Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee Treating disability in knee osteoarthritis with exercise therapy: a central role for self-efficacy and pain. Cohort profile: research on Osteoarthritis/Osteoporosis Against Disability study. The effect of exercise therapy on knee osteoarthritis: a randomized clinical trial Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. Capturing lay perspectives in a randomized control trial of a health promotion intervention for people with osteoarthritis of the knee. Adherence to a Web-Based Physical Activity Intervention for Patients With Knee and/or Hip Osteoarthritis: A Mixed Method Study A physiotherapist-delivered, combined exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a pilot study. A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Non-pharmacological care for patients with generalized osteoarthritis: design of a randomized clinical trial Primary care-based physical activity programs: effectiveness in sedentary older patients with osteoarthritis symptoms. The effectiveness of self‐management educational interventions for osteoarthritis of the knee Pain sensitisation and the risk of poor outcome following physiotherapy for patients with moderate to severe knee osteoarthritis: protocol for a prospective cohort study The effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a randomized clinical trial. Self-management approaches for osteoarthritis in the hand: a 2×2 factorial randomised trial
Arthritis has been identified as the most common cause of disability in the United States ( 1 , 2 ) . Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee , which often limits the ability to rise from a chair , st and comfortably , walk , and use stairs ( 3 , 4 ) . Acetaminophen and nonsteroidal anti-inflammatory drugs ( NSAIDs ) are commonly used to treat osteoarthritis . Use of NSAIDs can lead to gastric complications , increased risk for hospitalization , and death ( 5 ) . Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs , cortisone injections , and joint replacement surgery . Puett and Griffin ( 6 ) review ed 15 controlled trials of nonmedicinal , noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 ( 6 ) . The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee , but the optimal exercise regimen has not been determined . Fitness walking , aerobic exercise , and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee ( 6 - 12 ) . Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee ( 13 ) . Other research ers ( 14 , 15 ) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis . Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis ( 16 - 18 ) . Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function ( 19 ) . We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee , as applied by physical therapists with formal training in such an approach ( 20 ) . Our hypothesis was that physical therapy consisting of manual therapy to the knee , hip , ankle , and lumbar spine combined with range-of-motion , strengthening , and cardiovascular exercises would be more effective than placebo for improving function , decreasing pain and stiffness , and increasing the distance walked in 6 minutes . Methods Patients Eighty-three patients with osteoarthritis of the knee were r and omly assigned to receive treatment ( n=42 ; 15 men and 27 women [ mean age , 60 11 years ] ) or placebo ( n=41 ; 19 men and 22 women [ mean age , 62 10 years ] ) . All patients were referred by physicians to physical therapy for osteoarthritis of the knee . Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made . If the patients met our inclusion criteria , they were offered the opportunity to participate . The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [ 21 ] : 1 ) knee pain , age 38 years or younger , and bony enlargement ; 2 ) knee pain , age 39 years or older , morning stiffness for more than 30 minutes , and bony enlargement ; 3 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and bony enlargement ; or 4 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and age 38 years or older . Altman and colleagues found this criteria to be 89 % sensitive and 88 % specific ( 21 - 23 ) . Patients were required to be eligible for military health care , have had no surgical procedure on either lower extremity in the past 6 months , and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study . Patients had to have sufficient English- language skills to comprehend all explanations and to complete the assessment tools . They were also required to live within a 1-hour drive of the physical therapy clinic . Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled . Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up . Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study . The study was approved by the institutional review board of Brooke Army Medical Center , Fort Sam Houston , Texas . All patients completed an informed consent form and were advised of the risks of the study , including increased symptoms , injuries from falls , and cardiovascular events . No external funding was received for this study . Procedure Patients who met the inclusion criteria were r and omly assigned to one of two groups . Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment , determined by a r and om-number generator . When a patient was eligible and gave consent to participate , the treating therapist drew the next folder from the file , which determined the group of assignment . The treatment group received a combination of manual physical therapy and supervised exercise . The placebo group received ultrasound at a subtherapeutic intensity . Neither group was aware of the treatment that the other group was receiving . Demographic data collected for each patient included age , sex , occupation , height , weight , duration of symptoms , presence of symptoms in one or both knees , previous knee surgery , medications , and present activity level . Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis ( 24 ) . Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) score ( 25 ) and distance covered during a timed 6-minute walk test . The WOMAC Osteoarthritis Index consists of 24 questions , each corresponding to a visual analogue scale . This test has been shown to be a reliable , valid , and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee ( 26 ) . The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity ( 27 ) . All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment . After research assistants obtained pretreatment values for the dependent variables , patients returned to the treating physical therapist for thorough st and ardized clinical examination of the knee , hip , ankle , and lumbar spine . Treatment was initiated according to group assignment . The treatment group received manual physical therapy as indicated by the results of the examination . The manual therapy treatment techniques , consisting of passive physiologic and accessory joint movements , muscle stretching , and soft-tissue mobilization , were applied primarily to the knee . The same treatments were also administered to the lumbar spine , hip , or ankle if these areas showed limitation in active or passive movement , were symptomatic , or were contributing to overall lower limb dysfunction ( 28 - 31 ) . A minimal pain level was not exceeded in any treatment . The treatment group also performed a closely supervised st and ardized knee exercise program at each of the eight treatment sessions . This program consisted of active range-of-motion exercises for the knee , muscle strengthening exercises for the hip and knee , muscle stretching for the lower limbs , and riding a stationary bike . All of the activities were mutually reinforcing , with repeated gentle challenges to the end ranges of movement . An outline of the exercise program is shown in the Appendix Figure . The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance . The current literature provides efficient methods to produce the desired effects of increasing strength , flexibility , and range of motion ( 32 - 35 ) . At each session , the physical therapist examined the patient for adverse signs and symptoms , such as increased pain , joint effusion , and increased skin temperature over knee joints . These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed . Patients exercised in a painless or minimally painful manner . If any post-treatment or exercise soreness lasted more than a few hours , the regimen was decreased accordingly for that patient . The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10 % pulsed mode ( lowest setting and greatest cycle interruption ) to the area of knee symptoms . The placebo group received the same subjective and h and s-on objective reevaluation before and after each session as the treatment group . The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups . The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic . Both groups were treated twice weekly for 4 weeks , for a total of eight clinic treatments . Patients in the treatment group also performed the same exercises at home , except for the closed-chain strengthening exercises , on the days on which they were not treated in the physical therapy clinic . They also walked at home each day at a comfortable pace and distance . The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed h and out containing instructions and photographs of the exercises . Each patient maintained a home exercise 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 Since the proportion of the ageing population in Japan is increasing , a comprehensive and evidence based strategy is urgently required for the prevention of musculoskeletal diseases , including osteoarthritis ( OA ) and osteoporosis ( OP ) , both of which affect the activities of daily living ( ADL ) and quality of life ( QOL ) and increase morbidity and mortality . However , few prospect i ve , longitudinal studies for the purpose of developing such a strategy have been conducted , and little information is available regarding the prevalence and incidence of musculoskeletal disorders , including OA and OP , as well as pain and disability in the Japanese population . It is difficult to design rational clinical and public health approaches for the diagnosis , evaluation and prevention of OA and OP without such epidemiological data . The Research on Osteoarthritis/osteoporosis Against Disability ( ROAD ) study was established in 2005 by N.Y. , T.A. , H.O. , S.M. , H.K. and K.N. ( principal investigators ) . The principal investigators are affiliated with the 22nd Century Medical and Research Center , University of Tokyo Background : Knee osteoarthritis ( OA ) is the most common musculoskeletal disease among old individuals which affects ability for sitting on the chair , st and ing , walking and climbing stairs . Our objective was to investigate the short and long-term effects of the most simple and the least expensive exercise protocol s in combination to conventional conservative therapy for knee OA . Methods : It was a single blind RCT study with a 12-months follow-up . Totally , 56 patients with knee OA were assigned into 2 r and om groups . The patients in exercise group received exercise for knee muscles in combination with non-steroid anti-inflammatory drugs ( NSAIDs ) and 10 sessions acupuncture and physiotherapy modalities . Non-exercise group received similar treatments except exercise program . The changes in patients ’ pain and functional status were evaluated by visual analog scale ( VAS ) , knee and osteoarthritis outcome score ( KOOS ) question naire and functional tests ( 4 steps , 5 sit up , and 6 min walk test ) before and after treatment ( 1 and 3 months after intervention ) , and 1 year later at the follow-up . Results : The results showed that the patients with knee OA in exercise group had significant improvement in pain , disability , walking , stair climbing , and sit up speed after treatment at first and second follow-up when compared with their initial status and when compared with non-exercise group . At third follow up ( 1 year later ) there was significant difference between groups in VAS and in three items of KOOS question naire in functional status . Conclusion : Non aerobic exercises for muscles around knee can augment the effect of other therapeutic interventions like medical therapy , acupuncture , and modalities for knee OA Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , OBJECTIVE To assess the effectiveness of physical therapy , given either as an individually attended treatment or in a small group format , in terms of pain , physical function , and health related quality of life for patients with osteoarthritis ( OA ) of the knee . METHODS After 2 baseline assessment s , 126 patients were r and omized into one of 3 allocation arms : individual treatments ( n = 43 ) , small group format program ( n = 40 ) , and waiting list control ( n = 43 ) . After re assessment at 8 weeks , patients allocated to waiting list control were r and omized into one of the 2 active treatment arms . Assessment s included both self-report measures ( WOMAC , SF-36 ) and objective measures of physical performance ( gait analysis and muscle strength ) . RESULTS Both physical therapy treatment allocations result ed in significant improvements in pain , physical function , and health related quality of life above the control group ( st and ardized response mean 0.36 to 0.65 ) . Improvements in the self-report measures were substantiated by significant correlated improvements in knee extensor strength and fast walking speed ( rho 0.36 - 0.42 ) . There were no significant differences in effectiveness between the 2 physical therapy allocations for any of the measured outcomes . Improvements gained were maintained for at least 2 months . Responsiveness to treatment was modified by loss of medial joint space width , the interaction being significant for physical function , gait , and knee extensor strength . CONCLUSION Physical therapy , either as an individually delivered treatment or in a small group format , is an effective intervention for patients with knee OA . Responsiveness to this 8 week intervention was modified by loss of medial joint space width Osteoarthritis ( OA ) is a common and often disabling condition that predominately affects older adults . It is the commonest cause of locomotor disability and forms a major element of the workload in primary care . Previous studies suggest that there are both deficits in the knowledge patients have about their disease and extensive ' unmet ' information needs . This paper explores the patients ' perspective on the meaning and significance of living with arthritis , identified through quantitative and qualitative approaches undertaken during a trial that evaluated the effectiveness of a primary care-based patient education programme . This paper draws on qualitative and quantitative data from : the baseline interview ( knowledge of arthritis , satisfaction with services and support received in primary care ) ; patient diaries ( individual goals and reflections on treatment ) ; and group teaching sessions ( themes describing the patient 's experience ) . The different data sources were interrogated for common and divergent themes . One hundred and ninety-four participants were identified and 170 completed baseline interviews . Participants were predominantly female ( 73 % ) , with a mean age of 63 and arthritis of long-st and ing ; 55 % reported that they had had it for 5 years or more .  