Alternative models to support weight loss in chronic musculoskeletal conditions: effectiveness of a physiotherapist-delivered intensive diet programme for knee osteoarthritis, the POWER randomised controlled trial.

OBJECTIVES: To determine if physiotherapists can deliver a clinically effective very low energy diet (VLED) supplementary to exercise in people with knee osteoarthritis (OA) and overweight or obesity. METHODS: 88 participants with knee OA and body mass index (BMI) >27 kg/m2 were randomised to either intervention (n=42: VLED including two daily meal replacement products supplementary to control) or control (n=46: exercise). Both interventions were delivered by unblinded physiotherapists via six videoconference sessions over 6 months. The primary outcome was the percentage change in body weight at 6 months, measured by a blinded assessor. Secondary outcomes included BMI, waist circumference, waist-to-hip ratio, self-reported measures of pain, function, satisfaction and perceived global change, and physical performance tests. RESULTS: The intervention group lost a mean (SD) of 8.1% (5.2) body weight compared with 1.0% (3.2) in the control group (mean (95% CI) between-group difference 7.2% (95% CI 5.1 to 9.3), p<0.001), with significantly lower BMI and waist circumference compared with control group at follow-up. 76% of participants in the intervention group achieved ≥5% body weight loss and 37% acheived ≥10%, compared with 12% and 0%, respectively, in the control group. More participants in the intervention group (27/38 (71.1%)) reported global knee improvement than in the control group (20/42 (47.6%)) (p=0.02). There were no between-group differences in any other secondary outcomes. No serious adverse events were reported. CONCLUSION: A VLED delivered by physiotherapists achieved clinically relevant weight loss and was safe for people with knee OA who were overweight or obese. The results have potential implications for future service models of care for OA and obesity. TRIAL REGISTRATION NUMBER: NIH, US National Library of Medicine, Clinicaltrials.gov NCT04733053 (1 February 2021).

The OARSI Joint Effort Initiative: Priorities for osteoarthritis management program implementation and research 2024-2028.

Objective: The Joint Effort Initiative (JEI) is an international collaboration of clinicians, researchers, and consumer organisations with a shared vision of improving the implementation of osteoarthritis management programs (OAMPs). This study aimed to identify JEI's future priorities and guide direction. Design: A two-part international survey to prioritise topics of importance to our membership and research stakeholders. Survey one presented a list of 40 topics under 5 themes. Consenting participants were asked to choose their top three topics in each theme. A short list of 25 topics was presented in survey two. Participants were asked to rank the importance (100-point NRS scale, 100 â€‹= â€‹highest priority). Response frequency (median, IQR) was used to rank the top priorities by theme. Results: Ninety-five participants completed survey one (61% female, 48% clinicians) and 57 completed survey two. The top ranked topic/s were:i. Promotion and advocacy: support training for health professionals (median 85, IQR 24).ii. Education and training: incorporating behaviour change into OAMPs (80, 16), advanced OA skills (80, 30), and integration of OA education into clinical training (80, 36).iii. Improving OAMPs delivery: regular updates on changes to best-evidence OA care (84, 24).iv. Future research: improve uptake of exercise, physical activity, and weight-loss (89, 16).v. Enhancing relationships, alliances, and shared knowledge: promote research collaborations (81, 30), share challenges and opportunities for OAMP implementation (80, 23). Conclusions: These topics will set the JEI's research and collaboration agenda for the next 5 years and stimulate ideas for others working in the field.

Mechanisms of action of therapeutic exercise for knee and hip OA remain a black box phenomenon: an individual patient data mediation study with the OA Trial Bank.

OBJECTIVES: To evaluate mediating factors for the effect of therapeutic exercise on pain and physical function in people with knee/hip osteoarthritis (OA). METHODS: For Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA), individual participant data (IPD) were sought from all published randomised controlled trials (RCTs) comparing therapeutic exercise to non-exercise controls in people with knee/hip OA. Using the Counterfactual framework, the effect of the exercise intervention and the percentage mediated through each potential mediator (muscle strength, proprioception and range of motion (ROM)) for knee OA and muscle strength for hip OA were determined. RESULTS: Data from 12 of 31 RCTs of STEER OA (1407 participants) were available. Within the IPD data sets, there were generally statistically significant effects from therapeutic exercise for pain and physical function in comparison to non-exercise controls. Of all potential mediators, only the change in knee extension strength was statistically and significantly associated with the change in pain in knee OA (ß -0.03 (95% CI -0.05 to -0.01), 2.3% mediated) and with physical function in knee OA (ß -0.02 (95% CI -0.04 to -0.00), 2.0% mediated) and hip OA (ß -0.03 (95% CI -0.07 to -0.00), no mediation). CONCLUSIONS: This first IPD mediation analysis of this scale revealed that in people with knee OA, knee extension strength only mediated ±2% of the effect of therapeutic exercise on pain and physical function. ROM and proprioception did not mediate changes in outcomes, nor did knee extension strength in people with hip OA. As 98% of the effectiveness of therapeutic exercise compared with non-exercise controls remains unexplained, more needs to be done to understand the underlying mechanisms of actions.

