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Purpose of Study: Total knee (TKA) and hip (THA) arthroplasty procedures are recognized as effective treatments for osteoarthritis of the knee and hip joints which are the leading causes of lower extremity disability among older adults. Previous studies have demonstrated a variance in patients electing to undergo these interventions with non-White patients having significantly lower utilization rates. Our study examined if these disparities continued to exist during the COVID-19 pandemic period. Methods Used: This retrospective cohort study included 580 patients who underwent TKA or THA in 2020 and 2021 in a racially diverse region in Washington State. Demographic data, comorbidities, and post-surgical outcomes were recorded. Patients were stratified as those identifying as White (n=490, 84.5%) or Hispanic/ Latino (n=65, 11.2%). Patients identifying with other races (n=25, 4.3%) were excluded from the study due to small sample sizes. Differences between our two groups were examined using a chi-square test for categorical variables and an independent t-test for continuous variables. The level of significance was set at P < 0.05. Summary of Results: Compared to the White patients, Hispanic/ Latino identifying patients were younger (61.9+/-12.79 years versus 68.58+/-9.00 years;P <0.001), had lower Charlson Comorbidity Index scores (P=0.019), and were more likely to use non-Medicare or Medicaid insurance (P <0.001). No differences were observed in postoperative complication (P=0.632) and COVID-19 infection (P=0.465) rates between the groups. Conclusion(s): Although Hispanic/ Latino identifying patients in this region constitute 45.8% of our study population according to the most recent census tabulation, they accounted for only 11.2% of the patients in our study. These patients were also younger, had fewer comorbidities, and tended to use non-Medicare or Medicaid insurance suggesting an exclusive Hispanic/ Latino patient population electing to undergo TKA or THA procedures during the COVID-19 pandemic. Future studies controlling for osteoarthritis risk factors and patients' election of treatment options may explain these disparities we have observed.
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Purpose: Between 2008 and 2014 approximately 32.5 million adults in the United States reported a diagnosis of osteoarthritis (OA). The 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis (OA) of the hand, hip and knee recommend treating pain due to OA with analgesic therapy as part of multi-modal treatment program. A national survey conducted by the Centers for Disease Control found that patients with OA were likely to delay care during the pandemic. Given this new barrier to healthcare, access to analgesic therapy may have become even more limited. This study aimed to evaluate changes in analgesic prescribing practices for OA as a result of the COVID-19 pandemic. Method(s): A retrospective analysis was performed to identify new prescriptions, number of doses per order and refills of 73 topical and oral analgesics from encounters for OA. OA encounters were identified using 206 ICD-10 codes for OA from July 2019 to June 2021 at UC Davis Hospital and affiliated outpatient centers. Pre-pandemic data corresponds to 2019 data and data collected after this occurred during the pandemic. Counts of new prescriptions, number of doses per order and refills by fiscal quarter were analyzed using a two-factor Poisson Regression with an interaction between quarter and year with corresponding contrasts to detect a difference between 2019 and 2020 as well as 2019 and 2021 and quarters between these years. A follow-up Sidak step-down p-value adjustment was used to correct for type I error. All statistical analyses were done with a two-sided alpha of 0.05. The Poisson Regression was performed with SAS software for Windows version 9.4 (SAS Institute Inc., Cary, NC). Result(s): A total of 31,532 encounters with a primary diagnosis of OA occurred from July 2019 to June 2021. There was an increase in the number encounters with a primary diagnosis of OA (Figure 1) but there was no statistical difference in the medications ordered from 2019 to 2020, 2019 to 2021, and the quarters between these years as well. After adjusting for Type I error, there was a significant decrease in medication refills from 2019 to 2020 (p-value 0.0031, adjusted p-value 0.0425) as well as from 2019 to 2021 (p-value <0.0001, adjusted p-value 0.003) (Figure 2), and there was a significant decrease in number of doses of analgesia from 2019 to 2020 and an increase in number of doses from 2019 to 2021 (p-value <0.0001, adjusted p-value 0.003) (Figure 3). Conclusion(s): The COVID-19 pandemic has persistent impacts on the prescribing practices of analgesics for the treatment of OA. Our data suggests that since the COVID-19 pandemic, patients with OA were overall provided with more doses of analgesics and fewer refills. It is likely that barriers imposed by COVID-19 resulted in these changes in the way analgesics are provided for the treatment of OA. [Formula presented] [Formula presented] [Formula presented]Copyright © 2023
