Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative.

OBJECTIVE: To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA). DESIGN: We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7. RESULTS: A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics. CONCLUSION: The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Implementing international osteoarthritis guidelines in primary care: uptake and fidelity among health professionals and patients.

OBJECTIVE: This paper evaluates the implementation fidelity of a strategy and intervention used to implement osteoarthritis (OA) treatment recommendations in primary care. We also evaluate uptake of core treatment (patient information, exercise and referral to weight management) among OA patients. DESIGN: A stepped-wedge cluster-randomised controlled study (RCT) in primary care. The study involved general practitioners (GPs), physiotherapists (PTs) and patients with hip and/or knee OA in six Norwegian municipalities (clusters). Workshops for general practitioners (GPs) and PTs represented the main implementation activity. Uptake of core treatment (patient education, exercise and weight management) was evaluated using self-reported data from the patient intervention and control group, analysed with logistic regression models. Fidelity was evaluated using six components representing adherence to the content and dose instructions in the implementation strategy and assessed against a-priori criteria for high adherence. RESULTS: Data were collected from 40 GPs, 37 PTs and 393 OA patients. The patient-reported data showed statistically significant higher uptake for exercise, patient education and referral to support for weight reduction, among the intervention group compared to the control group (P < 0.05). Evaluation of fidelity showed high adherence to GP and PT workshop attendance and physiotherapy use, partly adherence to PT knowledge after workshops, and low adherence to exercise attendance, dose and progression instructions. CONCLUSIONS: The implementation strategy and intervention successfully improved OA patients' access to physiotherapy and uptake of recommended core treatment. However, the strategy was less effective in providing exercise programs with sufficient dose and progression and in supporting patients' adherence to the exercise program. TRIAL REGISTRATION: ClinicalTrials.gov NCT02333656.

Measurement properties for the revised patient-reported OsteoArthritis Quality Indicator questionnaire.

OBJECTIVES: To assess validity, reliability, responsiveness and interpretability of the revised OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2 (v2) assessing patient-reported quality of osteoarthritis care. METHODS: The OA-QI v2 (16 items, score range 0-100 (100 = best score)) was included in a longitudinal cohort study. Attendees of a 4.5 h osteoarthritis patient education programme at Diakonhjemmet Hospital, Norway, completed the OA-QI at four time points: 2 weeks before, immediately before, immediately after, and 3 months after the programme. Test-retest reliability and measurement error over a 2-week time period were assessed in those that had not seen health professionals in the interim. Construct validity and responsiveness were assessed with predefined hypotheses. Floor and ceiling effects, smallest detectable change (SDC95%) and minimal important change (MIC) were assessed to evaluate interpretability. RESULTS: The intraclass correlation coefficient for all 16 items was 0.89. For single items the test-retest kappa estimates ranged 0.38-0.85 and percent agreement 69-92%. Construct validity was acceptable with all six predefined hypotheses confirmed. Responsiveness was acceptable with 33 of 48 and three of four predefined hypotheses confirmed for single items and all items, respectively. There were no floor or ceiling effects. The SDC95% was 29.1 and 3.0 at the individual and group levels, respectively. MIC was 20.4. CONCLUSIONS: The OA-QI v2 had higher reliability estimates compared to v1, showed acceptable validity, and is the recommended version for future use. The results of responsiveness testing further support the use of the OA-QI v2 as an outcome measure in studies aiming to improve osteoarthritis care.

The importance of dose in land-based supervised exercise for people with hip osteoarthritis. A systematic review and meta-analysis.

PURPOSE: To compare effects of land-based exercise programmes with high vs low or uncertain compliance with dose recommendations among people with hip osteoarthritis (OA). DESIGN: A systematic review with meta-analyses of supervised exercise programmes in people with symptomatic hip OA was conducted. Dose of the exercise interventions was evaluated according to the American College of Sports Medicine's (ACSM) recommendations for developing and maintaining cardiorespiratory fitness, muscular strength and flexibility in healthy adults. Compliance ratios with the recommendations were calculated. Standardized Mean Differences (SMDs) were calculated in meta-analyses for the outcomes pain and self-reported physical function. Outcome effects were compared between the sub-groups of studies with interventions with "high" vs "uncertain" compliance with the ACSM recommendations. RESULTS: Twelve studies including 1202 participants were included. Seven were categorized with "high" and five with "uncertain" compliance with the ACSM recommendations. Ten studies had an overall low risk of bias. Comparing exercise with no exercise, the pooled SMD for pain was -0.42 (95% CI -0.58, -0.26) in the high compliance group, favouring exercise. In the uncertain compliance group the pooled SMD was 0.04 (95% CI -0.24, 0.31). For physical function the SMD was -0.41 (95% CI -0.58, -0.24) in the high compliance group and -0.23 (95% CI -0.52, 0.06) in the uncertain compliance group. CONCLUSIONS: The results show that land-based supervised exercise interventions with high compliance to the ACSM recommendations result in significantly larger improvements in pain and non-significantly larger improvement in self-reported physical function compared with land-based supervised exercise interventions with uncertain compliance.