Use of primary care services was high , with 41 % consulting their GP in the 2 weeks before interview . Levels of information were low , with less than 25 % receiving support/advice about the disease , pain management or its impact upon daily life . Set against negative perceptions of the quality of services , patients ' personal priorities were for improved pain management and enhanced mobility/functional ability . The combined quantitative and qualitative data provide insight into the patients ' perspective on the causes and impact of knee OA , individual goals desired from treatment and the quality of care . There is consistent evidence of unmet needs for information and support and the priority placed by patients on finding strategies to cope with OA and maintaining independence . Even within a tightly defined study sample participating in the intervention , a diversity of experience and goals were revealed , which highlights the importance of taking account of context ual factors and individual differences when evaluating complex interventions Background Web-based interventions show promise in promoting a healthy lifestyle , but their effectiveness is hampered by high rates of nonusage . Predictors and reasons for (non)usage are not well known . Identifying which factors are related to usage contributes to the recognition of subgroups who benefit most from Web-based interventions and to the development of new strategies to increase usage . Objective The aim of this mixed methods study was to explore patient , intervention , and study characteristics that facilitate or impede usage of a Web-based physical activity intervention for patients with knee and /or hip osteoarthritis . Methods This study is part of a r and omized controlled trial that investigated the effects of Web-based physical activity intervention .  A total of 199 participants between 50 - 75 years of age with knee and /or hip osteoarthritis were r and omly assigned to a Web-based intervention ( n=100 ) or a waiting list ( n=99 ) . This mixed methods study used only data from the individuals allocated to the intervention group . Patients were defined as users if they completed at least 6 out of 9 modules .  Logistic regression analyses with a stepwise backward selection procedure were executed to build a multivariate prediction usage model . For the qualitative part , semistructured interviews were conducted . Both inductive and deductive analyses were used to identify patterns in reported reasons for nonusage . Results Of the 100 participants who received a password and username , 46 completed 6 modules or more . Multivariate regression analyses revealed that higher age ( OR 0.94 , P=.08 ) and the presence of a comorbidity ( OR 0.33 , P=.02 ) predicted nonusage . The sensitivity analysis indicated that the model was robust to changes in the usage parameter . Results from the interviews showed that a lack of personal guidance , insufficient motivation , presence of physical problems , and low mood were reasons for nonusage . In addition , the absence of human involvement was viewed as a disadvantage and it negatively impacted program usage . Factors that influenced usage positively were trust in the program , its reliability , functionality of the intervention , social support from family or friends , and commitment to the research team . Conclusions In this mixed methods study , we found patient , intervention , and study factors that were important in the usage and nonusage of a Web-based PA intervention for patients with knee and /or hip osteoarthritis . Although the self-guided components offer several advantages , particularly in relation to costs , reach , and access , we found that older patients and participants with a comorbid condition need a more personal approach . For these groups the integration of Web-based interventions in a health care environment seems to be promising . Trial Registration The Netherl and s National Trial Register ( NTR ) : NTR2483 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=2483 ( Archived by Webcite at http://www.webcitation.org/67NqS6Beq ) 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 Context Despite their established benefit in patients with osteoarthritis , many treatment strategies are underused . Contribution In this r and omized trial , providing treatment recommendations to physicians in addition to telephone-based support to patients with knee or hip osteoarthritis result ed in modest improvements in physical function . Caution The relative contributions of the physician- and patient-based interventions to the observed improvement could not be assessed . Implication A combined physician and patient intervention may be beneficial in patients with knee or hip osteoarthritis . Osteoarthritis is one of the most common chronic health conditions and a leading cause of pain and disability ( 15 ) . Its prevalence is increasing , and this trend is expected to continue ( 6 , 7 ) . In addition to the substantial toll at the individual level ( 8) , osteoarthritis is placing an increasing burden on health care systems ( 9 , 10 ) . Evidence -based guidelines indicate that adequate management of hip and knee osteoarthritis requires both behavioral and clinical strategies ( 1114 ) .  