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Purpose: To describe the trends over time from 2008 to 2021 for people who have received first-line interventions for hip and knee osteoarthritis in Sweden and adherence of the healthcare staff to the national guidelines. Method(s): Descriptive registry-based study including people with hip or knee OA who participated in first-line interventions including education and exercise. Data were extracted from the Swedish Osteoarthritis registry between January 1st, 2008, and December 31, 2021. The registry contains patient-reported outcomes and physiotherapist-reported outcomes. In this study the following physiotherapist-reported outcomes were described over time: radiological examination before first-line treatment, if the first-line treatment was given the first time the patient seek health care caused of OA, which explanation patients had been given about their disease, intake of painkillers before the start of first-line treatment and the percent who got supervised exercise >10 times according to the guidelines of OA in Sweden. The following patient-reported outcomes were described over time: mean BMI at the first visit, and mean age at the first visit. To be included in the study, participants had to meet the following criteria: i) clinical diagnosis of OA, with hip or knee OA as the most symptomatic joint, ii) provided 3-month follow-up Results: A total of 175 764 participants with hip or knee OA were included in the study. The trends from 2008-2021 showed that the proportion of people who had a radiological examination before entering the first-line treatment decreased from 97 % to 65 % in men and from 95% to 62 % in women. The proportion of people who get assess to first-line treatment the first time they seek for their symptoms increased from 4 % to 10 % both in men and women. People that get the correct information about OA increased from 15% to 40 %, and people that get the explanation that OA was a tear and wear disease decreased from 30 % to 5%. The mean BMI (28) is unchanged over time. The mean age increased from 64 years to 67 years between 2008-2020 but decreased during the covid-19 pandemic to 64 years. The percentage that was given supervised exercise more than 10 times was constant between 2012-2020 at 30 % but decreased during the covid-19 pandemic to 20%. Conclusion(s): The results implicit that the implementation of a supported osteoarthritis self-management program in Sweden has been successful and changed the care given to people with OA in Sweden. However, the national guidelines for OA, published in 2012, have still not been fully implemented. We need to keep implementing the guidelines so all patients with osteoarthritis get the first-line treatment at the right time.Copyright © 2023
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We present a case of long-term organ functioning (ca.10 years) after allografting of a cadaveric kidney without usage of immunosuppressing drugs. In 2005, a patient suffering from a hypertensive form of chronic glomerulonephritis, have received an allogeneic graft of cadaveric kidney compatible for AB0 system, HLA antigens (A19, B07, DR04), and negative results of cross-match test. The graft function was immediately restored, with normalization of creatinine levels achieved 4-5 days after surgery. Immunosuppression with cyclosporine, solumedrol, cellcept, metypred and simulect was performed in the hospital. Pulse therapy with solumedrol was performed on the day +20 due to the development of initial rejection signs. The postoperative period proceeded without infectious complications. The patient was discharged being recommended to take cyclosporine, Cell-Sept and Metypred. Within a year after transplantation, the patient claimed for pain in the hip joint, and, therefore, metypred was completely canceled. Subsequently, the Cellcept was replaced with a Mayfortic. In 2007, the signs of coxarthrosis were revealed at computed tomography, followed by aseptic necrosis of the the right femur head. Deforming osteoarthritis of the right hip joint was detected, and the hip replacement surgery was suggested. In 2010, due to risk of side effects from ongoing immunosuppressive therapy, e.g., joint damage, the Mayfortic was canceled. In 2012, being in fear of original Sandimmun Neoral replacement by a generic drug, the patient completely refused cyclosporine therapy. In 2021, the endoprosthetics of the right hip joint was performed, and the surgical wound healed initially. Since 2012, the patient has not completely taken immunosuppressive therapy. Over this time period, the patient has never been admitted to the hospital for impaired functioning of the organ graft. Meanwhile, he monitored his graft function on regular basis undergoing biochemical analyses, clinical examination, ultrasound studies of the graft and made regular visits to the outpatient department. In 2021, a week after hip replacement, there was a slight increase in serum creatinine, followed by further increase to 230 mmol/L in 2021, and to 310 mmol/L in March 2022. In February 2022, the patient suffered mild respiratory infection (confirmed COVID-19). In March 2022, the first clinical signs of increasing nephropathy appeared, i.e., swelling of both lower extremities, with leukocytes in urine upon routine analysis, increased blood flow resistance in the main artery of the transplant shown by ultrasound study. Due to worsening of the patient's condition, he resumed taking the prescribed immunosuppressants. Copyright © 2022, SPb RAACI.
