Challenges of transforming evidence-based management of osteoarthritis into clinical practice in rural central Western India. Perceptions of an educational program.

PURPOSE: Osteoarthritis (OA) is a major threat to public health worldwide and is predicted to increase. Existing interventions to implement clinical practice guidelines (CPGs) seem to be used mainly in the Western world. We conducted a structured educational program on the evidence-based management of OA (BOA) for Indian physical therapists (PT). Our study aimed to describe Indian PTs' knowledge, attitudes and confidence on evidence-based management of OA, and their perceptions of a course on this subject. METHODS: The 2-day course included didactic parts and practical skills training. Thirty-five PTs participated and answered a questionnaire. Fourteen of them participated in focus group interviews. Questionnaire data are presented as medians and full ranges. Manifest content analysis was used to analyze interview data that are presented as catagories illustrated by interview quotes. The formal ethics permission was granted. RESULTS: 74% of PTs agreed that radiography determines the type of treatment required, and 69% agreed that a prescription for exercise is enough to ensure adherence. PTs agreed (mean 5 on 6-point scale) that exercises increasing pain should be advised against. Confidence in guiding the physical activity was generally high (≥5 on 6-point scales). Five categories reflected participants' perceptions of the course content: Shift in management focus, Need for cultural adaptation, Importance of social support, Development of organization and collaboration, and Feelings of hesitation. DISCUSSION: Our results indicate that in order to facilitate the implementation of CPGs, PT curricula may consider the inclusion of knowledge on CPGs, focus more on students' own reflections on transforming theory into practice, and incorporate training of basic skills required for implementation of self-management, body awareness, and neuromuscular fitness. If given access and mandates, PTs may play a major role in the early diagnosis and treatment of OA and thus contribute to the prevention of an epidemic of OA in India.

Approaches to osteoarthritis: a qualitative study among physical therapists in Maharashtra, India.

BACKGROUND AND OBJECTIVE: Osteoarthritis (OA) is a major and growing problem in India. Better knowledge dissemination and implementation of evidence-based practice in Indian physical therapy require a better understanding of approaches to OA (i.e. perceptions of the condition and its management by Indian physical therapists (PTs)) which was the aim of our study. DESIGN AND METHOD: We used qualitative content analysis to analyze semi-structured interviews with 19 PTs from Maharashtra state, purposefully selected to represent both sexes, different ages and different educational and professional backgrounds. FINDINGS: We identified a main overarching theme of meaning, OA as a degenerative and irreversible condition with the four descriptive themes Assessment, Standardized treatment protocol, Leadership and Patient compliance as PTs' approaches to OA. The descriptive themes indicate that much focus seems to be on pain, physical impairments and biomechanics, with initial treatments being mainly passive. Communication appears to be mainly unidirectional with the PTs instructing the patients, who are expected to comply with PTs instructions. Clinical practice guidelines (CPGs) were not mentioned. CONCLUSIONS: Our findings can inform the design of awareness campaigns on evidence-based OA management and increase the understanding of the educational needs of students and PTs in non-Western countries. It is important to recognize that CPGs are mainly based on studies carried out in Western countries and that there are context-specific barriers to implementation in other parts of the world that have large populations.

Physiotherapist or physician as primary assessor for patients with suspected knee osteoarthritis in primary care - a cost-effectiveness analysis of a pragmatic trial.

