[Impact of the COVID-19 Pandemic on Health-Related Quality of Life in Older Adults With Preoperative Knee Osteoarthritis].

BACKGROUND: Knee osteoarthritis is prevalent in older adults worldwide. Quality of life was negatively affected by the COVID-19 pandemic. PURPOSE: This study was designed to examine osteoarthritis severity and health-related quality of life (QOL) in older adults with knee osteoarthritis before total knee replacement during the COVID-19 pandemic and to identify the related predictors of QOL. METHODS: This cross-sectional correlation study involved convenience sampling in the orthopedic ward of a regional teaching hospital in central Taiwan from June 2020 to June 2021 using the Western Ontario and McMaster Universities Arthritis Index and the SF-36v2 Health Survey. The data were analyzed using Pearson's correlation coefficient analysis, independent samples t test, and one-way analysis of variance to determine correlations among demographic variables, osteoarthritis severity, and QOL. The predictors of QOL were examined using stepwise multiple linear regression analysis. RESULTS: A total of 60 older adults diagnosed with knee osteoarthritis were sampled. The average age was 70 years and the average osteoarthritis severity score was 70.45. Being male, having comorbidities, and having a relatively high level of monthly disposable income were associated with poorer QOL. Moreover, more severe knee pain, stiffness, and physical dysfunction were associated with better psychological QOL. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: During the COVID-19 pandemic, the severity of knee osteoarthritis affects preoperative quality of life in older adults. Clinicians should detect signs of pain and physical dysfunction in these patients in advance and intervene in a timely manner to improve their QOL before surgery.

Study protocol for a randomised controlled trial of diacerein versus placebo to treat knee osteoarthritis with effusion-synovitis (DICKENS).

BACKGROUND: There is an unmet need for treatments for knee osteoarthritis (OA). Effusion-synovitis is a common inflammatory phenotype of knee OA and predicts knee pain and structural degradation. Anti-inflammatory therapies, such as diacerein, may be effective for this phenotype. While diacerein is recommended for alleviating pain in OA patients, evidence for its effectiveness is inconsistent, possibly because studies have not targeted patients with an inflammatory phenotype. Therefore, we will conduct a multi-centre, randomised, placebo-controlled double-blind trial to determine the effect of diacerein on changes in knee pain and effusion-synovitis over 24 weeks in patients with knee OA and magnetic resonance imaging (MRI)-defined effusion-synovitis. METHODS: We will recruit 260 patients with clinical knee OA, significant knee pain, and MRI-detected effusion-synovitis in Hobart, Melbourne, Adelaide, and Perth, Australia. They will be randomly allocated to receive either diacerein (50mg twice daily) or identical placebo for 24 weeks. MRI of the study knee will be performed at screening and after 24 weeks of intervention. The primary outcome is improvement in knee pain at 24 weeks as assessed by a 100-mm visual analogue scale (VAS). Secondary outcomes include improvement in volumetric (ml) and semi-quantitative (Whole-Organ Magnetic Resonance Imaging Score, 0-3) measurements of effusion-synovitis using MRI over 24 weeks, and improvement in knee pain (VAS) at 4, 8, 12, 16, and 20 weeks. Intention-to-treat analyses of primary and secondary outcomes will be performed as the primary analyses. Per protocol analyses will be performed as the secondary analyses. DISCUSSION: This study will provide high-quality evidence to determine whether diacerein improves pain, changes disease trajectory, and slows disease progression in OA patients with effusion-synovitis. If diacerein proves effective, this has the potential to significantly benefit the substantial proportion (up to 60%) of knee OA patients with an inflammatory phenotype. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry ACTRN12618001656224 . Registered on 08 October 2018.

Changes in epidemiological characteristics of knee arthroplasty in eastern, northern and central China between 2011 and 2020.

