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OBJECTIVE The Osteoarthritis Research Society International (OARSI) recommends assessment of physical function using a performance-based test of stair negotiation, but was unable to recommend any specific test. We assessed the reliability, validity, responsiveness, measurement error, and minimum important change (MIC) of the 6-step timed Stair Climb Test (SCT). METHODS We used pooled data from 397 participants with hip or knee osteoarthritis (54% women) from four clinical trials (86% retained at 12-week follow-up). Construct validity was assessed by testing six a priori hypotheses against other OARSI-recommended physical function measures. A self-reported Global Rating of Change scale was used to classify participants as worsened, improved and stable. Participants who worsened in physical function were excluded from all analyses. Responsiveness and MIC were assessed using multiple anchor-based and distribution-based approaches. Test-retest reliability, standard error of measurement (SEM) and smallest detectable change (SDC) were assessed on stable participants. RESULTS Five of six hypotheses (83%) for construct validity were met. Test-retest reliability was excellent (intraclass correlation coefficient2,1 : 0.83; 95% confidence interval: 0.71, 0.90). The SEM and SDC values were 0.44 and 1.21 seconds respectively. We did not find adequate support for responsiveness. The MIC values ranged from 0.78 to 1.95 seconds using different approaches (median=1.37 seconds). CONCLUSION The 6-step timed SCT adequately assesses the construct of physical function in individuals with hip or knee osteoarthritis with excellent 12-week test-retest reliability. However, support for its responsiveness was inadequate to recommend its use as an outcome measure in people with osteoarthritis for research and clinical practice.

BACKGROUND Scalable knee osteoarthritis programs are needed to deliver recommended education, exercise, and weight loss interventions. OBJECTIVE To evaluate two 6-month, telehealth-delivered exercise programs, 1 with and 1 without dietary intervention. DESIGN 3-group, parallel randomized (5:5:2) trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000930280). SETTING Australian private health insurance members. PARTICIPANTS 415 persons with symptomatic knee osteoarthritis and a body mass index between 28 and 40 kg/m2 who were aged 45 to 80 years. INTERVENTION All groups received access to electronic osteoarthritis information (control). The exercise program comprised 6 physiotherapist consultations via videoconference for exercise, self-management advice, and behavioral counseling, plus exercise equipment and resources. The diet and exercise program included an additional 6 dietitian consultations for a ketogenic very-low-calorie diet (2 formulated meal replacements and a low-carbohydrate meal daily) followed by a transition to healthy eating, as well as nutrition and behavioral resources. MEASUREMENTS Primary outcomes were changes in knee pain (numerical rating scale [NRS] of 0 to 10, higher indicating worse) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; scale, 0 to 68, higher indicating worse) at 6 months (primary time point) and 12 months. Secondary outcomes were weight, physical activity, quality of life, mental health, global change, satisfaction, willingness to have surgery, orthopedic appointments, and knee surgery. RESULTS A total of 379 participants (91%) provided 6-month primary outcomes, and 372 (90%) provided 12-month primary outcomes. At 6 months, both programs were superior to control for pain (between-group mean difference in change on NRS: diet and exercise, -1.5 [95% CI, -2.1 to -0.8]; exercise, -0.8 [CI, -1.5 to -0.2]) and function (between-group mean difference in change on WOMAC: diet and exercise, -9.8 [CI, -12.5 to -7.0]; exercise, -7.0 [CI, -9.7 to -4.2]). The diet and exercise program was superior to exercise (pain, -0.6 [CI, -1.1 to -0.2]; function, -2.8 [CI, -4.7 to -0.8]). Findings were similar at 12 months. LIMITATION Participants and clinicians were unblinded. CONCLUSION Telehealth-delivered exercise and diet programs improved pain and function in people with knee osteoarthritis and overweight or obesity. A dietary intervention conferred modest additional pain and function benefits over exercise. PRIMARY FUNDING SOURCE Medibank, the Medibank Better Health Foundation Research Fund, and a National Health and Medical Research Council Centre of Research Excellence.

Objective To explore the relationships between participant characteristics, perceptions of a short educational video about osteoarthritis and its management, and immediate changes in behavioural determinants for effective self-management behaviours. Methods Seventy-eight participants with knee OA (77% female, mean age 63.0 ± 8.7) watched the 9-min video that included evidence-based content and was designed to foster empowerment to self-manage effectively. Data were collected by online questionnaire at baseline and immediately after watching the video. Associations were tested between baseline health and information processing characteristics (health literacy, need for cognition), perceptions of the video (enjoyment, helpfulness, believability, novelty and relevance) and pre-post changes in behavioural determinants (self-efficacy for managing arthritis, attitude to self-management or ‘activation’, and importance/confidence for physical activity). Results All behavioural determinants improved immediately after watching the video. Positive perceptions were associated with greater improvements in self-efficacy for arthritis (Spearman’s rho, ρ = 0.26–0.47). Greater perceived relevance was associated with increased self-rated importance of being physically active (ρ = 0.43). There were small positive associations between health literacy domains related to health information and positive viewer perceptions of the video. People with higher need for cognition may achieve greater improvement in confidence to be physically active (ρ = 0.27). Conclusion The educational video may help achieve outcomes important for increasing self-management behaviours in people with knee osteoarthritis. Positive perceptions appear to be important in achieving these improvements. People with lower health literacy and lower need for cognition may respond less well to this information about knee osteoarthritis delivered in this way.

Question: What were the experiences of physiotherapists and patients who consulted via videoconference during the COVID-19 pandemic and how was it implemented? Design: Mixed methods study with cross-sectional national online surveys and qualitative analysis of free-text responses. Participants: A total of 207 physiotherapists in private practice or community settings and 401 patients aged ≥ 18 years who consulted (individual and/or group) via videoconference from April to November 2020. Methods: Separate customised online surveys were developed for physiotherapists and patients. Data were collected regarding the implementation of videoconferencing (cost, software used) and experience with videoconferencing (perceived effectiveness, safety, ease of use and comfort communicating, each scored on a 4-point ordinal scale). Qualitative content analysis was performed of physiotherapists’ free-text responses about perceived facilitators, barriers and safety issues. Results: Physiotherapists gave moderate-to-high ratings for the effectiveness of and their satisfaction with videoconferencing. Most intended to continue to offer individual consultations (81%) and group classes (60%) via videoconferencing beyond the pandemic. For individual consultations and group classes, respectively, most patients had moderately or extremely positive perceptions about ease of technology use (94%, 91%), comfort communicating (96%, 86%), satisfaction with management (92%, 93%), satisfaction with privacy/security (98%, 95%), safety (99% both) and effectiveness (83%, 89%). Compared with 68% for group classes, 47% of patients indicated they were moderately or extremely likely to choose videoconferencing for individual consultations in the future. Technology was predominant as both a facilitator and barrier. Falls risk was the main safety factor. Conclusion: Patients and physiotherapists had overall positive experiences using videoconferencing for individual consultations and group classes. The results suggest that videoconferencing is a viable option for the delivery of physiotherapy care in the future.

Background Low back pain (LBP) and knee osteoarthritis (OA) are major contributors to disability worldwide. These conditions result in a significant burden at both individual and societal levels. Engagement in regular physical activity and exercise programs are known to improve physical function in both chronic LBP and knee OA populations. For people residing in rural areas, musculoskeletal conditions are often more frequent and disabling compared to urban populations, which could be the result of reduced access to appropriate health services and resources in rural settings. EHealth is an innovative solution to help provide equitable access to treatment for people with musculoskeletal pain living in rural settings. Methods/design We will conduct a randomised clinical trial investigating the effects of an eHealth intervention compared to usual care, for people with chronic non-specific LBP or knee OA in rural Australia. We will recruit 156 participants with non-specific chronic LBP or knee OA. Following the completion of baseline questionnaires, participants will be randomly allocated to either the eHealth intervention group, involving a tailored physical activity and progressive resistance exercise program remotely delivered by a physiotherapist (n = 78), or usual care (n = 78) involving referral to a range of care practices in the community. Outcomes will be measured at baseline, 3 and 6 months post-randomisation. The primary outcome will be physical function assessed by the Patient-Specific Functional Scale (PSFS). Secondary outcomes include pain intensity, physical activity levels, activity limitations, quality of life, pain coping. We will also collect process evaluation data such as recruitment rate, attendance and adherence, follow-up rate, participants’ opinions and any barriers encountered throughout the trial. Discussion The findings from this trial will establish the effectiveness of eHealth-delivered interventions that are known to be beneficial for people with LBP and knee OA when delivered in person. As a result, this trial will help to inform health care policy and clinical practice in Australia and beyond for those living in non-urban areas. Trial registration This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12618001494224) registered 09.05.2018.

Objective To qualitatively explore the perceptions and experiences of people with knee osteoarthritis (OA) who used an online automated pain coping skills training program (PCST). Methods This was a descriptive qualitative study (based on interpretivist methodology) embedded within a randomized controlled trial. Individual semistructured interviews were conducted with 12 people with knee OA who had participated in an 8-week automated online PCST program while also receiving exercise advice and support from a physical therapist via Skype. Interviews in this study focused specifically on the online PCST program, rather than the physical therapy component. Interviews were audiorecorded, transcribed verbatim, and thematically analyzed. Results Five themes arose: 1) easy to understand and follow (clearly explained, presented well), 2) better able to cope with pain (controlling pain, helping relax, pacing self, incorporating skills into exercise program), 3) anonymity and flexibility (no judgement by clinician, work at own pace, accessibility), 4) not always relatable or engaging (some techniques not useful, Americanization of the program, annoying character examples, time consuming and slow-paced), and 5) support from clinician desirable (follow-up from a clinician would be beneficial, worked in tandem with physical therapist-prescribed exercise, desire referral to the program by a trusted source). Conclusion People with knee OA had generally positive experiences using an online PCST program, suggesting that online PCST is a broadly acceptable and accessible way to help people with OA to manage their pain. User engagement may be enhanced by redesigning some aspects of the program and by provision of support from a clinician.