Smoking and alcohol use are associated with structural and inflammatory hand osteoarthritis features.

OBJECTIVES: To explore whether smoking and alcohol use are associated with hand osteoarthritis (OA) features in two different OA cohorts. METHOD: We studied 530 people with radiographic hand OA from the Musculoskeletal pain in Ullensaker STudy (MUST) and 187 people from the Oslo hand OA cohort [mean (sd) age 65 (8.0) and 62 (5.7) years, 71% and 91% women, respectively]. Smoking, alcohol use and hand pain were self-reported. Participants underwent conventional hand radiographs and ultrasound examination of 30 hand joints. The Kellgren-Lawrence sum score for radiographic OA severity (0-120 scale) and the proportion of participants having at least one joint with grey-scale synovitis (grade ≥1) were calculated. We studied whether smoking and alcohol use were cross-sectionally associated with radiographic OA, synovitis, and pain using adjusted linear and logistic regression analyses. RESULTS: Smoking was associated with less radiographic OA in both cohorts [ß = -4.71, 95% confidence interval (CI) -8.36 to -1.06 for current smoking in MUST and ß = -0.15, 95% CI -0.29 to -0.02 for smoking pack-years in the Oslo hand OA cohort]. Stratified analyses indicated that the association was present in men only. Being a monthly drinker (examined in MUST only) was significantly associated with present synovitis compared to never drinkers (odds ratio = 2.35, 95% CI 1.27 to 4.34) (no gender differences). Neither smoking nor alcohol was associated with hand pain. CONCLUSIONS: Smoking was associated with less radiographic hand OA whereas alcohol consumption was associated with present joint inflammation in hand OA. Future longitudinal studies are needed to explore the causal associations and explanatory mechanisms behind gender differences.

Limited effects of exercises in people with hand osteoarthritis: results from a randomized controlled trial.

OBJECTIVE: To determine the clinical effectiveness of an exercise programme on self-reported hand activity performance in people with hand osteoarthritis (OA). DESIGN: In this randomized, controlled trial, participants with physician-confirmed hand OA were randomly allocated to a 12-week exercise intervention (group- and home-based) or usual care. The primary outcome was self-reported hand activity performance at 3 months measured by the Functional Index for Hand Osteoarthritis (FIHOA) and a patient-generated measure of disability, the Patient-Specific Functional Scale (PSFS). RESULTS: Of 130 randomized participants (mean age 66 (standard deviation (SD) 9); female 90%), 120 (92%) and 119 (92%) completed the 3- and 6-month follow-ups. The adjusted mean difference for the exercise vs control group was -0.5 points (95% confidence interval (CI) -1.6, 0.6) for the FIHOA score (0-30 scale, 0 = best) and 0.9 points (95% CI 0.1, 1.7) for the PSFS score (0-10 scale, 10 = best). Small significant mean differences in favour of the intervention group were found for hand pain, hand stiffness and disease activity, whereas no mean differences were observed in hand dexterity or maximal grip strength. A significantly larger proportion in the intervention (46%) vs control group (16%) fulfilled the Outcome Measures in Rheumatological Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) responder criteria at 3 months (OR = 4.4, 95% CI 1.9, 10.2). At the 6-month follow-up, there were no significant group differences in any outcome. CONCLUSIONS: The exercise programme was well tolerated among people with hand OA, but resulted only in small, beneficial short-term improvements on self-reported measures and not on most performance-based tests. Future studies should address optimal grip strength exercises and dosage. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT01245842.

No strong relationship between body mass index and clinical hand osteoarthritis: results from a population-based case-control study.

OBJECTIVES: The aim of this population-based case-control study was to investigate whether a high body mass index (BMI) is a risk factor for clinical hand osteoarthritis (OA). METHOD: Persons living in Ullensaker municipality in Norway who were aged 20-52 years in 1990 reported height and weight in 1990, 1994, 2004, and 2010 (n = 1276). Cases (clinical hand OA in 2010, n = 59) were compared to controls (participants without self-reported OA or hand pain in 2010, n = 805) with regard to the prospectively measured BMI by means of a generalized estimating equation (GEE) analysis adjusted for age, sex, time, and education. RESULTS: The mean age of hand OA cases was 64 (SD = 7.5) years in 2010 and 78% were women. There was no association between total average BMI over the entire period and later clinical hand OA (p = 0.320). Cases had a higher mean BMI in 1990 [unstandardized B = 0.93, 95% confidence interval (CI) 0.07-1.79] and in 1994 (B = 0.75, 95% CI 0.22-1.28) but there were no differences between the groups in 2004 or 2010. CONCLUSIONS: The study lend support to the hypothesis that having a higher BMI when young or middle-aged might be associated with later hand OA.