OBJECTIVE: To explore changes in the epidemiological and clinical characteristics of patients who underwent knee arthroplasty (KA) over a 10-year period in China. METHODS: Medical records of patients with knee osteoarthritis (KOA), who underwent primary unilateral KA in 5 level I center hospitals in China between January 2011 and December 2020, were retrospectively reviewed and analyzed. To more clearly define changes over the years, patients were divided into two groups according to time of admission at 5-year intervals. Age, sex, body mass index (BMI), Kellgren-Lawrence (K-L) classification, comorbid diseases, surgical procedures, hospital stay, and hospitalization costs were compared between the two groups. RESULTS: A total of 23,610 patients with KOA (5400 male and 18,210 females; mean age: 65.7 ± 7.6 years) who underwent primary unilateral KA were included. The number of KAs increased in recent years (group A, n = 7606 vs. group B, n = 16,004). Significant differences were noted in age, sex, BMI, K-L classification, comorbidities, surgical procedures, hospital stay, and hospitalization costs between the two periods (P < 0.05). More than three-quarters of KA cases involved females, and the age at surgery tended to be younger than that reported in foreign countries. In group B, the proportion of overweight and grade III, number of comorbidities, and unicompartmental knee arthroplasty patients increased compared to that in group A; however, hospitalization costs and length of hospital stay decreased. CONCLUSIONS: Results suggested that the epidemiological characteristics of patients undergoing KA have changed over time. An analysis of the epidemiological characteristics of patients undergoing KA treatment may provide a scientific basis for the prevention and control of KOA.

Changes to consultations and diagnosis of osteoarthritis in primary care during the COVID-19 pandemic.

OBJECTIVE: General practitioners (GP) are often the first medical professionals to treat musculoskeletal complaints. Yet the impact of COVID-19 on primary care utilisation for musculoskeletal complaints is largely unknown. This study quantifies the impact of the pandemic on primary care utilisation for musculoskeletal complaints and specifically osteoarthritis (OA) in the Netherlands. DESIGN: We extracted data on GP consultations in 2015-2020 from 118,756 patients over 45 years of age and estimated reductions in consultations in 2020 as compared to 5-year average. Outcomes were GP consultations for: any musculoskeletal complaints, knee and hip OA, knee and hip complaints, and newly diagnosed knee and hip OA/complaints. RESULTS: The relative reductions in consultations ranged from 46.7% (95% confidence intervals (CI): 43.9-49.3%) (all musculoskeletal consultations) to 61.6% (95% CI: 44.7-73.3%) (hip complaints) at the peak of the first wave, and from 9.3% (95% CI: 5.7-12.7%) (all musculoskeletal consultations) to 26.6% (95% CI: 11.5-39.1%) (knee OA) at the peak of the second wave. The reductions for new diagnoses were 87.0% (95% CI: 71.5-94.1%) for knee OA/complaints, and 70.5% (95% CI: 37.7-86.0%) for hip OA/complaints at the peak of the first wave, and not statistically significant at the peak of the second wave. CONCLUSION: We observed 47% reduction in GP consultations for musculoskeletal disorders during the first wave and 9% during the second wave. For hip and knee OA/complaints, the reductions were over 50% during the first, and 10% during the second wave. This disruption may lead to accumulation of patients with severe OA symptoms and more requests for arthroplasty surgery.

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial.

BACKGROUND: A stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA). OBJECTIVE: To evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective. METHODS: An economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a 'high muscle strength subgroup', 'low muscle strength subgroup', and 'obesity subgroup' supplemented by a dietary intervention for the 'obesity subgroup' (experimental group), with usual ('non-stratified') exercise therapy (control group). Clinical outcomes included quality-adjusted life years - QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty. RESULTS: During 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning. CONCLUSIONS: We found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic.

Effect of motion control versus neutral walking footwear on pain associated with lateral tibiofemoral joint osteoarthritis: a comparative effectiveness randomised clinical trial.

OBJECTIVES: To determine if motion control walking shoes are superior to neutral walking shoes in reducing knee pain on walking in people with lateral knee osteoarthritis (OA). DESIGN: Participant-blinded and assessor-blinded, comparative effectiveness, superiority randomised controlled trial. SETTING: Melbourne, Australia. PARTICIPANTS: People with symptomatic radiographic lateral tibiofemoral OA from the community and our volunteer database. INTERVENTION: Participants were randomised to receive either motion control or neutral shoes and advised to wear them >6 hours/day over 6 months. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was change in average knee pain on walking over the previous week (11-point Numeric Rating Scale (NRS), 0-10) at 6 months. The secondary outcomes included other measures of knee pain, physical function, quality of life, participant-perceived change in pain and function, and physical activity. RESULTS: We planned to recruit 110 participants (55 per arm) but ceased recruitment at 40 (n=18 motion control shoes, n=22 neutral shoes) due to COVID-19-related impacts. All 40 participants completed 6-month outcomes. There was no evidence that motion control shoes were superior to neutral shoes for the primary outcome of pain (mean between-group difference 0.4 NRS units, 95% CI -1.0 to 1.7) nor for any secondary outcome. The number of participants experiencing any adverse events was similar between groups (motion control shoes: n=5, 28%; neutral shoes: n=4, 18.2%) and were minor. CONCLUSIONS: Motion control shoes were not superior to neutral shoes in improving knee pain on walking in symptomatic radiographic lateral tibiofemoral joint OA. Further research is needed to identify effective treatments in this important but under-researched knee OA subgroup. TRIAL REGISTRATION NUMBER: ACTRN12618001864213.

