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Total hip arthroplasty (THA) and total knee arthroplasty (TKA) bring relief of pain and functional disability to patients with end-stage osteoarthritis, and however, the literature on their impact on patients' level of physical activity (PA) is scarce. Cross-sectional study in patients who underwent THA/TKA surgery in the preceding 6-22 months and a random sample of persons aged >40 years from the Dutch general population, participating in a national survey. PA in minutes per week (min/week) and adherence to the Dutch recommendation for PA (NNGB yes/no) were measured by the short questionnaire to assess health-enhancing PA. Multivariable linear (total min/week) and logistic regression analyses (meeting recommendations PA), adjusting for confounders, were performed for THA and TKA separately. In total, 258 THA [62.3% female, aged 69.4 (9.1)] and 221 TKA [65.7% female, aged 69.5 (8.9)] patients and 4373 persons from the Dutch general population [51.4% female, aged 58.9 (11.6)] were included. The presence of THA was associated after adjusting for age, sex, BMI education and musculoskeletal comorbidities, with more total min/week spent on PA (THA 13.8% increase, 95% CI 1.6-27.6%), whilst both TJA groups were associated with adhering to NNGB (THA: OR 1.79, 95% CI 1.26-2.56; TKA: OR 1.73, 95% CI 1.20-2.51). As this study used questionnaires to compare the PA of THA/TKA patients to the general population, some recall and selection bias might have been induced. After surgery, overall, TJA patients are more likely to adhere NNGB than a representative sample of persons >40 years from the Dutch general population., Competing Interests: There are no conflicts of interest by any of the authors.

Background: This systematic review gives an overview of guidelines and original publications as well as the evidence on which the currently proposed indication criteria are based. Until now such a state-of-the-science overview was lacking., Methods: Websites of orthopaedic and arthritis organizations (English/Dutch language) were independently searched by two authors for THA/TKA guidelines for OA. Furthermore, a systematic search strategy in several databases through August 2014 was performed. Quality of the guidelines was assessed with the AGREE II instrument, which consists of 6 domains (maximum summed score of 6 indicating high quality). Also, the level of evidence of all included studies was assessed., Results: We found 6 guidelines and 18 papers, out of 3065 references. The quality of the guidelines summed across 6 domains ranged from 0.46 to 4.78. In total, 12 THA, 10 TKA and 2 THA/TKA indication sets were found. Four studies stated that no evidence-based indication criteria are available. Indication criteria concerning THA/TKA consisted of the following domains: pain (in respectively 11 and 10 sets), function (12 and 7 sets), radiological changes (10 and 9 sets), failed conservative therapy (8 and 4 sets) and other indications (6 and 7 sets). Specific cut-off values or ranges were often not stated and the level of evidence was low., Conclusion: The indication criteria for THA/TKA are based on limited evidence. Empirical research is needed, especially regarding domain specific cut-off values or ranges at which the best postoperative outcomes are achieved for patients, taking into account the limited lifespan of a prosthesis.

Background: This systematic review examines which patient related factors influence functional and clinical outcomes after total hip arthroplasty (THA) in patients with hip osteoarthritis (OA)., Methods: We performed a systematic review according to the PRISMA guidelines. We searched databases and trial registries for prospective studies including OA patients who underwent primary THA. Studies with preoperative measurements on predictors, with at least 1 year follow-up were included. Risk of bias and confounding was assessed for two domains: follow-up rate and looking at independent effects., Results: Thirty-five studies were included (138,039 patients). Only nine studies (29 %) had low risk of bias for all domains thus suggesting an overall low quality of evidence. Studies were heterogeneous in the predictors tested and in the observed directions of the associations. Overall, preoperative function (13 studies (37 %), 2 with low risk of bias) and radiological OA (6 studies (17 %), 1 with low risk of bias) were predictors with the most consistent findings. Worse preoperative function and more severe radiological OA were associated with larger postoperative improvement. However, these patients never reached the level of postoperative functioning as patients with better preoperative function or less severe radiological OA. For age, gender, comorbidity, pain and quality of life the results of studies were conflicting. For BMI, some studies (n = 5, 2 with low risk of bias) found worse outcomes for patients with higher BMI. However, substantial improvement was still achieved regardless of their BMI., Conclusion: There is not enough evidence to draw succinct conclusions on preoperative predictors for postoperative outcome in THA, as results of studies are conflicting and the methodological quality is low. Results suggest to focus on preoperative function and radiological osteoarthritis to decide when THA will be most effective. The present mapping of current evidence on the relationship between patient related factors and outcomes provides better information compared to individual studies and may help to set patient expectations before surgery. In addition, these findings may contribute to discussions on how to achieve the best possible postoperative outcome for specific patient groups., Trial Registration: This systematic review was registered in Prospero, registration number RD42014009977 .