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BACKGROUND: Intra articular (IA) injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) are of the new methods in the management of hip osteoarthritis (OA). The aim of this study was to compare the effectiveness of IA injections of PRP, HA and their combination in patients with hip OA. HA and PRP are two IA interventions that can be used in OA in the preoperative stages. Due to the different mechanisms of action, these two are proposed to have a synergistic effect by combining. METHODS: This is a randomized clinical trial with three parallel groups. In this study, patients with grade 2 and 3 hip OA were included, and were randomly divided into three injection groups: PRP, HA and PRP + HA. In either group, two injections with 2 weeks' interval were performed into the hip joint under ultrasound guidance. Patients were assessed before the intervention, 2 months and 6 months after the second injection, using the visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne questionnaires. RESULTS: One hundred five patients were enrolled randomly in HA, PRP and PRP + HA groups. All three groups showed significant improvement in WOMAC, VAS, and Lequesne at 2 months and 6 months compared with baseline. Comparison of the 3 groups demonstrated significant differences regarding WOMAC and Lequesne total scores and the activities of daily living (ADL) subscale of Lequesne (P = 0.041, 0.001 and 0.002, respectively), in which the observed improvement at 6th month was significantly higher in the PRP + HA and PRP groups compared to the HA group. CONCLUSION: Although all 3 interventions were associated with improvement of pain and function in patients with hip OA, the therapeutic effects of PRP and PRP + HA injections lasted longer (6 months), and the effects of these two interventions on patients' performance, disability, and ADL were superior to HA in the long run. Moreover, the addition of HA to PRP was not associated with a significant increase in the therapeutic results. TRIAL REGISTRATION: The study was registered at Iranian Registry of Clinical Trials (IRCT) website http://www.irct.ir/ , a WHO Primary Register setup, with the registration number of IRCT20130523013442N30 on 29/11/2019.
Subject(s)
Osteoarthritis, Hip , Platelet-Rich Plasma , Activities of Daily Living , Humans , Hyaluronic Acid/therapeutic use , Injections, Intra-Articular , Iran , Molecular Weight , Osteoarthritis, Hip/drug therapy , Osteoarthritis, Hip/therapy , Treatment Outcome , Ultrasonography, InterventionalABSTRACT
Background: Intermittent hypoxia conditioning reduces the levels of infam-matory parameters and cytokines (C-reactive protein, TNF-α, IL-4, IL-6, IL-8), increases the tolerance to acute hypoxia, the functional capacity and improves parameters of respiratory and cardiovascular systems [1-4]. Objectives: To evaluate the efficiency of the interval hypoxic-hyperoxic training (Reoxy therapy) in the rehabilitation of patients with osteoarthritis (OA) and post-COVID syndrome. Methods: 36 patients with OA (78% females, age of 43 to 68 years, generalized OA, OA of the knee or hip joints) where included in the randomized placebo-controlled study. Coronavirus infection COVID-19 were diagnosed from 12 to 26 weeks before the study. The main symptoms of post-COVID syndrome were dry cough, smell loss, breathlessness, weakness, fatigue, sleep disorders, cognitive symptoms, memory problems, anxiety, depression, headache, dizziness, joint and muscle pain. All patients were randomized into 3 groups. 13 study group patients received 10 Reoxy therapy procedures, 9 placebo group patients-10 placebo procedures of Reoxy therapy, 14 control group patients-only standard rehabilitation. The patients of all groups underwent 2-week standard rehabilitation program: 10 procedures of electrostatic massage for muscles and periar-ticular tissues, 10 sessions of general magnetic therapy, 10 group sessions of physical exercises with elements of breathing exercises. All patients received NSAIDs and SYSADOA at standard dosages. Intra-articular corticosteroids was not used. The study group patients were breathing hypoxic (FiO2 13-15%) and hyperoxic (FiO2 up to 40%) gas mixture through the mask in the interval mode with biofeedback using device «ReOxy» (Ai Mediq S.A., Luxembourg). 10-min hypoxic test (FiO2 12-13%) was performed before the frst and fourth procedures. The duration of 1-4 procedures was 30 min, 5-10 procedures-40 min. The placebo procedures were performed using the mask with the atmospheric air hole. Joint pain and general health on 100-mm VAS, Lequesne and WOMAC indexes, Spielberger-Khanin anxiety test, Beck depression inventory and breath-lessness on Modifed Borg scale were evaluated at baseline and at 2 weeks. Results: After 2 weeks in the study group pain on VAS decreased by 49,6% (p<0,05), Lequesne index-by 39,3% (p<0,05), WOMAC-by 1,4 times (p<0,01), anxiety level on Spielberger-Khanin test-by 40,9% (p<0,05), depression level on Beck depression inventory-by 64,1% (p<0,01), general health on VAS improved by 69,3% (p<0,01). The level of breathlessness on Modifed Borg scale in the study group initially was 2,5±0,9 score (moderate-slight breathlessness). After rehabilitation in the study group the level of breathlessness decreased to 0,3±0,4 score (extremely slight-no breathlessness). In the study group there were statistically signifcant differences from the placebo group (p<0,05) and the control group (p<0,05) in all parameters. Conclusion: 2-week complex rehabilitation program, including interval hypox-ic-hyperoxic training (Reoxy therapy), reduces pain, breathlessness, depression and anxiety, improves functional status and general health in patients with OA and post-COVID syndrome.