Optimising the process of knowledge mobilisation in Communities of Practice: recommendations from a (multi-method) qualitative study.

BACKGROUND: Communities of Practice (CoPs) offer a strategy for mobilising knowledge and integrating evidence-based interventions into musculoskeletal practice, yet little is known about their practical application in this context. This study aimed to (i) explore the process of knowledge mobilisation in the context of a CoP to implement evidence-based interventions in musculoskeletal care and (ii) co-develop recommendations to optimise the process of knowledge mobilisation in CoPs. METHODS: A qualitative study comprising observation of a CoP and related planning meetings (n = 5), and interviews with CoP stakeholders (including clinicians, lay members, managers, commissioners, academics) (n = 15) was undertaken. Data were analysed using thematic analysis and interpreted considering the Integrated Promoting Action on Research Implementation in Health Services theory. Public contributors were collaboratively involved at key stages of the study. RESULTS: Four themes were identified: identifying and interpreting knowledge, practical implementation of a CoP, culture and relationship building, and responding to the external context. Resource and infrastructure enabled the set-up, delivery and running of the CoP. Support for lay members is recommended to ensure effective participation and equity of power. CoP aims and purpose can develop iteratively, and this may enhance the ability to respond to contextual changes. Several recommendations for the practical application of CoPs are suggested to create the best environment for knowledge exchange and creation, support an equitable platform for participation, and help members to navigate and make sense of the CoP in a flexible way. CONCLUSION: This study identified how a CoP with diverse membership can promote partnership working at the intersection between knowledge and practice. Several important considerations for preparing for and operationalising the approach in implementation have been identified. Evaluation of the costs, effectiveness and impact of CoPs is needed to better understand the value added by the approach. More broadly, research is needed to explore the practical application of online CoPs and the role of international CoPs in optimising the uptake of innovations and best practice.

Effects of an Online Education Program on Physical Therapists' Confidence in Weight Management for People With Osteoarthritis: A Randomized Controlled Trial.

OBJECTIVE: To evaluate effects of an online education program about weight management for osteoarthritis on physical therapists' self-reported confidence in knowledge and skills in weight management and attitudes toward obesity. METHODS: In a 2-group randomized controlled trial, 80 physical therapists (58 female physical therapists) were randomized to education or control groups. The theoretically informed and evidence-informed online self-directed training program covered biopsychosocial elements of obesity and weight management. The primary outcome was self-reported confidence in knowledge in weight management using a customized validated tool (scale 14-70, higher scores indicating higher confidence) assessed at baseline and 6 weeks. Secondary measures included confidence in nutrition care, clinical skills in weight management, and weight stigma. Process measures evaluated participant experience. Differences in change between groups were compared using linear regression models adjusted for baseline scores and stratifying variables (clinical setting; confidence in weight management). Moderation analysis was performed using an interaction approach in a linear regression model and multivariable fractional polynomial interaction approach. RESULTS: A total of 79 participants (99%) completed outcome measures at 6 weeks. The education group demonstrated greater improvement in confidence in knowledge than the control group (adjusted mean difference 22.6 units, 95% confidence interval 19.6, 25.5). Greater improvement in knowledge was associated with lower baseline values (interaction P = 0.002). Secondary outcomes showed greater improvements in confidence in skills and nutrition care and in weight stigma domains favoring the education group. Over 90% of participants would recommend the program to peers. CONCLUSION: An online education program improves physical therapists' short-term confidence in knowledge and skills in weight management for people with osteoarthritis and reduces weight-stigmatized attitudes.

Cost-Effectiveness of Telehealth-Delivered Exercise and Dietary Weight Loss Programs for Knee Osteoarthritis Within a Twelve-Month Randomized Trial.