Questions What are the experiences of physiotherapists delivering care for people with knee osteoarthritis? How do these experiences align with the national Clinical Care Standard? Design A qualitative study using individual interviews. Participants Twenty-two Australian physiotherapists (mean age 34 years, 50% female) with experience in providing care for people with knee osteoarthritis. Methods Physiotherapists participated in semi-structured individual telephone interviews. Questions were informed by seven quality statements from the national Knee Osteoarthritis Clinical Care Standard. Thematic analysis was undertaken, with themes/subthemes inductively derived. Interview data were also deductively analysed according to the Clinical Care Standard. Results Five themes emerged. First, physiotherapists focused on biomedical assessment with little psychosocial consideration. They managed ‘mechanical’ aspects of knee osteoarthritis, aiming to restore functional ability. Second, physiotherapists’ perceived their role as primarily providing goal-orientated personalised exercise via short-term episodic care. Knee surgery was considered a last option, but physiotherapists ‘prepped’ patients who decided on surgery. Third, clinical challenges included patient comorbidity, unsatisfactory patient adherence and a patient’s desire for a ‘quick fix’. The other two themes were: physiotherapists described a mismatch between what they know and what they do regarding imaging, weight management and manual therapy; and physiotherapists viewed weight loss, medication and surgical advice as outside of their professional role. Conclusion Physiotherapists’ reported experiences of delivering care for people with knee osteoarthritis were mostly consistent with the quality care standard. Care may be improved by increasing the focus on psychosocial aspects of care, offering longer-term reviews, and being more proactive with advice and/or referral regarding weight loss, pain medications and knee surgery. By describing the potential benefits and harms of common osteoarthritis medications and surgical interventions, physiotherapists will ensure that their patients are fully informed about all their treatment options.

ObjectivesTo evaluate the association between psychological factors and pain exacerbations in people with hip OA.MethodsEligible participants with symptomatic hip OA were instructed to complete online questionnaires every 10 days over a 90-day follow-up period. In addition, they were required to complete the questionnaire whenever they perceived they were experiencing a hip pain exacerbation. Hip pain exacerbation was defined as an increase of 2 points in pain intensity compared with baseline on an 11-point numeric rating scale (0–10). The Depression, Anxiety and Stress Scale–21 Items, Positive and Negative Affect Schedule, Pain Catastrophizing Scale and Pain Self-Efficacy Questionnaire were used to evaluate psychological factors. The associations of these with risk of hip pain exacerbation were examined by conditional logistic regression.ResultsOf 252 participants recruited, 131 (52.0%) contributed both case and control period data and were included in the analysis. A significant association was found between Pain Catastrophizing Scale overall score (1 point increase) with hip pain exacerbations (odds ratio: 1.07, 95% CI: 1.04, 1.11). An increase of a minimal important change (5.5 points) of Pain Self-Efficacy Questionnaire score was associated with a lower odds of pain exacerbations (odds ratio: 0.74, 95% CI: 0.65, 0.85). No significant associations were found between Depression, Anxiety and Stress Scale–21 Items or Positive and Negative Affect Schedule scores with hip pain exacerbations.ConclusionBoth pain catastrophizing and pain self-efficacy beliefs were associated with pain exacerbations in people with hip OA, but other psychological factors including depression, anxiety and stress or positive and negative affects, were not associated with pain exacerbations.

ObjectivesOsteoarthritis is a leading cause of immobility and joint replacement, two strong risk factors for venous thromboembolism (VTE). We aimed to examine the relation of knee, hip and hand osteoarthritis to the risk of VTE and investigate joint replacement as a potential mediator.MethodsWe conducted three cohort studies using data from The Health Improvement Network. Up to five individuals without osteoarthritis were matched to each case of incident knee (n=20 696), hip (n=10 411) or hand (n=6329) osteoarthritis by age, sex, entry time and body mass index. We examined the relation of osteoarthritis to VTE (pulmonary embolism and deep vein thrombosis) using a multivariable Cox proportional hazard model.ResultsVTE developed in 327 individuals with knee osteoarthritis and 951 individuals without osteoarthritis (2.7 vs 2.0 per 1000 person-years), with multivariable-adjusted HR being 1.38 (95% CI 1.23 to 1.56). The indirect effect (HR) of knee osteoarthritis on VTE through knee replacement was 1.07 (95% CI 1.01 to 1.15), explaining 24.8% of its total effect on VTE. Risk of VTE was higher in hip osteoarthritis than non-osteoarthritis (3.3 vs 1.8 per 1000 person-years; multivariable-adjusted HR=1.83, 95% CI 1.56 to 2.13). The indirect effect through hip replacement yielded an HR of 1.14 (95% CI 1.04 to 1.25), explaining 28.1% of the total effect. No statistically significant difference in VTE risk was observed between hand osteoarthritis and non-osteoarthritis (1.5 vs 1.6 per 1000 person-years; multivariable-adjusted HR=0.88, 95% CI 0.67 to 1.16).ConclusionOur large population-based cohort study provides the first evidence that knee or hip osteoarthritis, but not hand osteoarthritis, was associated with an increased risk of VTE, and such an association was partially mediated through knee or hip replacement.

BACKGROUND: Recommended first-line management of lower limb osteoarthritis (OA) includes support for self-management, exercise and weight loss. However, many Australians with OA do not receive these. A National Osteoarthritis Strategy (the Strategy) was developed to outline a national plan to achieve optimal health outcomes for people at risk of, or with, OA. OBJECTIVE: The aim of this article is to identify priorities for action for Australians living with OA. DISCUSSION: The Strategy was developed in consultation with a leadership group, thematic working groups, an implementation advisory committee, multisectoral stakeholders and the public. Two priorities were identified by the 'living well with OA' working group: 1) support primary care practitioners in the delivery of high-value care to Australians with OA, and 2) enhance the uptake of high-value care by Australians with OA. Evidence-informed strategies and implementation plans were developed through consultation to address these priorities.

Summary Objective Different exercise types may yield different outcomes in osteoarthritis (OA) subgroups. The objective was to directly compare effectiveness of two exercise programs for people with medial knee OA and co-morbid obesity. Design We performed a participant- and assessor-blinded randomized controlled trial. 128 people ≥50 years with medial knee OA and body mass index ≥30 kg/m2 were recruited from the community. Interventions were home-based non-weight bearing (NWB) quadriceps strengthening or weight bearing (WB) functional exercise for 12 weeks. Primary outcomes were change in overall knee pain (numeric rating scale, range 0–10) and difficulty with physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0–68) over 12 weeks. Secondary outcomes included other pain measures, physical function, quality-of-life, global changes, physical performance, and lower-limb muscle strength. Results 123 (96%) participants were retained. There was no evidence of a between-group difference in change in pain (mean difference 0.73 units (95% confidence intervals (0.05,1.50)) or function (2.80 units (−1.17,6.76)), with both groups reporting improvements. For secondary outcomes, the WB group had greater improvement in quality-of-life (−0.043 units (−0.085,-0.001)) and more participants reporting global improvement (overall: relative risk 1.40 (0.98,2.01); pain 1.47 (0.97,2.24); function 1.43 (1.04,1.98). Although adverse events were minor, more NWB group participants reported ≥1 adverse event (26/66 (39%) vs 14/62 (23%), p = 0.04). Conclusions Both exercise types similarly improved primary outcomes of pain and function and can be recommended for people with knee OA and obesity. WB exercise may be preferred given fewer adverse events and potential additional benefits on some secondary outcomes. Registration Prospectively registered (Australian New Zealand Clinical Trials Registry #12617001013358, 14/7/2017).

Background First metatarsophalangeal (MTP) joint osteoarthritis (OA) is a common and painful problem that causes significant disability. There is limited research on assessment and treatment options, and the efficacy of current management strategies is unknown. The aim of this study was to determine how podiatrists and physical therapists in Australia and the United Kingdom (UK) manage people with first MTP joint OA. Methods A survey of podiatrists and physiotherapists was conducted. Potential respondents were recruited through professional representative organisations in Australia and the UK. Participants completed a bespoke online survey regarding the assessment and treatment approaches they most commonly use for patients with first MTP joint OA. Descriptive statistics were calculated and differences between professions compared using chi-square. Results Two hundred respondents (n = 113 (57%) podiatrists and n = 140 (70%) from Australia) completed the survey. Assessment tests were similar between professions and included x-ray (n = 151/164; 92%), range of motion (n = 127/141; 90%), and a pain scale (n = 78/99; 79%). Podiatrists were more likely than physical therapists to discuss over-the-counter medication (42% vs 17%; p p p p p p p Conclusion Podiatrists and physical therapists use an array of assessment and treatment approaches for people with first MTP joint OA, albeit there is limited evidence to support their clinical utility. Treatment strategies differ between professions, particularly with respect to medication, orthoses and exercise. It is unclear whether these commonly-used strategies improve symptoms associated with first MTP joint OA.