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Purpose: Osteoarthritis (OA) is a chronic and disabling condition affecting morbidity and mortality. Despite its high prevalence and the availability of international management guidelines, nearly half of patients do not receive recommended treatments. OA Management Programs (OAMPs) are an alternative care model to reduce barriers and enhance the receipt of evidence-based care. This study was designed to evaluate the fidelity and feasibility of an OAMP in a United States academic medical center and understand its patients' baseline characteristics. Methods: The OAMP, which opened on July 1, 2017, is focused on knee and hip osteoarthritis. A multi-disciplinary group, including patients with OA, designed the clinic model and operations based on international OAMP implementation recommendations considering local factors. The intended treatment dose was 1-6 appointments over 4-12 months with no more than two months between visits. At each appointment, patients had the opportunity to meet with a care team comprised of a medical provider (physician or advanced practice provider), registered dietitian, physical therapist, and mental health counselor. All providers had completed OA clinical competency training. Telemedicine video visits were also available after June 2020 due to the COVID-19 pandemic. Patients are asked to complete the patient questionnaires before their visit through a patient portal in the electronic health record. They are also provided with a tablet computer to complete the VR-12 and the HOOS and/or KOOS while in the clinic waiting room. For this study, a database was created for all adult patients who had at least one clinic visit from July 1, 2017, to January 15, 2021. Data was collected by an electronic health record data pull and a manual audit of visit notes. Primary outcomes related to clinic feasibility and fidelity included clinic operations and expansion, treatment duration, and number and type of appointments attended. Secondary outcomes included patients' baseline characteristics. Results: The 938 eligible patients attended an average of 2.7 visits over a mean of 114.4 days (±5.9). Patients utilized the OAMP differently: 371 (39.5%) of patients attended 1 visit, 348 (37.1%) attended 2-3, and 232 (24.7%) attended 4 or more. A total of 175 (18.66%) completed at least one telemedicine visit. Patient referrals came predominantly from primary care (61%%) and orthopedics (20.3%);8.6% were self-referred. The average time between seeking care and the first appointment is just over six weeks. Due to patient demand, the program has expanded from seeing six patients per week to seeing more than 40 patients per week. The expansion has required hiring and training an increased number of clinicians, starting with four clinicians in different specialties to 11 clinicians. The average patient was 62.2 years (±10.2), and most were female (72%). Nearly all were Caucasian (91.3%). Medicare (51.4%) was the most common type of insurance, followed by commercial insurance (38.3%). Half of the patients were employed (49%), while 32% were retired. At the initial visit, the average BMI was 40.9 (±10). The average Charlson Comorbidity Index score (CCI) was 2.1 (±1.3), indicating moderate severity of comorbid conditions. The baseline pain rating was moderate at 4.44 (±2.37) on a 1-10 pain scale. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Hip Injury and Osteoarthritis Outcome Score (HOOS) pain scores were 47.9 (±18) and 44.9 (±23.6), respectively showing moderate baseline levels of pain. Veterans-Rand 12 scores were low at the initial visit. The VR-12 physical and mental subscales were 25.66 (±7.35) and 48.15 (±10.76) lower than expected for an adult population. The average number of repetitions obtained from the 30-second chair rise test was 10.65 (±3.49), which is lower than age and gender norms. The completion rate of self-administered patient questionnaires was low, with less than half of patients completing all questionnaires at the initial visit. Conclusions: Baseline data reveals patie ts with high levels of pain, low function, and multiple comorbid conditions who are willing to attend multiple visits. The program has continued to expand to meet increased patient demand. Patient utilization of the clinic varied, with some patients attending only one appointment and others returning numerous times. Despite being invited back within two months, a subset of patients returned for a second appointment more than six months after their initial appointment. Completion rates of the self-questionnaires (HOOS/KOOS, VR-12) were low despite having options of how to complete these. The low completion rate indicates that instruments should be selected judiciously with careful consideration for which should be administered at every clinic visit. Clinic operations and growth are feasible with variable fidelity. The next steps will be an evaluation of patient utilization of the clinic and its impact on patients outcomes.
