOSAICS) study protocol.

BACKGROUND: There is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving 'quality markers' of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain. DESIGN: A mixed methods study with a nested cluster randomised controlled trial. METHOD: This study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive 'whole-system' evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations. DISCUSSION: The main output from the study will be to determine whether the MOAC intervention is clinically and cost effective. Additional outputs will be the development of the MOAC for patients consulting with joint pain in primary care, training and educational materials, and resources for patients and professionals regarding supported self-management and uptake of NICE guidance. TRIAL REGISTRATION: ISRCTN number: ISRCTN06984617.

Defining the content of an opportunistic osteoarthritis consultation with primary health care professionals: a Delphi consensus study.

OBJECTIVE: To define the core content for an opportunistic consultation between a health care professional (HCP) and a patient with osteoarthritis (OA) in primary care. METHODS: An ideas generation round and a 2-round Delphi postal consensus study allowed participants to rank the importance of tasks for an opportunistic consultation. The study was conducted with a lay group (n = 18) and 3 groups of HCPs (n = 30 for general practitioners, n = 19 for practice nurses, and n = 37 for allied health professionals). RESULTS: The ideas generation round formulated 35 consultation tasks. There was a 50% response rate to the 2-round postal exercise (n = 52). Consensus was reached on 12 tasks for an opportunistic OA consultation using a >80% level of agreement across all groups. Three of these consultation tasks were defined at 100%. The 3 tasks were questions asked by the HCP about how things are going with the condition, the type and amount of pain the patient has, and whether the patient is taking regular analgesia. CONCLUSION: In a Delphi study to define the content of an opportunistic primary care OA consultation, 12 consultation tasks provided the content of a comprehensive consultation. Three of these tasks with 100% agreement could be adopted in any multidisciplinary consultation for OA in primary care. Inquiring about the condition, the type and amount of pain the patient has, and whether analgesia is being taken forms a core set of questions that are considered important by both lay and health professional groups in an opportunistic consultation.

Inequalities in primary care management of knee pain and disability in older adults: an observational cohort study.

OBJECTIVES: To describe primary care management of knee pain, in relation to National Institute for Health and Clinical Excellence (NICE) OA guidelines, and examine variation in management by patient characteristics. METHODS: Subjects were 755 adults aged ≥50 years who responded to baseline and 3-year surveys and had consulted primary care for knee pain. Medical records (1997-2006) were searched. Associations of having interventions from the outer circle (adjunctive treatments or Step 3) of the NICE guidelines with self-reported socio-demographic and knee-specific factors were determined. RESULTS: Eighty per cent had received a Step 3 intervention. Thirty-eight per cent had been referred to secondary care, and 10% had received a knee replacement. Forty-three per cent had been prescribed an opioid and 41% an NSAID. Severe knee pain or disability at baseline and follow-up was the main association with receiving a Step 3 intervention [adjusted odds ratio (OR) 2.26; 95% CI 1.38, 3.70] and with referral (OR 2.57; 95% CI 1.72, 3.83). Older patients were less likely to be referred. Although non-significant, those of higher social class, in more affluent areas, older age or overweight or obese, appeared more likely to receive a knee replacement. Fifty per cent of those reporting severe knee pain or disability in both surveys had not been referred to secondary care. CONCLUSION: Most of the older adults who consult primary care with knee pain receive at least one Step 3 intervention from the OA guidelines. Inequalities in the management and referral of knee problems in primary care were generally not observed, although there were some trends towards differences in likelihood of total knee replacement.

Self management, joint protection and exercises in hand osteoarthritis: a randomised controlled trial with cost effectiveness analyses.

BACKGROUND: There is limited evidence for the clinical and cost effectiveness of occupational therapy (OT) approaches in the management of hand osteoarthritis (OA). Joint protection and hand exercises have been proposed by European guidelines, however the clinical and cost effectiveness of each intervention is unknown.This multicentre two-by-two factorial randomised controlled trial aims to address the following questions:• Is joint protection delivered by an OT more effective in reducing hand pain and disability than no joint protection in people with hand OA in primary care?• Are hand exercises delivered by an OT more effective in reducing hand pain and disability than no hand exercises in people with hand OA in primary care?• Which of the four management approaches explored within the study (leaflet and advice, joint protection, hand exercise, or joint protection and hand exercise combined) provides the most cost-effective use of health care resources METHODS/DESIGN: Participants aged 50 years and over registered at three general practices in North Staffordshire and Cheshire will be mailed a health survey questionnaire (estimated mailing sample n = 9,500). Those fulfilling the eligibility criteria on the health survey questionnaire will be invited to attend a clinical assessment to assess for the presence of hand or thumb base OA using the ACR criteria. Eligible participants will be randomised to one of four groups: leaflet and advice; joint protection (looking after your joints); hand exercises; or joint protection and hand exercises combined (estimated n = 252). The primary outcome measure will be the OARSI/OMERACT responder criteria combining hand pain and disability (measured using the AUSCAN) and global improvement, 6 months post-randomisation. Secondary outcomes will also be collected for example pain, functional limitation and quality of life. Outcomes will be collected at baseline and 3, 6 and 12 months post-randomisation. The main analysis will be on an intention to treat basis and will assess the clinical and cost effectiveness of joint protection and hand exercises for managing hand OA. DISCUSSION: The findings will improve the cost-effective evidence based management of hand OA. TRIAL REGISTRATION: identifier: ISRCTN33870549.

The Clinical Assessment Study of the Hand (CAS-HA): a prospective study of musculoskeletal hand problems in the general population.

