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Objectives: The objective of this study is to develop classification criteria for overall hand osteoarthritis (OA), interphalangeal OA and thumb base OA based on self-reported data and radiographic features., Methods: The classification criteria sets were developed in three phases. In phase 1, we identified criteria that discriminated hand OA from controls. In phase 2, we used a consensus-based decision analysis approach to derive a clinician-based evaluation of the relative importance of the criteria. In phase 3, we refined the scoring system, determined the cut-offs for disease classification and compared the sensitivity and specificity of the European Alliance of Associations for Rheumatology (EULAR) criteria with the 1990 American College of Rheumatology (ACR) criteria., Results: In persons with hand symptoms and no other disease (including psoriasis) or acute injury that can explain the hand symptoms (mandatory criteria), hand OA can be classified based on age, duration of morning stiffness, number of joints with osteophytes and joint space narrowing, and concordance between symptoms and radiographic findings. Using a sum of scores based on each diagnostic element, overall hand OA can be classified if a person achieves 9 or more points on a 0-15 scale. The cut-off for interphalangeal OA and thumb base OA is 8 points. While the EULAR criteria demonstrated better sensitivity than the ACR criteria in the phase 1 data set, the performance of the two criteria sets was similar in two external cohorts., Conclusions: International experts developed the EULAR criteria to classify overall hand OA, interphalangeal OA and thumb base OA in clinical studies using a rigorous methodology., Competing Interests: Competing interests: IKH reports personal fees from Novartis and GSK; research grants from Pfizer and IMI-APPROACH (both paid to the institution); and unpaid role as secretary general of OARSI, all outside of the submitted work. AA reports institutional research grants from AstraZeneca and Oxford Immunotech; and personal fees from UpToDate (royalty), Springer (royalty), Cadilla Pharmaceuticals (lecture fees), NGM Bio (consulting), Limbic (consulting) and Inflazome (consulting), all outside of the submitted work. FB reports shares of 4P Pharma and 4Moving Biotech; personal fees from Boehringer Ingelgeim, Galapagos, Gilead, GSK, Merck Sereno, MSD, Novartis, Pfizer, Roche, Sanofi, Servier and Viatris; and research grant from TRB Chemedica, all outside the submitted work.Sita Bierma-Zeinstra reports research grants from Dutch Arthritis Association, EU Horizon, EU ERC and ZonMW (paid to institution), personal fees from Pfizer, Infirst healthcare, and paid role as deputy editor of Osteoarthritis and Cartilage, all outside of the submitted work.Krysia Dziedzic reports research grants from National Institute for Health and Care Research (NIHR); royalty/licence for Textbook for Rheumatology Therapists; payment for lecture at Australian Rheumatology Association Conference in May 2022; Implementation Advisor Fellows and Scholars Programme National Institute for Health and Care Excellence (UK 2019-22), Steering group member of NICE Implementation subgroup and Steering group member of OARSI Joint Effort initiative, all paid to institution and outside of the submitted work.Martin Englund reports personal fees from Cellcolabs AB (Sweden) and Key2 Compliance (Sweden), outside of the submitted work. Ying Ying Leung reports grants from National Medical Research Council (NMRC/CSA-INV/0022/2017), and personal fees from AbbVie, DKSH, Janssen, Novartis and Pfizer, outside of the submitted work. EM reports personal fees from Expanscience, Keyrus Life Science, Pierre Fabre, Rottapharm, MEDA-Mylan, Sublimed, TRB Chemedica, outside the submitted work. RR reports personal fees from from Novartis, AbbVie, Pfizer, MSD, Janssen, Lilly; support for attending EULAR, ACR and SIR; advisory board for Janssen, Novartis and Abbvie, outside of the submitted work. TAS reports grants and personal fees from AbbVie and Roche, and personal fees from Sanofi, Takeda and Novartis, outside the submitted work. ZS reports personal fees from AbbVie, Pfizer, Roche, Novartis, Lilly, Gedeon Richter, Sobi/Galapagos, outside of the submitted work. RW reports institutional research grants from Pfizer and Amgen, unrelated to this work, and is a Senior Clinical Investigator of the Research Foundation Flanders (Belgium) (FWO) (1803023N). MK reports consulting fees from Abbvie, Pfizer, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Novartis and UCB (all paid to institution), outside of the submitted work. DF, JJE, MH-E, GH-B, CH, MLI, HJ, TK, CDM, MM, RHM, VR, MJPFR, FVG, LAS, CM, EG and HL report no conflicts of interest., (© European Alliance of Associations for Rheumatology, EULAR 2024. Re-use permitted under CC BY-NC-ND. No commercial re-use. No derivatives. See rights and permissions. Published by BMJ on behalf of EULAR.)

