Responders to Exercise Therapy in Patients with Osteoarthritis of the Hip: A Systematic Review and Meta-Analysis.

The Outcome Measures in Rheumatology workgroup (OMERACT), together with the Osteoarthritis Research Society International (OARSI) developed the OMERACT-OARSI responder criteria. These criteria are used to determine if a patient with osteoarthritis (OA) 'responds' to therapy, meaning experiences a clinically relevant effect of therapy. Recently, more clinical OA trials report on this outcome and most OA trials have data to calculate the number of responders according to these criteria. A systematic review and meta-analysis were performed on the response to exercise therapy, compared to no or minimal intervention in patients with hip OA using the OMERACT-OARSI responder criteria. The literature was searched for relevant randomized trials. If a trial fit the inclusion criteria, but number of responders was not reported, the first author was contacted. This way the numbers of responders of 14 trials were collected and a meta-analysis on short term (directly after treatment, 12 trials n = 1178) and long term (6-8 months after treatment, six trials n = 519) outcomes was performed. At short term, the risk difference (RD) was 0.14 (95% confidence interval (CI) 0.06-0.22) and number needed to treat (NNT) 7.1 (95% CI 4.5-17); at long term RD was 0.14 (95% CI 0.07-0.20) and NNT 7.1 (95% CI 5.0-14.3). Quality of evidence was moderate for the short term and high for the long term. In conclusion, 14% more hip OA patients responded to exercise therapy than to no therapy.

Are changes in pain, cognitive appraisals and coping strategies associated with changes in physical functioning in older adults with joint pain and chronic diseases?

BACKGROUND: As the population ages, the number of people with chronic diseases increases. Frequently, older people suffer from joint pain together with other chronic diseases, which can lead to decreased physical functioning. AIMS: To investigate the associations of the changes in cognitive appraisals, coping strategies and pain with the change in physical functioning in older people, who have chronic pain and chronic diseases. METHODS: Elderly persons (n = 407, mean age 77 years, and 62% female), with self-reported joint pain and at least two chronic diseases, filled in questionnaires about cognitive appraisals, coping strategies, pain intensity and physical functioning at baseline, at 6- and 18-month follow-ups. The associations of change in physical functioning with changes in cognitive appraisals, coping strategies and pain were modelled using generalized estimating equations (GEE). RESULTS: Increase in pain, in negative thinking about the consequences of pain, and in activity avoidance and decrease in self-efficacy beliefs were associated with a decline in physical functioning. DISCUSSION: Observed mean changes were small but large inter-individual variability was seen. This shows that cognitive appraisals and coping strategies are malleable. Statistical model of change clarifies the direction of longitudinal associations. CONCLUSIONS: The longitudinal findings suggest that joint pain, cognitive appraisals and coping strategies may determine physical functioning in older people who have chronic pain and comorbidity.

Self-perceived care needs in older adults with joint pain and comorbidity.

BACKGROUND: The aim of this study was to explore self-perceived care needs and determinants of identified needs in older adults with joint pain and comorbidity. METHODS: This is a cross-sectional study using baseline data from a cohort study of older adults in the Netherlands (≥65 years) with joint pain and comorbidity (n = 407). We used the Camberwell Assessment of Need for the Elderly (CANE) to assess self-perceived care needs. Regression analyses were conducted to examine the associations between needs and sociodemographic factors (age, gender, partner status and educational level), physical factors (pain intensity, comorbidity, frailty and physical functioning) and psychosocial factors (anxiety, depression and social support). RESULTS: Older adults with joint pain and comorbidity reported on average 4.0 care needs out of 13 CANE items, of which 0.3 were unmet. High levels of environmental and physical needs were reported, such as needs with regard to physical illness (91%), household (61%) and mobility/falls (53%). However, most of these needs were met. Only few people reported psychosocial needs, but a large proportion of these needs was unmet, especially regarding company (66.7%) and daytime activities (37%). Psychosocial needs were more often present in frail participants (OR 2.40, 95% CI 1.25-4.61), and those with less perceived social support (OR 1.05, 95% CI 1.01-1.08) and more depressive symptoms (OR 1.17, 95% CI 1.07-1.26). DISCUSSION/CONCLUSIONS: Unmet needs are mainly present in the psychosocial domain. Specific attention targeted at these unmet needs may improve psychosocial well-being of older adults with joint pain and comorbidity.

