ABSTRACT
Background: Exercise therapy is recommended as frst line treatment for knee osteoarthritis (OA), but it remains to be sub-optimally applied (1). Movement-evoked pain is a potential barrier to exercise adherence, but recent evidence suggests that such pain can be improved by training (2). Walking programs are low-cost, easily adopted and can be performed outdoors which can minimize the risk of SARS-CoV-2 transmission when in a group (3). Objectives: To explore the acute pain trajectories of individuals with knee OA during a 24-week outdoor walking intervention. In addition, to explore the effect of pain trajectories and/or baseline characteristics on retention and adherence. Methods: Individuals with clinical knee OA and bone marrow lesions (BMLs) on magnetic resonance imaging (MRI) were asked to follow a 24-week walking program. Every week consisted of two one hour supervised group sessions at various outdoor locations and one unsupervised session. At the start and end of every supervised group walk, knee pain was self-reported by participants to their trainer using a numerical rating scale (NRS) (0-10). The difference between the NRS pain values was considered as an acute pain change evoked by that walk. At baseline, the most affected knee of each participant was assessed using the Visual Analogue Scale (VAS) pain, the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) pain, stiffness and function, wellbeing (3 questionnaires) and the Osteoarthritis Research Society International (OARSI) recommended strength and performance measures. Results: In total, N = 24 participants started the program of whom N = 7 (29%) withdrew. Pain at the start of each walk decreased from NRS 2.5 (SD 1.6) at the frst walk (N = 24) to NRS 0.9 (SD 0.8) at the fnal walk (N = 17). This pain was estimated to decrease on NRS by-0.04 (95% CI-0.05 to-0.02) per supervised session, p < 0.001 during the frst 12 weeks and-0.01 (95% CI-0.02 to-0.004), p = 0.004 during the second twelve weeks of the program. The number (%) of participants who experienced an acute increase in pain decreased from 11 (45.8%) at the frst walk to 4 (23.5%) at the last walk. At baseline, non-adherent participants (<70% of group sessions) (N = 11) had lower physical performance scores, including the 30s Chair Stand Test (mean 10 (SD 1.7) stands versus mean 12.0 (SD 1.7) stands, p = 0.011), Fast Past Walk Test (1.23 (SD 0.14) meter per seconds (m/s) vs 1.50 (SD 0.20) m/s, p = 0.001), Six Minute Walk Test (418.8 (SD 75.9) m vs 529 (SD 72.6) m, p = 0.002), compared to adherent participants (N = 13). Non-adherent participants also had less severe self-reported symptoms including WOMAC stiffness (90.7 (SD 44.5) mm vs 121.5 (SD 17.0) mm, p = 0.031), compared to adherent participants. During the frst two weeks of walking, acute increases in pain on average (mean ≥0.5 NRS) were reported by a greater number of non-adherent (N = 5 (45.5%)) than adherent participants (n = 4 (30.8%)). Conclusion: This was an exploratory study and results need to be interpreted with caution due to the small sample size. The walking program resulted in clinically important improvements (MCIIs) (≥ 1 on NRS) (4) in start pain and acute pain changes. Improvements in start pain during the frst 12-weeks were comparable to improvements measured in the NEMEX program (2) and may suggest that 12 weeks of exercise is sufficient to achieve MCIIs in pain. Improvements in acute changes in pain were smaller, which may have been related to a foor effect (5). Lower physical performance scores at baseline and more acute increases in pain during the frst two weeks was associated with non-adherence. Participants with these characteristics may beneft from a lighter introduction to exercise.