Objectives: To evaluate mediating factors for the effect of therapeutic exercise on pain and physical function in people with knee/hip osteoarthritis (OA)., Methods: For Subgrouping and TargetEd Exercise pRogrammes for knee and hip OsteoArthritis (STEER OA), individual participant data (IPD) were sought from all published randomised controlled trials (RCTs) comparing therapeutic exercise to non-exercise controls in people with knee/hip OA. Using the Counterfactual framework, the effect of the exercise intervention and the percentage mediated through each potential mediator (muscle strength, proprioception and range of motion (ROM)) for knee OA and muscle strength for hip OA were determined., Results: Data from 12 of 31 RCTs of STEER OA (1407 participants) were available. Within the IPD data sets, there were generally statistically significant effects from therapeutic exercise for pain and physical function in comparison to non-exercise controls. Of all potential mediators, only the change in knee extension strength was statistically and significantly associated with the change in pain in knee OA (β -0.03 (95% CI -0.05 to -0.01), 2.3% mediated) and with physical function in knee OA (β -0.02 (95% CI -0.04 to -0.00), 2.0% mediated) and hip OA (β -0.03 (95% CI -0.07 to -0.00), no mediation)., Conclusions: This first IPD mediation analysis of this scale revealed that in people with knee OA, knee extension strength only mediated ±2% of the effect of therapeutic exercise on pain and physical function. ROM and proprioception did not mediate changes in outcomes, nor did knee extension strength in people with hip OA. As 98% of the effectiveness of therapeutic exercise compared with non-exercise controls remains unexplained, more needs to be done to understand the underlying mechanisms of actions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Multimorbidity is increasingly the norm; however, primary care remains focused on single diseases. Osteoarthritis, anxiety, and depression are frequently comorbid with other long-term conditions (LTCs), but rarely prioritized by clinicians., Objectives: To test the feasibility of a randomized controlled trial (RCT) of an intervention integrating case-finding and management for osteoarthritis, anxiety, and depression within LTC reviews., Methods: A pilot stepped-wedge RCT across 4 general practices recruited patients aged ≥45 years attending routine LTC reviews. General practice nurses provided usual LTC reviews (control period), then, following training, delivered the ENHANCE LTC review (intervention period). Questionnaires, an ENHANCE EMIS-embedded template and consultation audio-recordings, were used in the evaluation., Results: General practice recruitment and training attendance reached prespecified success criteria. Three hundred and eighteen of 466 (68%) of patients invited responded; however, more patients were recruited during the control period (206 control, 112 intervention). Eighty-two percent and 78% returned their 6-week and 6-month questionnaires, respectively. Integration of the ENHANCE LTC review into routine LTC reviews varied. Case-finding questions were generally used as intended for joint pain, but to a lesser extent for anxiety and depression. Initial management through referrals and signposting were lacking, and advice was more frequently provided for joint pain. The stepped-wedge design meant timing of the training was challenging and yielded differential recruitment., Conclusion: This pilot trial suggests that it is feasible to deliver a fully powered trial in primary care. Areas to optimize include improving the training and reconsidering the stepped-wedge design and the approach to recruitment by targeting those with greatest need., Trial Registration: ISRCTN registry (ISRCTN: 12154418). Date registered: 6 August 15. Date first participant was enrolled: 13 July 2015. https://www.isrctn.com/ISRCTN12154418?q=depression%20schizophrenia&filters=conditionCategory:Not%20Applicable&sort=&offset=5&totalResults=9&page=1&pageSize=20&searchType=basic-search., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Research on levels of physical activity (PA) in those with peripheral joint pain have only focused on single sites, in the knee or hips. This study investigated the levels of PA in adults with single-site and multisite peripheral joint pain compared to adults with no joint pain., Methods: Analysis of a cross-sectional population survey mailed to adults aged ≥45 years (n = 28,443) was conducted. Respondents reported any peripheral joint pain in the last 12 months in either the hands, hips, knees or feet; PA levels were self-reported using the short telephone activity rating scale. The association between PA levels, peripheral joint pain and outcomes of health status (physical and mental component scores, using SF-12) pain intensity (10-point scale) and health-related quality of life (HRQoL) (EQ-5D) were investigated using analysis of variance and ordinal regressions., Results: Compared to those with no joint pain, all pain groups reported lower levels of PA: joint pain in one site (odds ratio = 0.91, 95% CI: 0.83-0.99); two sites (0.74, 0.67-0.81), three sites (0.65, 0.59-0.72) and four sites (0.47, 0.42-0.53). Across all joint pain groups, levels of PA were associated with pain intensity, physical health status, mental health status and HRQoL., Discussion: Adults with more sites of peripheral joint pain were more likely to report lower levels of PA. Those with more sites of pain and lower levels of PA reported poorer outcomes. Health care providers should be aware that those with multisite joint pain are most likely to have low levels of PA., (© 2021 John Wiley & Sons Ltd.)

The philosophical underpinning of trials of complex interventions is critiqued for not taking into account causal mechanisms that influence potential outcomes. In this article, we draw from in-depth interviews (with practice nurses and patients) and observations of practice meetings and consultations to investigate the outcomes of a complex intervention to promote self-management (in particular exercise) for osteoarthritis in primary care settings. We argue that nurses interpreted the intervention as underpinned by the need to educate rather than work with patients, and, drawing from Habermasian theory, we argue that expert medicalised knowledge (system) clashed with lay 'lifeworld' prerogatives in an uneven communicative arena (the consultation). In turn, the advice and instructions given to patients were not always commensurate with their 'lifeworld'. Consequently, patients struggled to embed exercise routines into their daily lives for reasons of unsuitable locality, sense-making that 'home' was an inappropriate place to exercise and using embodied knowledge to test the efficacy of exercise on pain. We conclude by arguing that using Habermasian theory helped to understand reasons why the trial failed to increase exercise levels. Our findings suggest that communication styles influence the outcomes of self-management interventions, reinforce the utility of theoretically informed qualitative research embedded within trials to improve conduct and outcomes and indicate incorporating perspectives from human geography can enhance Habermas-informed research and theorising.