BACKGROUND: Over the next decade, the number of osteoarthritis consultations in health care is expected to increase. Physiotherapists may be considered equally qualified as primary assessors as physicians for patients with knee osteoarthritis. However, economic evaluations of this model of care have not yet been described. To determine whether physiotherapists as primary assessors for patients with suspected knee osteoarthritis in primary care are a cost-effective alternative compared with traditional physician-led care, we conducted a cost-effectiveness analysis alongside a randomized controlled pragmatic trial. METHODS: Patients were randomized to be assessed and treated by either a physiotherapist or physician first in primary care. A cost-effectiveness analysis compared costs and effects in quality adjusted life years (QALY) for the different care models. Analyses were applied with intention to treat, using complete case dataset, and missing data approaches included last observation carried forward and multiple imputation. Non-parametric bootstrapping was conducted to assess sampling uncertainty, presented with a cost-effectiveness plane and cost-effectiveness acceptability curve. RESULTS: 69 patients were randomized to a physiotherapist (n = 35) or physician first (n = 34). There were significantly higher costs for physician visits and radiography in the physician group (p < 0.001 and p = 0.01). Both groups improved their health-related quality of life 1 year after assessment compared with baseline. There were no statistically significant differences in QALYs or total costs between groups. The incremental cost-effectiveness ratio for physiotherapist versus physician was savings of 24,266 €/lost QALY (societal perspective) and 15,533 €/lost QALY (health care perspective). There is a 72-80% probability that physiotherapist first for patients with suspected knee osteoarthritis is less costly and differs less than ±0.1 in QALY compared to traditional physician-led care. CONCLUSION: These findings suggest that physiotherapist-led care model might reduce health care costs and lead to marginally less QALYs, but confidence intervals were wide and overlapped no difference at all. Health consequences depending on the profession of the first assessor for knee osteoarthritis seem to be comparable for physiotherapists and physicians. Direct access to physiotherapist in primary care seems to lead to fewer physician consultations and radiography. However, larger clinical trials and qualitative studies to evaluate patients' perception of this model of care are needed. CLINICAL TRIAL REGISTRATION: The study was retrospectively registered in clinicaltrial.gov, ID: NCT03822533.

High self-efficacy - a predictor of reduced pain and higher levels of physical activity among patients with osteoarthritis: an observational study.

BACKGROUND: Self-efficacy is considered a core component in self-management. However, there is a lack of knowledge about the association between self-efficacy and health-related outcomes in osteoarthritis. The aim of this study was to investigate whether self-efficacy at baseline was associated with change over time in pain and physical activity after a supported osteoarthritis self-management programme. METHODS: A total of 3266 patients with hip or knee osteoarthritis attended this observational, register-based study. Self-efficacy was assessed using the Arthritis Self-Efficacy Scale. Pain was estimated on a visual analogue scale and physical activity by self-reporting number of days per week the patients were physically active ≥30 min. Data were self-reported at baseline and at follow-ups after 3 and 12 months. Analyses were performed using a mixed linear model analysis and are presented with an unadjusted and an adjusted model. RESULTS: High vs low self-efficacy for pain management at baseline resulted in reduced pain and increased physical activity at the follow-ups; least squares means and standard error were 37.43 ± 0.40 vs 44.26 ± 0.40, for pain, and 5.05 ± 0.07 vs 4.90 ± 0.08 for physical activity. High self-efficacy for management of other symptoms resulted in lower pain and higher physical activity at follow-up: 35.78 ± 0.71 vs 41.76 ± 0.71 for pain, and 5.08 ± 0.05 vs 4.72 ± 0.05 for physical activity. Patients with obesity reported lower activity levels at the follow-ups. CONCLUSION: Self-efficacy at baseline was associated with change over time in pain and physical activity at 3 and 12 months after the supported osteoarthritis self-management programme. High self-efficacy had a positive effect on pain and physical activity, indicating the need for exploring and strengthening patients' self-efficacy. Patients with obesity may need further interventions and support during a self-management programme to achieve an increase in physical activity.

Change in self-efficacy after participation in a supported self-management program for osteoarthritis - an observational study of 11 906 patients.