Objective To investigate the feasibility of progressive resistance training for people with Prader-Willi syndrome (PWS), who have muscle weakness and very low muscle mass. Design Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis. Setting Community gymnasium. Participants Sixteen participants with PWS (eight female; mean age 25 years) were randomly assigned with 1:1 allocation to an experimental (n = 8) or control group (n = 8). Intervention Progressive resistance training was performed twice a week for 10 weeks. The training was supervised one-to-one by a physiotherapist and comprised seven exercises. The control group continued their usual activities and were offered the training after follow-up assessment. Main outcome measures Three domains of feasibility were evaluated: implementation (attendance and adherence), practicality (safety) and limited efficacy testing. Muscle strength (one repetition maximum for chest and leg press), physical function (box stacking test, timed stairs climb), muscle composition (US) and body composition (whole-body DXA scan) were measured before and after the intervention. Results Participants attended 92% of scheduled sessions and adhered by progressing their training resistance by 82% (range 60–140%). There was one unexpected serious adverse event unrelated to the intervention and several non-serious expected adverse events related to the intervention. Estimates of standardised mean differences indicated moderate to large effects in favour of the experimental group for arm (0.92, 95%CI −0.11 to 1.95) and leg strength (0.78, 95%CI −0.27 to 1.83). The effect was uncertain for secondary outcomes. Conclusions There is preliminary evidence showing progressive resistance training is feasible for people with Prader-Willi syndrome and may increase muscle strength. Clinical Trial Registration Australia New Zealand Clinical Trials Registry ACTRN12616000107426.

Background Although education, exercise, and weight loss are recommended for management of knee osteoarthritis, the additional benefits of incorporating weight loss strategies into exercise interventions have not been well investigated. The aim of this study is to compare, in a private health insurance setting, the clinical- and cost-effectiveness of a remotely-delivered, evidence- and theory-informed, behaviour change intervention targeting exercise and self-management (Exercise intervention), with the same intervention plus active weight management (Exercise plus weight management intervention), and with an information-only control group for people with knee osteoarthritis who are overweight or obese. Methods Three-arm, pragmatic parallel-design randomised controlled trial involving 415 people aged ≥45 and ≤ 80 years, with body mass index ≥28 kg/m2 and 2 and painful knee osteoarthritis. Recruitment is Australia-wide amongst Medibank private health insurance members. All three groups receive access to a bespoke website containing information about osteoarthritis and self-management. Participants in the Exercise group also receive six consultations with a physiotherapist via videoconferencing over 6 months, including prescription of a strengthening exercise and physical activity program, advice about management, and additional educational resources. The Exercise plus weight management group receive six consultations with a dietitian via videoconferencing over 6 months, which include a very low calorie ketogenic diet with meal replacements and resources to support behaviour change, in addition to the interventions of the Exercise group. Outcomes are measured at baseline, 6 and 12 months. Primary outcomes are self-reported knee pain and physical function at 6 months. Secondary outcomes include weight, physical activity levels, quality of life, global rating of change, satisfaction with care, knee surgery and/or appointments with an orthopaedic surgeon, and willingness to undergo surgery. Additional measures include adherence, adverse events, self-efficacy, and perceived usefulness of intervention components. Cost-effectiveness of each intervention will also be assessed. Discussion This pragmatic study will determine whether a scalable remotely-delivered service combining weight management with exercise is more effective than a service with exercise alone, and with both compared to an information-only control group. Findings will inform development and implementation of future remotely-delivered services for people with knee osteoarthritis. Trial registration Australian New Zealand Clinical Trials Registry: ACTRN12618000930280 (01/06/2018).

Hip and knee osteoarthritis (OA) are leading causes of global disability. Most research to date has focused on the knee, with results often extrapolated to the hip, and this extends to treatment recommendations in clinical guidelines. Extrapolating results from research on knee OA may limit our understanding of disease characteristics specific to hip OA, thereby constraining development and implementation of effective treatments. This review highlights differences between hip and knee OA with respect to prevalence, prognosis, epigenetics, pathophysiology, anatomical and biomechanical factors, clinical presentation, pain and non-surgical treatment recommendations and management. (c) 2021 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Objective\ud Therapeutic exercise is a recommended first‐line treatment for people with knee and hip osteoarthritis. However, there is little specific advice or practical resources to guide clinicians in its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim to synthesize current literature informing the implementation of therapeutic exercise for people with knee and hip osteoarthritis.\ud \ud Methods\ud Narrative review focusing on evidence from systematic reviews and randomized controlled trials.\ud \ud Results\ud Therapeutic exercise is safe for people with knee and hip osteoarthritis. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind‐body exercise) may be utilised at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically‐informed strategies to improve adherence to therapeutic exercise, such as patient education, goal setting, monitoring and feedback, may help maintain participation and optimise clinical benefits over the longer‐term. Sedentary behaviour is also a risk factor for disability and lower quality of life in people with knee and hip osteoarthritis, although limited evidence exists regarding how best to reduce this behaviour.\ud \ud Conclusion\ud Current evidence can be used to inform how to implement best practice therapeutic exercise, at a sufficient and appropriate dose, for people with knee and hip osteoarthritis.

Background A 24-week self-directed digitally delivered intervention was found to improve pain and function in people with knee osteoarthritis (OA). However, it is possible that this intervention may be better suited to certain subgroups of people with knee OA compared to others. Objective The aim of this study was to explore whether certain individual baseline characteristics moderate the effects of a self-directed digitally delivered intervention on changes in pain and function over 24 weeks in people with knee OA. Methods An exploratory analysis was conducted on data from a randomized controlled trial involving 206 people with a clinical diagnosis of knee OA. This trial compared a self-directed digitally delivered intervention comprising of web-based education, exercise, and physical activity program supported by automated exercise behavior change mobile phone text messages to web-based education alone (control). The primary outcomes were changes in overall knee pain (assessed on an 11-point numerical rating scale) and physical function (assessed using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale [WOMAC]) at 24 weeks. Five baseline patient characteristics were selected as the potential moderators: (1) number of comorbidities, (2) number of other painful joints, (3) pain self-efficacy, (4) exercise self-efficacy, and (5) self-perceived importance of exercise. Separate linear regression models for each primary outcome and each potential moderator were fit, including treatment group, moderator, and interaction between treatment group and moderator, adjusting for the outcome at baseline. Results There was evidence that pain self-efficacy moderated the effect of the intervention on physical function compared to the control at 24 weeks (interaction P=.02). Posthoc assessment of the mean change in WOMAC function by treatment arm showed that each 1-unit increase in baseline pain self-efficacy was associated with a 1.52 (95% CI 0.27 to 2.78) unit improvement in the control group. In contrast, a reduction of 0.62 (95% CI –1.93 to 0.68) units was observed in the intervention group with each unit increase in pain self-efficacy. There was only weak evidence that pain self-efficacy moderated the effect of the intervention on pain and that number of comorbidities, number of other painful joints, exercise self-efficacy, or exercise importance moderated the effect of the intervention on pain or function. Conclusions With the exception of pain self-efficacy, which moderated changes in function but not pain, we found limited evidence that our selected baseline patient characteristics moderated intervention outcomes. This indicates that people with a range of baseline characteristics respond similarly to the unsupervised digitally delivered exercise intervention. As these findings are exploratory in nature, they require confirmation in future studies.

Objective: Determine the feasibility of a 6-month exercise and weight management intervention for people with hip osteoarthritis (OA). Design: 18 participants with clinical and radiographic hip OA with a body mass index ≥28 ​kg/m2 and

ObjectiveEvaluate a physiotherapist-led telephone-delivered exercise advice and support intervention for people with knee osteoarthritis.MethodsParticipant-blinded, assessor-blinded randomised controlled trial. 175 people were randomly allocated to (1) existing telephone service (≥1 nurse consultation for self-management advice) or (2) exercise advice and support (5–10 consultations with a physiotherapist trained in behaviour change for a personalised strengthening and physical activity programme) plus the existing service. Primary outcomes were overall knee pain (Numerical Rating Scale, range 0–10) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, range 0–68) at 6 months. Secondary outcomes, cost-effectiveness and 12-month follow-up were included.Results165 (94%) and 158 (90%) participants were retained at 6 and 12 months, respectively. At 6 months, exercise advice and support resulted in greater improvement in function (mean difference 4.7 (95% CI 1.0 to 8.4)), but not overall pain (0.7, 0.0 to 1.4). Eight of 14 secondary outcomes favoured exercise advice and support at 6 months, including pain on daily activities, walking pain, pain self-efficacy, global improvements across multiple domains (overall improvement, improved pain, improved function and improved physical activity) and satisfaction. By 12 months, most outcomes were similar between groups. Exercise advice and support cost $A514/participant and did not save other health service resources.ConclusionTelephone-delivered physiotherapist-led exercise advice and support modestly improved physical function but not the co-primary outcome of knee pain at 6 months. Functional benefits were not sustained at 12 months. The clinical significance of this effect is uncertain.Trial registration numberAustralian New Zealand Clinical Trials Registry (#12616000054415).

Background Knee osteoarthritis (OA) is prevalent and often associated with meniscal tear. Physical therapy (PT) and exercise regimens are often used to treat OA or meniscal tear, but, to date, few programs have been designed specifically for conservative treatment of meniscal tear with concomitant knee OA. Clinical care and research would be enhanced by a standardized, evidence–based, conservative treatment program and the ability to study the effects of the contextual factors associated with interventions for patients with painful, degenerative meniscal tears in the setting of OA. This paper describes the process of developing both a PT intervention and a home exercise program for a randomized controlled clinical trial that will compare the effectiveness of these interventions for patients with knee pain, meniscal tear and concomitant OA. Methods This paper describes the process utilized by an interdisciplinary team of physical therapists, physicians, and researchers to develop and refine a standardized in-clinic PT intervention, and a standardized home exercise program to be carried out without PT supervision. The process was guided in part by Medical Research Council guidance on intervention development. Results The investigators achieved agreement on an in-clinic PT intervention that included manual therapy, stretching, strengthening, and neuromuscular functional training addressing major impairments in range of motion, musculotendinous length, muscle strength and neuromotor control in the major muscle groups associated with improving knee function. The investigators additionally achieved agreement on a progressive, protocol-based home exercise program (HEP) that addressed the same major muscle groups. The HEP was designed to allow patients to perform and progress the exercises without PT supervision, utilizing minimal equipment and a variety of methods for instruction. Discussion This multi-faceted in-clinic PT program and standardized HEP provide templates for in-clinic and home-based care for patients with symptomatic degenerative meniscal tear and concomitant OA. These interventions will be tested as part of the Treatment of Meniscal Tear in Osteoarthritis (TeMPO) Trial. Trial registration The TeMPO Trial was first registered at clinicaltrials.gov with registration No. NCT03059004 on February 14, 2017. TeMPO was also approved by the Institutional Review Board at Partners HealthCare/Brigham and Women’s Hospital.