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Purpose: Osteoarthritis (OA) is a chronic and disabling disease, affecting both morbidity and mortality. Prevalence is rising as the age and weight of the general population increase. Despite its high prevalence, nearly half of patients do not receive recommended treatments. Multiple barriers to receipt of evidence-based care have been identified and OA Management Programs (OAMPs) have been posited as an alternative care model to facilitate treatment. This mixed-methods study was designed to examine and evaluate patients’ perceptions of the acceptability and effectiveness of an OAMP at a U.S. academic medical center. Methods: Eligible patients included adults with knee or hip OA who completed at least one visit in the OAMP from July 1, 2017, to January 15, 2021 (n=938). These patients were divided into three groups based on the number of completed visits: 1 visit, 2-3 visits, or 4+ visits. Seventy patients from each group were randomly selected to receive a mailing that included: 1) the Osteoarthritis Quality Indicator (OA-QI) which queried receipt of guideline-recommended care;2) an invitation to participate in an interview regarding their OAMP care experience;3) the study’s informed consent document;and 4) an addressed, stamped envelope to return the completed OA-QI and consent form to investigators. Interviews of consenting patients were conducted in person or over the phone by a trained medical student who followed a semi-structured interview script. Interviews were recorded, transcribed, and analyzed using NVivo QSR 12, supplemented by a manual analysis to confirm themes. Results: Fifty-six patients (26.67%) completed the OA-QI and reported receiving an average of 13.24 (±2.85) of the 17 quality indicators. Thirty-four participants (60.7%) reported receiving at least 80% of the included quality indicators, 11 reported receiving 60-80%, and 11 (17.2%) reported receiving less than 60%. There was no statistical difference in OA-QI scores based on the number of OAMP appointments attended. Less than 60% of respondents reported being seen by a specialist for weight management. Every patient who returned the OA-QI had met with a registered dietitian for weight management as part of OAMP care. Seventeen patients (30%) reported not being referred to a joint specialist to evaluate for surgery for their severe symptoms. A total of 17 patient interviews were conducted, at which time data saturation was reached. Seventy-seven percent affirmed having had enough time to discuss their joint disease and treatment recommendations, 64.7% reported positive changes in their knowledge or beliefs about OA, and 64.7% had made at least some progress toward achieving their goals. Thirty percent cited a lack of proactiveness, motivation, or proper time management as barriers to starting or maintaining their treatment goals. Fifteen of the 17 participants responded to a query regarding confidence in self-managing their OA: 40% reported increased confidence, 40% reported no change, and one person reported a decrease. Two interviewees reported no change in confidence, but felt affirmed that they were “doing the right thing”. Rapport with providers was highly endorsed (88.2%), and telemedicine visits were mentioned as a mechanism for support and encouragement. Forty-one percent of interviewees had attended a group medical visit;non-attendance was attributed to distance to the clinic and group visit unavailability when COVID-19 arose. Fifty-nine percent of the interviewees endorsed a belief that OA could be managed without surgery;however, only 47% knew anyone who had successfully done so. Conclusions: Patients reported receiving a very high number of OA quality indicators, higher than reported in the literature for general populations. Interviewees were very satisfied with OAMP providers and nearly two-thirds affirmed positive changes in knowledge or beliefs regarding OA and progress toward meeting goals. Many patients did not recognize that the OAMP offers specialized care. They reported not receiving care from a specialist f r weight management despite having met with a registered dietitian. Others reported not being referred to a joint specialist to discuss surgery for their severe symptoms, although this discussion is a routine part of the OAMP’s services. These gaps in perception could potentially influence satisfaction and adherence. They suggest that improved communication regarding the OAMP’s specialized, evidence-based care may need to be provided. Additionally, many patients still believed that surgical intervention is an inevitable part of having OA, which may impede buy-in to minimally invasive OA management.
