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The OUTPAC cohort study evaluates the setup and implementation of a nationwide Danish initiative focused on the impact of structured outdoor physical activity (PA) on individuals with rheumatic diseases. This prospective cohort study includes more than 1600 participants, predominantly women (92%), with an average age of 65 years (range: 28-93). The cohort primarily consists of individuals with osteoarthritis (72%), rheumatoid arthritis (18%) and nonspecific lower back pain (13%). Volunteer instructors conducted interventions in outdoor settings, targeting strength, balance, physical capacity, mental health, and interaction with nature. Data collection involved questionnaires and physical tests in four primary outcome domains: quality of life, pain, physical function and activity, and mental health. Despite moderate pain (VAS mean: 48.3), high medication use (71%), and serious fatigue (54%), participants indicated having a good quality of life (EQ-5D-5L mean: 0.81) and average mental health (WHO-5 mean: 62.9). Baseline scores from physical tests showed results comparable to the general population aged 60-69 years. The OUTPAC project offers clinical insight into the implications of outdoor PA interventions on individuals with rheumatic disease while shedding light on the development and implementation of a large-scale nationwide outdoor PA intervention. Future analyses will examine short- and long-term changes and potential determinants.

Background: The high incidence of knee injuries in football/handball challenges effective prevention. Identifying tangible and modifiable factors associated with a knee injury may innovate preventive actions. Engaging key stakeholders can reveal crucial insights that could improve knee injury prevention in football/handball., Objective: To investigate football/handball stakeholders' perspectives on reasons for acute and severe knee injuries to generate a conceptual model on important factors associated with knee injuries in football/handball., Methods: Mixed-method participatory Group Concept Mapping was applied to collect statements from football/handball stakeholders (players/coaches/healthcare staff/researchers) on the question, ' What may explain why some players sustain a knee injury?' . Participants rated the importance and feasibility of screening for each statement. Multidimensional scaling and hierarchical cluster analysis produced a cluster map, forming the basis for developing a final conceptual model., Results: Stakeholders (n=37) generated and sorted 100 statements. Cluster analysis followed by cluster map validation yielded seven themes: (1) the player's physical and motor skill profile, (2) preparation and training, (3) footwear and playing surface, (4) the sport's impact on the risk of injury, (5) mental and physical fatigue, (6) history of injury and 7) genetics and context. A final conceptual model illustrating factors associated with knee injuries in football/handball was developed. Forty-six statements were identified as both important and feasible to screen for., Conclusions: Stakeholders' perspectives on knee injuries in football/handball revealed a complex interplay of factors. We developed a conceptual model fostering stakeholder dialogue for enhanced prevention. Key among its themes is 'preparation and training'., Competing Interests: MH is on the scientific advisory board of the Thuasne group. All other authors (RC, TA, MKZ, KT, JB, PMH, EB, EEW) have no conflicts of interests., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To explore what it means for patients with knee osteoarthritis (OA) to engage in online delivered exercise and education., Method: We combined participant observations and focus group interviews with knee OA patients who engaged in an 8-week program (12 exercise sessions and 2 education sessions) delivered online. Data underwent a three-level phenomenological-hermeneutic interpretation inspired by Ricoeur's narrative and interpretation theory., Results: We performed 17 participant observations during online group-based exercise sessions with twenty individuals with knee OA (12 females), median age 71 years (range: 48 to 81), and five focus group interviews with fifteen of the individuals. The following three themes emerged from the data analysis: 1. Exercise engagement portrays an experience of ownership of the exercise-based treatment, leading to better function and well-being and raising hope for the future 2. A good start but only halfway supported portrays perceived well-guided in performing knee OA exercise, however also some unmet support needs in the online format, and 3. Beneficial peer companionship with online constraints portrays a socially engaging peer forum that, at times, was limited by the online format., Conclusions: This phenomenological-hermeneutic study reflects that supervised online exercise and education facilitate identity mobility, potentially increasing self-efficacy to adopt weekly exercise habits in patients with knee OA. However, the program may benefit from enabling a more interactive approach between peer participants and combining the online format with physical group classes. Moreover, further individualization and focus on a gradual approach toward self-management are encouraged., Competing Interests: Dr. Skou is co-founder of Good Life with Osteoarthritis in Denmark (GLA:D®), a not-for profit initiative hosted at University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice. Furthermore, he is associate editor of the Journal of Orthopedic & Sports Physical Therapy and has received personal fees from Munksgaard, TrustMe-ED and Nestlé Health Science, all of which are outside the submitted work. Dr. Clausen is a board member of Danish Interdisciplinary Rheumatology Forum (DIRF). DIRF is a not-for profit national network for health professionals, within the rheumatic field., (© 2023 The Authors.)