Background and Purpose: There is no consensus on the impact of radiographic severity of hip and knee osteoarthritis (OA) on the clinical outcome of total hip arthroplasty (THA) and total knee arthroplasty (TKA). We assessed whether preoperative radiographic severity of OA is related to improvements in functioning, pain, and health-related quality of life (HRQoL) 1 year after THA or TKA., Patients and Methods: This prospective cohort study included 302 THA patients and 271 TKA patients with hip or knee OA. In the THA patients, preoperatively 26% had mild OA and 74% had severe OA; in the TKA patients, preoperatively 27% had mild OA and 73% had severe OA. Radiographic severity was determined according to the Kellgren and Lawrence (KL) classification. Clinical assessments preoperatively and 1 year postoperatively included: sociodemographic characteristics and patient-reported outcomes (PROMs): Oxford hip/knee score, hip/knee injury and osteoarthritis outcome score (HOOS/KOOS), SF36, and EQ5D. Change scores of PROMs were compared with mild OA (KL 0-2) and severe OA (KL 3-4) using a multivariate linear regression model., Results: Adjusted for sex, age, preoperative scores, BMI, and Charnley score, radiographic severity of OA in THA was associated with improvement in HOOS "Activities of daily living", "Pain", and "Symptoms", and SF36 physical component summary ("PCS") scale. In TKA, we found no such associations., Interpretation: The decrease in pain and improvement in function in THA patients, but not in TKA patients, was positively associated with the preoperative radiographic severity of OA.

Introduction: International evidence-based guidelines for the management of patients with hip and knee osteoarthritis (OA) recommend to start with (a combination of) non-surgical treatments, and using surgical intervention only if a patient does not respond sufficiently to non-surgical treatment options. Despite these recommendations, there are strong indications that non-surgical treatments are not optimally used in orthopaedic practice. To improve the adoption of non-surgical treatments, more insight is needed into barriers and facilitators of these treatments. Therefore, this study assessed which barriers and facilitators are associated with the use and prescription of different non-surgical treatments before hip and knee OA in orthopaedic practice among patients and orthopaedic surgeons in the Netherlands., Materials and Methods: We performed two internet-based surveys among 172 orthopaedic surgeons and 174 OA patients. Univariate association and multivariable regression techniques are used to identify barriers and facilitators associated with the use of non-surgical treatments., Results: Most barriers and facilitators among patients were associated with the use of physical therapy, lifestyle advice and dietary therapy. Among orthopaedic surgeons, most were associated with prescription of acetaminophen, dietary therapy and physical therapy. Examples of barriers and facilitators among patients included "People in my environment had positive experiences with a surgery" (facilitator for education about OA), and "Advice of people in my environment to keep on moving" (facilitator for lifestyle and dietary advice). For orthopaedic surgeons, examples were "Lack of knowledge about guideline" (barrier for lifestyle advice), "Agreements/ deliberations with primary care" and "Easy communication with a dietician" (facilitators for dietary therapy). Also the belief in the efficacy of these treatments was associated with increased prescription., Conclusions: Strategies to improve non-surgical treatment use in orthopaedic practice should be targeted at changing the beliefs of orthopedic surgeons, communication with other OA care providers and involving patient's environment in OA treatment.