Physical activity  and  weight management  are key behavioral strategies for managing hip and knee osteoarthritis , but most adults with osteoarthritis are physically inactive or overweight ( 15 , 16 ) . Similarly , despite strong evidence supporting several clinical strategies , such as joint injections , physical therapy , and pain medications , some of these treatments are underused , and studies have shown low rates of adherence to osteoarthritis quality indicators ( 1720 ) . Improvement in osteoarthritis management is needed at both the patient and provider levels . The purpose of our study was to examine a combined patient and provider intervention for management of osteoarthritis in primary care . Methods The Institutional Review Board of the Department of Veterans Affairs ( VA ) Medical Center in Durham , North Carolina , approved this study . Detailed methods have been published previously ( 21 ) . Study Design This was a cluster r and omized , controlled trial , with primary care providers ( PCPs ) assigned to an osteoarthritis intervention group or a usual care control group . R and omization was computer-generated , maintained by the study statistician , and stratified on the basis of the providers ' volume of female patients ( < 15 % vs. 15 % ) . We aim ed to enroll 10 patient participants ( 5 white and 5 nonwhite ) from each of 30 PCPs . Providers assigned to the osteoarthritis intervention group received the provider intervention , and their enrolled patient participants received the patient intervention . Patient participants in both groups continued with any usual medical care recommended by their providers . Because all patient participants were enrolled at the Durham VA Medical Center , usual care could include any of the st and ard treatments for osteoarthritis given by a PCP as well as referral to other providers or specialists . Provider and patient participants in the usual care group received no additional intervention during the study . Participants and Recruitment Primary care providers in the Ambulatory Care Service of the Durham VA Medical Center , with patient panels large enough to be likely to enroll 10 participants , were invited to participate . Patients were eligible if they had hip osteoarthritis ( based on radiographic evidence in the electronic medical record [ EMR ] ) , knee osteoarthritis ( based on radiographic evidence in the EMR or clinical criteria from the American College of Rheumatology [ 22 ] ) , or both , along with self-reported joint symptoms ( pain , aching , stiffness or swelling in or around a hip or knee joint with arthritis ) that were present on most days during the past month or for which the patient had used pain medications on most days during the past month ( 23 ) . Participants also had to be overweight ( body mass index [ BMI ] 25 kg/m2 ) and not currently adhering to physical activity recommendations from the U.S. Department of Health and Human Services ( 24 ) . Exclusion criteria are summarized in the Appendix Table . Potential participants were identified from the Durham VA Medical Center EMR , mailed an introductory letter , and called for a screening interview . Eligible patients completed consent and baseline assessment s at the Durham VA Medical Center and were subsequently informed of their group assignment by telephone . Study team members involved in screening and consent were blinded to r and omization . Potential patient participants were blinded to their PCP 's group assignment until after the baseline assessment s. Appendix Table . Exclusion Criteria Interventions Patient Intervention This was a 12-month intervention focusing on physical activity , weight management , and cognitive behavioral pain management strategies ( 21 ) . Telephone calls were scheduled twice per month for the first 6 months and monthly for the last 6 months and were delivered by a counselor with training in osteoarthritis and behavior change . Goal setting and action planning were major components of the intervention . The counselor used motivational interviewing strategies throughout the intervention ( 21 , 25 , 26 ) . Patient participants were given written educational material s corresponding to intervention topics , an exercise video for patients with osteoarthritis , and an audio CD of relaxation exercises . Provider Intervention This intervention involved delivery of the following patient-specific osteoarthritis treatment recommendations to PCPs , based on published