OBJECTIVE: To evaluate the cost-effectiveness of telehealth-delivered exercise and diet-plus-exercise programs within 12 months. METHODS: An economic evaluation within a 12-month, 3-arm, parallel randomized trial of two 6-month telehealth-delivered exercise programs, with and without a dietary component. A total of 415 people with knee osteoarthritis ages 45-80 years and body mass index of 28-40 kg/m2 were assigned to 1 of 2 telehealth-delivered exercise programs, 1 without (n = 172) and 1 with (n = 175) a dietary component (ketogenic very low calorie diet), or to an education control (n = 67), for 6 months, with 6 months follow-up. The primary economic outcomes were quality-adjusted life years (QALYs) and health system costs. Measured costs were the direct intervention (consultations, equipment/resources, and meal replacements) and health care use in 2020 Australian dollars ($AU1.5 = $US1). Secondary analysis included weight loss and work productivity gains. RESULTS: The clinical trial demonstrated greater improvements in pain and function compared to information only for individuals with knee osteoarthritis and overweight/obesity. We can be 88% confident that diet plus exercise is cost effective ($45,500 per QALY), 53% confident that exercise is cost-effective ($67,600 per QALY) compared to the control, and 86% confident that augmenting exercise with the diet program is cost effective ($21,100 per QALY). CONCLUSION: Telehealth-delivered programs targeting exercise with dietary intervention for people with knee osteoarthritis who have overweight/obesity are likely to be cost-effective, particularly if potential long-term gains from weight loss and work productivity are realized.

Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis.

BACKGROUND: Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both. METHODS: We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049). FINDINGS: Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0-100 scale (with 100 corresponding to worst pain), with a difference of -6·36 points (95% CI -8·45 to -4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, -3·77 points (-5·97 to -1·57, BoS 30·0%, τ2 14·4) in the medium term, and -3·43 points (-5·18 to -1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0-100 scale (with 100 corresponding to worst physical function), with a difference of -4·46 points in the short term (95% CI -5·95 to -2·98, BoS 10·5%, τ2 10·1), -2·71 points in the medium term (-4·63 to -0·78, BoS 33·6%, τ2 11·9), and -3·39 points in the long term (-4·97 to -1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks). INTERPRETATION: There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit. FUNDING: Chartered Society of Physiotherapy Charitable Trust and the National Institute for Health and Care Research.

Effectiveness of a telehealth physiotherapist-delivered intensive dietary weight loss program combined with exercise in people with knee osteoarthritis and overweight or obesity: study protocol for the POWER randomized controlled trial.

BACKGROUND: Obesity is associated with knee osteoarthritis (OA). Weight loss, alongside exercise, is a recommended treatment for individuals with knee OA and overweight/obesity. However, many patients cannot access weight loss specialists such as dietitians. Innovative care models expanding roles of other clinicians may increase access to weight loss support for people with knee OA. Physiotherapists may be well placed to deliver such support. This two-group parallel, superiority randomized controlled trial aims to compare a physiotherapist-delivered diet and exercise program to an exercise program alone, over 6 months. The primary hypothesis is that the physiotherapist-delivered diet plus exercise program will lead to greater weight loss than the exercise program. METHODS: 88 participants with painful knee OA and body mass index (BMI) > 27 kg/m2 will be recruited from the community. Following baseline assessment, participants will be randomised to either exercise alone or diet plus exercise groups. Participants in the exercise group will have 6 consultations (20-30 min) via videoconference with a physiotherapist over 6 months for a strengthening exercise program, physical activity plan and educational/exercise resources. Participants in the diet plus exercise group will have 6 consultations (50-75 min) via videoconference with a physiotherapist prescribing a ketogenic very low-calorie diet with meal replacements and educational resources to support weight loss and healthy eating, plus the intervention of the exercise only group. Outcomes are measured at baseline and 6 months. The primary outcome is percentage change in body weight measured by a blinded assessor. Secondary outcomes include self-reported knee pain, physical function, global change in knee problems, quality of life, physical activity levels, and internalised weight stigma, as well as BMI, waist circumference, waist-to-hip ratio, physical performance measures and quadriceps strength, measured by a blinded assessor. Additional measures include adherence, adverse events, fidelity and process measures. DISCUSSION: This trial will determine whether a physiotherapist-delivered diet plus exercise program is more effective for weight loss than an exercise only program. Findings will inform the development and implementation of innovative health service models addressing weight management and exercise for patients with knee OA and overweight/obesity. TRIAL REGISTRATION: NIH US National Library of Medicine, Clinicaltrials.gov NCT04733053 (Feb 1 2021).

Best Evidence Osteoarthritis Care: What Are the Recommendations and What Is Needed to Improve Practice?