Purpose: Describe the change in self-efficacy after a supported osteoarthritis self-management program.Materials and methods: An observational register-based study comprising 11 906 patients. Participants with hip or knee osteoarthritis self-reported at baseline, 3 and 12 months. Self-efficacy for pain and other symptoms were assessed with the Arthritis Self-efficacy Scale. Change was analyzed using a mixed-effect model for repeated measurements.Results: In total, 9440 (pain subscale) and 9361 (symptom subscale) patients reported self-efficacy scores at baseline and at least one follow-up. The lowest self-efficacy at baseline was reported by patients with low education, walking difficulties, comorbidity and low physical activity level. Overall, the self-efficacy scores improved at the 3-month follow-up and returned to baseline at the 12-month follow-up. Younger age (pain and symptom subscales) and exercise (pain subscale) were associated with a greater increase in self-efficacy. Obesity (pain subscale) and hip problems (pain and symptom subscales) were associated with lower self-efficacy at baseline and a greater decrease at follow-up.Conclusion: Self-efficacy was related to the level of education, physical activity, mobility, and comorbidity. In addition, hip problems or obesity were associated with greater difficulties in enhancing or maintaining self-efficacy. An increased focus on patients with hip problems or obesity might help to improve outcomes after supported self-management programs for osteoarthritis.IMPLICATIONS FOR REHABILITATIONSelf-efficacy increased more in younger patients and in those who opted for exercise as part of the intervention, which indicates that offering supported self-management early in the course of the disease might be important.Lower self-efficacy at baseline and reduced beliefs about their ability to manage pain indicate that patients with hip OA or obesity may need to be given a special focus by healthcare.Self-efficacy in managing pain and other symptoms seemed to increase after a supported self-management osteoarthritis program, but was not maintained at the 12-month follow-up, indicating that more on-going support might be needed to maintain self-efficacy.

Chronic widespread pain and its associations with quality of life and function at a 20- year follow-up of individuals with chronic knee pain at inclusion.

OBJECTIVE: To study the prevalence of chronic widespread pain (CWP) and chronic regional pain (CRP), and their association to quality of life, pain, physical function at a 20-year follow-up in a population based cohort with chronic knee pain at inclusion. METHODS: 121 individuals (45% women, mean age 64 years, range 54-73) with chronic knee pain from a population-based cohort study, answered a questionnaire and had radiographic knee examination at a 20-year follow-up. The responders were divided into three groups according to reported pain; individuals having no chronic pain (NCP), chronic widespread pain (CWP) and chronic regional pain (CRP). Pain and physical function were assessed using Knee injury and Osteoarthritis Outcome Score (KOOS). Health related quality of life (HRQL) was assessed with Euroqol-5D-3 L (EQ5D) and Short form 36 (SF36). The associations between pain groups and KOOS, EQ5D, and SF36 were analysed by multiple logistic regression, controlled for age, gender and radiographic changes indicating knee osteoarthritis (OA). RESULTS: The prevalence of CWP was 30%, and CWP was associated to worse scores in all KOOS subscales, controlled for age, gender and radiographic changes. CWP was also associated to worse scores in EQ-5D and in seven of the SF-36 subgroups, controlled for age, gender and radiographic changes. CONCLUSION: One third of individuals with chronic knee pain met the criteria for CWP. CWP was associated with patient reported pain, function and HRQL. This suggest that it is important to assess CWP in the evaluation of patients with chronic knee pain, with and without radiographic knee OA.

Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study.

BACKGROUND: In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care. METHODS: An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013-2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0-100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat. RESULTS: Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported. CONCLUSIONS: There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors. TRIAL REGISTRATION: Retrospectively registered at http://clinicaltrial.gov , ID: NCT03715764.

The effect of education and supervised exercise on physical activity, pain, quality of life and self-efficacy - an intervention study with a reference group.