Biomarkers of cardiovascular risk across phenotypes of osteoarthritis.

BACKGROUND: The objective of this study was to explore the associations between ultrasonographic and radiographic joint scores and levels of arterial CVD risk markers in patients with osteoarthritis (OA). Secondly, to compare the levels of arterial CVD risk markers between OA phenotypes and controls. METHOD: The "Musculoskeletal pain in Ullensaker" Study (MUST) invited residents of Ullensaker municipality with self-reported OA to a medical examination. OA was defined according to the American College of Rheumatology (ACR) criteria and phenotyped based on joint distribution. Joints of the hands, hips and knees were examined by ultrasonography and conventional radiography, and scored for osteosteophytes. Hands were also scored for inflammation by grey scale (GS) synovitis and power Doppler (PD) signal. Control populations were a cohort of inhabitants of Oslo (OCP), and for external validation, a UK community-based register (UKPC).Pulse pressure augmentation index (AIx) and pulse wave velocity (PWV) were measured using the Sphygmocor apparatus (Atcor®). Ankel-brachial index (ABI) was estimated in a subset of patients. In separate adjusted regression models we explored the associations between ultrasonography and radiograph joint scores and AIx, PWV and ABI. CVD risk markers were also compared between phenotypes of OA and controls in adjusted analyses. RESULTS: Three hundred and sixty six persons with OA were included (mean age (range); 63.0 (42.0-75.0)), (females (%); 264 (72)). Of these, 155 (42.3%) had isolated hand OA, 111 (30.3%) had isolated lower limb OA and 100 (27.3%) had generalized OA. 108 persons were included in the OCP and 963 persons in the UKPC; (mean age (range); OCP: 57.2 (40.4-70.4), UKPC: 63.9 (40.0-75.0), females (%); OCP: 47 (43.5), UKPC: 543 (56.4%). Hand osteophytes were associated with AIx while GS and PD scores were not related to CVD risk markers. All OA phenotypes had higher levels of AIx compared to OCP in adjusted analyses. External validation against UKPC confirmed these findings. CONCLUSIONS: Hand osteophytes might be related to higher risk of CVD. People with OA had higher augmented central pressure compared to controls.Words 330.

Animated Activity Questionnaire (AAQ), a new method of self-reporting activity limitations in patients with hip and knee osteoarthritis: Comparisons with observation by spouses for construct validity.

OBJECTIVE: The aim of the present study was to evaluate the construct validity of the Animated Activity Questionnaire (AAQ) for measuring activity limitations of patients with hip and knee osteoarthritis (HKOA). DESIGN: In a psychometric design, data from HKOA patients and their spouses in Norway and the Netherlands were collected independently of each other, using the AAQ, the Function of Daily Living (FDL) subscale from the Hip disability or Knee injury Osteoarthritis Outcome Scale (H/KOOS) and the Numerical Rating Scale for pain (NRS-pain). By showing standardized animations on a computer, the AAQ minimizes the influence of the patient's own frame of reference. Therefore, we expected a strong correlation (≥ 0.6) for the AAQ, between patients and spouses. By contrast, we expected a moderate correlation (0.3-0.6) between patients and spouses on the H/KOOS and the NRS-pain. Analyses were carried out by partial correlations. RESULTS: In total, 29 Norwegian and 30 Dutch patients with HKOA and their spouses participated. A high correlation between patient and spouse scores on the AAQ (r = 0.61) was confirmed, but the correlations between patient and spouses scores on the H/KOOS FDL subscale (0.55) and NRS-pain (0.64) were higher than expected, indicating that spouses may have insight not only into the observed activity limitations of the patient (as measured by the AAQ), but also into patients' subjectively perceived activity limitations (as measured by written questionnaires). CONCLUSIONS: The construct validity of the AAQ was supported by a high correlation between patients' and spouses' scores. Our hypothesis that spouses are less influenced by patients' subjective frame of reference in responding to self-report questionnaires may not be correct.

Self-reported quality care for knee osteoarthritis: comparisons across Denmark, Norway, Portugal and the UK.