Experiences of Health-Promoting Activities among Individuals with Knee Pain: The Halland Osteoarthritis Cohort.

Knee pain is an early sign of knee osteoarthritis (KOA) and a risk factor for chronic widespread pain (CWP). Early prevention is vital, and more research is needed to understand health-promoting activities for individuals with knee pain from a patient perspective. This study aimed to explore how individuals with knee pain experienced health-promoting activities. Explorative qualitative design with inductive approach was applied to explore the experiences of 22 individuals (13 women, 9 men; median age: 52). Semi-structured interviews were conducted and analysed using latent qualitative content analysis. The results revealed health-promoting activities in individuals with knee pain and were interpreted in the overall theme, striving for balance in everyday life. Two categories explored the content in health-promoting activities: (1) Caring for the body-being physically active, having a healthy diet, and utilising support; and (2) Managing life stressors-allowing for recovery, promoting vitality, and safeguarding healthy relationships. In conclusion, individuals with knee pain described various health-promoting activities. They strived for balance in everyday life by caring for the body and managing life stressors. We suggest that a broader approach to everyday life can be helpful in treatment plans and health promotion to manage and prevent KOA and CWP, while striving for a healthy lifestyle.

Effects of combining electrical stimulation of the calf and thigh muscles in patients with osteoarthritis of the knee: protocol for a double-blind, randomised, sham-controlled trial.

INTRODUCTION: Knee osteoarthritis (KOA) is a leading cause of disability and is characterised by degenerative changes causing pain and loss of function. Neuromuscular electrical stimulation (NMES) has been shown to influence muscle size and strength in healthy subjects. A novel self-administered NMES device has been developed to help manage the symptoms of KOA. This study aims to investigate the effects of combining NMES of the calf and quadriceps on individuals with KOA. METHODS AND ANALYSIS: 193 individuals with KOA will be recruited to a single-centre, double-blind, randomised, sham-controlled trial at the Respiratory Biomedical Research Centre, Leicester, UK. Participants will be randomised (1:1) to follow an 8-week home-based intervention using a NMES device or sham device. The NMES device consists of footplate electrodes and two quadriceps electrodes. Footplate stimulation will be completed daily for 30 min and quadriceps stimulation for 20 min, five times a week (compliance is recorded in a self-reported participant diary). The primary outcome is the Western Ontario and McMaster Universities Arthritis Index pain domain, taken at 8 weeks follow-up. Secondary outcomes will explore quadriceps muscle strength, swelling, health-related quality of life, exercise capacity, anxiety and depression, sleep, physical activity and self-reported compliance. A powered subgroup analysis for compliance to the active device will be complete for the primary outcome. Participant focus groups will be completed following recruitment of half of the participants and after all participants have been recruited. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the North-West Preston ethics committee (17/NW/0081). Participants are required to provide informed consent following review of the participant information sheet and discussion regarding study procedures with a member of the research team. The study results will be disseminated to the appropriate stakeholders through presentations, conferences and peer-reviewed journals. Results will be presented to participants following study completion at the Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester. TRIAL REGISTRATION NUMBER: ISRCTN registry, ISRCTN12112819 (date registered 1 May 2019). IRAS registry 219 693. University Hospitals of Leicester registry 91 017. Protocol Version 8.

Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness and safety of viscosupplementation for pain and function in patients with knee osteoarthritis. DESIGN: Systematic review and meta-analysis of randomised trials. DATA SOURCES: Searches were conducted of Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to 11 September 2021. Unpublished trials were identified from the grey literature and trial registries. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised trials comparing viscosupplementation with placebo or no intervention for knee osteoarthritis treatment. MAIN OUTCOME MEASURES: The prespecified primary outcome was pain intensity. Secondary outcomes were function and serious adverse events. Pain and function were analysed as standardised mean differences (SMDs). The prespecified minimal clinically important between group difference was -0.37 SMD. Serious adverse events were analysed as relative risks. METHODS: Two reviewers independently extracted relevant data and assessed the risk of bias of trials using the Cochrane risk of bias tool. The predefined main analysis was based only on large, placebo controlled trials with ≥100 participants per group. Summary results were obtained through a random effects meta-analysis model. Cumulative meta-analysis and trial sequential analysis under a random effects model were also performed. RESULTS: 169 trials provided data on 21 163 randomised participants. Evidence of small study effects and publication biases was observed for pain and function (Egger's tests with P<0.001 and asymmetric funnel plots). Twenty four large, placebo controlled trials (8997 randomised participants) included in the main analysis of pain indicated that viscosupplementation was associated with a small reduction in pain intensity compared with placebo (SMD -0.08, 95% confidence interval -0.15 to -0.02), with the lower bound of the 95% confidence interval excluding the minimal clinically important between group difference. This effect corresponds to a difference in pain scores of -2.0 mm (95% confidence interval -3.8 to -0.5 mm) on a 100 mm visual analogue scale. Trial sequential analysis for pain indicated that since 2009 there has been conclusive evidence of clinical equivalence between viscosupplementation and placebo. Similar conclusions were obtained for function. Based on 15 large, placebo controlled trials on 6462 randomised participants, viscosupplementation was associated with a statistically significant higher risk of serious adverse events than placebo (relative risk 1.49, 95% confidence interval 1.12 to 1.98). CONCLUSION: Strong conclusive evidence indicates that viscosupplementation leads to a small reduction in knee osteoarthritis pain compared with placebo, but the difference is less than the minimal clinically important between group difference. Strong conclusive evidence indicates that viscosupplementation is also associated with an increased risk of serious adverse events compared with placebo. The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021236894.

Patients' and clinicians' experiences with stratified exercise therapy in knee osteoarthritis: a qualitative study.

BACKGROUND: We have developed a model of stratified exercise therapy that distinguishes three knee osteoarthritis (OA) subgroups ('high muscle strength subgroup', 'low muscle strength subgroup', 'obesity subgroup'), which are provided subgroup-specific exercise therapy (supplemented by a dietary intervention for the 'obesity subgroup'). In a large clinical trial, this intervention was found to be no more effective than usual exercise therapy. The present qualitative study aimed to explore experiences from users of this intervention, in order to identify possible improvements. METHODS: Qualitative research design embedded within a cluster randomized controlled trial in a primary care setting. A random sample from the experimental arm (i.e., 15 patients, 11 physiotherapists and 5 dieticians) was interviewed on their experiences with receiving or applying the intervention. Qualitative data from these semi-structured interviews were thematically analysed. RESULTS: We identified four themes: one theme regarding the positive experiences with the intervention and three themes regarding perceived barriers. Although users from all 3 perspectives (patients, physiotherapists and dieticians) generally perceived the intervention as having added value, we also identified several barriers, especially for the 'obesity subgroup'. In this 'obesity subgroup', physiotherapists perceived obesity as difficult to address, dieticians reported that more consultations are needed to reach sustainable weight loss and both physiotherapists and dieticians reported a lack of interprofessional collaboration. In the 'high muscle strength subgroup', the low number of supervised sessions was perceived as a barrier by some patients and physiotherapists, but as a facilitator by others. A final theme addressed barriers to knee OA treatment in general, with lack of motivation as the most prominent of these. CONCLUSION: Our qualitative study revealed a number of barriers to effective application of the stratified exercise therapy, especially for the 'obesity subgroup'. Based on these barriers, the intervention and its implementation could possibly be improved. Moreover, these barriers are likely to account at least partly for the lack of superiority over usual exercise therapy. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR): NL7463 (date of registration: 8 January 2019).

The AAHKS Clinical Research Award: Are Minimum Two-Year Patient-Reported Outcome Measures Necessary for Accurate Assessment of Patient Outcomes After Primary Total Knee Arthroplasty?