Objectives: National and international evidence-based guidelines for hip and knee osteoarthritis (OA) recommend to start with non-surgical treatments, followed by surgical intervention if a patient does not respond sufficiently to non-surgical treatments, but there are indications that these are not optimally used. The aim of this study was to assess the extent to which all recommended non-surgical treatments were used by patients with hip or knee OA who receive(d) a total hip or knee replacement, as reported by patients and orthopaedic surgeons., Setting: We performed two cross-sectional internet-based surveys among patients and orthopaedic surgeons throughout the Netherlands., Participants: 195 OA patients either have undergone total knee arthroplasty or total hip arthroplasty no longer than 12 months ago or being on the waiting list for surgery with a confirmed date within 3 months and 482 orthopaedic surgeons were invited to participate., Primary and Secondary Outcome Measures: The use of recommended non-surgical treatments including education about OA/treatment options, lifestyle advice, dietary therapy, physical therapy, acetaminophen, NSAIDs and glucocorticoid injections., Results: 174 OA patients (93%) and 172 orthopaedic surgeons (36%) completed the surveys. Most recommended non-surgical treatments were given to the majority of patients (eg, 80% education about OA, 73% physical therapy, 72% acetaminophen, 80% NSAIDs). However, only 6% of patients and 10% of orthopaedic surgeons reported using a combination of all recommended treatments. Dietary therapy was used least frequently. Only 11% of overweight and 30% of obese participants reported having received dietary therapy and 28% of orthopaedic surgeons reported to prescribe dietary therapy to overweight patients., Conclusions: While most recommended non-surgical treatments were used frequently as single therapy, the combination is used in only a small percentage of OA patients. Especially, use of dietary therapy may be improved to help patients manage their symptoms, and potentially delay the need for joint arthroplasty., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The aim of the study was to examine the relationship between comorbidities and pain, physical function and health-related quality of life (HRQoL) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). A cross-sectional retrospective survey was conducted including 19 specific comorbidities, administered in patients who underwent THA or TKA in the previous 7-22 months in one of 4 hospitals. Outcome measures included pain, physical functioning, and HRQoL. Of the 521 patients (281 THA and 240 TKA) included, 449 (86 %) had ≥1 comorbidities. The most frequently reported comorbidities (>15 %) were severe back pain; neck/shoulder pain; elbow, wrist or hand pain; hypertension; incontinence of urine; hearing impairment; vision impairment; and cancer. Only the prevalence of cancer was significantly different between THA (n = 38; 14 %) and TKA (n = 52; 22 %) (p = 0.01). The associations between a higher number of comorbidities and worse outcomes were stronger in THA than in TKA. In multivariate analyses including all comorbidities with a prevalence of >5 %, in THA dizziness in combination with falling and severe back pain, and in TKA dizziness in combination with falling, vision impairments, and elbow, wrist or hand pain was associated with worse outcomes in most of the analyses. A broad range of specific comorbidities needs to be taken into account with the interpretation of patients' health status after THA and TKA. More research including the ascertainment of comorbidities preoperatively is needed, but it is conceivable that in particular, the presence of dizziness with falling, pain in other joints, and vision impairments should be assessed and treated in order to decrease the chance of an unfavorable outcome.

Purpose: To determine the effectiveness of an interactive educational intervention on a physiotherapy guideline for hip and knee osteoarthritis., Method: Physiotherapists were randomly allocated to a 3-h interactive educational course with the collaboration of three patient partners or no intervention. Assessments comprised questionnaires on adherence (score range 0-24), knowledge (score range 0-76), and barriers to use the guideline (score range 0-80). Assessments were conducted 1 week before the interactive course (T0) immediately after (T1), and 3 months thereafter (T2). Change scores were compared between the groups by means of Mann-Whitney U tests and linear mixed models., Results: 284 of 4328 eligible PTs (7%) were included. The intervention (n = 133) was significantly more effective than no intervention (n = 151) concerning self-reported adherence and knowledge with mean differences in change scores (95% CI) at T1 and T2 being 1.4 (0.7-2.0) and 0.9 (0.2-1.7) for adherence and 6.8 (4.5-9.1) and 3.9 (1.7-6.2) for knowledge, (all p values < 0.005). In both groups the barrier score increased at T1 and decreased at T2, with a significantly larger increase at T1 and decrease at T2 in the intervention group (mean differences 3.1 (1.8-4.4) and 3.3 (0.5-6.1), respectively., Conclusions: A short interactive educational course with patient participation on a PT guideline on hip and knee osteoarthritis showed a small to moderate positive effect on self-reported guideline adherence and knowledge, whereas for perceived barriers an advantage was only seen on the longer term.