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Purpose: Osteoarthritis (OA) affects more than 300 million people worldwide with the knee and hip joints among the most clinically prevalent. Pain, stiffness, and physical disability are hallmark symptoms that impair quality of life. Good Life with osteoArthritis from Denmark (GLA:D®) is an evidence-based program providing education and exercise-therapy for people with knee and hip OA, now offered in 8 countries. A key barrier to GLA:D® is the need to attend 14 in-person sessions over 8-weeks, particularly for those in rural areas or with substantial occupational or family caring responsibilities. In the COVID-19 pandemic we expanded implementation support for GLA:D®in Australia to provide it via telehealth. The aim of this mixed methods project was to evaluate the implementation of GLA:D® via telehealth in Australia using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Methods: Quantitative: People with knee or hip OA who reported completing GLA:D® via telehealth-only or a hybrid model of in-person and telehealth (minimum 3 telehealth sessions) at 3-month follow-up from March 2020-October 2021 were identified from the GLA:D®Australia registry. RE-AIM dimensions were examined descriptively. For the effectiveness domain mean differences [MD, (95% confidence intervals (CI)), effect size (ES)] from baseline to 3-month follow-up were calculated for pain (visual analogue scale, 0-100) and joint-related quality of life (knee injury and osteoarthritis outcome score or hip disability and osteoarthritis outcome score -quality of life sub-scales). Participants rated perceived recovery on a global rating of change (scale -3 to 3;1-3=recovered) and how satisfied they were with the GLA:D® program (scale 1-5;4,5=satisfied) at 3-month follow-up. Qualitative: One-on-one semi-structured interviews were conducted with 23 GLA:D® trained physiotherapists (n=12 telehealth adopters;n=11 non-adopters) from diverse (private/public practice, urban/rural) settings. Interviews were transcribed and analysed using a reflexive thematic approach guided by the RE-AIM QuEST framework. Results: Reach: 138 people (39 telehealth-only and 99 hybrid model;69% female) completed GLA:D.® Mean (SD) age and BMI were 64 (9) years 29.8 (5.5) kg/m2, respectively. Key themes on patient barriers and enablers for telehealth reach were technology literacy and access, personal preference and perceived value of telehealth, and availability of exercise equipment. Pandemic restrictions limiting access to in-person GLA:D® was an enabler. Effectiveness: For telehealth-only, average pain [MD=-10 (95%CI=-16, -4), ES=-0.54] and joint-related quality of life [MD=9 (95%CI=3, 14), ES=0.51] improved significantly. This was similar for hybrid model with average pain [MD=-11 (95%CI=-16, -6, ES=-0.43)] and joint-related quality of life [MD=12 (95%CI=8, 16, ES=0.65)] also improved. At 3-months, 81% of participants reported recovery and 88% were satisfied with GLA:D®. Most physiotherapists who adopted GLA:D® telehealth believed it was as effective as in-person for most patients and felt patients were better able to continue exercising at home upon completion. Adoption: 92 physiotherapists (74 health services) delivered GLA:D® via telehealth. Most physiotherapists who had adopted GLA:D® via telehealth stated it had become a normal part of their practice. Barriers to adoption included preferring, and greater confidence with providing, in-person GLA:D®. Implementation: Both education sessions were attended by 70% (n=96) of participants and 91% (n=125) attended more than 10 exercise-therapy sessions. GLA:D® telehealth implementation involved program modifications, including to assessment, exercise instruction, equipment modifications, and reduced fee structures. Maintenance: GLA:D® telehealth participants completed 3-month follow-ups throughout the entire study timeframe, with 16 (12%) in the final 2 months of evaluation, indicating ongoing participant engagement. Physio herapists stated GLA:D® telehealth was an opportunity for increased program access to immunocompromised, rural, and working patients. Barriers to sustainability identified included lack of personnel capacity, low patient demand, and a need for future telehealth training and support. Conclusions: Telehealth delivery of GLA:D® in Australia during the pandemic was most used as part of a hybrid model, combined with in-person delivery. Patient outcomes following GLA:D® via telehealth were comparable to published data related to in-person delivery, indicating it is an effective method to implement group-based care for OA. Yet, implementation was limited, impeded by low perceived value by patients and lack of confidence and training of physiotherapists. This evaluation will guide new strategies and training to support GLA:D via telehealth as a viable mode of program delivery in the future in Australia and internationally.