BACKGROUND: The two-year minimum follow-up after total knee arthroplasty (TKA) required by most academic journals is based on implant survivorship studies rather than patient-reported outcome measures (PROMs). Additionally, the COVID-19 pandemic placed an unprecedented burden on patients and staff and halted asymptomatic surveillance clinic visits to minimize exposure. The purpose of this study was to determine if clinically meaningful differences were observed in PROMs beyond one year after TKA. METHODS: A retrospective review was performed on prospectively collected PROMs after 1093 primary TKAs at a suburban academic center. PROMs related to pain, function, activity level, and satisfaction were compared by subsequent follow-up intervals preoperatively, at 4 months, 1 year, and minimum 2 years using paired data analysis techniques. RESULTS: Pain with level walking and while climbing stairs improved from preoperative levels to 4-month, 1-year, and minimum 2-year follow-up. The University of California Los Angeles activity level and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement improved over the same intervals. Patient satisfaction improved over postoperative follow-up intervals (84.0%, 87.3%, and 90.9%). While PROMs improved with statistical and clinical significance preoperatively to 4-month to 1-year follow-up, improvements from 1-year to minimum 2-year follow-up were small and did not reach minimum clinically important differences for nearly all PROMs, demonstrating significant overlap of the 95% confidence intervals. CONCLUSION: While long-term follow-up after TKA remains important for implant survivorship, it appears that one-year PROMs are as clinically reliable and meaningful as two-year PROMs. Therefore, it is reasonable to question the currently accepted 2-year minimum follow-up requirement used in peer-reviewed research involving PROMs. LEVEL OF EVIDENCE: Level III.

A Psycholgical Intervention Delivered by Automated Mobile Phone Messaging Stabilized Hip and Knee Function During the COVID-19 Pandemic: A Randomized Controlled Trial.

BACKGROUND: We conducted a randomized controlled trial to evaluate the effectiveness of acceptance and commitment therapy (ACT) delivered via a mobile phone messaging robot to patients who had their total hip arthroplasty or total knee arthroplasty procedures postponed due to the COVID-19 pandemic. METHODS: Ninety patients scheduled for total hip arthroplasty or total knee arthroplasty who experienced surgical delay due to the COVID-19 pandemic were randomized to the ACT group, receiving 14 days of twice daily automated mobile phone messages, or the control group, who received no messages. Minimal clinically important differences (MCIDs) in preintervention and postintervention patient-reported outcome measures were utilized to evaluate the intervention. RESULTS: Thirty-eight percent of ACT group participants improved and achieved MCID on the Patient-Reported Outcome Measure Information System Physical Health compared to 17.5% in the control group (P = .038; number needed to treat [NNT] 5). For the joint-specific Hip Disability and Osteoarthritis Outcome Score Joint Replacement and Knee Disability and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), 24% of the ACT group achieved MCID compared to 2.5% in the control group (P = .004; NNT 5). An improvement in the KOOS JR was found in 29% of the ACT group compared to 4.2% in the control group (P = .028; NNT 5). Fourteen percent of the ACT group participants experienced a clinical important decline in the KOOS JR compared to 41.7% in the control group (P = .027; NNT 4). CONCLUSION: A psychological intervention delivered via a text messaging robot improved physical function and prevented decline in patient-reported outcome measures in patients who experienced an unexpected surgical delay during the COVID-19 pandemic. LEVEL OF EVIDENCE: 1.

Referrals for physical therapy for osteoarthritis during the COVID-19 pandemic: A retrospective analysis.

BACKGROUND: Osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability among Americans. Physical therapy (PT) is recommended per the 2019 ACR /Arthritis Foundation Guideline for Treatment of OA of the Hand, Hip, and Knee. During COVID-19, access to healthcare has been altered in a variety of clinical settings, with the pandemic creating delays in healthcare, with an unknown impact on access to PT care for OA. OBJECTIVES: We sought to determine whether referrals to PT for OA were reduced in 2020 during the COVID-19 pandemic compared to 2019. METHODS: A retrospective analysis was done of 3586 PT referrals placed by the University of California, Davis for 206 OA ICD-10 codes from January to November 2019 and from January to November 2020. The numbers of PT referrals per month of each year were compared using both descriptive statistics and Poisson Regression analysis. RESULTS: A total of 1972 PT referrals for OA were placed from January to November 2019. Only 1614 referrals for OA were placed from January to November 2020, representing a significant decrease (p = 0.001). Month-by-month analysis of 2020 compared to 2019 revealed statistically significant drops in PT referrals for OA in April (p = 0.001), May (p = 0.001), and August (p = 0.001). CONCLUSIONS: These findings reveal a significant reduction in the number of referrals for PT for OA placed in 2020 during the first year of the COVID-19 pandemic. These reductions were particularly evident in the months following state-mandated actions and closures. Factors associated with this outcome may include decreased access to primary care providers, perceptions of PT availability by health care providers, decreased mobility limiting access to both clinic and PT appointments, and/or willingness to engage in PT by patients during the pandemic.