treatment guidelines ( 13 , 14 , 27 ) : refer to a physical therapist , refer for an evaluation for a knee brace , refer to MOVE ! ( the VA system 's weight management program that includes physical activity counseling [ 28 ] ) , perform or refer for an intra-articular injection , recommend a topical nonsteroidal anti-inflammatory drug ( NSAID ) or capsaicin , add a gastroprotective agent or remove an NSAID , discuss the possibility of a new or alternate pain medication , or refer to an orthopedic evaluation for joint replacement surgery . We developed algorithms ( Appendix ) to determine when each treatment option might be reasonable for a PCP to consider for a patient ( 21 ) . Study team members collected all information needed to complete the algorithm for each patient participant during baseline assessment s. Patient-specific recommendations were delivered to PCPs via the EMR as a progress note requiring an electronic signature . The study team monitored upcoming visits for participants in the osteoarthritis intervention group , and recommendations were delivered to PCPs about 1 week before the participants ' first routine visit after enrollment . The recommendations remained available to PCPs within the EMR , but no further communications were transmitted to osteoarthritis intervention providers . Outcome Measures Baseline and 12-month follow-up measures were completed in person , except for 36 participants who could not return to the Durham VA Medical Center at 12 months but completed some measures via telephone . The primary outcome was also assessed via telephone at 6 months . Outcomes assessors were blinded to r and omization . Participants were reimbursed $ 25 and $ 10 for completing in-person and telephone assessment s , respectively . Primary Outcome The primary outcome measure was total score on the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , a self-reported measure of lower extremity pain ( 5 items ) , stiffness ( 2 items ) , and function ( 17 items ) in the previous 2 weeks ( 2931 ) . All items are rated on a 5-point Likert scale ranging from none to extreme ; total scores range from 0 to 96 , with higher scores indicating worse symptoms and function . Secondary Outcomes We examined the WOMAC pain and function subscales separately . We also administered the Short Physical Performance Battery ( SPPB ) ( 32 ) , a commonly used performance measure in older adults that includes 3 tests of balance , a timed 8-foot walk , and 5 chair st and s. The total score ranges from 0 ( worst performance ) to 12 ( best performance ) . Depressive symptoms were assessed with the Patient Health Question naire-8 ( 33 ) , with scores ranging from 0 to 24 . Process Measures We collected additional process measures related to behaviors or outcomes intermediate to changes in symptoms or function . Self-reported physical activity was measured with the Community Healthy Activities Model Program for Seniors ( CHAMPS ) ( 34 , 35 ) , which assesses the frequency and duration of light to vigorous activities in the previous 4 weeks ; we report the weekly frequency and duration of all exercise as well as moderate- or higher-intensity exercise . CHAMPS has established testretest reliability and association with accelerometer-based physical activity among older adults ( 36 ) . Body mass index was calculated using measured height and weight ; when 12-month follow-up measures were administered via telephone , weight was self-reported . For all patient participants , we used the Durham VA Medical Center EMR to examine osteoarthritis-related referrals from PCPs and participants ' actual visits for physical therapy , evaluations for knee braces , joint injections , MOVE ! , and orthopedic consultation during the study . We assessed changes in oral and topical pain medication  by participant self-reports . For oral pain medications , we defined new use during the study as either no pain medication use at baseline but some use at follow-up or use of a different pain medication at follow-up than at baseline . For topical creams , we defined new users as those who reported using any type at follow-up but not at baseline . We acknowledge that use of new oral or topical pain medications may not necessarily have led to better pain control . We also report proportions of osteoarthritis intervention participants whose PCP received each treatment recommendation from the study team and , among those , proportions who had referrals and visits for those treatments . Participant Characteristics We collected patient participantreported information on age , sex , OBJECTIVE To determine whether amputees have an increased risk of knee pain or symptomatic osteoarthritis ( OA ) compared with nonamputees . DESIGN Retrospective cohort study . SETTING Veterans Administration Patient Treatment and Outpatient Care files . PARTICIPANTS All male unilateral ( transtibial or transfemoral ) traumatic amputee patients and a r and om sample of male nonamputees . Patients were excluded if they were younger than 40 years , had sustained a significant injury to their knee(s ) , or had a rheumatic disease . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURES The prevalence of knee pain and symptomatic knee OA . RESULTS The age and average weight-adjusted prevalence ratio of knee pain among transtibial amputees , compared with nonamputees , was 1.3 ( 95 % confidence interval [ CI ] , 0.7 - 2.1 ) for the knee of the intact limb and 0.2 ( 95 % CI , .05 - 0.7 ) for the knee of the amputated limb . The st and ardized prevalence ratio of knee pain in the intact limb and symptomatic OA among transfemoral amputees , compared with nonamputees , was 3.3 ( 95 % CI , 1.5 - 6.3 ) and 1.3 ( 95 % CI , 0.2 - 4.8 ) , respectively . CONCLUSIONS Stresses on the contralateral knee of amputees may contribute to secondary disability . Possible explanations include gait abnormalities , increased physiologic loads on the knee of the intact limb , and the hopping and stumbling behavior common in many younger amputees Background Non-pharmacological treatment ( NPT ) is a useful treatment option in the management of hip or knee osteoarthritis . To our knowledge however , no studies have investigated the effect of NPT in patients with generalized osteoarthritis ( GOA ) . The primary aim of this study is to compare the effectiveness of two currently existing health care programs with different intensity and mode of delivery on daily functioning in patients with GOA . The secondary objective is to compare the cost-effectiveness of both interventions . Methods / Design In this r and omized , single blind , clinical trial with active controls , we aim to include 170 patients with GOA . The experimental intervention consist of six self-management group sessions provided by a multi-disciplinary team ( occupational therapist , physiotherapist , dietician and specialized nurse ) . The active control group consists of two group sessions and four sessions by telephone , provided by a specialized nurse and physiotherapist . Both therapies last six weeks . Main study outcome is daily functioning during the first year after the treatment , assessed on the Health Assessment Question naire . Secondary outcomes are health related quality of life , specific complaints , fatigue , and costs . Illness cognitions , global perceived effect and self-efficacy , will also be assessed for a responder analysis . Outcome assessment s are performed directly after the intervention , after 26 weeks and after 52 weeks . Discussion This article describes the design of a r and omized , single blind , clinical trial with a one year follow up to compare the costs and effectiveness of two non-pharmacological interventions with different modes of delivery for patients with GOA.Trial registration Dutch Trial Register 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 Background Osteoarthritis ( OA ) is a common cause of pain and disability , and is the most common form of arthritis in the Western world . The most common joint to be affected is the knee . Pain and functional disability are common symptoms , which can lead to reduced quality of life and increase the risk of further morbidity . Current treatment aims to educate patients about the management of OA , reduce pain , improve function , decrease disability and reduce the progression of the disease . Education with clients has been described as a set of planned educational activities design ed to improve patients ' health behaviours and /or health status . The purpose of self‐education is to maintain or improve health , or , in some cases , to slow deterioration by increasing participant 's perception of self efficacy defined as an ability to control or manage various aspects of OA . To date , there is no systematic review of the literature undertaken to identify the effectiveness of self‐management educational activities for osteoarthritis of the knee . Objective The objective of this systematic review is to evaluate the effectiveness of  self‐management educational interventions on function and quality of life for adult subjects with OA of the knee . Search strategy A comprehensive search strategy was undertaken on data bases available from University of South Australia from their inception to January 2007 . Selection criteria R and omised controlled trials or clinical controlled trials were sought which evaluated any self management interventions for osteoarthritis knee . Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments . Data extraction was via the Joanna Briggs Institute st and ard data extraction form for evidence of effectiveness , and Review Manager Software was used to calculate comparative statistics . Results Thirteen trials were included in the review . Trials were clinical ly and method ologically heterogeneous . Pooled results indicate evidence of a beneficial effect from  self management strategies with reducing pain ( SMD ‐0.25 , 95%CI ‐0.36 to ‐0.13 , 11 trials 1379 participants ) . There was no effect on physical function ( SMD 0.13 , 95%CI ‐0.33 to ‐0.08 , eight trials , 1156 subjects ) . No beneficial effects were found from self management interventions with improving quality of life . We also found the exercise component of self management ( four trials ) demonstrated a benefit with reducing pain , improving function and quality of life . Exercise also offered a benefit over no exercise  . Overall method ological quality was moderate . Discussion Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain and improving function . Significant heterogeneity was found between trials . This was controlled for in the analysis but may be explained by heterogeneity in both the intervention and control group . The exercise component of self management programmes appears to contribute a significant benefit . Conclusion There is encouraging evidence of a small benefit from exercise in self management programs . Clear guidelines can not be provided for practice regarding the exercise content due to heterogeneity but overall benefit suggests this component should be emphasized and implemented in primary care self management programmes 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 OBJECTIVE To determine the effectiveness of exercise therapy in patients with osteoarthritis ( OA ) of the hip or knee . METHODS A r and omized single blind , clinical trial was conducted in a primary care setting . Patients with hip or knee OA by American College of Rheumatology criteria were selected . Two intervention groups were compared . Both groups received treatment from the patients ' general practitioner , including patient education and medication if necessary . The experimental group also received exercise therapy from a physiotherapist in primary care . The treatment period was 12 weeks . The main outcome measures were pain , medication use ( nonsteroidal antiinflammatory drugs , NSAID ) and observed disability . RESULTS A total of 201 patients were r and omized .  Exercise therapy was associated with a reduction of pain in the past week ( difference in change -17.0 ; 95 % CI -23.6 , -10.4 ) and observed disability ( -0.19 ; 95 % CI -0.38 ; -0.01 ) . Effect sizes were medium ( 0.58 ) and small ( 0.28 ) , respectively . No effect of  exercise therapy  was found for the use of NSAID . Additional beneficial effects ( p = 0.05 ) were found for the use of  paracetamol  ( effect size 0.33 ) , global effect as perceived by the patient ( effect size 0.68 ) , and muscle strength of the hip ( effect size 0.34 ) . CONCLUSION After 12 weeks , exercise therapy is effective in reducing pain and disability . The size of the effects is medium and small , respectively Background Osteoarthritis is the leading cause of disability in older adults . Evidence of effectiveness for self-management of h and osteoarthritis is lacking . Methods In this r and omised , factorial trial , we evaluated the effectiveness of joint protection versus no joint protection , and h and exercise versus no h and exercise in adults , 50 years of age or older , with h and osteoarthritis . Following a population survey ( n=12 297 ) , eligible individuals were r and omly assigned ( 1:1:1:1 ) to : leaflet and advice ; joint protection ; h and exercise ; joint protection plus h and exercise . Joint protection and h and exercises were delivered by nine occupational therapists , over four group sessions . The primary outcome was the OARSI/OMERACT responder criteria at 6 months . Outcomes were collected blind to allocation ( 3 , 6 , 12 m ) . Analysis was by intention to treat . Results Of 257 participants r and omised ( 65:62:65:65 ) ( mean age ( SD ) 66 years ( 9.1 ) ; female 66 % ) follow-up was 85 % at 6 m ( n=212 ) . Baseline characteristics and loss to follow-up were similar between groups . There were no reported treatment side effects . At 6 m 33 % assigned joint protection were responders compared with 21 % with no joint protection ( p=0.03 ) . Of those assigned h and exercises , 28 % were responders compared with 25 % with no exercises ( n.s . ) . Differences in secondary outcomes were not statistically significant , except for improvement in pain self-efficacy with joint protection ( 3 m p=0.002 ; 6 m p=0.001 ; 12 m p=0.03 ) . Conclusions These findings show that occupational therapists can support self-management in older adults with h and osteoarthritis , and that joint protection provides an effective intervention for medium term outcome . ( Funded by the Arthritis Research UK IS RCT N 33870549 )
Several individual RCTs demonstrated clinical ly important improvements in pain and disability with aerobic exercise .
Other PT interventions demonstrated no sustained benefit .
Individual RCTs showed similar benefits with aerobic , aquatic , and strengthening exercise .
Adverse events were uncommon and did not deter participants from continuing treatment .
Low-strength evidence suggested that only a few PT interventions were effective .
BACKGROUND Osteoarthritis is a leading cause of disability .
Nonsurgical treatment is a key first step .
PURPOSE Systematic literature review of physical therapy ( PT ) interventions for community-dwelling adults with knee osteoarthritis .