ABSTRACT
Purpose: 1) To collate into a repository, best-evidence online osteoarthritis management programmes (OAMPS), and 2) facilitate their implementation, in the context of the COVID-19 pandemic.The Osteoarthritis Research Society International Joint Effort Initiative (OARSI JEI) is a collaboration between international researchers, clinicians and knowledge brokers with an interest in the implementation of OAMPS. OAMPs are defined by the OARSI JEI as “models of evidence-based, non-surgical care that have been implemented in a real world setting and include the following four components: personalised OA care;delivered as a package of care with longitudinal reassessment and progression;comprising two or more elements of the core non-surgical, non-pharmacological interventions (education, exercise and weight loss);with optional adjunct treatments as required (e.g. assistive devices and psychosocial support)”. In 2020, COVID-19 presented a major barrier to the clinical delivery of traditional “in-person” OAMPS. In response, the OARSI JEI implementation group sought to create a repository resource for healthcare professionals (HCPs) seeking to access and signpost patients with OA to online, high-quality OAMPS. The resource also provided access to online HCP training. Methods: An existing community of practice (OARSI JEI implementation group) with access to patient and public involvement, was utilised to create and share an evidence-informed online OAMP repository via social media and OARSI networks. The project involved 5 key stages. Online OAMPS resource investigation: International research, implementation and HCP experts from the JEI implementation group (n=32) were invited to send all online OAMP resources that they were aware of to the reviewers (LS, JQ). These were captured in a spreadsheet with data extracted on programme name;country of origin;whether the resource targeted patients or HCPs;access details relating to required technology, sign in and any access costs;weblink;brief programme content summary;OARSI expert advocating for the programme quality (including whether the content is evidence informed). Screening for repository inclusion: Two reviewers (JQ, LS) screened the resources received against inclusion criteria (matching the OAMP definition, remotely deliverable via the internet, OARSI expert endorsed). Disagreements were resolved through discussion. Creating the online OA repository resource: Academics (JQ, LS, KD) provided content and feedback for a knowledge broker (LC) to create a pdf repository containing included online OAMP information, weblinks and summary information in the form of an infographic. Rapid social media knowledge mobilisation: The repository resource was initially hosted on the Keele Impact Accelerator Unit website and shared on completion with existing OARSI member JEI networks via social media (Twitter)(LC). Owners of online OAMPS also promoted their own programmes via social media. Reflection and learning: Project method strengths and limitations were discussed, critiqued and captured during an OARSI JEI community of practice meeting. Results: The final OARSI online repository included 7 OAMPS and linked training resources. The online repository is available at: with ongoing plans for hosting on the OARSI website. Fig. 1 illustrates the repository cover and Fig. 2 is the infographic repository summary. A relative dearth of online OAMPS meeting our prespecified criteria were identified which included: ESCAPE pain;The Joint Academy;JIGSAW-E (for pharmacists and physiotherapists);PEAK: Join2Move;Osteoarthritis Management Healthy Weight for life. Only JIGSAW-E, PEAK and the Join2Move app were widely available free resources for HCPs at the early stage of the COVID-19 pandemic. All online OAMPs were in English except the Join2Move app which is in Dutch. Content details of the included online OAMPs and online OAMP HCP training packages are summarised in Table 1. The initial Twitter launch tweet sharing the repository infographic and repository link has had 5,679 impre sions and 334 engagements to date and has been shared globally. Reflections and limitations: There is an urgent requirement for more high-quality OAMPs to be freely available for remote delivery and in a wider range of languages. This has relevance both during the COVID pandemic and more generally for rural, geographically isolated populations and low- and middle-income countries. In reacting to an emergency, rapidly evolving, time-pressured clinical pandemic context, there was a tension in matching the highest quality methods for searching, evaluating and synthesising online OAMPs in the shortest possible time. For example, full systematic review methods were deemed inappropriate and the project was not explicitly informed a-priori by a protocol or knowledge mobilisation theory, however, members of the team had knowledge mobilisation expertise. It is possible that we did not identify all online OAMPs. For example, no online OAMPS from South America, Africa or Asia were identified which may, in part, be explained by the geographical representation within the community of practice, with participants mostly from Europe, North America and Australasia. It is acknowledged that the pragmatic and rapid OAMP resource identification, screening and knowledge mobilisation from this project does not guarantee implementation into clinical practice. The existence of the OARSI JEI implementation group facilitated the timely execution of this project whilst the use of social media allowed the repository to be shared rapidly with many stakeholders. Future plans include the hosting of the repository and future JEI work on the OARSI website (to increase resource access);the formal synthesis of knowledge mobilisation metrics relating to the online repository and included OAMPS, and;the ongoing review of repository content in the light of new OAMPS. Conclusions: The OARSI-endorsed JEI implementation group facilitated the creation of an online OAMP repository in response to the COVID-19 pandemic and need for remotely delivered care. There is a dearth of widely available and remotely deliverable OAMPs internationally. This is likely to present a significant barrier to the delivery of best OA care, especially during COVID-19. OARSI can have a key role in supporting the implementation of best OA care. There is a need to actively broaden the diversity and national representation within the JEI implementation group and increase patient and public involvement to best serve the international OA populations, particularly from low- and middle-income countries, it seeks to inform. [Formula presented] [Formula presented] [Formula presented]
ABSTRACT