BACKGROUND: Individuals with knee and hip osteoarthritis (OA) are less physically active than people in general, and many of these individuals have adopted a sedentary lifestyle. In this study we evaluate the outcome of education and supervised exercise on the level of physical activity in individuals with knee or hip OA. We also evaluate the effect on pain, quality of life and self-efficacy. METHODS: Of the 264 included individuals with knee or hip OA, 195 were allocated to the intervention group. The intervention group received education and supervised exercise that comprised information delivered by a physiotherapist and individually adapted exercises. The reference group consisted of 69 individuals with knee or hip OA awaiting joint replacement and receiving standard care. The primary outcome was physical activity (as measured with an accelerometer). The secondary outcomes were pain (Visual Analog Scale), quality of life (EQ-5D), and self-efficacy (Arthritis Self-Efficacy Scale, pain and other symptoms subscales). Participants in both groups were evaluated at baseline and after 3 months. The intervention group was also evaluated after 12 months. RESULTS: No differences were found in the number of minutes spent in sedentary or in physical activity between the intervention and reference groups when comparing the baseline and 3 month follow-up. However, there was a significant difference in mean change (mean diff; 95% CI; significance) between the intervention group and reference group favoring the intervention group with regard to pain (13; 7 to 19; p < 0.001), quality of life (- 0.17; - 0.24 to - 0.10; p < 0.001), self-efficacy/other symptoms (- 5; - 10 to - 0.3; p < 0.04), and self-efficacy/pain (- 7; - 13 to - 2; p < 0.01). Improvements in pain and quality of life in the intervention group persisted at the 12-month follow-up. CONCLUSIONS: Participation in an education and exercise program following the Swedish BOA program neither decreased the average amount of sedentary time nor increased the level of physical activity. However, participation in such a program resulted in decreased pain, increased quality of life, and increased self-efficacy. TRIAL REGISTRATION: The trial is registered with ClinicalTrials.gov. Registration number: NCT02022566 . Retrospectively registered 12/18/2013.

Health enhancing physical activity in patients with hip or knee osteoarthritis - an observational intervention study.

BACKGROUND: Osteoarthritis is one of the leading causes of inactivity worldwide. The recommended level of health enhancing physical activity (HEPA) is at least 150 min of moderate intensity physical activity per week. The purpose of this study was to explore how the proportion of patients, who reached the recommended level of HEPA, changed following a supported osteoarthritis self-management programme in primary care, and to explore how reaching the level of HEPA was influenced by body mass index (BMI), gender, age and comorbidity. METHODS: An observational study was conducted using data from a National Quality Registry in which 6810 patients in primary care with clinically verified hip or knee osteoarthritis with complete data at baseline, 3 and 12 months follow-up before December 31st 2013 were included. HEPA was defined as self-reported physical activity of at least moderate intensity either a) at least 30 min per day on four days or more per week, or b) at least 150 min per week. HEPA was assessed at baseline, and again at 3 and 12 months follow-up. Cochran's Q test was used to determine change in physical activity over time. The association between reaching the level of HEPA and time, age, BMI, gender, and Charnley classification was investigated using the generalized estimation equation (GEE) model. RESULTS: The proportion of patients who reached the level of HEPA increased by 345 patients, from 77 to 82%, from baseline to 3 months follow-up. At 12 months, the proportion of patients who reached the level of HEPA decreased to 76%. Not reaching the level of HEPA was associated with overweight, obesity, male gender and Charnley category C, i.e. osteoarthritis in multiple joint sites (hip and knee), or presence of any other disease that affects walking ability. CONCLUSIONS: Following the supported osteoarthritis self-management programme there was a significant increase in the proportion of patients who reached the recommended level of HEPA after 3 months. Improvements were lost after 12 months. To increase physical activity and reach long-lasting changes in levels of physical activity, more follow-up sessions might be needed.

Osteoarthritis: Models for appropriate care across the disease continuum.

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition.

A Web-Based Platform for Patients With Osteoarthritis of the Hip and Knee: A Pilot Study.