Objectives: To investigate whether all-cause mortality and deaths due to cardiovascular disease are increased in patients who have consulted primary or secondary health care with symptoms and signs of osteoarthritis (OA)., Method: This study included 383 patients with symptomatic OA at multiple sites from the Genetics ARthrosis and Progression (GARP) study (mean age 60 years, 82% women, 3693 person-years of follow-up) and 459 patients with primary hand, knee, or hip OA from the Osteoarthritis Care Clinic (OCC) study (mean age 61 years, 88% women, 1890 person-years of follow-up). Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated for all-cause mortality and causes of deaths in comparison to the general population. Cox proportional hazard ratios (HRs) with 95% CIs were used to associate baseline characteristics with all-cause mortality., Results: In the GARP study, 26 patients died whereas 48 deaths were expected (SMR 0.54, 95% CI 0.37-0.79). The SMR was 0.47 (95% CI 0.29-0.76) in women and 0.73 (95% CI 0.39-1.35) in men. Similar results were found in the OCC study (SMR 0.45, 95% CI 0.25-0.82). Malignancy and cardiovascular disease were the main causes of deaths in GARP. Male sex (HR 3.04, 95% CI 1.38-6.69), increasing age (HR 1.10, 95% CI 1.05-1.16), and self-reported cancer (HR 8.29, 95% CI 3.12-22.03) were associated with increased mortality in GARP., Conclusions: Patients consulting health care for their OA are not at higher risk of death than the general population. These results suggest that the management of OA patients may not need to focus specifically on the treatment of cardiovascular risk factors and comorbidities.

Background: In a Dutch guideline on physiotherapy (PT) in hip and knee osteoarthritis, a number of recommendations on post-acute (i.e. after discharge from hospital) PT following total hip (THA) and total knee (TKA) arthroplasty were included. Little is known about the uptake of these recommendations in daily clinical practice., Objective: The aim of the present study was to determine the extent to which the guideline recommendations regarding post-acute PT after THA and TKA are followed in daily clinical practice., Methods: An online pilot survey on the delivery of post-acute, postoperative PT was sent to a random sample of 957 Dutch physiotherapists. The survey included questions on the application of recommended, neither recommended nor advised against, and advised against treatment modalities and various treatment modalities for which there were no formulated recommendations., Results: A total of 219 physiotherapists completed the questionnaire, with a mean age of 40 years (standard deviation 12.6), 55% female and 95% working in primary care. The vast majority reported the use of the recommended exercise modalities (muscle strengthening exercises (96%), and functional exercises (99%). Continuous passive motion, which was neither recommended nor advised against, and electrical muscle stimulation, which was not recommended, were provided by 1%. Reported treatment modalities for which there were no formulated recommendations included patient education (99%), gait training (95%), active range of motion (ROM) exercises (93%), balance exercises (86%), passive ROM exercises (58%), aerobic exercises (50%), massage (18%) and cold therapy (11%)., Conclusions: The vast majority of physiotherapists reported adhering to recommendations on post-acute postoperative PT in THA and TKA patients after discharge from hospital. Although yet to be confirmed in a larger nationwide survey, the relatively high frequency of use of many other treatment modalities, for which there were no formulated recommendations, suggests the need to extend the current set of recommendations to include evidence-based statements on additional treatment modalities., (Copyright © 2014 John Wiley & Sons, Ltd.)