Deep hip muscle retraining is a common objective of non-operative management for femoroacetabular impingement (FAI) syndrome. These muscles are considered to have an important role in hip joint stabilization, however, it is unclear whether their function is altered in the presence of hip pathology. This exploratory study aimed to investigate activation patterns of the hip muscles during two squatting tasks in individuals with and without FAI syndrome.Fifteen individuals with FAI syndrome (symptoms, clinical examination and imaging) and 14 age- and sex-comparable healthy controls underwent testing. Intramuscular fine-wire and surface electrodes recorded electromyographic activity of selected deep and superficial hip muscles during the squatting tasks. Activation patterns from individual muscles were compared between-groups using a wavelet-based linear mixed effects model (P 0.05).There were no between-group differences for squat depth or speed during descent or ascent for either task. Participants with FAI syndrome exhibited patterns of activation that differed significantly to controls across all muscles (P 0.05) when squatting using their preferred strategy. Unlike controls, participants with FAI syndrome exhibited a pattern of activation for obturator internus during descent that was similar in amplitude to ascent, despite the contrasting contraction type (i.e. eccentric vs concentric).Individuals with FAI syndrome appear to implement a protective strategy as the hip descends towards the impingement position. Future studies should examine patients prospectively to establish whether these strategies are counterproductive for pathology and warrant rehabilitation.

BackgroundKnee osteoarthritis (OA) is a highly prevalent condition. People with knee OA often have other co-morbidities such as obesity. Exercise is advocated in all clinical guidelines for the management of knee OA. It is often undertaken as a home-based program, initially prescribed by a physiotherapist or other qualified health care provider. However, adherence to home-based exercise is often poor, limiting its ability to meaningfully change clinical symptoms of pain and/or physical function. While the efficacy of short message services (SMS) to promote adherence to a range of health behaviours has been demonstrated, its ability to promote home exercise adherence in people with knee OA has not been specifically evaluated. Hence, this trial is investigating whether the addition of an SMS intervention to support adherence to prescribed home-based exercise is more effective than no SMS on self-reported measures of exercise adherence.MethodsWe are conducting a two-arm parallel-design, assessor-and participant-blinded randomised controlled trial (ADHERE) in people with knee OA and obesity. The trial is enrolling participants exiting from another randomised controlled trial, the TARGET trial, where participants are prescribed a 12-week home-based exercise program (either weight bearing functional exercise or non-weight bearing quadriceps strengthening exercise) for their knee by a physiotherapist and seen five times over the 12 weeks for monitoring and supervision. Following completion of outcome measures for the TARGET trial, participants are immediately enrolled into the ADHERE trial. Participants are asked to continue their prescribed home exercise program unsupervised three times a week for 24-weeks and are randomly allocated to receive a behaviour change theory-informed SMS intervention to support home exercise adherence or to have no SMS intervention. Outcomes are measured at baseline and 24-weeks. Primary outcomes are self-reported adherence measures. Secondary outcomes include self-reported measures of knee pain, physical function, quality-of-life, physical activity, self-efficacy, kinesiophobia, pain catastrophising, participant-perceived global change and an additional adherence measure.DiscussionFindings will provide new information into the potential of SMS to improve longer-term exercise adherence and ultimately enhance exercise outcomes in knee OA.Trial registrationProspectively registered with the Australian New Zealand Clinical Trials Registry. Reference: ACTRN12617001243303Date/version:August 2019/two

Physical therapists are key providers of conservative management for hip and/or knee osteoarthritis (OA), yet not all guideline recommendations are tailored to their scope of practice.To identify and prioritize the most important recommendations relevant to physical therapy practice for hip and/or knee OA.International physical therapists (n = 132) were invited to participate in an online modified Delphi survey, followed by a priority-ranking exercise. A total of 63 recommendations were extracted from 2 recent high-quality clinical guidelines. In 3 Delphi rounds, the panel identified those recommendations they considered to be most relevant to physical therapy practice for hip and knee OA. Any new recommendations were ascertained. For a recommendation to be included, at least 70% of respondents had to rate the recommendation as 7 or above on a numeric rating scale (0 is not important and 10 is extremely important). The panel prioritized recommendations that remained after the final round using decision-making software.Of 132 therapists from 14 countries, 62 completed round 1, 52 completed round 2, 45 completed round 3, and 35 completed the priority-ranking exercise. From an initial list of 70 potential recommendations (including 7 new recommendations), 30 were included in the priority-ranking exercise. The top recommendations were related to providing education and prescribing exercise and weight loss as core treatments, followed by individualized OA assessment and treatment and communication strategies.This study identified and ranked the most important recommendations relevant to physical therapy practice for hip and/or knee OA.

Background Assessment of home exercise adherence and the degree to which adherence influences changes in patient outcomes is limited by the use of self-reported measures. Objectives To determine the relationship between adherence to a home strengthening program, covertly measured by accelerometers in ankle cuff weights, and changes in self-reported pain, physical function, and knee extensor strength among people with chronic knee pain. Methods This is a secondary analysis of data from a clinical measurement study in 54 adults, aged 45 years or older, with chronic knee pain who completed a 12-week, home-based quadriceps-strengthening program. A triaxial accelerometer was concealed in the ankle cuff weight used for exercises to assess exercise adherence. Associations between exercise adherence and changes in pain and function (measured using the Western Ontario and McMaster Universities Osteoarthritis Index) and peak isometric knee extensor strength were examined using mixed-effects and linear regression models and fractional polynomials. Results Exercise adherence declined from a median of 90% (interquartile range, 70%–100%) in weeks 0 to 2 to 65% (interquartile range, 25%–90%) in weeks 10 to 12. Significant improvements were observed in knee pain (mean change, −3.2 units; 95% confidence interval [CI]: −2.4, −3.9 units), function (mean change, −10.1 units; 95% CI: −7.8, −12.4 units), and knee extensor strength (mean change, 0.34 Nm/kg; 95% CI: 0.26, 0.42 Nm/kg) across the group over the same period. Exercise adherence was not associated with changes in pain, function, and knee extensor strength over 2-week periods or over the entire 12 weeks. Conclusion Covertly measured adherence to a home strengthening program was not associated with changes in patient outcomes. These findings challenge the notion that greater exercise adherence leads to greater improvement in patient outcomes during a short-term intervention.

Background Knee osteoarthritis (OA) is a prevalent and chronic condition with no known cure. Exercise is advocated in all clinical guidelines due to its positive effects on symptoms. Despite this, exercise participation is often poor in people with knee OA with access to exercise treatments a known barrier. Internet-delivered exercise interventions have the potential to improve access to evidence-based exercise treatments and can benefit OA outcomes, although non-usage and low adherence potentially limit their effectiveness. Short message services (SMS) show promise in facilitating exercise adherence and may be one solution to improve adherence to internet-delivered exercise interventions. The combination of internet-delivered exercise and SMS adherence support has not been specifically evaluated in people with knee OA. Methods This protocol reports a two-arm parallel-design, assessor- and participant-blinded randomised controlled trial. This trial is recruiting 206 people aged 45 years and older, with a clinical diagnosis of knee OA from the Australian-wide community. Eligible and consenting participants are enrolled and randomised to receive access to either i) ‘My Knee Education’, an education control website containing OA and exercise information only or ii) a combined intervention that includes a website, ‘My Knee Exercise’, containing the same educational information as the control, guidance to increase general physical activity, and the prescription of a 24-week self-directed home-based lower-limb strengthening program in addition to a 24-week behaviour change SMS exercise adherence program. Outcome measures are being collected at baseline and 24-weeks. Primary outcomes are self-reported knee pain and physical function. Secondary outcomes include another self-reported measure of knee pain, function in sport and recreation, quality-of-life, physical activity, self-efficacy, participant satisfaction and perceived global change. Discussion This randomised controlled trial will provide evidence about the effectiveness of a combined intervention of internet-delivered OA and exercise education, physical activity guidance and prescription of a 24-week lower-limb strengthening exercise program supported by a behaviour change SMS program compared to internet delivered OA and exercise education alone. Trial registration ACTRN12618001167257/13th July 2018. Electronic supplementary material The online version of this article (10.1186/s12891-019-2714-x) contains supplementary material, which is available to authorized users.

OBJECTIVE To evaluate the association between hip injury/giving way and hip pain exacerbations in patients with symptomatic hip osteoarthritis (OA). METHODS We conducted an internet-based case-crossover study to assess hip injury and giving way for hip pain exacerbation. Eligible participants with symptomatic hip OA were followed up for 90 days and asked to complete online questionnaires at baseline and 10-day intervals (control periods). They also logged on to the study web site to complete questionnaires for an episode of a hip pain exacerbation (case periods) defined as an increase of 2 points in pain intensity compared with the baseline rating on a numeric rating scale (range 0-10). The relationship of hip injury and giving way to the risk of pain exacerbation was examined using conditional logistic regression. RESULTS Of 252 patients recruited into the study, we included 133 patients (53%) who provided data from both case and control periods. Hip injury during the last 7 days increased the risk of hip pain exacerbation (odds ratio [OR] 2.74 [95% confidence interval (95% CI) 1.62-4.62]). The hip giving way during the last 2 days was associated with an increased risk of hip pain exacerbation (OR 2.10 [95% CI 1.30-3.39]) and showed a significant relationship between the number of hip giving way events and the risk of hip pain exacerbations (P < 0.001). CONCLUSION Hip injury and episodes of the hip giving way were significantly related to pain exacerbation in patients with symptomatic hip OA. Methods to prevent exposure to injury may help to reduce the burden of pain in patients with hip OA.