Purpose: As a chronic condition, self-management via education and lifestyle treatments, such as exercise/physical activity and weight loss, is integral to minimizing pain and improving physical function in people with OA. However, OA care is suboptimal world-wide with under-use of lifestyle treatments a major problem. There are numerous barriers to uptake of, and adherence to, lifestyle treatments. One major barrier is difficulty accessing clinicians and/or enabling resources (due to geography, lack of clinicians, cost, inconvenience, or disability and more recently due to restrictions bought on by the COVID-19 pandemic). However, given the high adoption rate of computers, mobile devices and internet globally, digital health approaches provide opportunities for delivering lifestyle treatments remotely to people with OA and supporting them to self manage. The purpose of this presentation is to provide an overview of the research relating to the use of digital health approaches for the lifestyle management of OA. Methods: A narrative review was undertaken with a focus on evidence from systematic reviews and meta-analyses and randomised controlled trials (RCTs). Qualitative studies were also included to provide a more detailed understanding of patients’ and clinicians’ experiences and factors that may influence implementation. Although there are a variety of digital health approaches, those of most interest for this presentation were telehealth, mobile health and apps, web-based platforms, and wearable devices. Research related to digital health approaches for rehabilitation post joint replacement for OA was not covered. Results: A limited number of RCTs have investigated digital health approaches for lifestyle management in people with OA and most have been performed in those with knee OA. Of these RCTs, most have investigated care delivered via telehealth, either telephone or videoconference or internet-based programs. The focus has been on education and exercise/physical activity. There is some evidence that such interventions can reduce pain, improve function and increase physical activity compared to usual care or education control although this is not necessarily consistent across studies. Furthermore, adherence to internet-based programs without any clinician input can be problematic. Few studies have included cost-effectiveness analyses nor moderator analyses to explore patient subgroups who may respond best. Adequately-powered non-inferiority trial designs are needed to establish whether OA care delivered by telehealth or in person result in equivalent patient outcomes. Qualitative studies show that patients and clinicians describe mostly positive experiences but barriers to implementation exist. While many patient-facing apps available in the marketplace may be useful for OA, relatively few are specifically designed for OA. For example, a 2019 review (Choi et al. Health Informatics J. 2019) located only 23 such mobile apps. There is, however, a lack of research into the development and evaluation of apps for OA management. Conclusions: There is some evidence to show that digital health approaches for lifestyle management of OA are feasible, generally acceptable to patients and clinicians, and may be effective ways of improving patient outcomes. However, further high quality research is needed and with longer term follow up to confirm. This is particularly important given that the adoption of digital health services around the world has been dramatically accelerated by the global COVID-19 pandemic. This presents an opportunity to build on this momentum and drive innovation in research-informed digitally-enabled models of OA care.
ABSTRACT
BACKGROUND: The delivery of physiotherapy via telehealth could provide more equitable access to services for patients. Videoconference-based telehealth has been shown to be an effective and acceptable mode of service delivery for exercise-based interventions for chronic knee pain;however, specific training in telehealth is required for physiotherapists to effectively and consistently deliver care using telehealth. The development and evaluation of training programs to upskill health care professionals in the management of osteoarthritis (OA) has also been identified as an important priority to improve OA care delivery. OBJECTIVE: This study aims to explore physiotherapists' experiences with and perceptions of an e-learning program about best practice knee OA management (focused on a structured program of education, exercise, and physical activity) that includes telehealth delivery via videoconferencing. METHODS: We conducted a qualitative study using individual semistructured telephone interviews, nested within the Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis randomized controlled trial, referred to as the PEAK trial. A total of 15 Australian physiotherapists from metropolitan and regional private practices were interviewed following the completion of an e-learning program. The PEAK trial e-learning program involved self-directed learning modules, a mock video consultation with a researcher (simulated patient), and 4 audited practice video consultations with pilot patients with chronic knee pain. Interviews were audio recorded and transcribed verbatim. Data were thematically analyzed. RESULTS: A total of five themes (with associated subthemes) were identified: the experience of self-directed e-learning (physiotherapists were more familiar with in-person learning;however, they valued the comprehensive, self-paced web-based modules. Unwieldy technological features could be frustrating);practice makes perfect (physiotherapists benefited from the mock consultation with the researcher and practice sessions with pilot patients alongside individualized performance feedback, resulting in confidence and preparedness to implement new skills);the telehealth journey (although inexperienced with telehealth before training, physiotherapists were confident and able to deliver remote care following training;however, they still experienced some technological challenges);the whole package (the combination of self-directed learning modules, mock consultation, and practice consultations with pilot patients was felt to be an effective learning approach, and patient information booklets supported the training package);and impact on broader clinical practice (training consolidated and refined existing OA management skills and enabled a switch to telehealth when the COVID-19 pandemic affected in-person clinical care). CONCLUSIONS: Findings provide evidence for the perceived effectiveness and acceptability of an e-learning program to train physiotherapists (in the context of a clinical trial) on best practice knee OA management, including telehealth delivery via videoconferencing. The implementation of e-learning programs to upskill physiotherapists in telehealth appears to be warranted, given the increasing adoption of telehealth service models for the delivery of clinical care.