The longitudinal association of cognitive appraisals and coping strategies with physical functioning in older adults with joint pain and comorbidity: a cohort study.

BACKGROUND: Substantial variation exists in physical functioning (PF) among patients with comparable pain severity, which may be partly explained by underlying psychological processes, like cognitive appraisal of pain and coping with pain. It remains unclear to what extent such determinants contribute to changes in PF over time, especially in older populations. Therefore, we examined longitudinal associations of cognitive appraisals and coping strategies with PF, in older adults with joint pain and comorbidity. METHODS: A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over 18 months, with 6 month time-intervals. We measured PF (RAND-36), five cognitive appraisals (consequences, concerns, emotional representations, self-efficacy, catastrophizing), four coping strategies (ignoring pain, positive self-statement, increasing activity levels, activity avoidance) and three time-dependent covariates; pain intensity, anxiety and depressive symptoms. Longitudinal associations were analyzed with Generalized Estimated Equations (GEE), by testing auto-regressive models, adjusted for covariates. RESULTS: More negative thoughts about consequences of pain (ß = -0.54, 95% CI = -1.02; -0.06), more catastrophizing (ß = -0.67, 95% CI = -1.26; -0.07) and more activity avoidance (ß = -0.32, 95% CI = -0.57; -0.08) were significantly associated with subsequent deterioration in PF, whereas higher perceived self-efficacy (ß = 0.22, 95% CI = 0.12; 0.31) was associated with subsequent improvement in PF. Neither concerns, emotional representations, ignoring pain, positive self-statement nor increasing activity levels were longitudinally related to PF. CONCLUSIONS: More negative thoughts about consequences of pain, more catastrophizing and more activity avoidance contributed to deteriorated PF, whereas higher perceived self-efficacy contributed to improved PF. This knowledge may contribute to future management of functional limitations in older adults with joint pain and comorbidity.

Trajectories of physical functioning and their prognostic indicators: a prospective cohort study in older adults with joint pain and comorbidity.

OBJECTIVES: This study aimed to identify and characterize homogeneous subgroups of individuals with distinct trajectories of physical functioning (PF) and to examine prognostic indicators of deterioration in PF in a highly heterogeneous population of older adults with joint pain and comorbidity. STUDY DESIGN: A prospective cohort study among 407 older adults with joint pain and comorbidity provided data over a period of 18 months, with 6 month time-intervals. We used latent class growth modelling (LCGM) to identify underlying subgroups (clusters) with distinct trajectories of PF. Next, we characterized these subgroups and applied multivariable logistic regression analysis to identify prognostic indicators for deterioration in PF. MAIN OUTCOME MEASURES: We measures PF with the RAND-36 PF subscale and several potential sociodemographic, physical and psychosocial prognostic indicators. RESULTS: LCGM identified three clusters. Cluster 1 'good PF' contained 140 participants with good baseline PF and small improvements over time. Cluster 2 'moderate PF' contained 130 participants with moderate baseline PF and deterioration over time. Cluster 3 'poor PF' contained 137 participants with poor baseline PF and deterioration over time. After backward selection, the final model that could best distinguish between improved participants (cluster 1) and deteriorated participants (cluster 2-3) included the following prognostic indicators: higher age, more depressive symptoms, less perceived self-efficacy and more activity avoidance. CONCLUSIONS: Older adults with joint pain and comorbidity either improved or deteriorated in PF over time. The prognostic model facilitates the classification of patients, the provision of more accurate information about prognosis and helps to narrow the focus to the high risk group of poor PF.

Frequency, severity and determinants of functional limitations in older adults with joint pain and comorbidity: results of a cross-sectional study.