Objectives: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA., Methods: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested., Results: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good., Conclusion: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets., Competing Interests: Competing interests: IKH reports personal fees from Abbvie and Novartis, and research grants from Pfizer and IMI-APPROACH (both paid to the institution), all outside of the submitted work. FB reports being CEO of 4MOVING BIOTECH, received personal fees from 4P PHARMA, Boehringer, Bone Therapeutics, CellProthera, Galapagos, GSK, Lilly, Merck Sereno, MSD, Novartis, Pfizer, Servier and Peptinov, and research grant from TRB Chemedica and IMI-APPROACH (paid to the institution), all outside the submitted work. GHB reports personal fees from Pfizer, Sobi, Fresenius, Mylan, Tedec Meiji, Novartis, Sandoz and Faes, outside of the submitted work. EM reports personal fees from Expanscience, Mylan-Meda, TRB Chemedica, Pierre Fabre, Celgene and Fidia, and non-financial support from Pfizer, outside the submitted work. CDM and JJE report a research grant from BMS, outside the submitted work. RR reports personal fees from Abbvie, Celgene, Novartis, Pfizer and Lilly, outside of the submitted work. TAS reports personal fees from Sanofi, AbbVie, Roche and Takeda, outside of the submitted work. ZS reports personal fees from AbbVie, Roche, Pfizer, Berlin Chemie, UCB and Bristol-Myers, outside of the submitted work. RW reports personal fees from Abbvie, Galapagos, UCB, Bristol Myers Squib and Tilman, and grants from Amgen, outside the submitted work. ME reports serving on an advisory board for Pfizer (tanezumab) and research grant from IMI-APPROACH (paid to the institution), outside of the submitted work. SB-Z reports personal fees from Infirst healthcare, Pfizer and Osteoarthritis and Cartilage, outside the submitted work. PH is a co-inventor of the 1000minds software used in this study. MK reports personal fees from Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Novartis and UCB, and research grants from Pfizer, IMI-APPROACH (all paid to the institution), and royalties from Wolters Kluwer and Springer Verlag, all outside the submitted work. YYL reports grants from National Medical Research Council of Singapore, and personal fees from Abbvie, DKSH, Janssen, Novartis and Pfizer, all outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This study assessed the measurement properties of two commonly used self-report physical activity (PA) measures: the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and the Physical Activity Scale for the elderly (PASE) in adults with osteoarthritis., Methods: Secondary analysis of the MOSAICS cluster randomised controlled trial baseline and 3-month follow-up questionnaires, total scores and subdomains of the IPAQ-SF and PASE were compared. Intra-class correlations (ICC) were used to assess test-retest reliability, measurement error was assessed using standard error of measurement (SEM), smallest detectable change (SDC) and 95% limits of agreement (LoA). Responsiveness was assessed using effect size (ES), standard responsive measurement (SRM) and response ratio (RR)., Results: There was moderate correlation (r = 0.56) between the total IPAQ-SF scores (score ranges 0-16,398) and the total PASE scores (score ranges 0-400). Subdomain correlations were also moderate (ranges 0.39-0.57). The PASE showed greater reliability compared to the IPAQ-SF (ICC = 0.68; 0.61-0.74 95% CI and ICC = 0.64; 0.55-0.72, respectively). Measurement errors in both measures were large: PASE SEM = 46.7, SDC = 129.6 and 95% LoA ranges = -117 to 136, the IPAQ-SF SEM = 3532.2 METS -1 min-1 week , SDC = 9790.8 and 95% LoA ranges = -5222 to 5597. Responsiveness was poor: ES -0.14 and -0.16, SRM -0.21 and -0.21, and RR 0.12 and 0.09 for the IPAQ-SF and PASE, respectively., Discussion: The IPAQ-SF and PASE appear limited in reliability, measurement error and responsiveness. Researchers and clinicians should be aware of these limitations, particularly when comparing different levels of PA and monitoring PA levels changes over time in those with osteoarthritis., (© 2021 John Wiley & Sons Ltd.)

Background: Embedding research into practice is challenging. Barriers include: a shortage of time, lack of understanding of the evidence and a poor support in the clinical setting. A community of practice (CoP) model has been used to address these issues. Three 'Evidence into Practice' groups use a CoP model to assist the rapid translation of evidence into practice in primary and secondary care settings. We describe how a CoP model supports the functions, operations and outputs of three 'Evidence into Practice Groups'., Method: A CoP model is used to engage a broad range of clinicians, researchers, managers, patients and librarians in the complex process of acquiring research knowledge and then translating knowledge into practice. The CoP principles of Domain, Community and Practice are used to describe three 'Evidence into Practice Groups' who cater for different elements of the care and academic sector and engage a range of professional groups. This includes primary and secondary care engaging professionals such as general practitioners (GP), practice nurses, allied health professionals, researchers and librarians. All groups are clinically led, academically supported and follow similar processes to identify the best evidence and translate it into practice. As the groups reflect the context in which they work they have different operational arrangements for example frequency and time of meetings., Results: The CoP model enabled three 'Evidence into Practice Groups' over time to: engage over 180 clinical and academic staff; answer 130 clinical questions; improve clinical care, gain funding for two randomised controlled trials (enrolled over n = 7000 participants) and identify areas for further research, quality improvement audit and training., Conclusion: The CoP model encourages the rapid translation of evidence into practice by engaging staff to identify areas of clinical concern in their own context, thereby stimulating their interest and involvement. This creates a meaningful link between research and practice. Clinical leadership and the CoP model ensure that practice change is quick and efficient. This model can be replicated at scale. Consideration needs to be given to the key ingredients to achieve impact., (© 2021 John Wiley & Sons Ltd.)

Background: To improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention., Methods: Forty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models., Results: The PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment., Conclusion: This study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations., Trial Registration: ClinicalTrials.gov: NCT02876120 .

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., (Copyright © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Osteoarthritis (OA) is a complex musculoskeletal disease and a leading cause of pain and disability worldwide. Hip and knee OA alone are major contributors to global disability, having notable effects on individual well-being, increasing the reliance of individuals on health-care services and contributing to a rise in the socioeconomic burden. Consistent, coordinated and tailored approaches are important for providing appropriate care to all people with OA, but despite the scale of the challenge many individuals are still not offered the safe, best-evidence treatments recommended for OA care. This Review discusses the core priority treatments for OA, including exercise and physical activity, weight-loss, education and support for self-management. Additional physical or psychological evidence-based adjunctive therapies and combined therapies that can be used to tailor individual programmes are also discussed. These options include cognitive behavioural therapy, heat therapy, walking aids and splints, manual therapies and transcutaneous electrical nerve stimulation. International examples of OA treatment options, models of care and resources available are also given. Many challenges still need to be addressed to advance the uptake of these conditions, including further discussion around the risks and costs involved with all treatments.

In this brief report, we used data from a series of three related cohorts on pain and osteoarthritis (OA) of the knee, hand and foot, which were conducted in North Staffordshire, England. We used a common approach for sampling, data collection and coding, to estimate the relative prevalence of 10 different symptomatic radiographic OA subtypes in the knee, hand and foot and to compare their association with age, sex, socioeconomic position and body mass index. Overall, symptomatic hand OA was more common than knee or foot OA (22.4% vs 17.4% vs 16.5%), due mainly to the high prevalence of nodal interphalangeal joint OA among women. The first carpometacarpal joint OA was the most frequent subtype, with patellofemoral, tibiofemoral, (nodal) interphalangeal and midfoot OA also common. Of the risk factors examined, the greatest differences between subtypes appeared to be their associations with sex and obesity: sex differences were noticeably greater for all forms of hand OA except non-nodal interphalangeal joint OA, while obesity appeared most strongly associated with forms of knee OA. The prevalence of all subtypes was higher among older ages, and among those with lower educational attainment., (© 2020 John Wiley & Sons, Ltd.)

