Implementing international osteoarthritis guidelines in primary care: uptake and fidelity among health professionals and patients.

OBJECTIVE: This paper evaluates the implementation fidelity of a strategy and intervention used to implement osteoarthritis (OA) treatment recommendations in primary care. We also evaluate uptake of core treatment (patient information, exercise and referral to weight management) among OA patients. DESIGN: A stepped-wedge cluster-randomised controlled study (RCT) in primary care. The study involved general practitioners (GPs), physiotherapists (PTs) and patients with hip and/or knee OA in six Norwegian municipalities (clusters). Workshops for general practitioners (GPs) and PTs represented the main implementation activity. Uptake of core treatment (patient education, exercise and weight management) was evaluated using self-reported data from the patient intervention and control group, analysed with logistic regression models. Fidelity was evaluated using six components representing adherence to the content and dose instructions in the implementation strategy and assessed against a-priori criteria for high adherence. RESULTS: Data were collected from 40 GPs, 37 PTs and 393 OA patients. The patient-reported data showed statistically significant higher uptake for exercise, patient education and referral to support for weight reduction, among the intervention group compared to the control group (P < 0.05). Evaluation of fidelity showed high adherence to GP and PT workshop attendance and physiotherapy use, partly adherence to PT knowledge after workshops, and low adherence to exercise attendance, dose and progression instructions. CONCLUSIONS: The implementation strategy and intervention successfully improved OA patients' access to physiotherapy and uptake of recommended core treatment. However, the strategy was less effective in providing exercise programs with sufficient dose and progression and in supporting patients' adherence to the exercise program. TRIAL REGISTRATION: ClinicalTrials.gov NCT02333656.

The importance of dose in land-based supervised exercise for people with hip osteoarthritis. A systematic review and meta-analysis.

PURPOSE: To compare effects of land-based exercise programmes with high vs low or uncertain compliance with dose recommendations among people with hip osteoarthritis (OA). DESIGN: A systematic review with meta-analyses of supervised exercise programmes in people with symptomatic hip OA was conducted. Dose of the exercise interventions was evaluated according to the American College of Sports Medicine's (ACSM) recommendations for developing and maintaining cardiorespiratory fitness, muscular strength and flexibility in healthy adults. Compliance ratios with the recommendations were calculated. Standardized Mean Differences (SMDs) were calculated in meta-analyses for the outcomes pain and self-reported physical function. Outcome effects were compared between the sub-groups of studies with interventions with "high" vs "uncertain" compliance with the ACSM recommendations. RESULTS: Twelve studies including 1202 participants were included. Seven were categorized with "high" and five with "uncertain" compliance with the ACSM recommendations. Ten studies had an overall low risk of bias. Comparing exercise with no exercise, the pooled SMD for pain was -0.42 (95% CI -0.58, -0.26) in the high compliance group, favouring exercise. In the uncertain compliance group the pooled SMD was 0.04 (95% CI -0.24, 0.31). For physical function the SMD was -0.41 (95% CI -0.58, -0.24) in the high compliance group and -0.23 (95% CI -0.52, 0.06) in the uncertain compliance group. CONCLUSIONS: The results show that land-based supervised exercise interventions with high compliance to the ACSM recommendations result in significantly larger improvements in pain and non-significantly larger improvement in self-reported physical function compared with land-based supervised exercise interventions with uncertain compliance.

Does outpatient physical therapy with the aim of improving health-related physical fitness influence the level of physical activity in patients with long-term musculoskeletal conditions?

OBJECTIVE: To evaluate any change in self-reported level of physical activity in patients receiving a general physical exercise programme in addition to disease-specific physiotherapy treatment. DESIGN: Pre-post-intervention study. SETTING: Outpatient physiotherapy clinics. PARTICIPANTS: One hundred and ninety patients with long-term musculoskeletal conditions attending outpatient physiotherapy were recruited from seven physiotherapy clinics. INTERVENTIONS: Physiotherapy including disease-specific modalities and a general individually tailored exercise programme. Patients were evaluated at baseline and at the end of the programme. MAIN OUTCOME MEASURES: International Physical Activity Questionnaire short form (IPAQ-sf) and COOP WONCA functional assessment charts. RESULTS: Forty-two patients were excluded from the analysis because they did not complete the IPAQ-sf correctly or dropped out during the treatment period. There was a significant increase in the number of metabolic equivalent task (MET)-min/week for vigorous and moderate-intensity activities, walking and total physical activity. The number of exercise sessions per week increased from 1.8 [standard deviation (SD) 0.9] to 2.2 (SD 1.2) (P=0.001). The proportion of patients with a low level of physical activity decreased by 12%, and the proportion of the participants who did not/could not exercise decreased from 26% to 8%. The COOP WONCA charts showed significant improvements in the physical fitness, feelings, daily activities and social activities items. CONCLUSION: A significant increase was found in the number of MET-min/week for all activity levels. Therefore, a general physical exercise programme initiated by a physiotherapist led to a positive change in level of physical activity.

Patients with musculoskeletal conditions do less vigorous physical activity and have poorer physical fitness than population controls: a cross-sectional study.

OBJECTIVES: To compare physical activity and physical fitness in patients with various musculoskeletal conditions receiving physiotherapy in primary care with population controls. DESIGN: Cross-sectional. PARTICIPANTS: One hundred and sixty-seven patients with musculoskeletal conditions receiving physiotherapy in primary care and 313 population controls from various settings and geographical areas. MAIN OUTCOME MEASURES: Physical activity was measured with the International Physical Activity Questionnaire short-form (IPAQ-sf) and reported in metabolic equivalents (METs). The 6-minute walk test and 30-second sit-to-stand test reflected cardiorespiratory endurance and muscular strength, respectively. RESULTS: Differences in physical activity between the groups were explored using the Mann-Whitney U-test. The patient group reported significantly less vigorous activity compared with the control group {median 0 [interquartile range (IQR) 0 to 960] vs median 240 [IQR 0 to 1440] MET minutes/week, respectively)} (P=0.001). A similar proportion of patients (68%) and controls (75%) reached the recommended level of health-enhancing physical activity (P=0.11). Linear regression analyses adjusted for age, body mass index and gender showed significantly poorer fitness in the patient group compared with the control group, reflected by the 6-minute walk test and the 30-second sit-to-stand test {mean difference 69m [95% confidence interval (CI) 52 to 85; P≤0.001] and six repetitions [95% CI 5 to 7; P≤0.001], respectively}. CONCLUSIONS: Patients with various long-term musculoskeletal conditions receiving physiotherapy in primary care had significantly poorer physical fitness and reported less vigorous physical activity compared with population controls.