Multiple Psychological Factors Are Associated With Poorer Functioning in a Sample of Community-Dwelling Knee Osteoarthritis Patients Activity Increase Despite Arthritis (AÏDA): phase II randomised controlled trial of an active management booklet for hip and knee osteoarthritis in primary care. Treating disability in knee osteoarthritis with exercise therapy: a central role for self-efficacy and pain. An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip. Activity Increase Despite Arthritis (AÏDA): design of a Phase II randomised controlled trial evaluating an active management booklet for hip and knee osteoarthritis [ISRCTN24554946] The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results. A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. Effectiveness of a Web-Based Physical Activity Intervention in Patients With Knee and/or Hip Osteoarthritis: Randomized Controlled Trial Progressive resistance exercise in women with osteoarthritis of the knee: a randomized controlled trial Brief time-based activity pacing instruction as a singular behavioral intervention was not effective in participants with symptomatic osteoarthritis Pain sensitisation and the risk of poor outcome following physiotherapy for patients with moderate to severe knee osteoarthritis: protocol for a prospective cohort study Determinants of self-report outcome measures in people with knee osteoarthritis. Management of osteoarthritis (OA) with an unsupervised home based exercise programme and/or patient administered assessment tools. A cluster randomised controlled trial with a 2x2 factorial design. Primary care-based physical activity programs: effectiveness in sedentary older patients with osteoarthritis symptoms. A comparison of lower extremity muscle strength, obesity, and depression scores in elderly subjects with knee pain with and without radiographic evidence of knee osteoarthritis. The effects of an exercise program for older adults with osteoarthritis of the hip. Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials
Background Knee osteoarthritis ( OA ) is the most common type of arthritis and imposes a heavy burden on individual welfare among elderly people . There is preliminary evidence that psychological factors play a role in functional ability and pain in knee OA patients , particularly with respect to the surgery outcome . Less is known about psychological factors among community-dwelling patients with knee OA . Objectives We aim ed to determine which psychological factors are associated with pain and functional ability among community-dwelling knee OA patients using a comprehensive set of psychological question naires . Methods In the cross-sectional baseline setting of a prospect i ve , r and omized controlled intervention study , 111 patients aged from 35 to 75 years with clinical symptoms and radiographic grading of knee OA were included . They completed a comprehensive set of psychological question naires , including measures of re sources and coping , fear and catastrophizing , and distress . Results In cross-sectional comparisons , pain self-efficacy , fear of movement , pain catastrophizing , and elevated anxiety were associated with pain and a poorer functional ability . In logistic regression analysis , independent association was seen between pain self-efficacy and poorer functioning . Knee OA patients also reported elevated levels of anxiety . Conclusions The results reveal that both pain self-efficacy and negatively charged emotion and expectations toward pain are important factors when dealing with knee OA patients . Failure to consider these will probably contribute to prolonged disability and further pain . The results call for the routine assessment of multiple psychological factors in knee OA BACKGROUND The Hip & Knee Book : Helping you cope with osteoarthritis was developed to change disadvantageous beliefs and encourage physical activity in people with hip or knee osteoarthritis . AIM To assess the feasibility of conducting a definitive r and omised controlled trial ( RCT ) of this evidence -based booklet in people with hip or knee osteoarthritis . DESIGN Phase II feasibility r and omised controlled trial ( RCT ) . METHOD Computerised search es of patients ' record data bases identified people with osteoarthritis of the hip or knee , who were invited to participate in the RCT comparing the new booklet with a control booklet . Outcomes were measured at baseline , 1 month , and 3 months , and included : beliefs about hip and knee pain , exercise , and fear avoidance ; level of physical activity ; and health service use . RESULTS The trial methods were feasible in terms of recruitment , r and omisation , and follow-up , but most participants recruited had longst and ing established symptoms . After one and 3 months , there was a small relative improvement in illness , exercise , and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group ( n = 59 ) compared with the control group ( n = 60 ) , which provides some proof of principle for using these outcomes in future trials . CONCLUSION This feasibility study provided proof of principle for testing The Hip & Knee Book in a larger definitive RCT OBJECTIVE To examine the effects of aerobic and resistance exercise on self-efficacy beliefs in older adults with knee osteoarthritis ( OA ) and to determine whether self-efficacy and knee pain mediated the effects of the treatments on stair time performance and health perceptions . METHODS Measures of self-efficacy , knee pain , stair climbing performance , and health perceptions were collected prior to r and omization and again at an 18-month followup in older adults with knee OA who were assigned to 1 of 3 treatment conditions : aerobic exercise , resistance training , or health education control .  All analyses were conducted on the intention-to-treat principle . RESULTS Both exercise treatments increased self-efficacy for stair climbing in comparison to the health education control group . Both knee pain and self-efficacy mediated the effect of the treatments on stair climb time , whereas only knee pain mediated health perceptions . CONCLUSIONS The findings suggest that control beliefs and changes in physical symptoms such as knee pain are important outcomes in physical activity programs with patients who have OA of the knee . Moreover , these variables mediate the effects that such programs have on disability and health perceptions Implementation studies are recommended to assess the feasibility and effectiveness in real-life of programmes which have been tested in r and omized controlled trials ( RCTs ) . We report on an implementation study of two evidence -based exercise and health education programmes for older adults with osteoarthritis ( OA ) of the knee or hip . Three types of primary health-care providers ( n = 18 ) delivered the OA Knee programme ( n = 20 ) and the OA Hip programme ( n = 20 ) , supported by programme manuals and implementation guidelines , in four regions . The outcome measures were pain and mobility . The Knee programme had OA knowledge and self-efficacy as additional outcome measures . Differences in outcome measures and background variables of participants were assessed between the RCTs and the implementation study . Positive effects ( P < 0.05 ) were found for OA knowledge , pain and self-efficacy in the Knee programme ( n = 157 ) , and for pain in the Hip programme ( n = 132 ) . No effect was found for mobility . Effect sizes of the RCTs and the present study were comparable . Background variables did not explain the variance in the outcome measures . The outcomes of the previous RCTs and the implementation study were comparable , and indicated the ecological validity of the two programmes . The implication s for nationwide dissemination and implementation in The Netherl and s are discussed Background Hip and knee osteoarthritis is a common cause of pain and disability , which can be improved by exercise interventions . However , regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement . The best method of encouraging increased activity in this patient group is not known . A booklet has been developed for patients with hip or knee osteoarthritis . It focuses on changing disadvantageous beliefs and encouraging increased physical activity . Methods / Design This paper describes the design of a Phase II r and omised controlled trial ( RCT ) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs , and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour . A computerised search of four general medical practice patients ' record data bases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months . A r and om sample of 120 will be invited to participate in the RCT comparing the new booklet  with a control booklet , and we expect 100 to return final question naires . This trial will assess the feasibility of recruitment and r and omisation , the suitability of the control intervention and outcome measurement tools , and will provide an estimate of effect size . Outcomes will include beliefs about hip and knee pain , beliefs about exercise , fear avoidance , level of physical activity , health status and health service costs . They will be measured at baseline , one month and three months . Discussion We discuss the merits of testing effectiveness in a phase II trial , in terms of intermediate outcome measures , whilst testing the processes for a larger definitive trial . We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial . Trial registration Current Controlled Trials IS RCT Osteoarthritis ( OA ) of the knee leads to restrictions of physical activity and ability to perform activities of daily living . Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability . The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was developed to test the efficacy of lifestyle behavioral changes on physical function , pain , and disability in obese , sedentary older adults with knee OA . This controlled trial r and omized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups : Healthy Lifestyle Control ; Dietary Weight Loss ; Structured Exercise ; or Combined Exercise and Dietary Weight Loss . The weight-loss goal for the diet groups was a 5 % loss at 18 months . The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory . Exercise training consisted of aerobic and strength training for 60 minutes , three times per week in a group and home-based setting . The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index . Other measurements included timed stair climb , distance walked in 6 minutes , strength , gait , knee pain , health-related quality of life , knee radiographs , body weight , dietary intake , and cost-effectiveness of the interventions . We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks . The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA BACKGROUND Osteoarthritis ( OA ) of the knee is associated with a number of physical and psychological impairments . Unfortunately , very few treatment strategies are capable of addressing both types of impairments concurrently . We performed a pilot , r and omized controlled , proof of principle trial investigating the feasibility and effects of an intervention combining physical exercise and pain coping skills training ( PCST ) . METHODS Twenty patients with a clinical and radiographical diagnosis of tibiofemoral OA were r and omized to receive either 10 weeks of physiotherapist supervised exercises ( lower limb strengthening and walking ) combined with non-directive counseling ( NDC ) or the same exercise program delivered concurrently with PCST . Primary outcomes included self-reported pain and pain coping , while secondary outcomes included self efficacy and self-reported physical function . RESULTS Ten participants were r and omized to each group and both groups exhibited significant improvements in isometric knee strength , self-reported knee pain and physical function , self efficacy for control of pain management and other arthritis symptoms . Only those in the exercise + PCST group reported statistically significant improvements in pain control coping and rational thinking . No between-group differences existed in any outcome ( 0.07 < p < 0.98 ) . Based on our findings , 63 participants per group would be needed for future large-scale studies using similar outcome measures and design . CONCLUSIONS Our study showed that an intervention that combines exercise and PCST within the same treatment session and delivered by specially-trained physiotherapists is feasible and can improve both physical and psychological outcomes in individuals with knee OA . LEVEL OF EVIDENCE Level II Clinical Trials Registry number : ACTRN12609000623291 Background Patients with knee and /or hip osteoarthritis ( OA ) are less physically active than the general population , while the benefits of physical activity ( PA ) have been well documented . Based on the behavioral grade d activity treatment , we developed a Web-based intervention to improve PA levels in patients with knee and /or hip OA , entitled “ Join2move ” . The Join2move intervention is a self-paced 9-week PA program in which the patient ’s favorite recreational activity is gradually increased in a time-contingent way . Objective The aim of the study was to investigate whether a fully automated Web-based PA intervention in patients with knee and /or hip OA would result in improved levels of PA , physical function , and self-perceived effect compared with a waiting list control group . Methods The study design was a two-armed r and omized controlled trial which was not blinded . Volunteers were recruited via articles in newspapers and health-related websites . Eligibility criteria for participants were : ( 1 ) aged 50 - 75 years , ( 2 ) self-reported knee and /or hip OA , ( 3 ) self-reported inactivity ( 30 minutes of moderate PA , 5 times or less per week ) , ( 4 ) no face-to-face consultation with a health care provider other than general practitioners , for OA in the last 6 months , ( 5 ) ability to access the Internet weekly , and ( 6 ) no contra-indications to exercise without supervision . Baseline , 3-month , and 12-month follow-up data were collected through online question naires . Primary outcomes were PA , physical function , and self-perceived effect . In a subgroup of participants , PA was measured objective ly using accelerometers . Secondary outcomes were pain , fatigue , anxiety , depression , symptoms , quality of life , self-efficacy , pain coping , and locus of control . Results Of the 581 interested respondents , 199 eligible participants were r and omly assigned to the