Older adults with joint pain and comorbidity are especially at risk of becoming functionally impaired. Therefore, we studied the frequency and severity of functional limitations and identified potential modifiable determinants that may reduce functional limitations. A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided cross-sectional baseline data (n=407). Based on the International Classification of Functioning, Disability and Health (ICF) model, we measured Physical Functioning; PF, (Instrumental) Activities of Daily Living; (I)ADL, and participation. Apart from examining the frequency and severity, we identified determinants of functional limitations with multivariate regression analyses, by adding determinants in two steps: (1) only physical determinants, (2) physical and psychosocial determinants. Limitations in PF, ADL, IADL and participation were present in 66%, 31%, 61% and 47% of the participants, respectively. About 22% reported limitations on all four measures. Of the physical determinants, especially frailty and higher pain intensity were related to functional limitations. Remarkably, adding psychosocial determinants to the model weakened some of these relations. The psychosocial determinants were especially related to poor PF (i.e. anxiety symptoms, activity avoidance and poor general health perception) and participation restrictions (i.e. depressive symptoms, less social support). An inverse relation was present between self-efficacy and both outcomes. In conclusion, our sample reported substantial levels of functional limitations. More depressive symptoms, more activity avoidance and less social support were indicative of more functional limitations, whereas higher perceived self-efficacy was indicative of better functioning. Such psychosocial determinants should receive more attention in research.

Self-perceived met and unmet care needs of frail older adults in primary care.

In order to provide adequate care for frail older adults in primary care it is essential to have insight into their care needs. Our aim was to describe the met and unmet care needs as perceived by frail older adults using a multi-dimensional needs assessment, and to explore their associations with socio-demographic and health-related characteristics. Cross-sectional baseline data were used from the Frail older Adults: Care in Transition (ACT) study in the Netherlands, consisting of 1137 community dwelling frail older adults aged 65 and above. Patients were recruited through 35 primary care practices. Self-perceived care needs were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Socio-demographic characteristics included age, sex, partner status and educational level. Health-related characteristics included functional capacity, hospital admissions, chronic diseases and the degree of frailty. Frail older adults reported on average 4.2 care needs out of 13 CANE topics, of which 0.5 were unmet. The physical and environmental domain constituted the highest number of needs, but these were mostly met. Unmet needs were mainly found in the psychosocial domain. Regression analyses revealed that Activities of Daily Living (ADL) limitations and a higher frailty score were the most important determinants of both met and unmet care needs. A younger age and a higher educational level were associated with the presence of unmet care needs. In conclusion, most frail older adults in primary care report to receive sufficient help for their physical needs. More attention should be paid to their psychosocial needs.

Exploring the aggregation of four functional measures in a population of older adults with joint pain and comorbidity.

BACKGROUND: In clinical settings, it is important for health care providers to measure different aspects of functioning in older adults with joint pain and comorbidity. Besides the use of distinct measures, it could also be attractive to have one general measure of functioning that incorporates several distinct measures, but provides one summary score to quantify overall level of functioning, for example for the identification of older adults at risk of poor functional outcome. Therefore, we selected four measures of functioning: Physical Functioning (PF), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and participation, and tested the possibility to aggregate these measures into one general measure of functioning. METHODS: A prospective cohort study of older adults (≥65 years) with joint pain and comorbidity provided baseline data (n = 407) consisting of PF (PF subscale, RAND-36; 10 items), ADL (KATZ index; 6 items), IADL (Lawton index; 7 items) and participation (KAP; 6 items). We tested two models with confirmatory factor analysis: first, a bifactor model with all four measures and second, a bifactor model with PF, ADL and IADL and a correlated but distinct subgroup factor for participation. Several model fit indexes and reliability coefficients, such as explained common variance (ECV) and omegas were computed for both models. RESULTS: The first model fitted the data well, but the reliability analysis indicated multidimensionality and unique information in the subgroup factor participation. The second model showed similar model fits, but better reliability; ECV = 0.67, omega-t = 0.94, low omega-s = 0.18-0.22 on the subgroup factors and high omega of 0.82 on participation, which all were in favour of the second model. CONCLUSIONS: The results indicate that PF, ADL and IADL could be aggregated into one general measure of functioning, whereas participation should be considered as a distinct measure.