Background: There is no physiotherapy-specific quality indicator tool available to evaluate physiotherapy care for people with hip and/or knee osteoarthritis (OA). This study aimed to develop a patient-reported quality indicator tool (QUIPA) for physiotherapy management of hip and knee OA and to assess its reliability and validity., Methods: To develop the QUIPA tool, quality indicators were initially developed based on clinical guideline recommendations most relevant to physiotherapy practice and those of an existing generic OA quality indicator tool. Draft items were then further refined using patient focus groups. Test-retest reliability, construct validity (hypothesis testing) and criterion validity were then evaluated. Sixty-five people with hip and/or knee OA attended a single physiotherapy consultation and completed the QUIPA tool one, twelve- and thirteen-weeks after. Physiotherapists (n = 9) completed the tool post-consultation. Patient test-retest reliability was assessed between weeks twelve and thirteen. Construct validity was assessed with three predefined hypotheses and criterion validity was based on agreement between physiotherapists and participants at week one., Results: A draft list of 23 clinical guideline recommendations most relevant to physiotherapy was developed. Following feedback from three patient focus groups, the final QUIPA tool contained 18 items (three subscales) expressed in lay language. The test-retest reliability estimates (Cohen's Kappa) for single items ranged from 0.30-0.83 with observed agreement of 64-94%. The intraclass correlation coefficient (ICC) and 95% confidence interval (CI) for the Assessment and Management Planning subscale was 0.70 (0.54, 0.81), Core Recommended Treatments subscale was 0.84 (0.75, 0.90), Adjunctive Treatments subscale was 0.70 (0.39, 0.87) and for the total QUIPA score was 0.80 (0.69, 0.88). All predefined hypotheses regarding construct validity were confirmed. However, agreement between physiotherapists and participants for single items showed large measurement error (Cohen's Kappa estimates ranged from - 0.04-0.59) with the ICC (95% CI) for the total score being 0.11 (- 0.14, 0.34)., Conclusions: The QUIPA tool showed acceptable test-retest reliability for subscales and total score but inadequate reliability for individual items. Construct validity was confirmed but criterion validity for individual items, subscales and the total score was inadequate. Further research is needed to refine the QUIPA tool to improve its clinimetric properties before implementation.

Objective: Develop a generic trans-disciplinary, skills-based capability framework for health professionals providing care for people with OA., Design: e-Delphi survey. An international inter-professional Delphi Panel (researchers; clinicians; consumer representatives) considered a draft framework (adapted from elsewhere) of 131 specific capabilities mapped to 14 broader capability areas across four domains (A: person-centred approaches; B: assessment, investigation and diagnosis; C: management, interventions and prevention; D: service and professional development). Over three rounds, the Panel rated their agreement (Likert or numerical rating scales) on whether each specific capability in Domains B and C was essential (core) for all health professionals when providing care for all people with OA. Those achieving consensus (≥80% of Panel) rating of ≥ seven out of ten (Round 3) were retained. Generic domains (A and D) were included in the final framework and amended based on Panel comments., Results: 173 people from 31 countries, spanning 18 disciplines and including 26 consumer representatives, participated. The final framework comprised 70 specific capabilities across 13 broad areas i) communication; ii) person-centred care; iii) history-taking; iv) physical assessment; v) investigations and diagnosis; vi) interventions and care planning; vii) prevention and lifestyle interventions; viii) self-management and behaviour change; ix) rehabilitative interventions; x) pharmacotherapy; xi) surgical interventions; xii) referrals and collaborative working; and xiii) evidence-based practice and service development)., Conclusion: Experts agree that health professionals require an array of skills in person-centred approaches; assessment, investigation and diagnosis; management, interventions and prevention; and service and professional development to provide optimal care for people with OA., (Copyright © 2019 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objective: The Joint Effort Initiative was endorsed by Osteoarthritis Research Society International (OARSI) in 2018 as a collaboration between international researchers and clinicians with an interest in the implementation of osteoarthritis management programs (OAMPs). This study aimed to identify and prioritise activities for future work of the Joint Effort Initiative., Design: A survey was emailed to delegates of the 2018 OARSI World Congress attending a pre-conference workshop or with a known interest in OAMPs (n = 115). Delegates were asked about the most important issues regarding OAMP implementation. The top 20 issues were synthesised into 17 action statements, and respondents were invited to participate in a priority ranking exercise to determine the order of importance of the statements., Results: Survey respondents (n = 51, 44%) were most commonly female (71%), with an allied health background (57%), affiliated with universities (73%) from Oceania (37%), and Europe/UK (45%). The five highest ranked action statements were: CONCLUSION: Prioritising statements will bring focus to the future work of the Joint Effort Initiative in the future and provide a basis for longer-term actions., (Copyright © 2019 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Introduction: There is little research on identifying modifiable risk factors that predict future interference of pain with daily activity in people with joint pain, and the estimation of the corresponding population attributable risk (PAR). The present study therefore investigated modifiable predictors of pain interference and estimated maximum potential gain from intervention in adults with joint pain., Methods: A population-based cohort aged ≥50 years was recruited from eight general practices in North Staffordshire, UK. Participants (n = 1878) had joint pain at baseline lasting ≥3 months and indicated no pain interference. Adjusted associations of self-reported, potentially modifiable prognostic factors (body mass index, anxiety/depressive symptoms, widespread pain, inadequate joint pain control, physical inactivity, sleep problems, smoking and alcohol intake) with onset of pain interference 3 years later were estimated via Poisson regression, and corresponding PAR estimates were obtained., Results: Inadequate joint-specific pain control, insomnia and infrequent walking were found to be independently significantly associated with the onset of pain interference after 3 years, with associated PARs of 6.3% (95% confidence interval -0.3, 12.4), 7.6% (-0.4, 15.0) and 8.0% (0.1, 15.2), respectively, with only the PAR for infrequent walking deemed statistically significant. The PAR associated with insomnia, infrequent walking and inadequate control of joint pain simultaneously was 20.3% (8.6, 30.4)., Conclusions: There is potential to reduce moderately the onset of pain interference from joint pain in the over-50s if clinical and public health interventions targeted pain management and insomnia, and promoted an active lifestyle. However, most of the onset of significant pain interference in the over-50s, would not be prevented, even assuming that these factors could be eliminated., (© 2019 John Wiley & Sons, Ltd.)