intervention ( n=100 ) or waiting list control group ( n=99 ) . Response rates of question naires were 84.4 % ( 168/199 ) after 3 months and 75.4 % ( 150/199 ) after 12 months . In this study , 94.0 % ( 94/100 ) of participants actually started the program , and 46.0 % ( 46/100 ) reached the adherence threshold of 6 out of 9 modules completed . At 3 months , participants in the intervention group reported a significantly improved physical function status ( difference=6.5 points , 95 % CI 1.8 - 11.2 ) and a positive self-perceived effect ( OR 10.7 , 95 % CI 4.3 - 26.4 ) compared with the control group . No effect was found for self-reported PA . After 12 months , the intervention group showed higher levels of subjective ( difference=21.2 points , 95 % CI 3.6 - 38.9 ) and objective PA ( difference=24 minutes , 95 % CI 0.5 - 46.8 ) compared with the control group . After 12 months , no effect was found for physical function ( difference=5 points , 95 % CI −1.0 to 11.0 ) and self-perceived effect ( OR 1.2 , 95 % CI 0.6 - 2.4 ) . For several secondary endpoints , the intervention group demonstrated improvements in favor of the intervention group . Conclusions Join2move result ed in changes in the desired direction for several primary and secondary outcomes . Given the benefits and its self-help format , Join2move could be a component in the effort to enhance PA in sedentary patients with knee and /or hip OA . Trial Registration The Netherl and s National Trial Register : NTR2483 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=2483 ( Archived by WebCite at http://www.webcitation.org/67NqS6Beq ) Objective : To determine the effect of a progressive resistance exercise ( PRE ) program on women with osteoarthritis ( OA ) of the knee . Methods : Eligible subjects included women aged 40 to 70 years with pain between 3 and 8 on a 10-cm pain scale . Among the 144 subjects screened , 60 met the eligibility criteria and were r and omized to the experimental group ( EG ) or control group ( CG ) . Subjects in the EG participated in a 12-week PRE program twice a week and CG remained on a waiting list for physical therapy . The PRE program consisted of strengthening exercises for knee extensors , knee flexors , hip abductors and hip adductors , all performed with 50 % and 70 % of the one-repetition maximum ( 1RM ) using machines with free weights . Resistance was reevaluated every two weeks . Assessment s of pain , muscle strength , walking distance , function and quality of life were performed at baseline , six weeks and 12 weeks by a blinded assessor . Results : Twenty-nine female subjects were r and omly assigned to the EG and 31 were r and omly assigned to the CG . Repeated- measures ANOVA revealed significantly better results in the EG pain ( from 7.0±1.3 to 4.3±3.1 in the EG and from 7.0±1.2 to 6.6±1.5 in the CG - p<0.001 ) , function ( p<0.001 ) , some domains of quality of life ( physical function : p=0.002 ; physical role limitation : p=0.002 ; and pain : p=0.044 ) and muscle strength ( extensors : p<0.001 ; flexors : p=0.002 ; and abductors : p<0.001 ) . Conclusion : The PRE program was effective in reducing pain and improving function , some quality of life domains and strength in women with OA of the knee Abstract Osteoarthritis ( OA ) of the lower extremities is a prevalent cause of disability in which symptoms interfere with mobility and activity participation . Behavioral self-management for OA symptomatology is commonly recommended ; but these interventions are underutilized , unst and ardized in application , and at times , unavailable in the context of clinical care . For people with chronic pain , rehabilitation professionals may select to apply activity pacing instruction as one behavioral strategy to manage symptoms . Activity pacing is widely used in combination with other pharmacological and behavioral interventions but has not been studied as a singular behavioral intervention for people with OA . The purpose of this study was to evaluate the effectiveness of an occupational therapist-delivered , time-based activity pacing program for treatment of pain , fatigue , and physical function in people with symptomatic knee or hip OA . A 3-arm r and omized controlled trial was conducted in which 193 people were r and omized into tailored activity pacing , general activity pacing , or usual care arms . Assessment s were done at 10 weeks and 6 months after baseline . Using linear mixed models , Western Ontario and McMaster Universities Osteoarthritis Index pain scores changed over time , decreasing the most in the general and usual care groups ; only the usual care group had decreased pain over 6 months . The tailored and general activity pacing groups reported higher frequency of pacing behaviors than the usual care group at 10 weeks , but pacing was not sustained at 6 months . This trial does not support the use