BACKGROUND: Chronic conditions are the leading cause of disability throughout the world and the most expensive problem facing the health care systems. One such chronic condition is osteoarthritis (OA), a frequent cause of major disability. OBJECTIVE: To describe the effect on joint pain for the first users of a newly developed Web-based osteoarthritis self-managing program, Joint Academy, and to examine whether these patients would recommend other OA patients to use the program. METHODS: Patients with clinically established knee or hip OA according to national and international guidelines were recruited from an online advertisement. A trained physiotherapist screened the eligible patients by scrutinizing their answers to a standardized questionnaire. The 6-week program consisted of eight 2- to 5-minute videos with lectures about OA, effects of physical activity, self-management, and coping strategies. In addition, exercises to improve lower extremity physical function were introduced in daily video activities. During the course of the program, communication between physiotherapist and patients was based on an asynchronous chat. After 6 weeks, patients were able to continue without support from the physiotherapist. Patients reported their current pain weekly by using a numeric rating scale (range 0-10; 0=no pain, 10=worst possible pain) as long as they were in the program. In addition, after 6 weeks patients answered the question "What is the probability that you would recommend Joint Academy to a friend?" RESULTS: The eligible cohort consisted of 53 individuals (39 women; body mass index: mean 27, SD 5; age: mean 57, SD 14 years). With the continued use of the program, patients reported a constant change in pain score from mean 5.1 (SD 2.1) at baseline to mean 3.6 (SD 2.0) at week 12. Six patients participated for 30 weeks (mean 3.2, SD 2.1). Overall, the patients would highly recommend Joint Academy to other OA patients, suggesting that the platform may be useful for at least some in the vast OA population. CONCLUSIONS: Joint Academy, a Web-based platform for OA therapy, has the potential to successfully deliver individualized online treatment to many patients with OA that presently lack access to treatment.

Better Management of Patients with Osteoarthritis: Development and Nationwide Implementation of an Evidence-Based Supported Osteoarthritis Self-Management Programme.

BACKGROUND: Information and exercise are core treatments of osteoarthritis. Self-management and coping strategies with the disease are crucial to gain benefits. We developed a supported osteoarthritis self-management programme, delivered by trained physiotherapists, to facilitate patient and healthcare compliance. The programme combined peer- and healthcare professional-delivered information, and individually adapted exercise. METHODS: Physiotherapists were trained to deliver and evaluate the programme. Patient-reported compliance and satisfaction with the programme was assessed at three- and 12-month follow-ups. RESULTS: Data from 20,200 consecutive patients in 320 different care centres in Sweden showed that 97% attended the theory sessions and 83% volunteered for the optional individual exercise programme. The intervention was rated as good or very good by 94% of patients. After three months, 62% reported daily use of what they had learned during the course, and 91% reported weekly use. Corresponding numbers after 12 months were 37% and 72%. CONCLUSIONS: The supported osteoarthritis self-management programme is feasible in clinical practice, and seems useful and acceptable to patients.

Knee joint stabilization therapy in patients with osteoarthritis of the knee and knee instability: subgroup analyses in a randomized, controlled trial.

OBJECTIVE: To test whether knee stabilization therapy, prior to strength/functional training, may have added value in reducing activity limitations only in patients with knee osteoarthritis who have knee instability and (i) low upper leg muscle strength, (ii) impaired knee proprioception, (iii) high knee laxity, or (iv) frequent episodes of knee instability. DESIGN: Subgroup analyses in a randomized controlled trial comparing 2 exercise programmes (with/without knee stabilization therapy) (STABILITY; NTR1475). PATIENTS: Participants from the STABILITY-trial with clinical knee osteoarthritis and knee instability (n = 159). METHODS: Effect modification by upper leg muscle strength, knee proprioception, knee laxity, and patient-reported knee instability were determined using the interaction terms "treatment group subgroup factor", with the outcome measures WOMAC physical function (primary), numeric rating scale pain and the Get up and Go test (secondary). RESULTS: Effect modification by muscle strength was found for the primary outcome (p = 0.01), indicating that patients with greater muscle strength tend to benefit more from the experimental programme with additional knee stabilization training, while patients with lower muscle strength benefit more from the control programme. CONCLUSION: Knee stabilization therapy may have added value in patients with instability and strong muscles. Thus it may be beneficial if exercises target muscle strength prior to knee stabilization.

Differences in muscle activity during hand-dexterity tasks between women with arthritis and a healthy reference group.

