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We introduced a stepped‐care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high‐quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS. We used data from a 2‐year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures. Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice. After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient‐tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis.

To develop and validate a short form of the Cochin Hand Function Scale (CHFS), which measures hand disability, for use in systemic sclerosis, using objective criteria and reproducible techniques. Responses on the 18‐item CHFS were obtained from English‐speaking patients enrolled in the Scleroderma Patient‐Centered Intervention Network Cohort. CHFS unidimensionality was verified using confirmatory factor analysis, and an item response theory model was fit to CHFS items. Optimal test assembly (OTA) methods identified a maximally precise short form for each possible form length between 1 and 17 items. The final short form selected was the form with the least number of items that maintained statistically equivalent convergent validity, compared to the full‐length CHFS, with the Health Assessment Questionnaire (HAQ) disability index (DI) and the physical function domain of the 29‐item Patient‐Reported Outcomes Measurement Information System (PROMIS‐29). There were 601 patients included. A 6‐item short form of the CHFS (CHFS‐6) was selected. The CHFS‐6 had a Cronbach's alpha of 0.93. Correlations of the CHFS‐6 summed score with HAQ DI (r = 0.79) and PROMIS‐29 physical function (r = −0.54) were statistically equivalent to the CHFS (r = 0.81 and r = −0.56). The correlation with the full CHFS was high (r = 0.98). The OTA procedure generated a valid short form of the CHFS with minimal loss of information compared to the full‐length form. The OTA method used was based on objective, prespecified criteria, but should be further studied for viability as a general procedure for shortening patient‐reported outcome measures in health research.

Self‐management programs for patients with chronic illnesses, including rheumatic diseases, seek to enhance self‐efficacy for performing health management behaviors. No measure of self‐efficacy has been validated for patients with systemic sclerosis (SSc; scleroderma). The objective of this study was to assess the validity and internal consistency reliability of the Self‐Efficacy for Managing Chronic Disease (SEMCD) scale in SSc. English‐speaking SSc patients enrolled in the Scleroderma Patient‐centered Intervention Network Cohort who completed the SEMCD scale at their baseline assessment between March 2014 and June 2015 were included. Patients were enrolled from 21 sites in Canada, the US, and the UK. Confirmatory factor analysis (CFA) was used to evaluate the factor structure of the SEMCD scale. Cronbach's alpha was calculated to assess internal consistency reliability. Hypotheses on the direction and magnitude of Pearson's correlations with psychological and physical outcome measures were formulated and tested to examine convergent validity. A total of 553 patients were included. CFA supported the single‐factor structure of the SEMCD scale (Tucker Lewis Index = 0.99, comparative fit index = 0.99, root mean square error of approximation = 0.10). Internal consistency was high (α = 0.93), and correlations with measures of psychological and physical functioning were moderate to large (|r| = 0.48–0.67, P< 0.001), confirming study hypotheses. Scores from the SEMCD scale are valid for measuring self‐efficacy in patients with SSc, and results support using the scale as an outcome measure to evaluate the effectiveness of self‐management programs in SSc.

To evaluate, from a societal perspective, the cost utility and cost effectiveness of a nonpharmacologic face‐to‐face treatment program compared with a telephone‐based treatment program for patients with generalized osteoarthritis (GOA). An economic evaluation was carried out alongside a randomized clinical trial involving 147 patients with GOA. Program costs were estimated from time registrations. One‐year medical and nonmedical costs were estimated using cost questionnaires. Quality‐adjusted life years (QALYs) were estimated using the EuroQol (EQ) classification system, EQ rating scale, and the Short Form 6D (SF‐6D). Daily function was measured using the Health Assessment Questionnaire (HAQ) disability index (DI). Cost and QALY/effect differences were analyzed using multilevel regression analysis and cost‐effectiveness acceptability curves. Medical costs of the face‐to‐face treatment and telephone‐based treatment were estimated at €387 and €252, respectively. The difference in total societal costs was nonsignificantly in favor of the face‐to‐face program (difference €708; 95% confidence interval [95% CI] −€5,058, €3,642). QALYs were similar for both groups according to the EQ, but were significantly in favor of the face‐to‐face group, according to the SF‐6D (difference 0.022 [95% CI 0.000, 0.045]). Daily function was similar according to the HAQ DI. Since both societal costs and QALYs/effects were in favor of the face‐to‐face program, the economic assessment favored this program, regardless of society's willingness to pay. There was a 65–90% chance that the face‐to‐face program had better cost utility and a 60–70% chance of being cost effective. This economic evaluation from a societal perspective showed that a nonpharmacologic, face‐to‐face treatment program for patients with GOA was likely to be cost effective, relative to a telephone‐based program.

To systematically and comprehensively document the effectiveness of nonpharmacologic interventions on physical functioning and psychological well‐being in patients with systemic sclerosis (SSc). Multiple electronic databases were searched for studies on the effectiveness of nonpharmacologic interventions in SSc. Randomized clinical trials (RCTs), controlled clinical trials (CCTs), and observational designs (ODs) with ≥10 participants were included. Two reviewers independently assessed methodologic quality using the Downs and Black checklist. Twenty‐three studies (9 RCTs, 4 CCTs, and 10 ODs) were included. Studies assessing comparable interventions were grouped, resulting in data for 16 different interventions. The total number of patients included per study ranged from 10 to 53. Seventeen different outcome domains were assessed, with hand function, limitations in activities, and quality of life being assessed most frequently. Three studies, all RCTs, were rated as high quality. These RCTs reported that 1) a multifaceted oral health intervention improves mouth hygiene, and additional orofacial exercises did not improve mouth opening, 2) a multidisciplinary team‐care program improves limitations in activities, mouth opening, and hand grip strength, and 3) manual lymph drainage improves hand function, limitations in activities, and quality of life. The body of knowledge regarding nonpharmacologic care in SSc is very limited due to the wide variety in studied interventions and outcomes in the relatively uncommon but highly disabling disease. To structure and focus future research, an international consensus should be established to prioritize primary targets for nonpharmacologic treatment and the content of interventions and to agree on a core set of outcome measures.