of time-based pacing as a singular behavioral strategy for people with knee or hip OA Introduction Pain is the dominant symptom of knee osteoarthritis ( OA ) , and recent evidence suggests factors outside of local joint pathology , such as pain sensitisation , can contribute significantly to the pain experience . It is unknown how pain sensitisation influences outcomes from commonly employed interventions such as physiotherapy . The aims of this study are , first , to provide a comprehensive description of the somatosensory characteristics of people with pain associated with knee OA . Second , we will investigate if indicators of pain sensitisation in patients with knee osteoarthritis are predictive of non-response to physiotherapy . Methods and analysis This is a multicentre prospect i ve cohort study with 140 participants . Eligible patients with moderate to severe symptomatic knee osteoarthritis will be identified at outpatient orthopaedic and rheumatology clinics . A baseline assessment will provide a comprehensive description of the somatosensory characteristics of each participant by means of clinical examination , quantitative sensory testing , and vali date d question naires measuring pain and functional capacity . Participants will then undergo physiotherapy treatment . The primary outcome will be non-response to physiotherapy on completion of the physiotherapy treatment programme as defined by the Osteoarthritis Research Society International treatment responder criteria . A principal component analysis will identify measures related to pain sensitisation to include in the predictive model . Regression analyses will explore the relationship between responder status and pain sensitisation while accounting for confounders . Ethics and dissemination This study has been approved by St James ’ Hospital/AMNCH Research Ethics Committee and by the St Vincent 's Healthcare Group Ethics and Medical Research Committee . The results will be presented at international conferences and published in a peer review journal . Trial registration number NCT02310945 OBJECTIVES To identify the determinants of self-report mobility measures in people with knee osteoarthritis ( OA ) and to compare self-report measures with physical performance . DESIGN Cross-sectional , prospect i ve . SETTING Motor performance laboratory and human mobility research center . PARTICIPANTS A convenient sample of 54 participants with medial compartment knee OA ( 32 women , 22 men ; age 68.3+/-8.7y ; range , 50 - 87y ) . Three participants were excluded because of the presence of lateral knee OA on radiographs . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES Self-reports were recorded by using the Western Ontario McMaster Universities Osteoarthritis Index ( WOMAC ) and the Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ) . Performance measures included the  six-minute walk test ( 6MWT ) , Timed Up & Go ( TUG ) test , and a st and ardized stair-climbing task ( STR ) . RESULTS Stepwise linear regression analysis identified models that included pain , quadriceps and hamstrings strength , and depression to explain 62 % to 73 % of the variance in scores on the physical functioning subscale of the WOMAC and the SF-36 . These self-report measures had a moderate relation ( r range , .46-.64 ) with performance measures ( 6MWT , TUG , STR ) . CONCLUSIONS Self-report measures were strongly related to pain ; physical performance measures were strongly related to self-efficacy . Regression models showed that self-report scores reflect pain , knee strength , and depression . The relation between self-report and performance measures was moderate , suggesting that these examine different aspects of mobility BACKGROUND Diary recording of pain and disabling activities in osteoarthritis ( OA ) is widely recommended , but , to our knowledge , its impact on symptoms has not been investigated . Exercise programmes have been shown to be effective when patients are closely supervised by nurses or physiotherapists ; however , data are lacking on the efficacy of an unsupervised home based exercise regimen in patients with OA . OBJECTIVES To evaluate the clinical efficacy of patient administered assessment tools and an unsupervised home based exercise programme alone or in combination in patients with OA . METHODS The study was a 24 week , open cluster r and omised controlled trial with a factorial design . Rheumatologists ( n = 867 ) were assigned to four groups according to the treatment given : st and ardised tools ( ST ; n = 220 ) , exercises ( EX ; n = 213 ) , both tools and exercises ( ST+EX ; n = 213 ) , or usual care ( n = 221 ) . Each rheumatologist was to enroll four patients who met the American College of Rheumatology criteria for OA ( three with knee OA , one with hip OA ) . " Tools " consisted of weekly recording of pain and disabling activities in a