Objective: To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care., Design: A 2-year observational prospective cohort study., Setting: General practices in the region of Nijmegen in the Netherlands., Participants: Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP)., Interventions: Multifaceted interventions were developed to implement the strategy., Main Outcome Measures: Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments., Results: Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS in 58% of the patients, which was mainly caused by the underuse of lifestyle advice and dietary therapy. In 57% of the consultations, the patient reported to have been advised to make a follow-up appointment. No determinants that influenced all three aspects of care were identified., Conclusions: Consistency with the SCS was found in about half of the patients for each of the three aspects of care. Health care can be further optimized by encouraging GP s to use X-rays more appropriately and to make more use of lifestyle advice, dietary therapy and follow-up appointments., (© The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Objective: To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels., Methods: For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models., Results: Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use., Conclusion: After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities., (Copyright © 2014 by the American College of Rheumatology.)

Background: National and international evidence-based guidelines for hip and knee osteoarthritis recommend to start with (a combination of) conservative treatments, followed by surgical intervention if a patient does not respond sufficiently to conservative treatment options. Despite these recommendations, there are strong indications that conservative treatments are not optimally used in orthopedic practice. Our study aims to quantify the use of conservative treatments in Dutch orthopedic practice and to explore the barriers and facilitators for the use of conservative treatments that should be taken into account in a strategy to improve the embedding of conservative treatments in hip and knee osteoarthritis in orthopedic practice., Methods: This study consists of three phases. First, current use of conservative treatments in patients with hip and knee osteoarthritis will be explored using an internet-based survey among at least 100 patients to identify the underused conservative treatments. Second, barriers and facilitators for the use of conservative treatments in orthopedic practice will be identified using semi-structured interviews among 10 orthopedic surgeons and 5 patients. The interviews will be followed by an internet-based survey among approximately 450 orthopedic surgeons and at least 100 patients in which the identified barriers and facilitators will be ranked by importance. Finally, an implementation strategy will be developed based on the results of the previous phases using intervention mapping., Discussion: The developed strategy is likely to result in an optimal and standardized use of conservative treatment options in hip and knee osteoarthritis in orthopedic practice, because it is focused on identified barriers and facilitators. In addition, the results of this study can be used as an example for optimizing the use of conservative care in other patient groups. In a subsequent study, the developed implementation strategy will be assessed on its effectiveness, feasibility and costs.

Background: To enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet "Care for Osteoarthritis" was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient's active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet., Methods: Seventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients' view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach., Results: Three core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient's perceptions about OA and its manageability, and 3) the patient's perceptions about the usefulness of the booklet and patient's information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers' endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients' perceptions about the usefulness of the booklet and patients' information needs were both identified as barriers as well as facilitators for booklet use., Conclusions: This study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.

Objective: The aim of the present study was to develop process quality indicators for physiotherapy care based on key recommendations of the Dutch physiotherapy guideline on hip and knee osteoarthritis (OA)., Methods: Guideline recommendations were rated for their relevance by an expert panel, transformed into potential indicators and incorporated into a questionnaire, the Quality Indicators for Physiotherapy in Hip and Knee Osteoarthritis (QIP-HKOA). Adherence with each indicator was rated on a Likert scale (0 = never to 4 = always). The QIP-HKOA was administered to groups of expert (n = 51) and general (n = 134) physiotherapists (PTs) to test its discriminative power. Reliability was tested in a subgroup of 118 PTs by computing the intraclass correlation coefficient (ICC). QIP-HKOA items were included if they were considered to be related to the cornerstones of physiotherapy in hip and knee OA (exercises and education), had discriminative power and/or if they were followed by <75% of PTs in both groups., Results: Nineteen indicators were derived from 41 recommendations. Twelve indicators were considered to be the cornerstones of physiotherapy care; six indicators had discriminative power and/or were followed by <75% PTs in both groups, resulting in an 18-item QIP- HKOA. The QIP-HKOA score was significantly higher with expert [60.73; standard deviation (SD) 5.67] than with general PTs (54.65; SD 6.17) (p < 0.001). The ICC of the QIP-HKOA among 46/118 PTs was 0.89., Conclusion: The QIP-HKOA, based on 18 process indicators derived from a physiotherapy guideline on hip and knee OA was found to be reliable and discriminated between expert and general PTs. Its ability to measure improvement in the quality of the process of physiotherapy care needs to be further examined., (Copyright © 2012 John Wiley & Sons, Ltd.)