BACKGROUND: Pain in the hand affects an estimated 12-21% of the population, and at older ages the hand is one of the most common sites of pain and osteoarthritis. The association between symptomatic hand osteoarthritis and disability in everyday life has not been studied in detail, although there is evidence that older people with hand problems suffer significant pain and disability. Despite the high prevalence of hand problems and the limitations they cause in older adults, little attention has been paid to the hand by health planners and policy makers. We plan to conduct a prospective, population-based, observational cohort study designed in parallel with our previously reported cohort study of knee pain, to describe the course of musculoskeletal hand problems in older adults and investigate the relative merits of different approaches to classification and defining prognosis. METHODS/DESIGN: All adults aged 50 years and over registered with two general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to the survey who indicate that they have experienced hand pain or problems within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, hand assessment, screening test of lower limb function, digital photography, plain x-rays, anthropometric measurement and brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months, and (iii) repeat postal questionnaire at 3 years. DISCUSSION: This paper describes the protocol for the Clinical Assessment Study of the Hand (CAS-HA), a prospective, population-based, observational cohort study of community-dwelling older adults with hand pain and hand problems based in North Staffordshire.

The Knee Clinical Assessment Study-CAS(K). A prospective study of knee pain and knee osteoarthritis in the general population: baseline recruitment and retention at 18 months.

BACKGROUND: Selective non-participation at baseline (due to non-response and non-consent) and loss to follow-up are important concerns for longitudinal observational research. We investigated these matters in the context of baseline recruitment and retention at 18 months of participants for a prospective observational cohort study of knee pain and knee osteoarthritis in the general population. METHODS: Participants were recruited to the Knee Clinical Assessment Study-CAS(K)--by a multi-stage process involving response to two postal questionnaires, consent to further contact and medical record review (optional), and attendance at a research clinic. Follow-up at 18-months was by postal questionnaire. The characteristics of responders/consenters were described for each stage in the recruitment process to identify patterns of selective non-participation and loss to follow-up. The external validity of findings from the clinic attenders was tested by comparing the distribution of WOMAC scores and the association between physical function and obesity with the same parameters measured directly in the target population as whole. RESULTS: 3106 adults aged 50 years and over reporting knee pain in the previous 12 months were identified from the first baseline questionnaire. Of these, 819 consented to further contact, responded to the second questionnaire, and attended the research clinics. 776 were successfully followed up at 18 months. There was evidence of selective non-participation during recruitment (aged 80 years and over, lower socioeconomic group, currently in employment, experiencing anxiety or depression, brief episode of knee pain within the previous year). This did not cause significant bias in either the distribution of WOMAC scores or the association between physical function and obesity. CONCLUSION: Despite recruiting a minority of the target population to the research clinics and some evidence of selective non-participation, this appears not to have resulted in significant bias of cross-sectional estimates. The main effect of non-participation in the current cohort is likely to be a loss of precision in stratum-specific estimates e.g. in those aged 80 years and over. The subgroup of individuals who attended the research clinics and who make up the CAS(K) cohort can be used to accurately estimate parameters in the reference population as a whole. The potential for selection bias, however, remains an important consideration in each subsequent analysis.

Social networks and pain interference with daily activities in middle and old age.

Social networks have emerged as important in the development and progression of disability in aging cohorts. We have previously reported that pain that interferes with daily activities is common and increases incrementally from middle age into later life. The current study has investigated whether pain interference in this age group is related to social network characteristics. 5215 community-dwelling adults aged 50 years and over participating in the North Staffordshire Osteoarthritis Project (NorStOP) and identified as currently experiencing pain formed the sample for the present analysis. Questions on pain-related interference and the number and frequency of contact with children, close relatives, close friends, and confidant were included in the baseline postal questionnaire. The number and frequency of contact for most social ties declined with age. Being widowed (Age-adjusted OR: 1.30; 95%CI: 1.10, 1.54), the absence of close friends (2.07; 1.64, 2.63), and the absence of close relatives for women (2.24; 1.66, 3.04) were associated with increased likelihood of pain interference with daily activities. The absence of children was linked to lower levels of pain interference (0.76; 0.64, 0.91). The associations with close friends and children were reduced but remained significant after adjusting for sociodemographic factors. The association with close friends became non-significant after adjusting for depression suggesting this may form part of the pathway linking close friends networks and pain interference. Pain-related interference shows similar associations with social networks as all-cause disability and may benefit similarly from a public health perspective.

The Knee Clinical Assessment Study--CAS(K). A prospective study of knee pain and knee osteoarthritis in the general population.

BACKGROUND: Knee pain affects an estimated 25% of the adult population aged 50 years and over. Osteoarthritis is the most common diagnosis made in older adults consulting with knee pain in primary care. However, the relationship between this diagnosis and both the current disease-based definition of osteoarthritis and the regional pain syndrome of knee pain and disability is unclear. Expert consensus, based on current evidence, views the disease and the syndrome as distinct entities but the clinical usefulness of these two approaches to classifying knee pain in older adults has not been established. We plan to conduct a prospective, population-based, observational cohort study to investigate the relative merits of disease-based and regional pain syndrome-based approaches to classification and prognosis of knee pain in older adults. METHODS: All patients aged 50 years and over registered with three general practices in North Staffordshire will be invited to take part in a two-stage postal survey. Respondents to this survey phase who indicate that they have experienced knee pain within the previous 12 months will be invited to attend a research clinic for a detailed assessment. This will consist of clinical interview, physical examination, digital photography, plain x-rays, anthropometric measurement and a brief self-complete questionnaire. All consenting clinic attenders will be followed up by (i) general practice medical record review, (ii) repeat postal questionnaire at 18-months.