diary . A home based exercise programme was performed daily at least four times per week with the aid of videotape and booklet . In addition to exercise and assessment , all patients received 12.5 mg or 25 mg of the non-steroidal anti-inflammatory drug rofecoxib once daily . Outcome variables were : pain ( measured on a visual analogue scale , 0 - 100 ) ; Western Ontario and McMaster Universities Osteoarthritis Index , function subscale ( 0 - 100 ) ; and patient assessment of the quality of care ( 0 - 100 ) . RESULTS Overall , 2957 patients with OA ( 2216 knee , 741 hip ) were included . After 24 weeks , both pain and function improved in the ST , EX , ST+EX , and usual care groups ( mean ( SD ) -17 ( 27 ) , -20 ( 29 ) , -15 ( 27 ) , -19 ( 29 ) ; and -11 ( 19 ) , -12 ( 19 ) , -10 ( 19 ) , -11 ( 20 ) , respectively ) , without significant differences between groups . However , patients in the EX and ST+EX groups were more likely to agree that their rheumatologist had done his best to preserve their functional and physical activities . CONCLUSION Although patients ' assessment s favoured the exercise programme , results from this study failed to demonstrate a short term symptomatic effect of the two non-pharmacological treatments ( weekly recording of condition and exercise ) in patients with OA concurrently receiving nonsteroidal anti-inflammatory drugs OBJECTIVE This study examined , in a group of older patients , ( a ) the effectiveness of an invitation to participate in a program providing individualized physical activity advice in a primary care setting and ( b ) the changes in self-reported physical activity and symptoms in patients with osteoarthritis ( OA ) . METHODS Healthy , sedentary community-dwelling men and women aged 60 years or more were invited to participate . Following r and om allocation , the intervention group received individualized physical activity advice at baseline and at 3 , 6 , and 12 months followup . RESULTS Of the 299 people who satisfied the study 's inclusion criteria , a subgroup of 69 people reported pain and stiffness of the hip or knee at baseline . These patients reported increases in frequency and time of walking and vigorous exercise ( all P < 0.001 ) , with no change to OA symptom scores ( pain and stiffness ) , and a small decline in physical functioning was reported at 12 months followup in the control group only ( P = 0.027 ) . At the 12-month followup more intervention participants than control participants ( P = 0.013 ) reported a greater intention to exercise . CONCLUSIONS An offer of primary care-based physical activity advice , with an emphasis on the benefits for general health ( rather than " treatment " for OA ) , will attract individuals with OA symptoms . Although the present study was unable to demonstrate intervention-control group differences for the majority of outcomes , intention to exercise did appear to be positively influenced OBJECTIVE To determine , in subjects with knee pain but no radiographic changes of tibiofemoral or patellofemoral compartment osteoarthritis ( OA ) , whether mean body weight , quadriceps and hamstring strength , lower extremity muscle mass , depression scores , and perceptions of their general health status differed from those of subjects with symptomatic knee OA . METHODS Subjects were 25 women and 10 men with knee pain and radiographic evidence of OA at the baseline examination , and 21 women and 16 men who had knee pain at the baseline examination but no radiographic evidence of knee OA at either baseline examination or followup evaluation performed , on average , 31 months later . These individuals were a subset of a cohort of 462 independently living elderly individuals recruited by telephone interview after r and om selection through r and om digit dialing of households in central Indiana . Data from an additional 134 subjects who had neither knee pain nor radiographic changes of OA at either the baseline or followup examination were analyzed for comparison . Lower extremity muscle strength was measured by isokinetic dynamometry , lean tissue ( i.e. , muscle ) mass in the lower extremities by dual x-ray absorptiometry , depression by Center for Epidemiology Depression ( CES-D ) scale . knee pain by Western Ontario McMaster University OA instrument , and perceived general health status by the Medical Outcome Survey Short Form-36 . RESULTS In contrast to those with symptomatic knee OA , those who had knee pain but no radiographic evidence of OA were less obese , had hamstring as well as quadriceps weakness , and had CES-D scores high enough to qualify for a diagnosis of clinical depression . CONCLUSION Among subjects with knee pain but no OA-- and among women in this subset , in particular -- knee pain may be a manifestation of depression . rather than of joint disease OBJECTIVE . Evaluation of an 8-week exercise program with