BACKGROUND: Impaired hand function is common in patients with arthritis and it affects performance of daily activities; thus, hand exercises are recommended. There is little information on the extent to which the disease affects activation of the flexor and extensor muscles during these hand-dexterity tasks. The purpose of this study was to compare muscle activation during such tasks in subjects with arthritis and in a healthy reference group. METHODS: Muscle activation was measured in m. extensor digitorium communis (EDC) and in m. flexor carpi radialis (FCR) with surface electromyography (EMG) in women with rheumatoid arthritis (RA, n = 20), hand osteoarthritis (HOA, n = 16) and in a healthy reference group (n = 20) during the performance of four daily activity tasks and four hand exercises. Maximal voluntary isometric contraction (MVIC) was measured to enable intermuscular comparisons, and muscle activation is presented as %MVIC. RESULTS: The arthritis group used a higher %MVIC than the reference group in both FCR and EDC when cutting with a pair of scissors, pulling up a zipper and-for the EDC-also when writing with a pen and using a key (p < 0.02). The exercise "rolling dough with flat hands" required the lowest %MVIC and may be less effective in improving muscle strength. CONCLUSIONS: Women with arthritis tend to use higher levels of muscle activation in daily tasks than healthy women, and wrist extensors and flexors appear to be equally affected. It is important that hand training programs reflect real-life situations and focus also on extensor strength.

Dissatisfied patients after total knee arthroplasty: a registry study involving 114 patients with 8-13 years of followup.

BACKGROUND AND PURPOSE: In 2003, an enquiry by the Swedish Knee Arthroplasty Register (SKAR) 2-7 years after total knee arthroplasty (TKA) revealed patients who were dissatisfied with the outcome of their surgery but who had not been revised. 6 years later, we examined the dissatisfied patients in one Swedish county and a matched group of very satisfied patients. PATIENTS AND METHODS: 118 TKAs in 114 patients, all of whom had had their surgery between 1996 and 2001, were examined in 2009-2010. 55 patients (with 58 TKAs) had stated in 2003 that they were dissatisfied with their knees and 59 (with 60 TKAs) had stated that they were very satisfied with their knees. The patients were examined clinically and radiographically, and performed functional tests consisting of the 6-minute walk and chair-stand test. All the patients filled out a visual analog scale (VAS, 0-100 mm) regarding knee pain and also the Hospital and Anxiety and Depression scale (HAD). RESULTS: Mean VAS score for knee pain differed by 30 mm in favor of the very satisfied group (p < 0.001). 23 of the 55 patients in the dissatisfied group and 6 of 59 patients in the very satisfied group suffered from anxiety and/or depression (p = 0.001). Mean range of motion was 11 degrees better in the very satisfied group (p < 0.001). The groups were similar with regard to clinical examination, physical performance testing, and radiography. INTERPRETATION: The patients who reported poor response after TKA continued to be unhappy after 8-13 years, as demonstrated by VAS pain and HAD, despite the absence of a discernible objective reason for revision.

Similar problem in the activities of daily living but different experience: a qualitative analysis in six rheumatic conditions and eight European countries.

OBJECTIVE: The aim of the present study was to compare and contrast the concepts of functioning in daily life which were important to patients with different rheumatological conditions. METHOD: The study comprised a qualitative analysis of 44 focus groups in eight European countries, in 229 patients with fibromyalgia, hand osteoarthritis, psoriatic arthritis, rheumatoid arthritis, systemic lupus erythematosus and systemic sclerosis, using the World Health Organization, 2001 International Classification of Functioning, Disability and Health as a framework. Concepts and - where necessary - also sub-concepts and transcripts were combined and compared independently by two researchers who, in case of disagreement, achieved consensus through discussion. RESULTS: Twenty concepts out of 109 (e.g. body image, fatigue, emotional issues, mobility and hand function) were similarly described in all six diseases. However, even if the same concept was mentioned, patients' experiences were different, such as mental AND physical aspects limiting the ability to drive in patients with fibromyalgia compared with ONLY physical problems in all other diseases. Within body functions and structures, several concepts were relevant for certain conditions only. CONCLUSION: A large number of similar problems are mentioned as 'typical' by patients with different rheumatic conditions. These could probably be targeted, using a disease-specific approach, in interventions by non-physician health professionals.

Risk of sick leave and disability pension in working-age women and men with knee osteoarthritis.