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I-IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

The subject of the study is to investigate whether health-related quality of life (HRQoL), pain and function of patients with hip or knee osteoarthritis (OA) improves after a specialist care intervention coordinated by a physical therapist and a nurse practitioner (NP) and to assess satisfaction with this care at 12 weeks. This observational study included all consecutive patients with hip or knee OA referred to an outpatient orthopaedics clinic. The intervention consisted of a single, standardized visit (assessment and individually tailored management advice, to be executed in primary care) and a telephone follow-up, coordinated by a physical therapist and a NP, in cooperation with an orthopaedic surgeon. Assessments at baseline and 10 weeks thereafter included the short form-36 (SF-36), EuroQol 5D (EQ-5D), hip or knee disability and osteoarthritis outcome score (HOOS or KOOS), the intermittent and constant osteoarthritis pain questionnaire (ICOAP) for hip or knee and a multidimensional satisfaction questionnaire (23 items; 4 point scale). Eighty-seven patients (57 female), mean age 68 years (SD 10.9) were included, with follow-up data available in 63 patients (72 %). Statistically significant improvements were seen regarding the SF-36 physical summary component score, the EQ-5D, the ICOAP scores for hip and knee, the HOOS subscale sports and the KOOS subscales pain, symptoms and activities of daily living. The proportions of patients reporting to be satisfied ranged from 79 to 98 % per item. In patients with hip and knee OA pain, function and HRQoL improved significantly after a single-visit multidisciplinary OA management intervention in specialist care, with high patient satisfaction.

Background: To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs' views regarding specific recommendations in the SCS and their working procedures with regard to OA., Methods: A survey was conducted among a random sample of Dutch GPs. Questions included the GP's demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP's views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs' agreement with the SCS recommendations., Results: Four hundred fifty-six GPs (37%) aged 30-65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs' agreement could be explained by the GPs' attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice., Conclusion: In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs' attitudes regarding the SCS recommendations regarding the sequence for care.

Objective: To compare the effectiveness of two educational courses aiming to improve adherence to recommendations in a Dutch physiotherapy practice guideline for hip and knee OA., Methods: Physiotherapists (PTs) from three regions in The Netherlands were invited to participate in a study comparing an interactive workshop (IW) with conventional education (CE). Participants were randomly assigned to one of the two courses. Satisfaction with the course (scale 0-10), knowledge (score range 0-76) and guideline adherence (score range 0-72) were measured at baseline, immediately after the educational course and 3 months after that. Data were analysed using a linear mixed model., Results: In total, 203 (10%) PTs participated in the IW (n = 108) and the CE (n = 95). There were no differences between groups at baseline. Satisfaction was significantly higher in the IW than in the CE group [mean scores (S.D.) 7.5 (1.1) and 6.7 (1.6), respectively (P < 0.001)]. A significantly greater improvement in adherence was seen over time in the IW group compared with the CE group (F = 3.763, P = 0.024), whereas the difference in improvement of knowledge was not significant (F = 1.283, P = 0.278)., Conclusion: An IW led to greater satisfaction and was more effective in improving adherence to recommendations in a PT guideline on hip and knee OA than CE, whereas the increase in knowledge did not differ significantly.