Background: 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., Objective: To identify and prioritize the most important recommendations relevant to physical therapy practice for hip and/or knee OA., Methods: 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., Results: 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., Conclusion: This study identified and ranked the most important recommendations relevant to physical therapy practice for hip and/or knee OA. J Orthop Sports Phys Ther 2019;49(7):501-512. doi:10.2519/jospt.2019.8676 .

Objective: To identify and evaluate the measurement properties of self-report physical activity instruments suitable for patients with osteoarthritis (OA)., Methods: We conducted a comprehensive 2-stage systematic review using multiple electronic databases, from inception until July 2018. In the stage 1 review, we sought to identify all self-report physical activity instruments used in individuals with joint pain attributable to OA in the foot, knee, hip, or hand. In the stage 2 review, we searched for and appraised studies investigating the measurement properties of the instruments identified. In both stages of the review, we screened all articles for study eligibility criteria, completed data extraction using the Qualitative Attributes and Measurement Properties of Physical Activity questionnaire checklist, and conducted methodology quality assessments using a modified COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) checklist. Measurement properties for each physical activity instrument were evaluated and combined, using narrative synthesis., Results: In the stage 1 review, we identified 23 unique self-report physical activity instruments. In the stage 2 review, we identified 54 studies that evaluated the measurement properties of 13 of the 23 instruments identified. Instrument reliability varied from inadequate to adequate (intraclass correlation coefficient ≥0.7). Instrument construct and criterion validity assessment showed small to moderate correlations with direct measures of physical activity. Instrument responsiveness was assessed in only 1 instrument and was unable to detect changes in comparison to accelerometers., Conclusion: Although many instruments were identified as being potentially suitable for use in patients with OA, none demonstrated adequate measurement properties across all domains of reliability, validity, and responsiveness. Further high-quality assessment of self-report physical activity instruments is required before such measures can be recommended for use in OA research., (© 2018, American College of Rheumatology.)

Since publication of the European League Against Rheumatism (EULAR) recommendations for management of hand osteoarthritis (OA) in 2007 new evidence has emerged. The aim was to update these recommendations. EULAR standardised operating procedures were followed. A systematic literature review was performed, collecting the evidence regarding all non-pharmacological, pharmacological and surgical treatment options for hand OA published to date. Based on the evidence and expert opinion from an international task force of 19 physicians, healthcare professionals and patients from 10 European countries formulated overarching principles and recommendations. Level of evidence, grade of recommendation and level of agreement were allocated to each statement. Five overarching principles and 10 recommendations were agreed on. The overarching principles cover treatment goals, information provision, individualisation of treatment, shared decision-making and the need to consider multidisciplinary and multimodal (non-pharmacological, pharmacological, surgical) treatment approaches. Recommendations 1-3 cover different non-pharmacological treatment options (education, assistive devices, exercises and orthoses). Recommendations 4-8 describe the role of different pharmacological treatments, including topical treatments (preferred over systemic treatments, topical non-steroidal anti-inflammatory drugs (NSAIDs) being first-line choice), oral analgesics (particularly NSAIDs to be considered for symptom relief for a limited duration), chondroitin sulfate (for symptom relief), intra-articular glucocorticoids (generally not recommended, consider for painful interphalangeal OA) and conventional/biological disease-modifying antirheumatic drugs (discouraged). Considerations for surgery are described in recommendation 9. The last recommendation relates to follow-up. The presented EULAR recommendations provide up-to-date guidance on the management of hand OA, based on expert opinion and research evidence., Competing Interests: Competing interests: The individual declaration of conflicts of interest is available on demand at the EULAR secretariat and is summarised below: MK has received consultancy fees/fee as local investigator of industry driven trials from AbbVie, GlaxoSmithKline, Merck, Levicept (all through institution) and has received research funding (through the institution) from Pfizer and APPROACH-IMI. FJB has received honoraria from Boehringer Ingelheim España, SA, Boehringer Ingelheim International GmbH, Fundación Española de Reumatología (FER), Janssen Cilag International NV, Pfizer Inc, Sanofi-Aventis Recherche & Developpement, Bristol-Myers Squibb International Corporation, Bristol Myers Squibb Research and Development, Hospira Inc., Grunenthal GmbH, Bioiberica, UCB, Gebro and research funding (all through institution) from Novartis Farmacéutica, SA, Bristol, Menarini International Operations Luxembourg SA, AbbVie Deutschland GmbH & Co KG, Boehringer Ingelheim España, SA, Boehringer Ingelheim International GmbH, Fundación Española de Reumatología (FER), Janssen Cilag International NV, Gedeon Richter Plc, Pfizer Inc, Glaxosmithkline Research & Development Limited, YL Biologics Limited, Amgen, Inc, Sanofi-Aventis Recherche & Developpement, Gilead Sciences, Inc, Eli Lilly and Company, Ablynx NV, Bristol-Myers Squibb International Corporation, Bristol-Myers Squibb Research and Development, Hospira Inc, Astellas Pharma Europe BV, TRB Chemedica International SA, Archigen Biotech Limited, ONO Pharma UK Ltd, UCB Biosciences GMBH, Nichi-Iko Pharmaceutical Co, Ltd, Genentech Inc Grunenthal GmbH, Celgene Corporation. MD has received research funding from AstraZeneca for a PI-led ’sons of gout' study and honoraria for advisory boards on osteoarthritis and gout from AstraZeneca, Grunenthal, Mallinckrodt and Roche. KSD is part-funded by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. GHB has received honoraria from Pfizer, AstraZeneca, Roche, Glaxo, Expanscience and research funding (all through institution) from Pfizer and Roche. EM has received honoraria from Celgène, Expanscience, Fidia, Genevrier, Ibsa, LCA, Rottapharm-Meda-Mylan-France, Rottapharm Biotech-Italy, TRB Chemedica. RR has received honoraria from AbbVie, MSD, Celgene, Janssen, Pfizer, UCB and research funding from HORIZON 2020 (going through the institution). JSS has received honoraria from AbbVie, Amgen, AstraZeneca, Astro, BMS, Celgene, Celltrion, Chugai, Gilead, Glaxo, ILTOO, Janssen, Lilly, Medimmune, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi, UCB and research funding from AbbVie, AstraZeneca, Janssen, Lilly, MSD, Pfizer, Roche. JSS is Editor-in-Chief of ARD and Editor of Rheumatology (Textbook). TS has received honoraria from AbbVie, Janssen, MSD, Novartis and Roche and grant support from AbbVie (going through the institution). ZS has received honoraria from AbbVie, Roche, Pfizer, Berlin Chemie, UCB, Bristol-Myers. RW has received honoraria from AbbVie, UCB, Bristol-Meyers Squibb, MSD, Janssen-Cilag, Menarini. LC has received research funding (through the institution) from Pharmaceutical laboratories (AbbVie Spain, Bristol-Myers Squibb, Celgene, Eisai Farmacéutica, Gebro Pharma, Grünenthal Pharma, LEO Pharma, Merck Sharp & Dohme España, Novartis Farmaceutica, Pfizer, Roche Farma, Sanofi Aventis, UCB Pharma), Scientific societies (Academia de Dermatología y Venereología, Asociación Emeritense de Reumatología, Eular, Italian Society of Rheumatology, Sociedad Castellano-Manchega, SORCOM, SEDISA, SEIO, Sociedad Española de Neumología y Cirugía Torácica, SERPE, Societat Catalana de Reumatología), Contract Research organisations (Scientia Salus, Continuing Medical Communication, Mediaevents AA, Congresos Eventos y Azafatas, Meed Comunicación, Proyectos Incentivos y Congresos), Research groups and Foundations (AIRE-MB, FISABIO, Fundació Parc Taulí, Fundación Asturcor , Fundación Clínic, Fundación de Investigación Sanitaria Illes Balears, Fundación Española de Reumatología, Fundación para la Investigación Biomédica del Hospital Universitario de La Princesa, Fundación para la Investigación Biomédica del Hospital Universitario 12 de Octubre, Fundación Pública Andaluza para la Investigación de Málaga en Biomedicina y Salud, Hospital Universitario Fundación Alcorcón, Reumacare), Individual researchers (Dr Ramón Mazzuchelli, Dr Xavier Juanola, Dr Afnan Abdelkader) and is director of Instituto de Salud Musculoesquelética., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome., Methods: We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452., Findings: Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported., Interpretation: A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care., Funding: Arthritis Research UK., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The aims of the present study was to examine the associations between the severity of pain and anxiety in a community population reporting joint pain, and to investigate the management of joint pain in the presence of comorbid anxiety., Methods: A population survey was carried out of people aged ≥45 years, registered with eight general practices in Cheshire, Shropshire and Staffordshire, UK. Respondents were asked to report pain intensity in their hands, hips, knees and feet (on a numerical rating scale), anxiety symptoms (Generalized Anxiety Disorder seven-item [GAD-7] scale) and guideline-recommended treatments used to manage pain. Clinical anxiety was defined by a GAD-7 score of 10 or more., Results: A total of 11,222 respondents with joint pain were included in the analysis, with 1,802 (16.1%) reporting clinical anxiety. Respondents reporting more severe pain were more likely to report clinical anxiety (severe versus mild pain, odds ratio [OR] 5.36, 95% confidence interval [CI] 4.56 to 6.31). The number of pain sites was also positively associated with clinical anxiety (four versus one site; OR 3.64, 95% CI 3.09 to 4.30). Those with clinical anxiety were less likely to undertake general fitness exercises (OR 0.60, 95% CI 0.52 to 0.70), but more likely to diet (OR 1.43, 95% CI 1.21 to 1.69), use walking aids (OR 1.53, 95% CI 1.32 to 1.77) and assistive devices (OR 1.24, 95% CI 1.04 to 1.49), and more likely to use opioids (OR 1.34, 95% CI 1.18 to1.52)., Conclusions: Anxiety is common among patients presenting to primary care with joint pain. Patients with anxiety are likely to manage their joint pain differently to those without. Case-finding to identify and treat anxiety would be appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention., (Copyright © 2018 John Wiley & Sons, Ltd.)