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Purpose: Osteoarthritis (OA) has a disproportionately significant effect on social, economic and healthcare domains. Systematic reviews and clinical guidelines indicate strong evidence for the management of OA through targeted exercise and education interventions. Throughout the COVID-19 pandemic, there has been a rapid increase in digital health utilization which has the potential to provide accessible, cost-effective and time-effective care. The aim of this study is to investigate the effectiveness of digitally delivered exercises in management of OA of the hip or knee. Methods: Databases of PubMed, PEDro, EMBASE & CINAHL were searched with the concepts of “Osteoarthritis”, “Digital” & “Randomised Controlled trials”. Synonyms within each concept were search with the OR operator, and combined between concepts with the AND operator. Titles and s were screened for eligibility by two reviewers [AS1] and conflicts were resolved by consensus, or a third reviewer. Articles were screened according to the following criteria: Participants- people with hip or knee OA;Intervention- had to include a form of exercise prescription being delivered digitally (requiring internet);Comparison- no intervention or comparison intervention;Outcome- pain was the primary outcome for this review. Full-texts of potentially eligible articles were screened by one reviewer and checked by a second. Means, standard deviations or 95% Confidence Intervals (CI) of post-test results were used to calculate standardised mean differences (SMDs). Data was stratified by time points, mode of delivery and OA type (knee or hip). Data were pooled in a random effects meta-analysis where two or more studies were identified within a subgroup. Results: 7327 studies were identified through database searching. After title and , and full-text screening, 10 studies were included within this systematic review. There was a total of 3,402 participants included within this meta-analysis. Studies included participants with hip or knee OA (n=3 studies), knee OA only (n=7 studies). There were no studies on hip OA only. Interventions ranged from exercise delivered via web-based, app-based and video-conferencing, with comparisons including waitlisting, usual care or usual physiotherapy, alternate modes of delivery, and education only via digital means. Overall Pain Results: Digitally delivered exercise had significantly better outcomes for pain at short term (≤3 months) SMD and 95% CI [-0.44 (-0.73, -0.15)], medium term (3 to 6 months [-0.24(-0.46, - 0.02)]) and long term (>6 months [-0.20 (-0.38, -0.03)]). Knee Osteoarthritis only: 7 studies reported on knee OA. Digital exercise interventions were superior to the comparison at short term (95%CI -0.68(-1.11, -0.24)), and long term (95%CI -0.30(-0.49, -0.12). There was no difference between digital exercise intervention and the comparison at the medium term (95%CI -0.29(-0.60, 0.02) time-point. App Based intervention: 4 studies used an app based digital intervention to deliver exercise prescription. App based was superior to the comparison in the short term [-0.45(-0.79, -0.10)], but there was no difference at the medium term [-0.12(-0.34, 0.10)] Web Based intervention: 5 studies used a web-based platform to deliver exercise interventions. These were superior to the comparison for the outcome of pain short term [-0.16(-0.32, -0.01)], but there was no difference in the medium [95%CI -0.29(-0.60, 0.02], and long term [95%CI -0.16(-0.33, 0.02)]. Conclusions: The data indicates that exercises delivered digitally are more effective than any comparisons including waitlisting, usual care or physiotherapy, alternate modes of delivery, or education component only in management of hip and knee osteoarthritis. There is robust evidence to suggest an increased effect within the first 3 months of implementation across all modes of delivery (Video, Web or App-based). Improvements in pain symptoms is an important outcome as this can be associated with improvement in function, health, and returning to activiti s of daily living. Additionally, pain is the predominant factor for seeking healthcare, so improvements within community-dwelling patients with OA may reduce burdens on hospital and health services, and subsequent costs for hospital admissions due to OA. The significant benefit of a digital service which provides exercises for patients with OA is the ability to inform, educate and promote exercise with patients from the convenience of their own home regardless of geographical proximity to a health service. This would suggest that this can be a highly-cost effective method of delivering high-quality care across a multitude of regions & population groups. Given that exercise delivered digitally is not-inferior to usual care, alternate modes of delivery of exercises, or education only, the uptake of digital care on the future of management in OA must be considered. Further research may be required on user engagement with technology to determine optimisation of delivery service.