Background and Purpose: Hip precautions are routinely prescribed to patients with osteoarthritis to decrease dislocation rates after total hip arthroplasty (THA) using a posterior approach. However, recommendations have been based on very low certainty of evidence. We updated the evidence on the influence of hip precautions on early recovery following THA by this systematic review., Materials and Methods: We performed systematic searches for randomized controlled trials (RCT) and non-randomized (NRS) studies in MEDLINE, Embase, PEDro, and CINAHL published from 2016 to July 2022. 2 reviewers independently included studies comparing postoperative precautions with minimal or no precautions, extracted data, and assessed the risk of bias. Random effects meta-analyses were used to synthesize the results. The certainty of the evidence was rated by the Grading of Recommendations Assessment and Evaluation approach. The critical outcome was the risk of hip dislocations within 3 months of surgery. Other outcomes were long-term risk of dislocation and reoperation, self-reported and performance-based assessment of function, quality of life, pain, and time to return to work., Results: 4 RCTs and 5 NRSs, including 8,835 participants, were included. There may be no or negligible difference in early hip dislocations (RCTs: risk ratio [RR] 1.8, 95% confidence interval [CI] 0.6-5.2; NRS: RR 0.9, CI 0.3-2.5). Certainty in the evidence was low for RCTs and very low for NRSs. Finally, precautions may reduce the performance-based assessment of function slightly, but the evidence was very uncertain. For all other outcomes, no differences were found (moderate to very low certainty evidence)., Conclusion: The current evidence does not support routinely prescribing hip precautions post-surgically for patients undergoing THA to prevent hip dislocations. However, the results might change with high-quality studies.

Objective: To explore clinicians' attitudes and beliefs about physical activity and exercise therapy as treatment for individuals with knee and/or hip osteoarthritis (OA)., Method: This was a scoping review, mapping available knowledge about the topic derived from qualitative research designs and methods. A comprehensive search of selected databases (MEDLINE, EMBASE; CINAHL; Web of Science) was conducted and data were analysed thematically., Results: Twelve articles met inclusion criteria. Thematic analysis identified three interrelated main themes: 1) Understandings of OA and its trajectory and management; 2) Attitudes to activity and exercise as part of OA management; 3) Clinicians' perceived knowledge of and expertise in OA management. Findings highlight that many clinicians involved in knee/hip OA management, particularly general practitioners and physiotherapists, perceive OA to be a low priority 'wear-and-tear' disease with expected progression of symptoms, making joint replacement surgery eventually inevitable. Further, many clinicians appear to lack knowledge about and interest in physical activity and exercise therapy in the management of knee/hip OA, and seem to show uncertainty about the effectiveness and safety of physical activity and exercise therapy on joint health., Conclusion: Clinicians' attitudes and beliefs about physical activity and exercise therapy in OA seem to reflect an outdated narrative which describes OA as a wear-and-tear disease with inevitable disease progression to joint replacement surgery. Clinicians need to adopt a contemporary narrative, which accurately reflects current knowledge and evidence-based practice, thereby ensuring consistent utilisation of exercise therapy as first-line care as recommended in OA guidelines., (Copyright © 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background and purpose - The UCLA Activity Scale (UCLA) is a questionnaire assessing physical activity level from 1 (low) to 10 (high) in patients undergoing hip or knee arthroplasty (HA/KA). After translation and cultural adaptation, we evaluated the measurement properties of the Danish UCLA.Patients and methods - After dual panel translation, cognitive interviews were performed among 55 HA/KA patients. An orthopedic surgeon and a physiotherapist estimated UCLA scores for 80 KA patients based on short interviews. Measurement properties were evaluated in 130 HA and 134 KA patients preoperatively and 1-year postoperatively.Results - To suit Danish patients of today, several adaptations were required. Prior to interviews, 4 patients were excluded, and 11 misinterpreted the answer options. Examiners rated the remaining 65 patients (mean age 67 years) 0.2-1.6 UCLA levels lower than patients themselves. The 130 HA and 134 KA patients (mean age 71/68 years) changed from 4.3 (SD 1.9)/4.5 (1.8) preoperatively to 6.6 (1.8)/6.2 (1.0) at 1-year follow-up. 103 (79%) HA and 89 (66%) KA patients reported increased activity. Effect sizes were large (1.2/0.96). Knee patients reaching minimal important change (MIC, ≥ 8 Oxford Knee Score points) had higher 1-year UCLA scores than patients not reaching MIC.Interpretation - Original scale development was undocumented. Content validity was questionable, and there was discrepancy between patient and examiner estimates. UCLA appears valuable for measuring change in self-reported physical activity on a group level. 4 out of 5 HA patients and 2 out of 3 KA patients were more physically active 1 year after joint replacement surgery.

