Physical therapy vs. internet-based exercise training (PATH-IN) for patients with knee osteoarthritis: study protocol of a randomized controlled trial.

BACKGROUND: Physical activity improves pain and function among individuals with knee osteoarthritis (OA), but most people with this condition are inactive. Physical therapists play a key role in helping people with knee OA to increase appropriate physical activity. However, health care access issues, financial constraints, and other factors impede some patients from receiving physical therapy (PT) for knee OA. A need exists to develop and evaluate other methods to provide physical activity instruction and support to people with knee OA. This study is examining the effectiveness of an internet-based exercise training (IBET) program designed for knee OA, designed by physical therapists and other clinicians. METHODS/DESIGN: This is a randomized controlled trial of 350 participants with symptomatic knee OA, allocated to three groups: IBET, standard PT, and a wait list (WL) control group (in a 2:2:1 ratio, respectively). The study was funded by the Patient Centered Outcomes Research Institute, which conducted a peer review of the proposal. The IBET program provides patients with a tailored exercise program (based on functional level, symptoms, and current activity), video demonstrations of exercises, and guidance for appropriate exercise progression. The PT group receives up to 8 individual visits with a physical therapist, mirroring standard practice for knee OA and with an emphasis on a home exercise program. Outcomes are assessed at baseline, 4 months (primary time point) and 12 months (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include objective physical function, satisfaction with physical function, physical activity, depressive symptoms and global assessment of change. Linear mixed models will be used to compare both the IBET and standard PT groups to the WL control group, examine whether IBET is non-inferior to PT (a treatment that has an established evidence base for knee OA), and explore whether participant characteristics are associated with differential effects of IBET and/or standard PT. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill. DISCUSSION: The IBET program could be disseminated widely at relatively low cost and could be an important resource for helping patients with knee OA to adopt and maintain appropriate physical activity. This trial will provide an important evaluation of the effectiveness of this IBET program for knee OA. TRIAL REGISTRATION: NCT02312713.

Fall Risk and Utilization of Balance Training for Adults With Symptomatic Knee Osteoarthritis: Secondary Analysis From a Randomized Clinical Trial.

BACKGROUND AND PURPOSE: Knee osteoarthritis (KOA) is a common disease that hinders activity participation in older adults. Associated symptoms and physiological changes can increase risk of falling in individuals with KOA. Balance training can decrease fall risks in older adults. Limited evidence exists regarding utilization of balance training in physical therapy (PT) for this population. This secondary data analysis investigated the proportion of participants at high risk for falling in the PhysicAl THerapy vs. INternet-based Exercise Training for Patients with Osteoarthritis (PATH-IN) study and the frequency with which balance training was utilized as an intervention in PT. METHODS: PATH-IN study participants (N = 344) performed the Four-Stage Balance Test and the Timed Up and Go (TUG) test during baseline assessment. Participants were randomly allocated to PT, an Internet-based exercise program, or a control group. Participants were classified as being at high risk for falling if they did not progress to the single-leg stance (SLS) during the Four-Stage Balance Test, were unable to maintain SLS for 5 seconds, or took longer than 13.5 seconds to complete the TUG test. The proportion of participants at high risk for falling was calculated for all participants and separately for those allocated to PT. In addition, PT notes were coded for balance training and the frequency of balance training utilization was calculated. RESULTS AND DISCUSSION: Upon enrollment, 35.5% (N = 122) of all participants and 36.2% (N = 50) of those allocated to PT were at high risk for falling. Of participants allocated to PT with documentation available for coding (N = 118), 35.5% (N = 42) were at high risk for falling. Balance training was provided to 62.7% (N = 74) during at least one PT session. Of those classified as being at high risk for falling, 33.3% (N = 14) did not receive balance training. CONCLUSIONS: The finding of high fall risks in more than one-third of all participants with KOA is consistent with previous reports of a higher risk of falling in this population. Many PT participants did receive some balance training; however, one-third of participants at high risk for falling did not. Balance training for individuals with KOA at high risk for falling may be underutilized.

Fear of Movement and Associated Factors Among Adults With Symptomatic Knee Osteoarthritis.

OBJECTIVE: To examine the frequency of and factors associated with fear of movement (FOM) among patients with symptomatic knee osteoarthritis (KOA), using the new Brief Fear of Movement (BFOM) measure. METHODS: Participants (n = 350) enrolled in a clinical trial completed the BFOM scale prior to randomization. The relationships of BFOM with the following characteristics were examined: age, sex, race, education, pain and activities of daily living (ADL) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS), knee symptom duration, depressive symptoms (8-item Patient Health Questionnaire [PHQ-8]), history of falls and knee injury, family history of knee problems, self-efficacy for exercise (SEE), and unilateral balance test. A proportional odds logistic regression model examined multivariable associations of participant characteristics with a 3-level BFOM variable (agreement with 0, 1-2, or ≥3 items). RESULTS: The majority of participants (77%) agreed with at least 1 item on the BFOM scale, and 36% endorsed 3+ items, suggesting a high degree of FOM. In the multivariable model, the following remained significant after backward selection: age (odds ratio [OR] 0.79 per 10-point increase, 95% confidence interval [95% CI] 0.66-0.95), KOOS ADL (OR 0.86 per 10-point increase, 95% CI 0.76-0.97), PHQ-8 (OR 1.15, 95% CI 1.08-1.22), and SEE (OR 0.87 per 10-point increase, 95% CI 0.78-0.96). CONCLUSION: FOM was common among patients with symptomatic KOA, and this could negatively impact physical activity. Psychological variables were significantly associated with FOM, suggesting behavioral and psychological interventions may decrease FOM and improve outcomes among individuals with symptomatic KOA.

Differential Diagnosis and Intervention of Proximal Median Nerve Entrapment: A Resident's Case Problem.

Study Design Resident's case problem. Background Entrapment neuropathies represent a diagnostic challenge and require a comprehensive understanding of the nerve's path and the anatomical structures that may cause compression of the nerve. This resident's case problem details the evaluation and differential diagnosis process for median nerve entrapment resulting from forceful and repetitive pronation/supination motions. Diagnosis Median nerve compression syndromes include pronator syndrome, anterior interosseous nerve syndrome, and carpal tunnel syndrome. A cluster of clinical special tests were performed to determine the anatomical site of median nerve entrapment. Based on the patient's history and clinical test results, a diagnosis of pronator syndrome was determined. Provocation testing specific to pronator syndrome assisted with further localizing the site of entrapment to the pronator teres muscle, which guided effective management strategies. Discussion This resident's case problem illustrates the importance of detailed anatomical knowledge and a differential diagnostic process when evaluating a patient with signs and symptoms of an entrapment neuropathy of the median nerve. Electrodiagnostic studies are useful in ruling out carpal tunnel and anterior interosseous nerve syndromes, but are often inconclusive in cases of pronator syndrome. Therefore, a diagnosis of pronator syndrome in this case problem was based on a detailed understanding of median nerve anatomy, potential sites of compression, and unique clinical features associated with this condition. Level of Evidence Differential diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(9):800-808. Epub 5 Aug 2016. doi:10.2519/jospt.2016.6723.