Objective The aim of the study was to evaluate whether a web-based exercise programming system improves adherence to a home exercise program for people with musculoskeletal conditions. Design Eligible patients with a musculoskeletal condition presenting to a physical therapist in private practice were randomized to the following: (a) control (home exercise prescribed by therapist’s usual methods) or (b) intervention (home exercise prescribed using a web-based exercise programming system). The primary outcome was self-rated exercise adherence measured at week 3 via 11-point Numeric Rating Scales. Secondary outcomes were satisfaction with exercise delivery and confidence in ability to undertake prescribed exercise. Process measures were also included. Results We enrolled 305 participants, with loss to follow-up of 14.5% (22/152) and 13.7% (21/153) in intervention and control groups, respectively. Compared with controls, the intervention group reported higher exercise adherence (mean difference Numeric Rating Scale units (95% confidence intervals): adherence overall −1.0 [−1.6 to −0.3] and regarding number of exercises in session −0.7 [−1.3 to −0.1], number of repetitions −0.8 [−1.4 to −0.2], and number of sessions −1.0 [−1.6 to −0.3]). The intervention group showed greater confidence to exercise than control, with no difference in satisfaction. Conclusions A web-based exercise programming system improved home exercise adherence and confidence in ability to undertake exercise, although the clinical relevance of the results needs to be established.

ContextPoor quadriceps force control has been observed after anterior cruciate ligament (ACL) reconstruction but has not been examined after ACL injury. Whether adaptations within the central nervous system are contributing to these impairments is unknown.ObjectiveTo examine quadriceps force control in individuals who had sustained a recent ACL injury and determine the associations between cortical excitability and quadriceps force control in these individuals.DesignCross-sectional study.SettingResearch laboratory.Patients or Other ParticipantsEighteen individuals with a recent unilateral ACL injury (6 women, 12 men; age = 29.6 ± 8.4 years, height = 1.74 ± 0.07 m, mass = 76.0 ± 10.4 kg, time postinjury = 69.5 ± 42.5 days) and 18 uninjured individuals (6 women, 12 men; age = 29.2 ± 6.8 years, height = 1.79 ± 0.07 m, mass = 79.0 ± 8.4 kg) serving as controls participated.Main Outcome Measure(s)Quadriceps force control was quantified as the root mean square error between the quadriceps force and target force during a cyclical force-matching task. Cortical excitability was measured as the active motor threshold and cortical silent period. Outcome measures were determined bilaterally in a single testing session. Group and limb differences in quadriceps force control were assessed using mixed analyses of variance (2 × 2). Pearson product moment correlations were performed between quadriceps force control and cortical excitability in individuals with an ACL injury.ResultsIndividuals with an ACL injury exhibited greater total force-matching error with their involved (standardized mean difference [SMD] = 0.8) and uninvolved (SMD = 0.9) limbs than did controls (F1,27 = 11.347, P = .03). During the period of descending force, individuals with an ACL injury demonstrated greater error using their involved (SMD = 0.8) and uninvolved (SMD = 0.8) limbs than uninjured individuals (F1,27 = 4.941, P = .04). Greater force-matching error was not associated with any cortical excitability measures (P > .05).ConclusionsQuadriceps force control was impaired bilaterally after recent ACL injury but was not associated with selected measures of cortical excitability. The findings highlight a need to incorporate submaximal-force control tasks into rehabilitation and “prehabilitation,” as the deficits were present before surgery.

Objectives The aims of the present study were to determine how well physiotherapists implemented person-centred practice principles and behaviour change techniques after a workshop, and to evaluate whether self-audit of performance differed from audits of an experienced training facilitator. Methods Eight physiotherapists each completed a 2-day workshop followed by two telephone consultations with four patients with knee osteoarthritis. The training facilitator audited audio-recordings of all consultations, and therapists self-audited 50% of consultations using a tool comprising: (a) 10 person-centred practice principles rated on a numerical rating scale of 0 (need to work on this) to 10 (doing really well); and (b) seven behaviour change techniques rated with an ordinal scale (using this technique effectively; need to improve skill level; or need to learn how to apply this technique). Results Physiotherapists showed "moderate" fidelity to person-centred principles, with mean scores between 5 and 7 out of 10. For behaviour change techniques, the training facilitator believed that physiotherapists were using three of seven techniques "effectively" during most consultations and "needed to improve skill levels" with most other techniques. Physiotherapists scored themselves significantly lower than the training facilitator for two of 10 person-centred principles, and tended to rate their skills using behaviour change techniques less favourably. Conclusions Physiotherapists performed moderately well when implementing person-centred practice principles and behaviour change techniques immediately after training, but had room for improvement, particularly for skills relating to providing management options and changing thinking habits. Physiotherapists' self-ratings of performance generally did not differ from expert ratings; however, they underestimated their ability to implement some principles and techniques.

Objective.To evaluate the association of sleep quality, sleep duration, and fatigue with hip pain exacerbations in persons with symptomatic hip osteoarthritis (OA).Methods.Participants (n = 252) were followed for 90 days and asked to complete online questionnaires at 10-day intervals (control periods). A hip pain exacerbation (case periods) was defined as an increase of 2 points in pain intensity compared with baseline on a numeric rating scale (0–10). Subjective sleep quality and sleep duration were assessed using the Pittsburgh Sleep Quality Index, and fatigue was measured by Multidimensional Assessment of Fatigue in both periods. Univariable and multivariable conditional logistic regressions were used to assess the association.Results.Of the 252 participants, 130 (52%) were included in the final analysis. Univariate association analysis showed that both poor sleep quality and greater fatigue were associated with increased odds of pain exacerbations (OR 1.72, 95% CI 1.04–2.86; OR 1.92, 95% CI 1.21–3.05, respectively). Short sleep duration was not associated with pain exacerbations. Poor sleep quality and greater fatigue remained associated with pain exacerbations after adjustment for physical activity and night pain levels in multivariable analysis. There was no significant interaction between sleep quality and fatigue (p = 0.21).Conclusion.Poor sleep quality and greater fatigue were related to pain exacerbation in persons with symptomatic hip OA. Sleep disorders and fatigue should be considered when dealing with pain exacerbations.

Objective To explore physiotherapists' perceptions before and after delivering exercise advice via telephone to patients with knee osteoarthritis (OA). Methods We performed a descriptive qualitative study (based on interpretivist methodology) embedded within a randomized controlled trial. Before and after providing exercise therapy to patients with knee OA, all 8 physiotherapists who were involved in the trial participated in semi-structured interviews via telephone. Interviews were audio recorded, transcribed verbatim, and thematically analyzed. Results Prior to delivering the intervention, physiotherapists thought that the telephone should be used only for follow-up rather than as the primary mode of providing care. They believed that telephone-delivered care would be convenient and cost-saving for patients, would provide increased opportunity for patient education, and also increase access to services, but that the lack of visual and physical contact with patients would be problematic. After delivering the intervention, physiotherapists reflected that telephone-delivered care exceeded their expectations, noting positive patient outcomes including improved pain, function, and confidence. The focus on communication allowed more personal conversations with patients and shifted patient expectations of care away from manual therapies and toward self-management. Numerous implementation considerations were identified, including the need for clinician training in communication skills, written resources for patients to supplement telephone calls, and careful deliberation of how to schedule telephone consultations during the usual in-person consultations in the clinic. Conclusion Although physiotherapists were initially skeptical about the effectiveness of telephone-delivered service models to patients with knee OA, perceptions shifted once they experienced delivery of care via this nontraditional method. Our findings suggest that firsthand experience may be necessary for physiotherapists to embrace new models of service delivery.

Objectives: The aim of the present study was to explore the attitudes of individuals with knee osteoarthritis (OA) towards the role of physiotherapists in weight management in knee OA. Methods: The study took the form of a qualitative semi-structured telephone interview study. Participants included 13 purposively sampled individuals with symptomatic knee OA who were overweight or obese by body mass index. Each participated in a semi-structured telephone interview exploring their perspectives regarding the potential role of physiotherapists in weight management in knee OA. Data were transcribed and analysed using a thematic approach. Results: Three main themes were identified, which highlighted that individuals with knee OA: (a) recognize that weight management is complex; (b) consider that a special skill set is required by clinicians for weight management; and (c) expressed ambivalence towards physiotherapists' role in weight management, with a focus on the role of exercise prescription. Conclusions: Although participants were open to physiotherapists taking on a weight management role within a multidisciplinary team, they were uncertain about whether physiotherapists had the skills and scope of practice needed to address this complex issue. The findings highlight the importance of engagement by physiotherapists in meaningful dialogue with patients, to understand better their experiences, expectations and preferences, and establish if, when and how to integrate patients in weight management discussions in the treatment plan for their knee OA.