Experience of the COVID-19 pandemic as lived by patients with hip and knee osteoarthritis: an Italian qualitative study.

OBJECTIVE: To examine the experience of the COVID-19 pandemic as lived by people with hip and knee osteoarthritis (OA), in Italy. DESIGN: A qualitative study based on semi-structured interviews. SETTING: Urban and suburban areas in northern Italy. PARTICIPANTS: A total of 11 people with OA were enrolled through a purposeful sampling and completed the study. PRIMARY OUTCOME MEASURE: The experience of Italian people with OA during the COVID-19 pandemic. RESULTS: Four themes were brought to the forefront from the analysis of the interviews. (1) Being Stressed for the Limited Social Interactions and for the Family Members at High Risk of Infection, as the interviewees were frustrated because they could not see their loved ones or felt a sense of apprehension for their relatives. (2) Recurring Strategies to Cope with the Pandemic such as an active acceptance towards the situation. (3) Being Limited in the Possibility of Undergoing OA Complementary Treatments and Other Routine Medical Visits. (4) Being Unaware of the Importance of Physical Activity as First-Line Interventions which was an attitude already present before the pandemic. CONCLUSION: The COVID-19 pandemic and related restrictions impacted the quality of life and the care of individuals with hip and knee OA. The social sphere seemed to be the most hindered. However, the interviewees developed a good level of acceptance to deal with the pandemic. When it came to their care, they faced a delay of routine medical visits not related to OA and of other complementary treatments (eg, physical therapies) to manage OA. Finally, a controversial result that emerged from these interviews was that first-line interventions for OA (ie, therapeutic exercise) was not sought by the interviewees, regardless of the restrictions dictated by the pandemic. Policy-making strategies are thus necessary to support the awareness of the importance of such interventions.

Systematic Review Shows Tele-Rehabilitation Might Achieve Comparable Results to Office-Based Rehabilitation for Decreasing Pain in Patients with Knee Osteoarthritis.

Background and Objectives This systematic review aims to evaluate the efficacy of Tele-Rehabilitation for decreasing pain in patients with knee osteoarthritis (OA). Materials and Methods: Following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), three electronic databases (CINAHL, PubMed, PEDro), along with the addition of grey literature, were used to collect information. Randomized control trials (RCTs) comparing tele-rehabilitation (TR) to office-based-rehabilitation (OB) were critically appraised using the 2005 University of Oxford Standard. A total of 139 articles (PubMed = 132, CINAHL = 5, PEDro = 0, grey literature = 2) were acquired. Results: After the screening, three RCTs were included in our review. Their results show no statistically significant differences between TR and OB intervention. Furthermore, their results showed an overall reduction in pain in both groups from the baseline to the end of the study. However, each intervention's clinical efficiency was dependent on the exercise protocol itself and not on the method of delivery. There is a potential ceiling effect to the amount of therapy a patient can receive in which additional therapy would no longer lead to improved recovery. Conclusions: Our review suggests evidence that TR's efficacy is similar to that of OB for improvement of WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score parameters in patients suffering from knee OA.

The EPIPHA-KNEE trial: Explaining Pain to target unhelpful pain beliefs to Increase PHysical Activity in KNEE osteoarthritis - a protocol for a multicentre, randomised controlled trial with clinical- and cost-effectiveness analysis.

BACKGROUND: Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program. METHODS: Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes. DISCUSSION: We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020).

Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study.