This article provides an overview of osteoarthritis (OA) management recommendations and strategies to improve clinical practice concordance with clinical guidelines. In many countries, the primary point of care for a person with OA is typically general practitioners and physiotherapists. Optimal primary care focuses on core OA treatments, namely education for self-management and lifestyle interventions encompassing increased physical activity, therapeutic exercise, and weight loss (if indicated). Quality indicators are used in clinical practice and research to determine the quality of care and in some settings, are used as knowledge translation tools to address existing evidence-to-practice gaps.

Comparing Video-Based, Telehealth-Delivered Exercise and Weight Loss Programs With Online Education on Outcomes of Knee Osteoarthritis : A Randomized Trial.

BACKGROUND: Scalable knee osteoarthritis programs are needed to deliver recommended education, exercise, and weight loss interventions. OBJECTIVE: To evaluate two 6-month, telehealth-delivered exercise programs, 1 with and 1 without dietary intervention. DESIGN: 3-group, parallel randomized (5:5:2) trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000930280). SETTING: Australian private health insurance members. PARTICIPANTS: 415 persons with symptomatic knee osteoarthritis and a body mass index between 28 and 40 kg/m2 who were aged 45 to 80 years. INTERVENTION: All groups received access to electronic osteoarthritis information (control). The exercise program comprised 6 physiotherapist consultations via videoconference for exercise, self-management advice, and behavioral counseling, plus exercise equipment and resources. The diet and exercise program included an additional 6 dietitian consultations for a ketogenic very-low-calorie diet (2 formulated meal replacements and a low-carbohydrate meal daily) followed by a transition to healthy eating, as well as nutrition and behavioral resources. MEASUREMENTS: Primary outcomes were changes in knee pain (numerical rating scale [NRS] of 0 to 10, higher indicating worse) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; scale, 0 to 68, higher indicating worse) at 6 months (primary time point) and 12 months. Secondary outcomes were weight, physical activity, quality of life, mental health, global change, satisfaction, willingness to have surgery, orthopedic appointments, and knee surgery. RESULTS: A total of 379 participants (91%) provided 6-month primary outcomes, and 372 (90%) provided 12-month primary outcomes. At 6 months, both programs were superior to control for pain (between-group mean difference in change on NRS: diet and exercise, -1.5 [95% CI, -2.1 to -0.8]; exercise, -0.8 [CI, -1.5 to -0.2]) and function (between-group mean difference in change on WOMAC: diet and exercise, -9.8 [CI, -12.5 to -7.0]; exercise, -7.0 [CI, -9.7 to -4.2]). The diet and exercise program was superior to exercise (pain, -0.6 [CI, -1.1 to -0.2]; function, -2.8 [CI, -4.7 to -0.8]). Findings were similar at 12 months. LIMITATION: Participants and clinicians were unblinded. CONCLUSION: Telehealth-delivered exercise and diet programs improved pain and function in people with knee osteoarthritis and overweight or obesity. A dietary intervention conferred modest additional pain and function benefits over exercise. PRIMARY FUNDING SOURCE: Medibank, the Medibank Better Health Foundation Research Fund, and a National Health and Medical Research Council Centre of Research Excellence.

The attitudes towards, and beliefs about, physical activity in people with osteoarthritis and comorbidity: A qualitative investigation.

OBJECTIVE: To investigate the attitudes towards, and beliefs about, physical activity (PA) in older adults with osteoarthritis (OA) and comorbidity to understand experiences and seek ways to improve PA participation. METHODS: Semi-structured interviews with adults aged ≥45, with self-reported OA and comorbidity (N = 17). Face-to-face interviews explored participant perspectives regarding; (1) attitudes and beliefs about PA in the context of OA and comorbidity and (2) how people with OA and comorbidity could be encouraged to improve and maintain PA levels. Data were transcribed verbatim and inductive thematic analysis was undertaken using a framework approach. RESULTS: Participants did not conceptualise multiple long-term conditions (LTCs) together and instead self-prioritised OA over other LTCs. Barriers to PA included uncertainty about both the general management of individual LTCs and the effectiveness of PA for their LTCs; and, negative perceptions about their health, ageing and PA. Participants experienced dynamic and co-existing barriers to PA, and problematized this as a multi-level process, identifying a barrier, then a solution, followed by a new barrier. Facilitators of PA included social support and support from knowledgeable healthcare professionals (HCPs), together with PA adapted for OA and comorbidity and daily life. PA levels could be increased through targeted interventions to increase self-efficacy for managing OA alongside other LTCs and self-efficacy for PA. CONCLUSION: People with OA and comorbidity experience complicated PA barriers. To increase PA levels, tailored PA interventions could include HCP and social support to anticipate and overcome multi-level PA barriers and target increased self-efficacy for LTC management and PA.

