Better Knee, Better Me™: effectiveness of two scalable health care interventions supporting self-management for knee osteoarthritis - protocol for a randomized controlled trial.

BACKGROUND: Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese. METHODS: Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m2 and < 41 kg/m2 and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed. DISCUSSION: This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).

Advanced musculoskeletal physiotherapy: Barriers and enablers to multi-site implementation.

OBJECTIVES: Advanced musculoskeletal physiotherapy (AMP) services are a safe, effective model of care, but without broad-scale healthcare implementation to date. The aim of the present study was to identify the barriers and enablers to implementation of 12 AMP services from the perspective of clinical staff. METHODS: In a qualitative study, 12 participants (physiotherapists), from 12 different healthcare networks (seven metropolitan, three regional, two rural), were included. Their departments implemented AMP services (orthopaedic postoperative joint replacement review, n = 10; general orthopaedic, n = 1; emergency, n = 1; and neurosurgery n = 1) over a 12-month period. Participants completed a structured survey specifically designed for the study. Thematic analysis was used, with themes mapped to the validated Theoretical Domains Framework. RESULTS: Nine major themes emerged from the data regarding barriers and enablers to the implementation of the AMP services from the perspective of clinical staff. These were: demand/capacity; model of care; the organization; stakeholders; communication; planning and processes; evaluation; workforce; and learning and assessment framework. Important enablers included engagement and buy-in from key stakeholders and medical staff, and well-established AMP learning frameworks for training and operational frameworks. Barriers included competitive funding environment, and issues that hindered effective communication. The knowledge, skills, availability, motivation and experience of the advanced musculoskeletal physiotherapists had a large impact on the implementation. CONCLUSIONS: The study identified a number of factors that should be considered for successful implementation of AMP services across healthcare services or wider healthcare networks.

A Model of Care for Osteoarthritis of the Hip and Knee: Development of a System-Wide Plan for the Health Sector in Victoria, Australia.

Osteoarthritis (OA) imposes a significant burden to the person, the health system and the community. Models of Care (MoCs) drive translation of evidence into policy and practice and provide a platform for health system reform. The Victorian MoC for OA of the hip and knee was developed following a best-practice framework, informed by best-evidence and iterative cross-sector consultation, including direct consumer consultation. Governance and external expert advisory committees consisting of local OA care champions facilitated the development and consultation processes. The MoC outlines key components of care, care that is not recommended, and suggests phased implementation strategies. This paper describes the MoC development process and lessons learned.

Advanced musculoskeletal physiotherapists in post arthroplasty review clinics: a state wide implementation program evaluation.

OBJECTIVE: To evaluate outcomes following a state-wide implementation of post arthroplasty review (PAR) clinics for patients following total hip and knee arthroplasty, led by advanced musculoskeletal physiotherapists in collaboration with orthopaedic specialists. DESIGN AND SETTING: A prospective observational study analysed data collected by 10 implementation sites (five metropolitan and five regional/rural centres) between September 2014 and June 2015. MAIN OUTCOME MEASURES: The Victorian Innovation and Reform Impact Assessment Framework was used to assess efficiency, effectiveness (access to care, safety and quality, workforce capacity, utilisation of skill sets, patient and workforce satisfaction) and sustainability (stakeholder engagement, succession planning and availability of ongoing funding). RESULTS: 2362 planned occasions of service (OOS) were provided for 2057 patients. Reduced patient wait times from referral to appointment were recorded and no adverse events occurred. Average cost savings across 10 sites was AUD$38 per OOS (Baseline $63, PAR clinic $35), representing a reduced pathway cost of 44%. Average annual predicted total value of increased orthopaedic specialist capacity was $11,950 per PAR clinic (range $6149 to $23,400). The Australian Orthopaedic Association review guidelines were met (8/10 sites, 80%) and patient-reported outcome measures were introduced as routine clinical care. High workforce and patient satisfaction were expressed. Eighteen physiotherapists were trained creating a sustainable workforce. Eight sites secured ongoing funding. CONCLUSIONS: The PAR clinics delivered a safe, cost-efficient model of care that improved patient access and quality of care compared to traditional specialist-led workforce models.

Differences in presentation, progression and rates of arthroplasty between hip and knee osteoarthritis: Observations from an osteoarthritis cohort study-a clear role for conservative management.

AIM: To describe the natural progression and the rates of arthroplasty of a cohort of hip and knee osteoarthritis (OA) patients. METHODS: An observational study of 247 consecutive patients who attended an OA clinic between May 2008 and August 2009. Follow-up survey was conducted from July 2014 to December 2014, with the primary end point being joint replacement surgery. RESULTS: One hundred and sixty-seven patients had knee OA and 80 patients had hip OA. When adjusted for other variables (age, gender, body mass index, Kellgren-Lawrence stage, symptom duration, presence of OA elsewhere and pain score), patients with hip OA demonstrated 86% increased hazard of surgery compared to knee OA patients (95% CI increase of 19% to 193%). At 6 years after initial consultation, 67% of patients with knee OA did not require a knee replacement surgery, while 40% (30, 51) of hip OA patients did not undergo surgery (95% CI: 59-74%). Overall at 6 years, 58% of patients (95% CI: 51-64%) did not undergo joint replacement surgery. CONCLUSION: Knee and hip OA patients appear to behave differently, with hip OA patients more likely to undergo arthroplasty. There is a significant number of both hip OA and knee OA patients who did not require arthroplasty at the end of 6 years, suggesting a major role for conservative therapy.

