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Yoga is a mind-body exercise typically done in groups in person, but this delivery method can be inconvenient, inaccessible, and costly. Effective online programs may increase access to exercise for knee osteoarthritis.To evaluate the effectiveness of an unsupervised 12-week online yoga program.Two-group superiority randomized trial. (Australian New Zealand Clinical Trials Registry: ACTRN12620000012976).Community.212 adults with symptomatic knee osteoarthritis.Both groups received online osteoarthritis information (control). The yoga group also received access to an unsupervised online yoga program delivered via prerecorded videos over 12 weeks (1 video per week, with each session to be performed 3 times per week), with optional continuation thereafter.Primary outcomes were changes in knee pain during walking (0 to 10 on a numerical rating scale) and physical function (0 to 68 on the Western Ontario and McMaster Universities Osteoarthritis Index) at 12 weeks (primary time point) and 24 weeks, analyzed using mixed-effects linear regression models. Secondary outcomes were self-reported overall knee pain, stiffness, depression, anxiety, stress, global change, quality of life, self-efficacy, fear of movement, and balance confidence. Adverse events were also collected.A total of 195 (92%) and 189 (89%) participants provided 12- and 24-week primary outcomes, respectively. Compared with control at 12 weeks, yoga improved function (between-group mean difference in change, -4.0 [95% CI, -6.8 to -1.3]) but not knee pain during walking (between-group mean difference in change, -0.6 [CI, -1.2 to 0.1]), with more yoga participants than control participants achieving the minimal clinically important difference (MCID) for both outcomes. At 12 weeks, knee stiffness, quality of life, and arthritis self-efficacy improved more with yoga than the control intervention. Benefits were not maintained at 24 weeks. Adverse events were minor.Participants were unblinded.Compared with online education, an unsupervised online yoga program improved physical function but not knee pain at 12 weeks in people with knee osteoarthritis, although the improvement did not reach the MCID and was not sustained at 24 weeks.National Health and Medical Research Council and Centres of Research Excellence.

Introduction Uptake of telehealth has surged, yet no previous studies have evaluated the clinimetric properties of clinician-administered performance-based tests of function, strength, and balance via telehealth in people with chronic lower limb musculoskeletal pain. This study investigated the: (i) test–retest reliability of performance-based tests via telehealth, and (ii) agreement between scores obtained via telehealth and in-person. Methods Fifty-seven adults aged ≥45 years with chronic lower limb musculoskeletal pain underwent three testing sessions: one in-person and two via videoconferencing. Tests included 30-s chair stand, 5-m fast-paced walk, stair climb, timed up and go, step test, timed single-leg stance, and calf raises. Test–retest reliability and agreement were assessed via intraclass correlation coefficients (ICC; lower limit of 95% confidence interval (CI) ≥0.70 considered acceptable). ICCs were interpreted as poor (0.9). Results Test–retest reliability was good-excellent with acceptable lower CI for stair climb test, timed up and go, right leg timed single-leg stance, and calf raises (ICC = 0.84–0.91, 95% CI lower limit = 0.71–0.79). Agreement between telehealth and in-person was good-excellent with acceptable lower CI for 30-s chair stand, left leg single-leg stance, and calf raises (ICC = 0.82–0.91, 95% CI lower limit = 0.71–0.85). Discussion Stair climb, timed up and go, right leg timed single-leg stance, and calf raise tests have acceptable reliability for use via telehealth in research and clinical practice. If re-testing via a different mode (telehealth/in-person), clinicians and researchers should consider using the 30-s chair stand test, left leg timed single-leg stance, and calf raise tests.