Background: Osteoarthritis (OA) is a leading cause of pain and disability. NICE OA guidelines (2008) recommend that patients with OA should be offered core treatments in primary care. Assessments of OA management have identified a need to improve primary care of people with OA, as recorded use of interventions concordant with the NICE guidelines is suboptimal in primary care. The aim of this study was to i) describe the patient-reported uptake of non-pharmacological and pharmacological treatments recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and ii) determine whether patient characteristics or OA diagnosis impact uptake., Methods: A cross-sectional survey mailed to adults aged ≥45 years (n = 28,443) from eight general practices in the UK as part of the MOSAICS study. Respondents who reported the presence of joint pain, a consultation in the previous 12 months for joint pain, and gave consent to medical record review formed the sample for this study., Results: Four thousand fifty-nine respondents were included in the analysis (mean age 65.6 years (SD 11.2), 2300 (56.7%) females). 502 (12.4%) received an OA diagnosis in the previous 12 months. More participants reported using pharmacological treatments (e.g. paracetamol (31.3%), opioids (40.4%)) than non-pharmacological treatments (e.g. exercise (3.8%)). Those with an OA diagnosis were more likely to use written information (OR 1.57; 95% CI 1.26,1.96), paracetamol (OR 1.30; 95% CI 1.05,1.62) and topical NSAIDs (OR 1.30; 95% CI 1.04,1.62) than those with a joint pain code. People aged ≥75 years were less likely to use written information (OR 0.56; 95% CI 0.40,0.79) and exercise (OR 0.37; 95% CI 0.25,0.55) and more likely to use paracetamol (OR 1.91; 95% CI 1.38,2.65) than those aged < 75 years., Conclusion: The cross-sectional population survey was conducted to examine the uptake of the treatments that are recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and to determine whether patient characteristics or OA diagnosis impact uptake. Non-pharmacological treatment was suboptimal compared to pharmacological treatment. Implementation of NICE guidelines needs to examine why non-pharmacological treatments, such as exercise, remain under-used especially among older people.