Introduction: Although Total Hip and Knee Replacements (THR/TKR) improve Health-Related Quality of Life (HRQoL) at the group level, up to 30% of patients are dissatisfied after surgery due to unfulfilled expectations. We aimed to assess whether the pre-operative radiographic severity of osteoarthritis (OA) is related to the improvement in HRQoL after THR or TKR, both at the population and individual level., Methods: In this multi-center observational cohort study, HRQoL of OA patients requiring THR or TKR was measured 2 weeks before surgery and at 2-5 years follow-up, using the Short-Form 36 (SF36). Additionally, we measured patient satisfaction on a 11-point Numeric Rating Scale (NRSS). The radiographic severity of OA was classified according to Kellgren and Lawrence (KL) by an independent experienced musculoskeletal radiologist, blinded for the outcome. We compared the mean improvement and probability of a relevant improvement (defined as a patients change score ≥ Minimal Clinically Important Difference) between patients with mild OA (KL Grade 0-2) and severe OA (KL Grade 3+4), whilst adjusting for confounders., Results: Severe OA patients improved more and had a higher probability of a relevant improvement in physical functioning after both THR and TKR. For TKR patients with severe OA, larger improvements were found in General Health, Vitality and the Physical Component Summary Scale. The mean NRSS was also higher in severe OA TKR patients., Discussion: Patients with severe OA have a better prognosis after THR and TKR than patients with mild OA. These findings might help to prevent dissatisfaction after THR and TKR by means of patient selection or expectation management.

Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an evidence-based, multidisciplinary, patient-centered, stepped care strategy. A national, multidisciplinary, steering group developed the strategy in three phases: (1) consensus among steering group members (first draft); (2) written consultation of 23 representatives of patient organizations and professional associations involved in osteoarthritis care (second draft); (3) consensus of the final draft after discussion in two rounds during a conference with representatives from the different disciplines. The final stepped care strategy presents, in three tiers, the optimal order for non-surgical treatment modalities. It recommends that more advanced options should only be considered if options listed in previous steps failed to produce satisfactory results. Hence, the first step treatment options can be offered to all patients but may also be provided through self care (education, life style advice, and acetaminophen). The second step (exercise therapy, dietary therapy, and non-steroidal anti-inflammatory drugs) and third step treatment options (multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation) can be considered for people with persisting complaints. Trough a consensus procedure, we succeeded to develop a multidisciplinary, patient-centered, stepped care strategy based on national guidelines. This strategy provides a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options.

Background: An update of a Dutch physiotherapy practice guideline in Hip and Knee Osteoarthritis (HKOA) was made, based on current evidence and best practice., Methods: A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters: initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 17 experts from different professional backgrounds. A second draft was field-tested by 45 physiotherapists., Results: In total 11 topics were selected. For the initial assessment, three recommendations were formulated, pertaining to history taking, red flags, and formulating treatment goals. Concerning treatment, 7 recommendations were formulated; (supervised) exercise therapy, education and self management interventions, a combination of exercise and manual therapy, postoperative exercise therapy and taping of the patella were recommended. Balneotherapy and hydrotherapy in HKOA, and thermotherapy, TENS, and Continuous Passive Motion in knee OA were neither recommended nor discouraged. Massage therapy, ultrasound, electrotherapy, electromagnetic field, Low Level Laser Therapy, preoperative physiotherapy and education could not be recommended. For the evaluation of treatment goals the following measurement instruments were recommended: Lequesne index, Western Ontario and McMaster Universities osteoarthritis index, Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score, 6-minute walktest, Timed Up and Go test, Patient Specific Complaint list, Visual Analoge Scale for pain, Intermittent and Constant OsteoArthritis Pain Questionnaire, goniometry, Medical Research Council for strength, handheld dynamometer., Conclusions: This update of a Dutch physiotherapy practice guideline on HKOA included 11 recommendations on the initial assessment, treatment and evaluation. The implementation of the guideline in clinical practice needs further evaluation.

In the Netherlands the current, conservative management of osteoarthritis of the hip and knee is heterogeneous and suboptimal. Existing guidelines only provide indications for certain interventions, but they do not provide recommendations about the sequence of these treatments. A step-by-step treatment strategy has now been developed in addition to the guidelines. Its aim is to optimize and clarify the conservative policy for osteoarthritis. In addition, communication between patients and professionals and between professionals themselves must be encouraged. According to the treatment strategy, relatively advanced interventions are considered only after simpler interventions have had insufficient results. A care booklet has also been developed that contains information for patients about osteoarthritis, treatment options, healthcare professionals and the treatment strategy.