To evaluate effects of general osteoarthritis (OA) information in addition to a treatment option grid and general practitioner (GP) recommendation to exercise on treatment beliefs and intentions.An online randomized trial of 735 people 45 years old or older without OA who were recruited from a consumer survey network. Participants read a hypothetical scenario about visiting their GP for knee problems and were randomized to the following: i) 'general information', ii) 'option grid' (general information plus option grid), or iii) 'option grid plus recommendation' (general information plus option grid plus GP exercise recommendation). The primary outcome was an agreement that exercise is the best management option (0-10 numeric rating scale; higher scores indicating higher agreement that exercise is best). The secondary outcomes were beliefs about other management options and management intentions. Linear regression models estimated the mean (95% confidence interval [CI]) between-group difference in postintervention scores, adjusted for baseline.Option grid plus recommendation led to higher agreement that exercise is the best management by a mean of 0.4 units (95% CI: 0.1-0.6) compared with general information. There were no other between-group differences for the primary outcome. Option grid led to higher agreement that surgery was best, and x-rays were necessary, compared with general information (mean between-group differences: 0.7 [CI: 0.2-1.1] and 0.5 [CI: 0.1-1.0], respectively) and option grid plus recommendation (0.5 [CI: 0.1-0.9] and 0.9 [CI: 0.4-1.3]).Addition of an option grid and GP exercise recommendation to general OA information led to more favorable views that exercise was best for the hypothetical knee problem. However, differences were small and of unclear clinical importance.

ObjectivesTo determine if motion control walking shoes are superior to neutral walking shoes in reducing knee pain on walking in people with lateral knee osteoarthritis (OA).DesignParticipant-blinded and assessor-blinded, comparative effectiveness, superiority randomised controlled trial.SettingMelbourne, Australia.ParticipantsPeople with symptomatic radiographic lateral tibiofemoral OA from the community and our volunteer database.InterventionParticipants were randomised to receive either motion control or neutral shoes and advised to wear them >6 hours/day over 6 months.Primary and secondary outcome measuresThe primary outcome was change in average knee pain on walking over the previous week (11-point Numeric Rating Scale (NRS), 0–10) at 6 months. The secondary outcomes included other measures of knee pain, physical function, quality of life, participant-perceived change in pain and function, and physical activity.ResultsWe planned to recruit 110 participants (55 per arm) but ceased recruitment at 40 (n=18 motion control shoes, n=22 neutral shoes) due to COVID-19-related impacts. All 40 participants completed 6-month outcomes. There was no evidence that motion control shoes were superior to neutral shoes for the primary outcome of pain (mean between-group difference 0.4 NRS units, 95% CI −1.0 to 1.7) nor for any secondary outcome. The number of participants experiencing any adverse events was similar between groups (motion control shoes: n=5, 28%; neutral shoes: n=4, 18.2%) and were minor.ConclusionsMotion control shoes were not superior to neutral shoes in improving knee pain on walking in symptomatic radiographic lateral tibiofemoral joint OA. Further research is needed to identify effective treatments in this important but under-researched knee OA subgroup.Trial registration numberACTRN12618001864213.

Background In March 2020, staff began dealing with the effects of COVID-19. When the complementary therapy team returned from furlough, they created a new programme of support for patients, carers and staff, working remotely and social distanced as hands-on treatments were put on hold. Aims To use the hospice complementary therapists’ skills and experience to support staff and strengthen the resilience of healthcare workers. To provide much needed support to patients and carers to improve their mental health and wellbeing through this challenging time. Methods Access to one-to-one consultations with an Ayrshire Hospice complementary therapist, remotely via video call or telephone and face-to-face where safe to do so. Bespoke aromatherapy products to support wellbeing delivered inhouse and to homes. Relaxation and self-management advice for staff, patients and carers. A comfortable space in which to relax and recharge and provide socially distanced treatments – such as Reiki, yoga, qi gong, mindfulness. Wellbeing group sessions for staff x weekly online: Massage self-treatment, qi gong, relaxation, mindfulness, breathwork, yoga. Regular relaxation sessions for patients and carers on new virtual day services. Staff access to recorded wellbeing sessions on the intranet. Evaluation developed – Identification of key issues experienced by staff Outcomes Support service to staff evaluated extremely well - evidence of feeling supported and understood, improved sleep, stress reduction. Self-help tools given to empower people to manage their own wellbeing moving forward. Staff have continued access to weekly wellbeing sessions on the intranet. Future plans to share the library of our recorded wellbeing sessions with outside agencies such as local council and prison, for a small cost and use for fundraising. Ability to reach patients and carers to support them without the need to travel to the hospice. Blended approach to delivering complementary therapy service to reach more people.