OBJECTIVES: To investigate sick leave and disability pension in working-age subjects with knee osteoarthritis (OA) compared with the general population. METHODS: Population-based cohort study: individual-level inpatient and outpatient Skåne Health Care Register data were linked with data from the Swedish Social Insurance Agency. In 2009 all working-age (16-64 years) Skåne County residents who in 1998-2009 had been diagnosed with knee OA (International Classification of Diseases-10 code M17) were identified and their sick leave and disability pension in 2009 related to those of the general working-age population (n=789 366) standardised for age. RESULTS: 15 345 working-age residents (49.6% women) with knee OA were identified. Compared with the general population, the RR (95% CI) of having had one or more episodes of sick leave during the year was 1.82 (1.73 to 1.91) for women and 2.03 (1.92 to 2.14) for men with knee OA. The corresponding risk for disability pension was 1.54 (1.48 to 1.60) for women and 1.36 (1.28 to 1.43) for men with knee OA. The annual mean number of sick days was 87 for each patient with knee OA and 57 for the general population (age- and sex-standardised). Of all sick leave and disability pension in the entire population, 2.1% of days were attributable to knee OA or associated comorbidity in the patients with knee OA (3.1% for sick leave and 1.8% for disability pension). CONCLUSIONS: Subjects with doctor-diagnosed knee OA have an almost twofold increased risk of sick leave and about 40-50% increased risk of disability pension compared with the general population. About 2% of all sick days in society are attributable to knee OA.

Is knee osteoarthritis a symmetrical disease? Analysis of a 12 year prospective cohort study.

BACKGROUND: The aim of this study was to document the development of bilateral knee osteoarthritis over a 12 year period using a middle-aged population-based cohort with knee pain at inclusion. METHODS: One hundred and forty three patients aged 35 to 54 were recruited from a population based cohort of 279 subjects who had knee pain at baseline and assessed with clinical and radiographic data, with 5 and 12 year follow up. The data was analysed with regard to the development and progression of uni- and bilateral knee osteoarthritis over 12 years. A definition of KL = 1 was used to define radiographic disease. RESULTS: 24 of the 30 (80%) patients with unilateral disease at baseline developed bilateral disease after 12 years. At baseline 37 patients (26%) had bilateral disease, whereas that number increased to 65 (52%) at 5 years and 100 (70%) at the 12 year follow up. The most common pattern was medial compartment involvement in both knees. Six patients had lateral compartment disease in one knee and medial in the other whereas only two had lateral compartment disease bilaterally. CONCLUSIONS: Bilateral knee osteoarthritis is very common with time, as the majority of sufferers will eventually develop radiographic disease in both knees. Clinicians need to be aware of the 'joint at risk' and researchers need to remember to account for both knees when assessing the relationship between physical function, pain and structural disease. The other knee should not be used for comparison, even if it appears to be normal at baseline.

Relationship between finger flexion and extension force in healthy women and women with rheumatoid arthritis.

OBJECTIVE: Balance between flexor and extensor muscle activity is essential for optimal function. The purpose of this pilot study was to compare the relationship between maximum finger flexion force and maximum finger extension force in women with rheumatoid arthritis and healthy women. METHODS: Twenty healthy women (median age 61 years) and 20 women with rheumatoid arthritis (median age 59.5 years, median disease duration 16.5 years) were included in the study. Finger extension force was measured with an electronic device, EX-it, and finger flexion force using Grippit. The Grip Ability Test and the score from the patient-reported outcome Disability Arm Shoulder and Hand were used to evaluate activity limitations. RESULTS: Patients with rheumatoid arthritis showed significantly decreased hand function compared with healthy controls. A correlation was found between extension force and flexion force in the healthy group (r = 0.65, p = 0.002),but not in the rheumatoid arthritis group (r = 0.25, p = 0.289). CONCLUSION: Impaired hand function appears to influence the relationship between maximum finger flexion and extension force. This study showed a difference in the relationship between maximum finger flexion and extension force in healthy controls and those with rheumatoid arthritis.