Background: Previous research has identified similar prognostic factors in patients with musculoskeletal (MSK) conditions regardless of pain presentation, generating opportunities for management based on prognosis rather than specific pain presentation., Methods: Data from seven RCTs (2483 participants) evaluating a range of primary care interventions for different MSK pain conditions were used to investigate the course of symptoms and explore similarities and differences in predictors of outcome. The value of pain site for predicting changes in pain and function was investigated and compared with that of age, gender, social class, pain duration, widespread pain and level of anxiety/depression., Results: Over the initial three months of follow-up, changes in mean pain intensity reflected an improvement, with little change occurring after this period. Participants with knee pain due to osteoarthritis (OA) showed poorer long-term outcome (mean difference in pain reduction at 12 months -1.85, 95% CI -2.12 to -1.57, compared to low back pain). Increasing age, manual work, longer pain duration, widespread pain and increasing anxiety/depression scores were significantly associated with poorer outcome regardless of pain site. Testing of interactions showed some variation between pain sites, particularly for knee OA, where age, manual work and pain duration were most strongly associated with outcome., Conclusions: Despite some differences in prognostic factors for trial participants with knee OA who were older and had more chronic conditions, similarity of outcome predictors across regional MSK pain sites provides evidence to support targeting of treatment based on prognostic factors rather than site of pain., Significance: Individual patient data analysis of trials across different regional musculoskeletal pain sites was used to evaluate course and prognostic factors associated with pain and disability. Overall, similarity of outcome predictors across these different pain sites supports targeting of treatment based on prognostic factors rather than pain site alone., (© 2018 European Pain Federation - EFIC®.)

A number of controversies and challenges exist for the management of OA in health care. This paper describes the challenges and gaps in OA care, particularly in relation to population health management, complex interventions and outcomes. It sets this in the context of competing health priorities and multimorbidity, access to high quality conservative care, non-pharmacological therapies, resource limitations and models of care. The overuse of some therapies and neglect of others are discussed, as well as the potential for self-management. The roles of patient and public involvement and the healthcare team are highlighted in enhancing best care for OA and providing solutions for closing the evidence-to-practice gap. Implementation of models of care offer one solution to the challenges and progress of such implementation is described. Areas for further research are highlighted.

Objective: To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice., Method: Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England., Participants: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression., Results: 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3)., Conclusion: Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months., Trial Registration: ISRCTN06984617., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To determine common patterns of recorded primary care for osteoarthritis (OA), and patient and provider characteristics associated with the quality of recorded care., Design: An observational study nested within a cluster-randomised controlled trial., Setting: Eight UK general practices who were part of the Management of Osteoarthritis in Consultations study., Participants: Patients recorded as consulting within the eight general practices for clinical OA., Primary Outcomes: Achievement of seven quality indicators of care (pain/function assessment, information provision, exercise/weight advice, analgesics, physiotherapy), recorded through an electronic template or routinely recorded in the electronic healthcare records, was identified for patients aged ≥45 years consulting over a 6-month period with clinical OA. Latent class analysis was used to cluster patients based on care received. Clusters were compared on patient and clinician-level characteristics., Results: 1724 patients (median by practice 183) consulted with clinical OA. Common patterns of recorded quality care were: cluster 1 (38%, High ) received most quality indicators of care; cluster 2 (11%, Moderate ) had pain and function assessment, and received or were considered for other indicators; cluster 3 (17%, Low ) had pain and function assessment, and received or were considered for paracetamol or topical non-steroidal anti-inflammatory drugs; cluster 4 (35%, None ) had no recorded quality indicators. Patients with higher levels of recorded care consulted a clinician who saw more patients with OA, consulted multiple times and had less morbidity. Those in the High cluster were more likely to have recorded diagnosed OA and have knee/hip OA., Conclusions: Patterns of recorded care for OA fell into four natural clusters. Appropriate delivery of core interventions and relatively safe pharmacological options for OA are still not consistently recorded as provided in primary care. Further research to understand clinical recording behaviours and determine potential barriers to quality care alongside effective training for clinicians is needed., Trial Registration Number: ISRCTN06984617; Results., Competing Interests: Competing interests: KPJ reports grants from National Institute for Health Research, grants from Arthritis Research UK, during the conduct of the study. KSD reports grants from Arthritis Research UK Centre in Primary Care grant, grants from National Institute for Health Research (NIHR) Programme Grant (RP-PG-0407-10386), during the conduct of the study; grants from Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002), non-financial support from National Institute of Health and Care Excellence, other from Bone and Joint Decade 2015 Conference Oslo, non-financial support from National Institute of Health and Care Excellence Quality Standards, grants from EIT-Health, other from Osteoarthritis Research Society International, outside the submitted work; and Member of the NICE Osteoarthritis Guidelines Development Group CG 59 (2008) and CG 177 (2014). The other authors declare no competing interests., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Research into musculoskeletal conditions often focusses on pain at single sites, such as the knee, yet several studies have previously reported the high prevalence of multiple sites of musculoskeletal pain. The most common form of musculoskeletal condition is arthritis, with osteoarthritis (OA) the most common cause of joint pain in adults 45 years and over. However, there is limited recognition of the prevalence of multisite peripheral joint pain in those either living with or at risk of OA, therefore this study set out to estimate the prevalence of multisite peripheral joint pain in adults 45 years and older, and its impact on several dimensions of health., Methods: A cross-sectional population survey was mailed to adults (n = 28,443) aged 45 years and over from eight general practices in the North West Midlands, United Kingdom (UK). Prevalence rates were established for multisite peripheral joint pain (pain in two or more sites; hands, hips, knees, feet). Impact was measured for general health (SF-12 MCS & PCS), QoL (EQ-5D), pain intensity (0-10 numerical ratings scale) and the number of consultations with a range of health care professionals., Results: Of 15,083 responders (53%), multisite peripheral joint pain was reported by 54%. Peripheral joint pain was present in n = 11,928, of which 68% reported pain in multiple sites. Multisite peripheral joint pain was shown to be significantly associated with reduced physical (Mean difference = -5.9 95% CI -6.3,-5.5) and mental (-2.8 95% CI -3.2,-2.4) components of the SF-12, reduced QoL (-0.14 95% CI -0.15, -0.13), increased pain (+0.70 95% CI 0.62, 0.79) and increased odds of consultations with GPs (OR 2.4 95% CI 2.2, 2.6) and practice nurses (OR 2.6 (95% CI 2.1, 3.2) when compared to single site pain., Conclusions: Multisite peripheral joint pain is prevalent in the population in adults 45 years and over and has a significant negative impact on several dimensions of health. Health care professionals should consider joint pain beyond the index site in order to address holistic management.