BACKGROUND: This randomized controlled study compared standard supervised physiotherapy (SPT) with a self-developed, home-based, enhanced knee flexion exercise program involving a low stool (KFEH) in patients who underwent total knee arthroplasty (TKA). METHODS: Patients were recruited from July 2014 to December 2015 and randomly assigned to one of two groups: KFEH (n = 60) and SPT (n = 59). Outcomes (joint function) were evaluated according to the Knee Society Score (KSS), visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and range of motion (ROM) assessment at selected time points (preoperatively; 1 week; 1, 3, and 6 months; and 1 year after surgery). RESULTS: Pain and functional improvement were observed in both groups. Non-inferiority of KFEH was evident 12 months postoperatively; however, patients in the KFEH group exhibited better ROM at 1 month (P < 0.01). Absolute WOMAC and KSS scores were slightly better in the KFEH group, although the difference was not statistically significant. There was no difference in VAS scores and complication rates between the two groups. Additionally, the home program would save patient time and decrease the economic burden associated with in-hospital SPT. CONCLUSION: Considering rehabilitation and economic efficiency as well as the COVID pandemic, a home-based enhanced knee flexion exercise program for TKA rehabilitation is recommended.

Modified Gait Parameters at the Knee Joint During Midstance in Patients with Osteoarthritis (preprint)

Background: and Objectives: Sports medicine, orthopaedic and rehabilitation physicians use gait analysis and goniometry to evaluate and diagnose patients with neuro-musculo-skeletal diseases. Goniometry is a measuring method that shows the joint’s range of motion. Three-dimensional goniometry has been used in order to assess the patients in a kinematic manner, but they are not affordable, so, phone apps come handy to any orthopaedic or rehabilitation physician so we can have a clear image of the progress made by the patient after the rehabilitation program or should something happen and the patient cannot come to the facility, such as the Covid-19 pandemic, when some orthopaedic and most of the rehabilitation facilities have been temporarily closed. Midstance has been chosen as the moment of the gait evaluation in this paper since it has an important role in stability. The objective of this paper is to figure out if the measurements taken during midstance at the knee joint of the subjects can be statistically significant and used during usual examinations. Materials and Methods: Four groups of subjects: patients suffering from hip, knee, hip and knee osteoarthritis and a control group volunteered their participation, being asked to normally walk while their gait was recorded and uploaded into Angles App – a phone based videogoniometer. Results: Patients suffering from hip osteoarthritis have a higher knee angle on the right side than the ones suffering from knee osteoarthritis, hip and knee osteoarthritis and the control group. Female patients suffering from hip osteoarthritis also presented a more flexed knee than the ones suffering from knee osteoarthritis and the ones in the control group, the knee flexion presenting itself as a compensation mechanism. Conclusion: Video goniometry can help us make an orthopaedic, rehabilitation or neurology database for each assessment with constant updates of the evolution of the osteoarthritis patient’s treatment.

Both younger and elderly patients in pain are willing to undergo knee replacement despite the COVID-19 pandemic: a study on surgical waiting lists.

PURPOSE: To identify factors influencing patient's availability to re-schedule primary total knee replacement (TKR) or revision (RKR) surgery after the lockdown (March-May 2020) during the COVID-19 pandemic. METHODS: A prospective cohort study through a telephone survey was performed in 156 patients (143 for primary and 13 for revision) included in the TKR and RKR surgical waiting list before March 2020. Contact of each patient with COVID-19, stress and anxiety, perceived pain, and function were obtained in the interviews, and also the preference of each patient to have re-scheduled surgery (early or late). Finally, we registered their response (acceptance or refusal) when surgery was effectively re-scheduled. RESULTS: 88 out of 156 patients waiting for knee replacement (76/143 of those waiting for TKR, 12/13 of those waiting for RKR) declared themselves ready for surgery in less than 1 month. When re-scheduled, 115 patients underwent surgery and 41 refused. Significantly different preferences were found for age (more prone to surgery if under 65), revision surgery (more readily available), pain (7.9 ± 1.7/10 in NRS in those undergoing surgery, 5.6 ± 2.3/10 in those refusing, p = 0.000), or COVID-19 diagnosis, but not other close contact with COVID-19, comorbidities, stress, or anxiety. A logistic regression model confirmed that revision surgery (OR 9.33), perceived severe pain (OR 5.21), and age under 65 years (OR 5.82) were significantly associated with patient preference. The probability of patients over 65 to prefer early surgery reached 60% only with pain at or above 9/10. CONCLUSIONS: Surgical timing preferences for knee replacement vary between patients older than 65 years (immediate surgery only when pain is intense) and younger patients (immediate surgery no matter the amount of pain). Even if COVID-19 severely stroke our population, the need for knee replacement stood in the young population and even in the aged population at risk for COVID when pain was important.