To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles.We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient‐oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5‐meter walking time, muscle strength, and range of motion. Data were analyzed according to intent‐to‐treat principle.Both treatments showed short‐term and long‐term beneficial within‐group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5‐meter walking test at week 65.Because both interventions resulted in beneficial long‐term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.

To systematically review studies describing the course of functioning in patients with osteoarthritis (OA) of the hip or knee and identifying potential prognostic factors.A systematic search was performed. Studies involving patients with hip or knee OA, >6 months of followup, and outcome measures on functional status or pain were included. Methodologic quality was assessed using a standardized set of 11 criteria; a qualitative data analysis was performed.Approximately 6,500 titles and abstracts were screened and 48 publications were considered for inclusion. Eighteen studies, 4 of which met the high methodologic quality criteria, were included. For hip OA, there was limited evidence that functional status and pain do not change during the first 3 years of followup. After 3 years, however, a worsening of functional status and pain was seen. For knee OA, there was conflicting evidence for the first 3 years and limited evidence for worsening of pain and functional status after 3 years. Furthermore, limited evidence was established for negative associations between future functional status and laxity, proprioceptive inaccuracy, age, body mass index, and knee pain intensity. In contrast, greater muscle strength, better mental health, better self‐efficacy, social support, and more aerobic exercise were protective factors in the first 3 years.Pain and functional status in hip or knee OA seem to deteriorate slowly, with limited evidence for worsening after 3 years of followup. In specific subgroups, prognosis in the first 3 years of followup was either worse or better, as both risk factors and protective factors were identified. Prognostic factors included biomechanical factors, psychological factors, clinical factors, and treatment modalities. To strengthen the evidence, further high‐quality longitudinal research on hip or knee OA functioning is needed.

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To examine the effect of 2 different recruitment methods on the characteristics of participants with osteoarthritis (OA) of the hip or knee and on the efficacy of an exercise program.In a clinical trial on the effectiveness of exercise therapy in OA of the hip or knee, 2 groups of patients were recruited: one group through referrals by physiotherapists (PT group, n = 110) and one group invited by newspaper articles (NP group, n = 90). At baseline, demographic, clinical, and psychosocial data were collected and compared between the 2 groups using chi‐square and Student's t‐tests. After 13 weeks of exercise therapy and followup assessments at weeks 39 and 65, the main outcome measures (pain, physical function, and global perceived effect) were assessed and compared by multiple regression analysis.The NP group reported less pain and tiredness at baseline, although more joints were affected with osteoarthritis. The PT group scored higher on the scale ‘powerful‐others’ of locus of control. After adjusting for baseline differences, the effect of treatment after 13, 39, and 65 weeks was comparable for both groups for all outcome measures.Recruitment method affects clinical characteristics and physical functioning of patients recruited for the study. A mix of recruitment strategies does not seem to affect treatment outcome, on the condition that adjustments are made for baseline differences.

To determine the effectiveness of a manual therapy program compared with an exercise therapy program in patients with osteoarthritis (OA) of the hip.A single‐blind, randomized clinical trial of 109 hip OA patients was carried out in the outpatient clinic for physical therapy of a large hospital. The manual therapy program focused on specific manipulations and mobilization of the hip joint. The exercise therapy program focused on active exercises to improve muscle function and joint motion. The treatment period was 5 weeks (9 sessions). The primary outcome was general perceived improvement after treatment. Secondary outcomes included pain, hip function, walking speed, range of motion, and quality of life.Of 109 patients included in the study, 56 were allocated to manual therapy and 53 to exercise therapy. No major differences were found on baseline characteristics between groups. Success rates (primary outcome) after 5 weeks were 81% in the manual therapy group and 50% in the exercise group (odds ratio 1.92, 95% confidence interval 1.30, 2.60). Furthermore, patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion. Effects of manual therapy on the improvement of pain, hip function, and range of motion endured after 29 weeks.The effect of the manual therapy program on hip function is superior to the exercise therapy program in patients with OA of the hip.

To evaluate adherence and satisfaction of patients with rheumatoid arthritis (RA) in a long‐term intensive dynamic exercise program.A total of 146 RA patients started an intensive (strength and endurance training for 75 minutes, twice a week, for 2 years) exercise program (Rheumatoid Arthritis Patients In Training) aimed at improving physical fitness. Program attendance and satisfaction were examined. Additional assessments at baseline were done to find possible predictors of attendance.Median (interquartile range) age and disease duration of the patients were 54 (45–61) and 5 (3–10) years, respectively. After 2 years, 118 (81%) patients still participated in an exercise class. The median attendance rate of all patients was 74%. Low attendance was weakly associated with high disease activity, low functional ability, and low quality of life at baseline but not with the severity of joint damage at baseline. At the end, 78% of all participants would (strongly) recommend the program to other RA patients.Adherence and satisfaction of RA patients with an intensive dynamic exercise program over a prolonged time can be high. Disease severity parameters do not strongly predict the compliance of participants in an intensive exercise program.

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