AIMS: To determine: 1) inter-rater reliability of quantitative measurements of ultrasound-detected synovitis, meniscal extrusion, and osteophytes; and 2) construct (convergent) validity via correlations and absolute agreements between ultrasound- and gold-standard magnetic resonance imaging (MRI)-outcomes in knee osteoarthritis. METHODS: Dynamic ultrasound images for supra-patellar synovitis, meniscal extrusion, and osteophytes were acquired and quantified by a physician operator, musculoskeletal ultrasonographer, and medical student independently. On the same day, 3T MRI images were acquired. Effusion-synovitis, meniscal extrusion, and osteophytes were quantified on sagittal or coronal proton-density-weighted fat-suppressed noncontrast TSE sequences, respectively. Intra-class correlation coefficients (ICCs), Pearson's correlations (r), and Bland-Altman plots were used to analyze inter-rater reliability, and correlations, and agreements between the two imaging modalities. RESULTS: Eighty-nine participants [48 females (53.9%)] with mean (standard deviation) age of 61.5 ± 6.9 years were included. The inter-rater reliability was excellent for osteophytes (ICC range = 0.90-0.96), meniscal extrusion (ICC range = 0.90-0.93), and synovitis (ICC range = 0.86-0.88). The correlations between ultrasound pathologies and their MRI counterparts were very strong (ICC range = 0.85-0.98) except for lateral meniscal extrusion [0.66 (95% CI, 0.52-0.76)]. Bland-Altman plots showed 0.01, 0.05, 0.10, 0.53, and 0.60 mm larger size in ultrasound medial tibial and medial femoral osteophytes, medial meniscal extrusions, synovitis, and lateral meniscal extrusions with 95% limits of agreements [±0.39, ±0.44, ±0.85, ±0.70, and ±0.90 (SDs)] than MRI measures, respectively. The lines of equality were within 95% CI of the mean differences (bias) only for medial osteophytes and medial meniscal extrusion. CONCLUSION: The quantitative assessment of synovitis, meniscal extrusion, and osteophytes generally showed excellent inter-rater reliability and strong correlations with MRI-based measurements. Absolute agreement was strong for medial tibiofemoral pathologies.

BackgroundDespite 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.MethodsTwo-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.DiscussionWe 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 registrationAustralian New Zealand Clinical Trials Registry:ACTRN12620001041943(13/10/2020).

Background: Bony morphology is central to the pathomechanism of femoroacetabular impingement syndrome (FAIS), however isolated radiographic measures poorly predict symptom onset and severity. More comprehensive morphology measurement considered together with patient factors may better predict symptom presentation. This study aimed to determine the morphological parameter(s) and patient factor(s) associated with symptom age of onset and severity in FAIS. Methods: 99 participants (age 32.9 ± 10.5 years; body mass index (BMI 24.3 ± 3.1 kg/m2; 42% females) diagnosed with FAIS received standardised plain radiographs and magnetic resonance scans. Alpha angle in four radial planes (superior to anterior), acetabular version (AV), femoral torsion, lateral centre-edge, anterior centre-edge (ACEA) and femoral neck-shaft angles were measured. Age of symptom onset (age at presentation minus duration of symptoms), international Hip Outcome Tool-33 (iHOT-33) and modified UCLA activity scores were recorded. Backward stepwise regression assessed morphological parameters and patient factors (age, sex, BMI, symptom duration, annual income, private/public healthcare system accessed) to determine variables independently associated with onset age and iHOT-33 score. Results: Earlier symptom onset was associated with larger superoanterior alpha angle ( p = 0.007), smaller AV ( p = 0.023), lower BMI ( p = 0.010) and public healthcare system access ( p = 0.041) (r2 = 0.320). Worse iHOT-33 score was associated with smaller ACEA ( p = 0.034), female sex ( p = 0.040), worse modified UCLA activity score ( p = 0.010) and public healthcare system access ( p 2 = 0.340). Conclusions: Age of symptom onset was chiefly predicted by femoral and acetabular bony morphology measures, whereas symptom severity predominantly by patient factors. Factors measured explained a small amount of variance in the data; additional unmeasured factors may be more influential.

BackgroundArthroscopic surgery for femoroacetabular impingement syndrome (FAI) is known to lead to self-reported symptom improvement. In the context of surgical interventions with known contextual effects and no true sham comparator trials, it is important to ascertain outcomes that are less susceptible to placebo effects. The primary aim of this trial was to determine if study participants with FAI who have hip arthroscopy demonstrate greater improvements in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to participants who undergo physiotherapist-led management.MethodsMulti-centre, pragmatic, two-arm superiority randomised controlled trial comparing physiotherapist-led management to hip arthroscopy for FAI. FAI participants were recruited from participating orthopaedic surgeons clinics, and randomly allocated to receive either physiotherapist-led conservative care or surgery. The surgical intervention was arthroscopic FAI surgery. The physiotherapist-led conservative management was an individualised physiotherapy program, named Personalised Hip Therapy (PHT). The primary outcome measure was change in dGEMRIC score between baseline and 12 months. Secondary outcomes included a range of patient-reported outcomes and structural measures relevant to FAI pathoanatomy and hip osteoarthritis development. Interventions were compared by intention-to-treat analysis.ResultsNinety-nine participants were recruited, of mean age 33 years and 58% male. Primary outcome data were available for 53 participants (27 in surgical group, 26 in PHT). The adjusted group difference in change at 12 months in dGEMRIC was -59 ms (95%CI − 137.9 to - 19.6) (p = 0.14) favouring PHT. Hip-related quality of life (iHOT-33) showed improvements in both groups with the adjusted between-group difference at 12 months showing a statistically and clinically important improvement in arthroscopy of 14 units (95% CI 5.6 to 23.9) (p = 0.003).ConclusionThe primary outcome of dGEMRIC showed no statistically significant difference between PHT and arthroscopic hip surgery at 12 months of follow-up. Patients treated with surgery reported greater benefits in symptoms at 12 months compared to PHT, but these benefits are not explained by better hip cartilage metabolism.Trial registration detailsAustralia New Zealand Clinical Trials Registry reference:ACTRN12615001177549. Trial registered 2/11/2015.

Background Patients with Systemic Lupus Erythematosus (SLE) often experience pain and other symptoms that negatively impact quality of life. Interventions that enhance the use of behavioral and cognitive coping strategies may lead to improved outcomes among patients with SLE. Pain coping skills training (PCST) programs have been shown to improve outcomes among patients with other rheumatic conditions, but there have been no trials of PCST among patients with SLE. This study was a preliminary assessment of the feasibility and efficacy of painTRAINER, an automated, internet-based PCST program, among patients with SLE. Methods Participants (n = 60) with SLE from one health care system were randomly assigned with equal allocation to painTRAINER or a wait list control group. PainTRAINER involves 8 modules; participants were instructed to complete one module weekly, along with practice activities for each cognitive or behavioral coping skill. Outcome measures were assessed at baseline and 9-week follow-up, including the Pain Catastrophizing Scale, PROMIS Subscales (Pain Interference, Physical Function, Sleep Disturbance, Anxiety, Depression, Fatigue and Participation), and the LupusPRO questionnaire. Mean changes in outcomes from baseline to follow up and Cohen’s d effect sizes were computed. Results Effect sizes for the painTRAINER group (relative to the wait list group) were small, with changes being greatest for the PROMIS Depression score (d = − 0.32). Among those randomized to the painTRAINER group, 50% accessed the program (“painTRAINER users”). Most of those who did not access the program stated that they did not receive instructions via email. Effect sizes for “painTRAINER users” (relative to wait list) were larger than for the whole painTRAINER group: Pain Catastrophizing d = − 0.60, PROMIS Pain Interference d = − 0.3., PROMIS Depression d = − 0.44, LupusPRO Health-Related Quality of Life d = 0.30. Conclusions PainTRAINER users reported meaningful improvements in multiple physical and psychological outcomes, supporting the potential of PCST programs to benefit individuals with SLE. However, strategies are needed to improve engagement with the program and tailor content to comprehensively address key SLE symptoms and challenges. Trial registration NCT03933839, May 1, 2019.

Question: What are the core capabilities that physiotherapists need in order to deliver quality care via videoconferencing? Design: A three-round modified e-Delphi survey. Participants: An international Delphi panel comprising a Steering Group and experts in the field, including physiotherapy researchers, physiotherapy clinicians, representatives of physiotherapy organisations, and consumers. Methods: The draft framework was developed by the research team and Steering Group, based on relevant documents identified within the literature. The panel considered a draft framework of 73 specific capabilities mapped across eight domains. Over three rounds, panellists rated their agreement (Likert or numerical rating scales) on whether each capability was essential (core) for physiotherapists to deliver quality care via videoconferencing. Those capabilities achieving consensus, defined as 75% of the panel ratings being ≥ 7 out of 10 in Round 3, were retained. Results: A total of 130 panellists from 32 countries participated in Round 1, with retention rates of 65% and 60% in Rounds 2 and 3, respectively. The final framework comprised 60 capabilities across seven domains: compliance (n = 7 capabilities); patient privacy and confidentiality (n = 4); patient safety (n = 7); technology skills (n = 7); telehealth delivery (n = 16); assessment and diagnosis (n = 7); and care planning and management (n = 12). Conclusion: This framework outlines the specific core capabilities required of physiotherapists to provide quality care via videoconferencing. The core capability framework provides guidance for physiotherapists to deliver care via videoconferencing and will help inform future development of physiotherapy curricula and professional development initiatives in the delivery of telehealth.

Background: Anterior cruciate ligament reconstruction (ACLR) together with concomitant meniscal injury are risk factors for the development of tibiofemoral (TF) osteoarthritis (OA), but the potential effect on the patellofemoral (PF) joint is unclear. The aim of this study was to: (i) investigate change in patellar cartilage morphology in individuals 2.5 to 4.5 years after ACLR with or without concomitant meniscal pathology and in healthy controls, and (ii) examine the association between baseline patellar cartilage defects and patellar cartilage volume change.Methods: 32 isolated ACLR participants, 25 ACLR participants with combined meniscal pathology and nine healthy controls underwent knee magnetic resonance imaging (MRI) with 2-year intervals (baseline = 2.5 years post-ACLR). Patellar cartilage volume and cartilage defects were assessed from MRI using validated methods. Results: Both ACLR groups showed patellar cartilage volume increased over 2 years (p < 0.05), and isolated ACLR group had greater annual percentage cartilage volume increase compared with controls (mean difference 3.6%, 95% confidence interval (CI) 1.0%, 6.3%, p = 0.008) and combined ACLR group (mean difference 2.2%, 95% CI 0.2%, 4.2%, p = 0.028). Patellar cartilage defects regressed in the isolated ACLR group over 2 years (p = 0.02). Baseline patellar cartilage defect score was positively associated with annual percentage cartilage volume increase (B = 0.02; 95% CI 0.003, 0.03; p = 0.02) in the pooled ACLR participants. Conclusions: Hypertrophic response was evident in the patellar cartilage of ACLR participants with and without meniscal pathology. Surprisingly, the increase in patellar cartilage volume was more pronounced in those with isolated ACLR. Although cartilage defects stabilise in the majority of ACLR participants, the severity of patellar cartilage defects at baseline influenced the magnitude of the cartilage hypertrophic response over the subsequent ~2 years.