Social participation in older adults with joint pain and comorbidity; testing the measurement properties of the Dutch Keele Assessment of Participation.

OBJECTIVE: The Keele Assessment of Participation (KAP) questionnaire measures person-perceived participation in 11 aspects of life. Participation allows fulfilment of valued life activities and social roles, which are important to older adults. Since we aimed to use the KAP in a larger Dutch cohort, we examined the measurement properties of KAP in a Dutch sample of older adults with joint pain and comorbidity. DESIGN: Cohort study. SETTING: A community-based sample in Amsterdam, the Netherlands and North Staffordshire, UK. PARTICIPANTS: Participants were aged 65 years and over, had at least two chronic diseases (identified through general practice consultation) and reported joint pain on most days (questionnaire). The Dutch cohort provided baseline data (n=407), follow-up data at 6 months (n=364) and test-retest data 2 weeks after 6 months (n=122). The UK cohort provided comparable data (n=404). OUTCOME MEASURES: The primary outcome was person-perceived participation, as measured with the KAP. The measurement properties examined were the following: structural validity (factor analysis), internal consistency (Cronbach's α), reliability (intraclass correlation coefficients; ICC), construct validity (hypothesis testing), responsiveness (hypothesis testing and area under the curve) and cross-cultural validity (differential item functioning; DIF). RESULTS: Factor analysis revealed two domains: KAPd1: 'participation in basic activities' and KAPd2: 'participation in complex activities', with Cronbach's α of 0.74 and 0.57 and moderate test-retest reliability: ICC of 0.63 and 0.57, respectively. Further analyses of KAPd1 showed poor construct validity and responsiveness. Despite the uniform DIF in item 'interpersonal relations', the total KAPd1 score seemed comparable between the Dutch and UK sample. CONCLUSIONS: Only KAP domain 'participation in basic activities' showed good internal consistency and sufficient reliability. KAPd2 lacks sufficient measurement properties for application in studies, although items may be used as single items. Further development of the concept 'participation' may help the development and validation of instruments to measure participation.

Functional outcome in older adults with joint pain and comorbidity: design of a prospective cohort study.

BACKGROUND: Joint pain is a highly prevalent condition in the older population. Only a minority of the older adults consult the general practitioner for joint pain, and during consultation joint pain is often poorly recognized and treated, especially when other co-existing chronic conditions are involved. Therefore, older adults with joint pain and comorbidity may have a higher risk of poor functional outcome and decreased quality of life (QoL), and possibly need more attention in primary care. The main purpose of the study is to explore functioning in older adults with joint pain and comorbidity, in terms of mobility, functional independence and participation and to identify possible predictors of poor functional outcome. The study will also identify predictors of decreased QoL. The results will be used to develop prediction models for the early identification of subgroups at high risk of poor functional outcome and decreased QoL. This may contribute to better targeting of treatment and to more effective health care in this population. METHODS/DESIGN: The study has been designed as a prospective cohort study, with measurements at baseline and after 6, 12 and 18 months. For the recruitment of 450 patients, 25 general practices will be approached. Patients are eligible for participation if they are 65 years or older, have at least two chronic conditions and report joint pain on most days. Data will be collected using various methods (i.e. questionnaires, physical tests, patient interviews and focus groups). We will measure different aspects of functioning (e.g. mobility, functional independence and participation) and QoL. Other measurements concern possible predictors of functioning and QoL (e.g. pain, co-existing chronic conditions, markers for frailty, physical performance, psychological factors, environmental factors and individual factors). Furthermore, health care utilization, health care needs and the meaning and impact of joint pain will be investigated from an older person's perspective. DISCUSSION: In this paper, we describe the protocol of a prospective cohort study in Dutch older adults with joint pain and comorbidity and discuss the potential strengths and limitations of the study.