ABSTRACT
Purpose: Greater access to smartphones and mobile app technology, coupled with the COVID-19 pandemic, has fueled a growing interest in mobile health apps. Patients with knee and/or hip osteoarthritis (OA) may benefit from mobile apps when seeking additional guidance and advice. Clinicians may leverage these apps for symptom monitoring, activity tracking, and exercise program delivery. Integrating mobile apps into patient care may empower self-management and enhance communication, therapeutic alliance, and treatment adherence. Mobile apps could also facilitate access to healthcare services and reduce costs. However, little is known about the quality of these apps. We aimed to synthesize and evaluate current available mobile apps for adults with knee/hip OA. Methods: We searched Apple App Store, Android Google Play, and Amazon App Store for mobile health apps targeting management of knee/hip OA. Inclusion criteria for appraisal: available in English;containing search terms of “knee”, “knee OA”, “hip”, “hip OA”, “osteoarthritis”, “arthritis”, “physical therapy”, “rehabilitation”, and/or “rehab” in the app description;targeting knee and/or hip OA;and free to download. Exclusion criteria for appraisal: apps specific for rheumatoid arthritis;unavailable for download;could not be opened due to incompatibility;requiring subscription, passwords, institutional accounts, download fees, or additional accessories (e.g. motion sensor) for usage. The search was terminated for each search term when the last 10 apps on a platform did not meet the inclusion criteria, consistent with the methodology used in prior research. Paired reviewers rated apps using the adapted Mobile App Rating Scale (MARS) (score range 0-132, higher is better) that appraises apps by technical aspects, engagement, functionality, aesthetics, information, quality, and relevant information to the subject matter. Disagreements were resolved by discussion between 2 reviewers. Apps that scored ≥3/5 on overall app quality or totaled ≥80/132 were included in the final descriptive summary. Results: Among 797 identified apps, 41 met inclusion/exclusion criteria for MARS appraisal. As shown in Figure 1, 17 apps met the pre-determined score thresholds for final summary. Their key characteristics are summarized in Table 1. The median MARS score was 86 (interquartile range = 23 and ranged from 63 to 115). App features varied. Common app features were exercise recommendations, education, goal setting, and improving well-being. Many apps allowed for social media sharing and included measures to protect privacy. 11 apps demonstrated low to moderate credibility. Jointfully Osteoarthritis (Apple), My Arthritis (Apple), and Jointfully Osteoarthritis (Android) were the top three rated apps. They also were the only apps receiving an overall 5/5 quality rating. Conclusions: While many no-cost apps targeting knee/hip OA management exist, only three were rated highly. Features varied widely in our sample. Future research is needed to identify optimal app designs and functions for self-management strategies tailored to patients with knee/hip OA. Evaluating whether incorporating mobile apps in patient care improves outcome, treatment adherence, and patient satisfaction will help guide clinical practice recommendations. [Formula presented] [Formula presented]
ABSTRACT
Objective: Teriparatide for sever osteoporosis is followed by antiresorptive drugs, and one option in patients with gastric intolerance is zolendronic acid or denosumab (1-5). During pandemic lockdown, the access to bone assessment was limited (1-5). Type 1 diabetic patients are particularly at risk for bone loss, but also for COVID-19 infection, thus the importance of respecting the pandemic rules (1-5). We aim to introduce a female case diagnosed with severe menopausal osteoporosis that was followed during post-teriparatide sequence of medication, including during pandemic days. Case report: This is a type 1 diabetic female of 77 y who was first diagnosed with menopausal osteoporosis 8 y ago (lumbar T-score of-3.1 SD) and started medication with weekly alendronate in addition to vitamin D supplements. After 3 y, she suffered a single spontaneous vertebral fracture thus teriparatide was initiated for 2 y (with good tolerance): lumbar T-score went from -3.1 to -1.9 SD. In the meantime, due to bilateral coxarthrosis she needed bilateral hip replacement. Further on, she continued with biannually denosumab for 8 injections, reaching a lumbar BMD-DXA 0.942 g/cm2, T-score of -2 SD, Z-score of -0.8 SD so an intravenous perfusion with zolendronic acid 5 mg was administered plus vitamin D supplements. While she had no additional fracture and glycated haemoglobin A1c remained around 6.2-6.4%, one year later, the pandemic started, so only bone turnover markers (BTM) were assessed, not DXA: suppressed CrossLaps=0.22 ng/mL (normal: 0.33-0.782 ng/ mL), osteocalcin=11 ng/mL (normal: 15-46 ng/mL), P1NP=27 pg/mL (normal: 15-45 pg/mL). She continued with vitamin D, and 20 months after injection CrossLaps remained low (=22 ng/mL) with normal osteocalcin (=15 ng/mL), P1NP (=28 pg/mL) and stationary BMD. Conclusion: Zolendronic acid effect in osteoporotic patients is easy to access by blood assays if DXA is not available, while lack of BTM increase is suggestive for a good outcome.