Background The delivery of physiotherapy via telehealth could provide more equitable access to services for patients. Videoconference-based telehealth has been shown to be an effective and acceptable mode of service delivery for exercise-based interventions for chronic knee pain; however, specific training in telehealth is required for physiotherapists to effectively and consistently deliver care using telehealth. The development and evaluation of training programs to upskill health care professionals in the management of osteoarthritis (OA) has also been identified as an important priority to improve OA care delivery. Objective This study aims to explore physiotherapists’ experiences with and perceptions of an e-learning program about best practice knee OA management (focused on a structured program of education, exercise, and physical activity) that includes telehealth delivery via videoconferencing. Methods We conducted a qualitative study using individual semistructured telephone interviews, nested within the Physiotherapy Exercise and Physical Activity for Knee Osteoarthritis randomized controlled trial, referred to as the PEAK trial. A total of 15 Australian physiotherapists from metropolitan and regional private practices were interviewed following the completion of an e-learning program. The PEAK trial e-learning program involved self-directed learning modules, a mock video consultation with a researcher (simulated patient), and 4 audited practice video consultations with pilot patients with chronic knee pain. Interviews were audio recorded and transcribed verbatim. Data were thematically analyzed. Results A total of five themes (with associated subthemes) were identified: the experience of self-directed e-learning (physiotherapists were more familiar with in-person learning; however, they valued the comprehensive, self-paced web-based modules. Unwieldy technological features could be frustrating); practice makes perfect (physiotherapists benefited from the mock consultation with the researcher and practice sessions with pilot patients alongside individualized performance feedback, resulting in confidence and preparedness to implement new skills); the telehealth journey (although inexperienced with telehealth before training, physiotherapists were confident and able to deliver remote care following training; however, they still experienced some technological challenges); the whole package (the combination of self-directed learning modules, mock consultation, and practice consultations with pilot patients was felt to be an effective learning approach, and patient information booklets supported the training package); and impact on broader clinical practice (training consolidated and refined existing OA management skills and enabled a switch to telehealth when the COVID-19 pandemic affected in-person clinical care). Conclusions Findings provide evidence for the perceived effectiveness and acceptability of an e-learning program to train physiotherapists (in the context of a clinical trial) on best practice knee OA management, including telehealth delivery via videoconferencing. The implementation of e-learning programs to upskill physiotherapists in telehealth appears to be warranted, given the increasing adoption of telehealth service models for the delivery of clinical care.

Exercise therapies are advocated in osteoarthritis (OA) clinical guidelines. However, challenges to accessing exercise may be limiting widespread uptake.To evaluate the effects of a self-directed web-based strengthening exercise and physical activity program supported by automated behavior-change text messages on knee pain and function for people with knee OA.The participant-blinded and assessor-blinded randomized clinical trial enrolled 206 people who met clinical criteria for knee OA in communities across Australia from July 2018 to August 2019, with follow-up taking place at 24 weeks.The control group was given access to a custom-built website with information on OA and the importance of exercise and physical activity. The intervention group was given access to the same information plus a prescription for a 24-week self-directed strengthening regimen and guidance to increase physical activity, supported by automated behavior-change text messages encouraging exercise adherence.Primary outcomes were change in overall knee pain (numeric rating scale, 0-10) and difficulty with physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0-68) over 24 weeks. Secondary outcomes were another knee pain measure, sport and recreation function, quality of life, physical activity, self-efficacy, overall improvement, and treatment satisfaction.Of 206 participants, 180 (87%; mean [SD] age, 60 [8.4] years; 109 [61%] women) completed both 24-week primary outcomes. The intervention group showed greater improvements in overall knee pain (mean difference, 1.6 units; 95% CI, 0.9-2.2 units; P .001) and physical function (mean difference, 5.2 units; 95% CI, 1.9-8.5 units; P = .002) compared with the control. There was evidence of differences in the proportion of participants exceeding the minimal clinically important improvement in pain (intervention group, 72.1%, vs control, 42.0%; risk difference, 0.30 [95% CI, 0.16-0.44]; P . 001) and function (intervention group, 68%, vs control, 40.8%; risk difference, 0.27 [95% CI, 0.13-0.41]; P .001) favoring the intervention. Between-group differences for all secondary outcomes favored the intervention except for physical activity, self-efficacy for function, and self-efficacy for exercise, for which there was no evidence of differences.This randomized clinical trial found that a self-directed web-based strengthening exercise regimen and physical activity guidance supported by automated behavior-change text messages to encourage exercise adherence improved knee pain and function at 24 weeks. This unsupervised, free-to-access digital intervention is an effective option to improve patient access to recommended OA exercise and/or to support clinicians in providing exercise management for people with knee OA at scale across the population.Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001167257.

ObjectivePhysiotherapists commonly provide non-surgical care for people with knee osteoarthritis (OA). It is unknown if patients are receiving high-quality physiotherapy care for their knee OA. This study aimed to explore the experiences of people who had recently received physiotherapy care for their knee OA in Australia and how these experiences aligned with the national Clinical Care Standard for knee OA.DesignQualitative study using semistructured individual telephone interviews and thematic analysis, where themes/subthemes were inductively derived. Questions were informed by seven quality statements of the OA of the Knee Clinical Care Standard. Interview data were also deductively analysed according to the Standard.SettingParticipants were recruited from around Australia via Facebook and our research volunteer database.ParticipantsInterviews were conducted with 24 people with recent experience receiving physiotherapy care for their knee OA. They were required to be aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee.ResultsSix themes emerged: (1) presented with a pre-existing OA diagnosis (prior OA care from other health professionals; perception of adequate OA knowledge); (2) wide variation in access and provision of physiotherapy care (referral pathways; funding models; individual vs group sessions); (3) seeking physiotherapy care for pain and functional limitations (knee symptoms; functional problems); (4) physiotherapy management focused on function and exercise (assessment of function; various types of exercises prescribed; surgery, medications and injections are for doctors; adjunctive treatments); (5) professional and personalised care (trust and/or confidence; personalised care) and (6) physiotherapy to postpone or prepare for surgery.ConclusionPatients’ experiences with receiving physiotherapy care for their knee OA were partly aligned with the standard, particularly regarding comprehensive assessment, self-management, and exercise.

Objectives The benefits of exercise are well established for psychological well-being, but it is unknown whether one type of exercise can be recommended over another for psychological well-being in knee osteoarthritis (OA). This study aimed to compare the effectiveness of different types of exercise on psychological well-being in people with knee OA. Methods Five databases including MEDLINE, EMBASE, Cochrane Register of Controlled Trials, CINAHL and PEDro) were searched from inception until April 2021. Randomised controlled trials comparing the effect of exercise with a non-exercise control or another type of exercise on overall mental health, depressive symptoms or anxiety in people with knee OA. Trial data were extracted independently by two researchers. Network meta-analyses using random-effect models were conducted. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to appraise evidence certainty. Results Strengthening exercise was more beneficial for overall mental health on the Short Form survey compared to aerobic (mean difference 15.88, 95%CI [6.77, 24.99]), mixed (12.77, 95%CI [5.12, 20.42]) and mind-body (12.51, [4.25, 20.77]) exercise based on 13 trials (n = 796). Strengthening exercise (standardised mean difference 6.81, [5.03, 8.58]), and mixed exercise (6.64, [4.88, 8.40]),) were more beneficial for depressive symptoms than stretching exercise based on 6 trials (n = 627). No differences were observed for anxiety based on 4 trials (n = 557). Certainty of the evidence ranged from very low to low. Conclusion The available evidence supports the recommendation of strengthening exercise as the most beneficial for overall mental health, and strengthening exercise or mixed exercise over stretching exercise for depressive symptoms. No exercise recommendations can be made for anxiety.

Importance Thigh muscle weakness is associated with knee discomfort and osteoarthritis disease progression. Little is known about the efficacy of high-intensity strength training in patients with knee osteoarthritis or whether it may worsen knee symptoms. Objective To determine whether high-intensity strength training reduces knee pain and knee joint compressive forces more than low-intensity strength training and more than attention control in patients with knee osteoarthritis. Design, Setting, and Participants Assessor-blinded randomized clinical trial conducted at a university research center in North Carolina that included 377 community-dwelling adults (≥50 years) with body mass index (BMI) ranging from 20 to 45 and with knee pain and radiographic knee osteoarthritis. Enrollment occurred between July 2012 and February 2016, and follow-up was completed September 2017. Interventions Participants were randomized to high-intensity strength training (n = 127), low-intensity strength training (n = 126), or attention control (n = 124). Main Outcomes and Measures Primary outcomes at the 18-month follow-up were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) knee pain (0 best-20 worst; minimally clinically important difference [MCID, 2]) and knee joint compressive force, defined as the maximal tibiofemoral contact force exerted along the long axis of the tibia during walking (MCID, unknown). Results Among 377 randomized participants (mean age, 65 years; 151 women [40%]), 320 (85%) completed the trial. Mean adjusted (sex, baseline BMI, baseline outcome values) WOMAC pain scores at the 18-month follow-up were not statistically significantly different between the high-intensity group and the control group (5.1 vs 4.9; adjusted difference, 0.2; 95% CI, −0.6 to 1.1;P = .61) or between the high-intensity and low-intensity groups (5.1 vs 4.4; adjusted difference, 0.7; 95% CI, −0.1 to 1.6;P = .08). Mean knee joint compressive forces were not statistically significantly different between the high-intensity group and the control group (2453 N vs 2512 N; adjusted difference, −58; 95% CI, −282 to 165 N;P = .61), or between the high-intensity and low-intensity groups (2453 N vs 2475 N; adjusted difference, −21; 95% CI, −235 to 193 N;P = .85). There were 87 nonserious adverse events (high-intensity, 53; low-intensity, 30; control, 4) and 13 serious adverse events unrelated to the study (high-intensity, 5; low-intensity, 3; control, 5). Conclusions and Relevance Among patients with knee osteoarthritis, high-intensity strength training compared with low-intensity strength training or an attention control did not significantly reduce knee pain or knee joint compressive forces at 18 months. The findings do not support the use of high-intensity strength training over low-intensity strength training or an attention control in adults with knee osteoarthritis. Trial Registration ClinicalTrials.gov Identifier:NCT01489462

Objectives: This study examined whether risk factors for knee osteoarthritis (KOA) pain such as age, gender, body mass index (BMI), baseline pain, and other putative risk factors for knee osteoarth...