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

Background Differences in pain self-efficacy between individuals with chronic low back pain (CLBP) may partly explain why response to exercise varies. The aim of this study was to determine if pain self-efficacy influences initial forward bending following an exercise intervention in adults with CLBP. Methods A total of 69 adults (18-65 years old) with moderate-severe CLBP-related disability who presented to a primary care physiotherapy clinic in Melbourne, Australia underwent baseline assessment of pain self-efficacy, pain intensity and kinesiophobia, prior to participation in one of two 12-week exercise interventions. Two outcome measures (lumbar and hip flexion range of motion (ROM) over the first quarter of forward bending from stance), were assessed at baseline, 6 and 12-weeks. Multiple linear mixed-effects modelling was performed for each outcome measure. Results For every 10-point increase in baseline pain self-efficacy, lumbar flexion ROM during initial bending decreased by an estimated mean 0.51 (95% CI: -1.41, 0.39) and 0.94 (95% CI: -1.75, -0.13) degrees at 6 and 12-weeks, respectively. Similarly, hip flexion ROM during initial bending decreased by an estimated mean 1.64 (95% CI: -3.70, 0.41) and 1.43 (95% CI: -3.34, 0.48) degrees at 6 and 12-weeks, respectively, per 10-point increase in baseline pain self-efficacy. Conclusions Pain self-efficacy did not influence initial forward bending following a 12-week exercise intervention. As the exercises were not targeted to improve bending, further research is required to verify these findings. Key message Pain self-efficacy may not explain variations in initial forward bending following an exercise intervention in adults with CLBP.

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

To determine whether patients presenting to the emergency department (ED) with possible benign paroxysmal positional vertigo (BPPV) are managed in accordance with best practice guidelines, and whether physiotherapists are involved in their care. Retrospective observational study. Ninety-six consecutive patients presenting to one of three EDs with vertigo, dizziness or imbalance symptoms documented at triage. Individuals with a clear non-vestibular cause of symptoms were excluded. Proportional adherence to clinical practice guidelines by medical and physiotherapy clinicians, primary diagnosis, incidence of falls, admission to hospital, and referral to a physiotherapy service. Adherence to clinical practice guidelines by both professions was low, with only 25 (26%, 95% CI: 18–36%) and 3 (14%, 95% CI: 4–36%) patients assessed by a medical clinician or physiotherapist, respectively, receiving the gold-standard Dix–Hallpike test. Sixty-four (67%) individuals were given a diagnosis of undifferentiated dizziness. Of the 26 (27%) patients with a primary BPPV diagnosis, only three (12%) were treated with a canalith-repositioning technique, and four (15%) reviewed by a physiotherapist. Adherence to best-practice guidelines for the management of BPPV in individuals presenting to the ED is low, and physiotherapists are seldom involved in their management.

Objective To identify factors related to single-leg standing balance in individuals with medial compartment knee osteoarthritis (OA). Methods This cross-sectional study assessed clinical, demographic, and biomechanical measures in 57 individuals and their relationships with single-leg standing balance. Differences in age, mass, symptoms, knee pain, radiographic severity, lower extremity alignment, and hip and knee extension as well as hip abduction torques were compared between those who could and could not perform 3 trials of single-leg standing balance. Multiple regression was used to identify predictors of center of pressure (COP) path length in those who could complete the task. Results Thirty-four individuals (60%) successfully completed all 3 single-leg standing balance trials and were significantly younger (P = 0.003) than those who could not. No other variable was significantly different between the groups. Disease severity, number of painful knees, lower extremity alignment, pain intensity, and quadriceps torque were all significant predictors of COP path length. Specifically, better single-leg standing balance (smaller COP path length) was related to more severe radiographic changes and stronger quadriceps, those with bilateral symptoms, and to less varus malalignment and knee pain. Conclusion Single-leg standing balance in those with medial knee OA is related to the modifiable factors lower extremity alignment, knee pain, and quadriceps strength. Given the reduced balancing ability in this patient population, interventions targeting these factors are necessary.

Objective To compare the strength of the hip musculature in people with symptomatic medial knee osteoarthritis (OA) with asymptomatic controls. Methods Eighty-nine people with knee OA and 23 controls age >50 years were recruited from the community. The maximal isometric strength (torque relative to body mass) of the hip abductors, adductors, flexors, extensors, and internal and external rotators was evaluated using hand-held dynamometry or a customized force transducer apparatus. Univariate linear models with age and sex included as covariates were used to compare muscle strength between groups. Results In people with knee OA, significant strength deficits were evident for all hip muscle groups evaluated (P < 0.05). Compared with controls, strength deficits ranged from 16% (hip extensors) to 27% (hip external rotators) after accounting for differences in sex and age between groups. Conclusion People with knee OA demonstrate significant weakness of the hip musculature compared with asymptomatic controls. It is not clear if hip muscle weakness precedes the onset of knee OA or occurs as a consequence of disease. Findings from this study support the inclusion of hip strengthening exercises in rehabilitation programs.