strength training and lifestyle advice for older adults with osteoarthritis ( OA ) of the hip . Outcome measures were pain , hip function , disability , quality of life ( QOL ) , and body mass index ( BMI ) . METHODS Inclusion criteria for this r and omized controlled trial were : age > or=55 years , clinical diagnosis of OA according to American College of Rheumatology criteria , and living independently . Interview and physical data were collected at baseline , post-test , and followup ( 3 mo ) by trained interviewers and physical therapists with vali date d instruments : Harris Hip Score , Sickness Impact Profile , Groningen Activity Restriction Scale , functional tests ( walking , timed Up & Go , ascending and descending stairs , and toe reaching ) , and visual analog scales ( pain and QOL ) . Data were analyzed on an intention-to-treat basis . Effect sizes were calculated . RESULTS There were 109 participants ( 55 experimental , 54 controls ) . The 15 participants who dropped out were characterized by less tolerance to pain and younger age . The program had a positive effect on pain ( moderate effect at post-test and small effect at followup ) , hip function ( small effect at post-test ) , self-reported disability ( small effect at followup ) , and the timed Up & Go test ( small effect at followup ) . It did not affect QOL , other measures of observed disability , or BMI . CONCLUSION The exercise program had positive effects on pain and hip function , which are important mediators of disability . This study fulfilled a need for older adults with hip OA and provides evidence of the benefit of exercise in the management of hip OA Background Osteoarthritis ( OA ) of the hip and knee are among the most common chronic conditions , result ing in substantial pain and functional limitations . Adequate management of OA requires a combination of medical and behavioral strategies . However , some recommended therapies are under-utilized in clinical setting s , and the majority of patients with hip and knee OA are overweight and physically inactive . Consequently , interventions at the provider-level and patient-level both have potential for improving outcomes . This manuscript describes two ongoing r and omized clinical trials being conducted in two different health care systems , examining patient-based and provider-based interventions for managing hip and knee OA in primary care . Methods / Design One study is being conducted within the Department of Veterans Affairs ( VA ) health care system and will compare a Combined Patient and Provider intervention relative to usual care  among n = 300 patients ( 10 from each of 30 primary care providers ) . Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only , Provider Only , and Combined ( Patient + Provider ) interventions relative to usual care  among n = 560 patients across 10 clinics . Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis , are overweight , and do not meet current physical activity guidelines . The 12-month , telephone-based patient intervention focuses on physical activity , weight management , and cognitive behavioral pain management . The provider intervention involves provision of patient-specific recommendations for care ( e.g. , referral to physical therapy , knee brace , joint injection ) , based on evidence -based guidelines . Outcomes are collected at baseline , 6-months , and 12-months . The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index ( self-reported pain , stiffness , and function ) , and secondary outcomes are the Short Physical Performance Test Protocol ( objective physical function ) and the Patient Health Question naire-8 ( depressive symptoms ) . Cost effectiveness of the interventions will also be assessed . Discussion Results of these two studies will further our underst and ing of the most effective strategies for improving hip and knee OA outcomes in primary care setting s . Trial registration NCT01130740 ( VA ) ; NCT 01435109 ( NIH
In knee OA , strong evidence was found that avoidance of activities is associated with activity limitations via muscle weakness ( mediation by muscle weakness ) , strong evidence was found for an association between muscle weakness and activity limitations , and weak evidence was found that pain and psychological distress are associated with muscle weakness via avoidance of activities ( mediation by avoidance ) .
In hip OA , weak evidence was found for mediation by muscle weakness ; and strong evidence was found for an association between muscle weakness and activity limitations .
The avoidance model in patients with knee and hip osteoarthritis ( OA ) hypothesizes that pain and psychological distress lead to avoidance of activities , and thereby to muscle weakness and activity limitations .
This paper systematic ally review s the scientific evidence for the validity of this avoidance model .