Objective: To evaluate the effectiveness of oral glucosamine in subgroups of people with hip or knee osteoarthritis (OA) based on baseline pain severity, body mass index (BMI), sex, structural abnormalities and presence of inflammation using individual patient data., Methods: After a systematic search of the literature and clinical trial registries, all randomised controlled trials (RCTs) evaluating the effect of any oral glucosamine substance in patients with clinically or radiographically defined hip or knee OA were contacted. As a minimum, pain, age, sex and BMI at baseline and pain as an outcome measure needed to be assessed., Results: Of 21 eligible studies, six (n=1663) shared their trial data with the OA Trial Bank. Five trials (all independent of industry, n=1625) compared glucosamine with placebo, representing 55% of the total number of participants in all published placebo-controlled RCTs. Glucosamine was no better than placebo for pain or function at short (3 months) and long-term (24 months) follow-up. Glucosamine was also no better than placebo among the predefined subgroups. Stratification for knee OA and type of glucosamine did not alter these results., Conclusions: Although proposed and debated for several years, open trial data are not widely made available for studies of glucosamine for OA, especially those sponsored by industry. Currently, there is no good evidence to support the use of glucosamine for hip or knee OA and an absence of evidence to support specific consideration of glucosamine for any clinically relevant OA subgroup according to baseline pain severity, BMI, sex, structural abnormalities or presence of inflammation., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objective: To determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice., Design: Two-arm cluster randomised controlled trial., Setting: Eight general practices in Cheshire, Shropshire, or Staffordshire UK., Participants: General practitioners and nurses with patients consulting with clinical OA., Intervention: Following six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators., Outcomes: Quality of OA care over six months recorded in the medical record., Results: 1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4-28%), exercise (4-22%) and weight loss (1-15%) in intervention practices but not controls (1-3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38)., Conclusions: The intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care., Trial Registration Number: ISRCTN06984617., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Despite a lack of service provision for people with osteoarthritis (OA), each year 1 in 5 of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery., Methods: A training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires., Results: The pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics., Conclusions: A significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE., Trial Registration: The cluster trial linked to this training was conducted from May 2012 through February 2014 by the Arthritis Research UK Primary Care Centre, Keele University, UK (Trial registration number ISRCTN06984617 ).

Background: Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months., Method/design: A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up., Discussion: The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions., Trial Registration: Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

Background: The National Institute for Health and Care Excellence's Osteoarthritis (OA) guidelines recommended that future research should consider the benefits of combination therapies in people with OA across multiple joint sites. However, the clinical effectiveness of such approaches to OA management is unknown. This systematic review therefore aimed to identify the clinical and cost effectiveness of multidisciplinary approaches targeting multiple joint sites for OA in primary care., Methods: A systematic review of randomised controlled trials. Computerised bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, PsychINFO, BNI, HBE, HMIC, AMED, Web of Science and Cochrane). Studies were included if they met the following criteria; a randomised controlled trial (RCT), a primary care population with OA across at least two different peripheral joint sites (multiple joint sites), and interventions undertaken by at least two different health disciplines (multidisciplinary). The Cochrane 'Risk of Bias' tool and PEDro were used for quality assessment of eligible studies. Clinical and cost effectiveness was determined by extracting and examining self-reported outcomes for pain, function, quality of life (QoL) and health care utilisation. The date range for the search was from database inception until August 2015., Results: The search identified 1148 individual titles of which four were included in the review. A narrative review was conducted due to the heterogeneity of the included trials. Each of the four trials used either educational or exercise interventions facilitated by a range of different health disciplines. Moderate clinical benefits on pain, function and QoL were reported across the studies. The beneficial effects of exercise generally decreased over time within all studies. Two studies were able to show a reduction in healthcare utilisation due to a reduction in visits to a physiotherapist or a reduction in x-rays and orthopaedic referrals. The intervention that showed the most promise used educational interventions delivered by GPs with reinforcement by practice nurses., Conclusions: There are currently very few studies that target multidisciplinary approaches suitable for OA across multiple joint sites, in primary care. A more consistent approach to outcome measurement in future studies of this nature should be considered to allow for better comparison.

Objective: To evaluate the efficacy of intra-articular (IA) glucocorticoids for knee or hip osteoarthritis (OA) in specific subgroups of patients with severe pain and inflammatory signs using individual patient data (IPD) from existing trials., Design: Randomized trials evaluating one or more IA glucocorticoid preparation in patients with knee or hip OA, published from 1995 up to June 2012 were selected from the literature. IPD obtained from original trials included patient and disease characteristics and outcomes measured. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). The subgroup factors assessed included severe pain (≥70 points, 0-100 scale) and signs of inflammation (dichotomized in present or not) at baseline. Multilevel regression analyses were applied to estimate the magnitude of the effects in the subgroups with the individuals nested within each study., Results: Seven out of 43 published randomized clinical trials (n = 620) were included. Patients with severe baseline pain had a significantly larger reduction in short-term pain, but not in mid- and long-term pain, compared to those with less severe pain at baseline (Mean Difference 13.91; 95% Confidence Interval 1.50-26.31) when receiving IA glucocorticoid injection compared to placebo. No statistical significant interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo and to tidal irrigation at all follow-up points., Conclusions: This IPD meta-analysis demonstrates that patients with severe knee pain at baseline derive more benefit from IA glucocorticoid injection at short-term follow-up than those with less severe pain at baseline., (Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition., (Published by Elsevier Ltd.)

Musculoskeletal conditions represent one of the largest causes of years lived with disability in high-income economies. These conditions are predominantly managed in primary care settings, and yet, there is a paucity of evidence on which approaches work well in increasing the uptake of best practice and in closing the evidence-to-practice gap. Increasingly, musculoskeletal models of service delivery (as components of models of care) such as integrated care, stratified care and therapist-led care have been tested in primary health care pathways for joint pain in older adults, for low back pain and for arthritis. In this chapter, we discuss why implementation of these models is important for primary care and how models are implemented using three case examples: we review implementation theory, principles and outcomes; we consider the role of health economic evaluation; and we propose key evidence gaps in this field. We propose the following research priorities for this area: investigating the generalisability of models of care across, for example, urban and rural settings, and for different musculoskeletal conditions; increasing support for self-management; understanding the importance of context in choosing a model of care; detailing how implementation has been undertaken; and evaluation of implementation and its impact., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)