OBJECTIVES: To assess and compare patient perceived quality of osteoarthritis (OA) management in primary healthcare in Denmark, Norway, Portugal and the UK. METHODS: Participants consulting with clinical signs and symptoms of knee OA were identified in 30 general practices and invited to complete a cross-sectional survey including quality indicators (QI) for OA care. A QI was considered as eligible if the participant had checked 'Yes' or 'No', and as achieved if the participant had checked 'Yes' to the indicator. The median percentage (with IQR and range) of eligible QIs achieved by country was determined and compared in negative binominal regression analysis. Achievement of individual QIs by country was determined and compared using logistic regression analyses. RESULTS: A total of 354 participants self-reported QI achievement. The median percentage of eligible QIs achieved (checked 'Yes') was 48% (IQR 28%, 64%; range 0-100%) for the total sample with relatively similar medians across three of four countries. Achievement rates on individual QIs showed a large variation ranging from 11% (referral to services for losing weight) to 67% (information about the importance of exercise) with significant differences in achievement rates between the countries. CONCLUSIONS: The results indicated a potential for improvement in OA care in all four countries, but for somewhat different aspects of OA care. By exploring these differences and comparing healthcare services, ideas may be generated on how the quality might be improved across nations. Larger studies are needed to confirm and further explore the findings.

Development and preliminary testing of a computerized animated activity questionnaire in patients with hip and knee osteoarthritis.

OBJECTIVE: To develop an Animated Activity Questionnaire (AAQ) based on video animations for assessing activity limitations in patients with hip/knee osteoarthritis (OA) that combines the advantages of self-reported questionnaires and performance-based tests without many of their limitations and to preliminarily assess its reliability and validity. We hypothesized that the AAQ would correlate highly with performance-based tests and moderately with self-reported questionnaires. METHODS: Item selection was based on the pilot AAQ, prespecified conditions, the International Classification of Functioning, Disability, and Health core set for OA, existing measurement instruments, and focus groups of patients. Test-retest reliability was assessed in 30 of 110 patients. In 110 patients, correlations were calculated between the AAQ and the self-reported Hip Disability/Knee Injury and Osteoarthritis Outcome Score activities of daily living subscale (H/KOOS). In 45 of 110 patients, correlations with performance-based tests (stair climbing test, timed up and go test, and 30-second chair stand test) were calculated. RESULTS: In total, 17 basic daily activities were chosen for the AAQ. Video animations were made showing a person performing each activity with 3-5 different levels of difficulty. Patients were asked to select the level that best matched their own performance. Reliability was high (intraclass correlation coefficient 0.97 [95% confidence interval 0.93-0.98]); the AAQ correlated highly with performance-based tests (0.62), but higher with the H/KOOS (0.76) than expected. CONCLUSION: A computerized AAQ for assessing activity limitations was developed. Content validity was considered good. Preliminary validation results showed high reliability, but construct validity needs further study with a larger sample size. Continuing research will focus on construct validity and crosscultural validity.

No strong temporal relationship between obesity and multisite pain--results from a population-based 20-year follow-up study.

BACKGROUND: Multisite pain and obesity are cross-sectionally related and are common conditions that may influence each other through socio-demographic, lifestyle and/or health-related factors. The aim of the present study was to examine the cross-sectional and prospective associations between overweight/obesity and multisite pain in a general population. METHODS: In a 20-year population-based prospective cohort study, persons aged 20-62 years in 1990 participated in postal surveys in 1990, 1994, 2004 and 2010 (n = 855). Multisite pain was defined as reporting ≥ 2 number of pain sites (NPS) on the Standardized Nordic Questionnaire. Overweight was defined as body mass index (BMI) 25-30 kg/m(2) and obesity as BMI ≥ 30 kg/m(2). To exploit all measurement times, generalized estimating equation analyses adjusting for age, sex, educational and occupational status, smoking, sleep quality, mental distress and physical activity were employed. RESULTS: The mean age was 41 years at baseline and 57% were women. Overweight/obesity and NPS were significantly associated cross-sectionally. Being overweight/obese was associated with reporting future NPS ≥ 2 [overweight: odds ratio (OR), 1.40, 95% confidence interval (CI), 1.12-1.75, obese: OR, 1.54, 95% CI, 1.04-2.28]. Having NPS ≥ 2 was not associated with becoming overweight, but increased the OR for future obesity (OR 1.27, 95% CI, 1.02, 1.59). Smoking was a confounder in this relationship. CONCLUSIONS: Being overweight or obese was associated with future multisite pain, although the magnitude of the association was small and the dose-response relationship observed in cross-sectional analyses disappeared in prospective analyses. There was less evidence that having multisite pain was a predictor of future overweight/obesity.