Physiotherapy-led arthroplasty review clinic: a preliminary outcomes analysis.

OBJECTIVE: With the rising demand for Orthopaedics in the healthcare sector, service delivery innovations need to be explored to accommodate the increasing workload. Senior Musculoskeletal Physiotherapists have the specialised skills in the assessment of musculoskeletal conditions to determine the impact of surgery on patient outcomes. The aim of the present study was to compare outcomes between a physiotherapy-led arthroplasty review clinic (PT clinic) and the traditional model of orthopaedic surgeon review (OS clinic) after hip and knee replacement. METHODS: This study was a retrospective case-controlled audit using a comprehensive database. Twenty-four patients who had a hip arthroplasty and 52 patients who had a knee arthroplasty were reviewed solely by the PT clinic at 3, 6 and 12 months after surgical reviews. These patients were matched 1:2 against patients seen only by the OS clinic. The outcome measures included International Knee Score (IKS), Harris Hip Score (HHS) and the Short Form (SF)-12. RESULTS: There were no significant differences in HHS or SF-12 scores for patients after hip arthroplasty. Significant differences for knee arthroplasty were observed favouring the PT clinic; IKS, PT clinic 147.6 (37.07), OS clinic 135.4 (35.68), P≤0.01, and physical component of the SF-12, PT clinic 41.98 (10.45), OS clinic 37.20 (10.44), P<0.01. CONCLUSION: Implementation of a physiotherapy-led arthroplasty review clinic appears to be a safe and effective service alternative to reviews conducted by orthopaedic surgeons. WHAT IS KNOWN ABOUT THE TOPIC?: Osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability and the burden of the disease is rapidly increasing. Joint arthroplasty surgery is the mainstay of treatment for people with end-stage OA; it is a high-cost, high-volume procedure that dominates surgical wait lists around Australia. Long-term follow up is encouraged by the Arthroplasty Society of Australia and endorsed by the Australian Orthopaedics Association, but it is acknowledged that it is impossible to achieve this with solely orthopaedic surgeon reviews, an issue that is only going to worsen with the increased demand for surgery. Physiotherapists have become involved in many advanced scope roles within public health care, and emerging research suggests that patients are highly satisfied with their care in these types of clinics. WHAT DOES THIS PAPER ADD?: Although it has been shown that patients are satisfied in physiotherapy-led advanced clinics, there is a paucity of evidence in the outcomes of patients attending these clinics. Implementation of a physiotherapy-led arthroplasty review clinic demonstrated that outcome measures in this patient cohort were not compromised and, following knee joint arthroplasty, may even be improved. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: The findings of this study indicate that joint review clinics involving physiotherapists acting in an advanced scope role are unlikely to compromise patient outcomes. The use of this role substitution on a broader scale can be recommended.

The effect of joint aspiration and corticosteroid injections in osteoarthritis of the knee.

AIM: To evaluate the benefits of knee joint aspiration and injection in knee osteoarthritis (OA). METHODS: A retrospective, pilot study involved 110 patients with knee OA from a dedicated OA clinic in a Melbourne tertiary hospital from 2007 to 2009. Only those who had completed two Multiple Attribute Prioritization Tool (MAPT) questionnaires within 6 months of the initial review were included. The MAPT was designed to help prioritise patients on orthopedic waiting lists. Three groups were analyzed: patients who had no corticosteroid injection or aspiration, patients who received corticosteroid injections, and patients who received both joint aspiration with corticosteroid injections. RESULTS: Patients who had both joint aspiration and injection reported an improvement in pain compared with those who had no injection (56.3%vs. 32.2%, P = 0.03). Those who had joint injections also did better than those without injection (62.7%vs. 32.2%, P = 0.001). Reduced analgesia use was noted in 12.5% of patients with aspiration and injection compared with 1.7% with no injection or aspiration (P = 0.03). Improved walking distance was noted in 22.4% of patients who had injections compared with 8.5% of patients with no injections (P = 0.03). No significant differences in MAPT scores among the different treatment groups were noted. CONCLUSION: This pilot study appears to show a beneficial trend in giving corticosteroid injections and to aspirate the knee in OA patients. Further studies are needed to address the mechanical benefits, quadriceps strengthening and pain reduction with knee aspiration, as well as the effects that different volumes of fluid may have on knee mechanics and symptoms.

Physiotherapy management of knee osteoarthritis.

Knee osteoarthritis (OA) is a prevalent chronic joint disease causing pain and disability. Physiotherapy, which encompasses a number of modalities, is a non-invasive treatment option in the management of OA. This review summarizes the evidence for commonly used physiotherapy interventions. There is strong evidence to show short-term beneficial effects of exercise on pain and function, although the type of exercise does not seem to influence treatment outcome. Delivery modes, including individual, group or home exercise are all effective, although therapist contact may improve benefits. Attention to improving adherence to exercise is needed to maximize outcomes in the longer-term. Knee taping applied with the aim of realigning the patella and unloading soft tissues can reduce pain. There is also evidence to support the use of knee braces in people with knee OA. Biomechanical studies show that lateral wedge shoe insoles reduce knee load but clinical trials do not support symptomatic benefits. Recent studies suggest individual shoe characteristics also affect knee load and there is current interest in the effect of modified shoe designs. Manual therapy, while not to be used as a stand-alone treatment, may be beneficial. In summary, although the research is not equivocal, there is sufficient evidence to indicate that physiotherapy interventions can reduce pain and improve function in those with knee OA.