Background: Little is known about how a prior knee injury affects the clinical profile of individuals with knee osteoarthritis (KOA) although this is potentially important to personalize care., Objectives: To compare individual and clinical characteristics of individuals with KOA with and without a self-reported prior knee injury., Design: Secondary data analysis of baseline data from the Good Life with osteoArthritis in Denmark (GLA:D®) registry., Methods: Individuals with symptomatic KOA, self-reporting a prior knee injury requiring a doctor's assessment, were compared to individuals without prior knee injury on a range of individual and clinical characteristics using multivariable logistic regression., Results: The analysis included 10,973 individuals with KOA of which 54% self-reported a prior knee injury. The average age was 64 years and 73% were female. We found that being male (Odds Ratio (OR): 0.99), having longer symptom duration of knee pain (OR: 1.07), having more painful body sites (OR: 1.03), being able to do more chair rises (OR: 1.02) and being more physically active in a week (2-4 days; OR:1.33) (>4 days; OR: 1.24) were associated with self-reporting a prior knee injury whereas being older (OR: 0.99), having higher BMI (OR: 0.99) and higher quality of life (OR: 0.98) were not associated with reporting a prior knee injury., Conclusion: The overall pattern of our findings rather than specific characteristics indicates that individuals with KOA and a history of a self-reported knee injury have a somewhat different clinical profile than their non-injured peers., (Copyright © 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objectives: To investigate the effects of lower limb strength training in addition to neuromuscular exercise and education (ST + NEMEX-EDU) compared to neuromuscular exercise and education alone (NEMEX-EDU) on self-reported physical function in patients with knee osteoarthritis (KOA)., Design: Patient-blinded, parallel-group randomized controlled trial (RCT)., Methods: The trial included 90 patients in secondary care with radiographic and symptomatic KOA, ineligible for knee replacement. Both groups exercised twice weekly for 12 weeks. Additional strength training consisted of a single, fatiguing knee extension set (30-60RM) before four sets of leg-press (8-12RM). Primary outcome was the between-group difference on the subscale activities of daily living from the Knee Injury and Osteoarthritis Outcome Score (KOOS ADL ) at 12 weeks. Secondary outcomes included KOOS symptoms, pain, function in sport and recreation, and quality of life, 40 m walk, stair climb, leg extension power, EuroQol-5D-5L, pain medication usage, and adverse events., Results: There was no statistically significant between-group difference in KOOS ADL at 12-weeks; adjusted mean difference -1.15 (-6.78 to 4.48). Except for the stair climb test, which demonstrated an adjusted mean difference of 1.15 (0.09-2.21) in favor of ST + NEMEX-EDU, all other outcomes showed no statistically significant between-group differences. Neither group improved leg extension power., Conclusion: The addition of lower-limb strength training, using a low-dose approach, to neuromuscular exercise and education carried no additional benefits on self-reported physical function or on most secondary outcomes. Both groups displayed similar improvements at 12-week follow-up. Hence, the current low-dose strength training approach provided no additional clinical value in this group of KOA patients. Trial identifier (ClinicalTrials.gov): NCT03215602., (Copyright © 2020 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

(n-3) PUFA influence immune function in adults and may also affect immune maturation during development. This randomized trial is, to our knowledge, the first to investigate whether fish oil supplementation in late infancy modifies immune responses. The study was a 2 x 2 intervention in 64 healthy Danish infants, who received cow's milk or infant formula alone or with fish oil (FO) (3.4 +/- 1.1 mL/d) from 9 to 12 mo of age. Before and after the intervention, fatty acid composition of erythrocyte membranes, plasma IgE, C-reactive protein, and soluble IL-2 receptor concentrations were measured. TNF-alpha, INF-gamma, and IL-10 concentrations in whole-blood cultures, stimulated for 22 h with LPS+phytohemaglutinin (PHA) or Lactobacillus paracasei, were also determined. IgA was measured in feces when infants were 10 mo of age. FO supplementation effectively raised erythrocyte (n-3) PUFA (P < 0.001), increased L. paracasei-induced INF-gamma (P = 0.05) and tended to reduce LPS+PHA-induced IL-10 (P = 0.08). The FO intervention did not affect any of the other analyzed immune variables. The erythrocyte content of eicosapentanoic acid was negatively associated with LPS+PHA-induced IL-10 (r = -0.38, P = 0.02). Feeding milk rather than formula did not affect cytokine production, but plasma soluble IL-2 receptor concentration was greater in the formula group than in the cow's milk group (P = 0.03). Since the capacity to produce INF-gamma has been proposed as a maturation marker for the immune system in early life, this study suggests a faster immune maturation with FO supplementation with no apparent reduction in immune activation. The implications for later health need further investigation.