The relationship between multisite peripheral joint pain and physical activity levels in older adults: A cross-sectional survey.

INTRODUCTION: Research on levels of physical activity (PA) in those with peripheral joint pain have only focused on single sites, in the knee or hips. This study investigated the levels of PA in adults with single-site and multisite peripheral joint pain compared to adults with no joint pain. METHODS: Analysis of a cross-sectional population survey mailed to adults aged ≥45 years (n = 28,443) was conducted. Respondents reported any peripheral joint pain in the last 12 months in either the hands, hips, knees or feet; PA levels were self-reported using the short telephone activity rating scale. The association between PA levels, peripheral joint pain and outcomes of health status (physical and mental component scores, using SF-12) pain intensity (10-point scale) and health-related quality of life (HRQoL) (EQ-5D) were investigated using analysis of variance and ordinal regressions. RESULTS: Compared to those with no joint pain, all pain groups reported lower levels of PA: joint pain in one site (odds ratio = 0.91, 95% CI: 0.83-0.99); two sites (0.74, 0.67-0.81), three sites (0.65, 0.59-0.72) and four sites (0.47, 0.42-0.53). Across all joint pain groups, levels of PA were associated with pain intensity, physical health status, mental health status and HRQoL. DISCUSSION: Adults with more sites of peripheral joint pain were more likely to report lower levels of PA. Those with more sites of pain and lower levels of PA reported poorer outcomes. Health care providers should be aware that those with multisite joint pain are most likely to have low levels of PA.

New developments in osteoarthritis pharmacological therapies.

OA is an increasingly common, painful condition with complex aetiology and limited therapies. Approaches to expanding our therapeutic armamentarium have included repurposing existing therapies used for other rheumatological conditions, modifying existing OA preparations to enhance their benefits, and identifying new therapeutics. HCQ and low-dose MTX have been unsuccessful in improving hand OA pain or reducing structural progression. Anti-IL-6 and anti-GM-CSF also did not improve symptoms in hand OA trials, but IL-1 remains an intriguing target for large-joint OA, based on reduced joint replacements in a post hoc analysis from a large cardiovascular disease trial. The peripheral nociceptive pathway appears an attractive target, with mAbs to nerve growth factor and IA capsaicin demonstrating efficacy; tropomyosin receptor kinase A inhibitors are at an earlier stage of development. Limited evidence suggests pharmacological therapies can modify cartilage and bone structural progression, though evidence of synchronous symptom benefits are lacking.

Improving osteoarthritis management in primary healthcare: results from a quasi-experimental study.

BACKGROUND: To improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention. METHODS: Forty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models. RESULTS: The PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment. CONCLUSION: This study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02876120 .

Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model?

The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.

The association between comorbidity and physical activity levels in people with osteoarthritis: Secondary analysis from two randomised controlled trials.

OBJECTIVE: To determine whether comorbidity presence, frequency or type is associated with Physical Activity (PA) levels in people with Osteoarthritis (OA). DESIGN: Secondary data analysis of adults aged ≥45, with OA related pain recruited to the BEEP trial (knee pain, n = 514) (ISRCTN93634563) and the MOSAICS trial (peripheral joint pain, n = 525) (ISRCTN06984617). Comorbidities considered were respiratory, cardiovascular diseases (CVD), depression, type 2 diabetes and obesity. Self-report PA was measured using the Physical Activity Scale for the Elderly (PASE). Linear regression models were used to estimate the mean change (ß) in PA with comorbidity presence, frequency and type adjusting for potential confounding covariates. RESULTS: In the BEEP trial comorbidity presence was associated with a decrease in PASE score (ß = -32.25 [95% confidence interval (95% CI) -48.57, -15.93]). Each additional comorbidity was associated with an incrementally lower PASE score, one comorbidity (ß = -24.42 [-42.45, -6.38]), two comorbidities ß = -34.76 [-56.05, -13.48]), and three or more comorbidities ß = -73.71 [-106.84, -40.58]) compared to those with no comorbidity. This pattern was similar in MOSAICS, but with a plateau in association from two comorbidities onward. In BEEP and MOSAICS, respiratory (ß = -40.60 [-60.50, -20.35]; ß = -11.82 [-34.95, 11.31]) and CVD (ß = -27.15 [-53.25, -1.05]; ß = -30.84 [-51.89, -9.80]) comorbidities were associated with the largest reduction in PASE scores respectively. CONCLUSION: Comorbidity presence and frequency is associated with lower PA levels and respiratory and CVD comorbidities have the greatest impact. Future exploratory work needs to be done to understand how and why comorbidity is associated with PA levels in people with OA.

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).