Background Anterior cruciate ligament reconstruction (ACLR) together with concomitant meniscal injury are risk factors for the development of tibiofemoral (TF) osteoarthritis (OA), but the potential effect on the patellofemoral (PF) joint is unclear. The aim of this study was to: (i) investigate change in patellar cartilage morphology in individuals 2.5 to 4.5 years after ACLR with or without concomitant meniscal pathology and in healthy controls, and (ii) examine the association between baseline patellar cartilage defects and patellar cartilage volume change. Methods Thirty two isolated ACLR participants, 25 ACLR participants with combined meniscal pathology and nine healthy controls underwent knee magnetic resonance imaging (MRI) with 2-year intervals (baseline = 2.5 years post-ACLR). Patellar cartilage volume and cartilage defects were assessed from MRI using validated methods. Results Both ACLR groups showed patellar cartilage volume increased over 2 years (p p = 0.008) and combined ACLR group (mean difference 2.2, 95% CI 0.2, 4.2%, p = 0.028). Patellar cartilage defects regressed in the isolated ACLR group over 2 years (p = 0.02; Z = − 2.33; r = 0.3). Baseline patellar cartilage defect score was positively associated with annual percentage cartilage volume increase (Regression coefficient B = 0.014; 95% CI 0.001, 0.027; p = 0.03) in the pooled ACLR participants. Conclusions Hypertrophic response was evident in the patellar cartilage of ACLR participants with and without meniscal pathology. Surprisingly, the increase in patellar cartilage volume was more pronounced in those with isolated ACLR. Although cartilage defects stabilised in the majority of ACLR participants, the severity of patellar cartilage defects at baseline influenced the magnitude of the cartilage hypertrophic response over the subsequent ~ 2 years.

BACKGROUND: Experts recommend that persons with knee osteoarthritis wear stable supportive shoes; however, evidence suggests that flat flexible shoes may be more beneficial. OBJECTIVE: To compare flat flexible with stable supportive shoes for knee osteoarthritis symptoms. DESIGN: Participant- and assessor-blinded randomized trial. (Prospectively registered with the Australian New Zealand Clinical Trials Registry [ACTRN12617001098325]). SETTING: Community. PARTICIPANTS: 164 patients with moderate to severe symptomatic radiographic medial knee osteoarthritis. INTERVENTION: Flat flexible (n = 82) or stable supportive shoes (n = 82), worn for at least 6 hours a day for 6 months. MEASUREMENTS: Primary outcomes were changes in walking pain (measured by an 11-point numerical rating scale) and physical function (as assessed by the Western Ontario and McMaster Universities Osteoarthritis Index subscale of 0 to 68 points) at 6 months. Secondary outcomes included additional pain and function measures, physical activity, and quality of life. Other measures included adverse events. RESULTS: Of 164 participants recruited, 161 (98%) completed 6-month primary outcomes. No evidence was found that flat flexible shoes were superior to stable supportive shoes in primary outcomes. Evidence did show a between-group difference in change in pain favoring stable supportive shoes (mean difference, 1.1 units [95% CI, 0.5 to 1.8 units]; P = 0.001) but not function (mean difference, 2.3 units [CI, -0.9 to 5.5 units]; P = 0.167). Improvements in knee-related quality of life and ipsilateral hip pain favored stable supportive shoes (mean difference, -5.3 units [CI, -10.0 to -0.5 units] and 0.7 units [CI, 0.0 to 1.4 units], respectively). Flat flexible shoes were not superior to stable supportive shoes for any secondary outcome. Fewer participants reported adverse events with stable supportive shoes (n = 12 [15%]) compared with flat flexible shoes (n = 26 [32%]) (risk difference, -0.17 [CI, -0.30 to -0.05]). LIMITATION: No "usual shoes" control group and a select patient subgroup, which may limit generalizability. CONCLUSION: Flat flexible shoes were not superior to stable supportive shoes. Contrary to our hypothesis, stable supportive shoes improved knee pain on walking more than flat flexible shoes. PRIMARY FUNDING SOURCE: National Health and Medical Research Council.

Background We recently developed a model of stratified exercise therapy, consisting of (i) a stratification algorithm allocating patients with knee osteoarthritis (OA) into one of the three subgroups (‘high muscle strength subgroup’ representing a post-traumatic phenotype, ‘low muscle strength subgroup’ representing an age-induced phenotype, and ‘obesity subgroup’ representing a metabolic phenotype) and (ii) subgroup-specific exercise therapy. In the present study, we aimed to test the construct validity of this algorithm. Methods Data from five studies (four exercise therapy trial cohorts and one cross-sectional cohort) were used to test the construct validity of our algorithm by 63 a priori formulated hypotheses regarding three research questions: (i) are the proportions of patients in each subgroup similar across cohorts? (15 hypotheses); (ii) are the characteristics of each of the subgroups in line with their proposed underlying phenotypes? (30 hypotheses); (iii) are the effects of usual exercise therapy in the 3 subgroups in line with the proposed effect sizes? (18 hypotheses). Results Baseline data from a total of 1211 patients with knee OA were analyzed for the first and second research question, and follow-up data from 584 patients who were part of an exercise therapy arm within a trial for the third research question. In total, the vast majority (73%) of the hypotheses were confirmed. Regarding our first research question, we found similar proportions in each of the three subgroups across cohorts, especially for three cohorts. Regarding our second research question, subgroup characteristics were almost completely in line with the proposed underlying phenotypes. Regarding our third research question, usual exercise therapy resulted in similar, medium to large effect sizes for knee pain and physical function for all three subgroups. Conclusion We found mixed results regarding the construct validity of our stratification algorithm. On the one hand, it is a valid instrument to consistently allocate patients into subgroups that aligned our hypotheses. On the other hand, in contrast to our hypotheses, subgroups did not differ substantially in effects of usual exercise therapy. An ongoing trial will assess whether this algorithm accompanied by subgroup-specific exercise therapy improves clinical and economic outcomes.

Background The therapeutic alliance between patients and physical therapists has been shown to influence clinical outcomes in patients with chronic low back pain when consulting in-person. However, no studies have examined whether the therapeutic alliance developed between patients with knee osteoarthritis and physical therapists during telephonic consultations influences clinical outcomes. Objective This study aims to investigate whether the therapeutic alliance between patients with knee osteoarthritis and physical therapists measured after the second consultation is associated with outcomes following telephone-delivered exercise and advice. Methods Secondary analysis of 87 patients in the intervention arm of a randomized controlled trial allocated to receive 5 to 10 telephone consultations with one of 8 physical therapists over a period of 6 months, involving education and prescription of a strengthening and physical activity program. Separate regression models investigated the association between patient and therapist ratings of therapeutic alliance (measured after the second consultation using the Working Alliance Inventory Short Form) and outcomes (pain, function, self-efficacy, quality of life, global change, adherence to prescribed exercise, physical activity) at 6 and 12 months, with relevant covariates included. Results There was some evidence of a weak association between patient ratings of the alliance and some outcomes at 6 months (improvements in average knee pain: regression coefficient −0.10, 95% CI −0.16 to −0.03; self-efficacy: 0.16, 0.04-0.28; global improvement in function: odds ratio 1.26, 95% CI 1.04-1.39, and overall improvement: odds ratio 1.26, 95% CI 1.06-1.51; but also with worsening in fear of movement: regression coefficient −0.13, 95% CI −0.23 to −0.04). In addition, there was some evidence of a weak association between patient ratings of the alliance and some outcomes at 12 months (improvements in self-efficacy: regression coefficient 0.15, 95% CI 0.03-0.27; global improvement in both function, odds ratio 1.19, 95% CI 0.03-1.37; and pain, odds ratio 1.14, 95% CI 1.01-1.30; and overall improvement: odds ratio 1.21, 95% CI 1.02-1.42). The data suggest that associations between therapist ratings of therapeutic alliance and outcomes were not strong, except for improved quality of life at 12 months (regression coefficient 0.01, 95% CI 0.0003-0.01). Conclusions Higher patient ratings, but not higher therapist ratings, of the therapeutic alliance were weakly associated with improvements in some clinical outcomes and with worsening in one outcome. Although the findings suggest that patients who perceive a stronger alliance with their therapist may achieve better clinical outcomes, the observed relationships were generally weak and unlikely to be clinically significant. The limitations include the fact that measures of therapeutic alliance have not been validated for use in musculoskeletal physical therapy settings. There was a risk of type 1 error; however, findings were interpreted on the basis of clinical significance rather than statistical significance alone. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12616000054415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369204