Importance There is limited evidence supporting use of physical therapy for hip osteoarthritis. Objective To determine efficacy of physical therapy on pain and physical function in patients with hip osteoarthritis. Design, Setting, and Participants Randomized, placebo-controlled, participant- and assessor-blinded trial involving 102 community volunteers with hip pain levels of 40 or higher on a visual analog scale of 100 mm (range, 0-100 mm; 100 indicates worst pain possible) and hip osteoarthritis confirmed by radiograph. Forty-nine patients in the active group and 53 in the sham group underwent 12 weeks of intervention and 24 weeks of follow-up (May 2010-February 2013) Interventions Participants attended 10 treatment sessions over 12 weeks. Active treatment included education and advice, manual therapy, home exercise, and gait aid if appropriate. Sham treatment included inactive ultrasound and inert gel. For 24 weeks after treatment, the active group continued unsupervised home exercise while the sham group self-applied gel 3 times weekly. Main Outcomes and Measures Primary outcomes were average pain (0 mm, no pain; 100 mm, worst pain possible) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, 0 no difficulty to 68 extreme difficulty) at week 13. Secondary outcomes were these measures at week 36 and impairments, physical performance, global change, psychological status, and quality of life at weeks 13 and 36. Results Ninety-six patients (94%) completed week 13 measurements and 83 (81%) completed week 36 measurements. The between-group differences for improvements in pain were not significant. For the active group, the baseline mean (SD) visual analog scale score was 58.8 mm (13.3) and the week-13 score was 40.1 mm (24.6); for the sham group, the baseline score was 58.0 mm (11.6) and the week-13 score was 35.2 mm (21.4). The mean difference was 6.9 mm favoring sham treatment (95% CI, −3.9 to 17.7). The function scores were not significantly different between groups. The baseline mean (SD) physical function score for the active group was 32.3 (9.2) and the week-13 score was 27.5 (12.9) units, whereas the baseline score for the sham treatment group was 32.4 (8.4) units and the week-13 score was 26.4 (11.3) units, for a mean difference of 1.4 units favoring sham (95% CI, −3.8 to 6.5) at week 13. There were no between-group differences in secondary outcomes (except greater week-13 improvement in the balance step test in the active group). Nineteen of 46 patients (41%) in the active group reported 26 mild adverse effects and 7 of 49 (14%) in the sham group reported 9 mild adverse events ( P = .003). Conclusions and Relevance Among adults with painful hip osteoarthritis, physical therapy did not result in greater improvement in pain or function compared with sham treatment, raising questions about its value for these patients. Trial Registration anzctr.org.au Identifier:ACTRN12610000439044

SummaryObjectiveTo determine whether hip abductor and adductor muscle strengthening reduces medial compartment knee load and improves symptoms in people with medial tibiofemoral OA and varus malalignment.MethodsIn a randomised controlled trial, 89 participants were randomly allocated to a hip strengthening group or to a control group with no intervention. The strengthening group performed a physiotherapist-supervised home exercise program targeting the hip abductor and adductor muscles for 12 weeks. The primary outcome was the peak external knee adduction moment measured using three-dimensional gait analysis by a blinded assessor. Secondary outcomes included a pain numeric rating scale, Western Ontario and McMaster Universities Osteoarthritis Index, step test, stair climb test, maximum isometric strength of hip and quadriceps muscles and participant-perceived rating of overall change. Intention-to-treat analyses were performed using linear regression modelling adjusting for baseline outcomes and other characteristics.ResultsThe trial was completed by 76/89 participants (85%). There was no significant between-group difference in change in the knee adduction moment [mean difference (95% confidence interval (CI)) 0.134 (−0.069 to 0.337) Nm/BW×HT%]. All pain, physical function and muscle strength measures showed significantly greater improvement in the strengthening group (all P