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Summary Objective To investigate heterogeneous effects of a combination of conservative therapies compared with an education comparator for thumb base (TB) osteoarthritis (OA) according to clinically relevant characteristics. Methods Pre-planned subgroup analysis of the COMBO trial (n = 204) which compared a combination of education on self-management and ergonomic principles, a prefabricated neoprene splint, hand exercises, and diclofenac sodium gel, with education alone for radiographic and symptomatic TB OA. Primary outcomes were change in pain (visual analogue scale [VAS], 0–100 mm) and hand function (Functional Index for Hand Osteoarthritis questionnaire, 0–30) from baseline to week-6. Other outcomes were grip and tip-pinch strength and patient's global assessment (PGA) (VAS, 0–100 mm). Possible treatment effect modifiers were the presence of interphalangeal joint pain, erosive hand OA, radiographic thumb carpometacarpal joint subluxation (higher vs equal or lower than the sample mean), and baseline radiographic OA severity (Kellgren Lawrence grade). Linear regression models were fitted, adding interaction terms for each subgroup of interest. Results The treatment effects of the combined intervention at 6 weeks were greater in participants with lower joint subluxation compared with those with greater subluxation (pain −11.6 [95%CI −22.2, −9.9] and 2.6 [−5.5, 10.7], respectively, difference between the subluxation groups 14.2 units (95% CI 2.3, 26.1), p-value 0.02; and PGA −14.0 [−22.4, −5.5] and 1.5 [−6.2, 9.3), respectively, difference between the subluxation groups 15.5 units (95% CI 4.2, 26.8), p-value 0.03). There was no statistically significant heterogeneity for the other subgroups. Conclusion A combination of conservative therapies may provide greater benefits over 6 weeks in individuals with lower joint subluxation, although the clinical relevance is uncertain given the wide confidence intervals. Treatment strategies may need to be customized for those with greater joint subluxation. Trial registration number ACTRN 12616000353493.

Objectives To examine whether a hip brace can improve hip health quality-of-life (QoL) and is well-tolerated in people with femoroacetabular impingement syndrome (FAIS) or symptomatic labral tears after 6 weeks of wear. Design Parallel, two-arm, exploratory randomized trial. Setting Hospital and private clinics of orthopaedic surgeons. Participants Individuals >18 years with FAIS or labral tears. Interventions Usual conservative care versus usual conservative care plus a hip brace. Main outcomes Patient-reported outcomes were assessed with the International Hip Outcome Tool (iHOT-33), and Copenhagen Hip and Groin Outcome Scores (HAGOS). Brace acceptability was measured using the Quebec User Evaluation of Satisfaction with Assistive Technology survey. Independent t-tests assessed between-group differences. Results Thirty-eight participants were recruited, 19 each group, 60% women, mean age 39.3 ± 11.8 years, body mass index 25.3 ± 4.4 kg/m2, iHOT-33 36.6 ± 24.8. Three participants dropped out (one usual care, 2 braced). The mean between-group difference for iHOT-33 was 19.4 (95% confidence interval [CI] 1.68-37.06, P = 0.03) favoring the brace. There were improvements in most HAGOS subscale scores favoring the brace. Issues with brace tolerability for some participants were perceived comfort and effectiveness. Three brace-related adverse events were reported. Conclusion Between-group differences favored the braced group for hip health QoL, pain, symptoms, and function. Although these were promising results, the CIs for the estimates were wide, the small sample size likely a contributing factor. Our results suggest that further investigation of the brace is warranted, we calculated sample sizes and made recommendations for the design of a future trial.

The study aimed to determine how much change in neurogenic claudication spinal surgeons expect in patients following lumbar decompression for lumbar spine stenosis (LSS), and radicular leg pain following microdiscectomy. Secondary aims were to identify surgeons’ preferences regarding surgical techniques for lumbar decompression, and their rating of the quality of current evidence for lumbar decompression. All Australian spine surgeons were invited, of whom 71 completed the survey (31% response rate). Only registered spinal surgeons were included. The online survey, administered using REDCap, included 4 sections: demographics and background; expected change in symptoms on a +/− 100% scale (−100% worst, 0% no change and 100% best possible); surgical preference; and rating of current evidence for lumbar decompression compared with other treatments. There were 71 complete responses, 76% were neurosurgeons (N = 54), predominantly male (96%; N = 68). On average, surgeons expected an 86% (median: 87%, inter-quartile range (IQR): 80%, 91%) improvement in neurogenic claudication following lumbar decompression for LSS and 89% (median: 91%, IQR: 85%, 95%) improvement in radicular pain following microdiscectomy. A multiple linear regression found no surgeon characteristics were associated with expected change following surgery. The preferred surgical technique for LSS was full laminectomy (58%; N = 41). Thirty-five percent of surgeons accurately rated the evidence supporting the superiority of lumbar decompression compared with non-surgical care for LSS as low quality. Spine surgeons expect large symptom improvements following lumbar decompression and microdiscectomy. Understanding of the current evidence was higher for lumbar decompression with fusion, than for decompression alone for LSS.

OBJECTIVE: The aim of the review was to appraise clinical practice guidelines and their recommendations for the treatment of lumbar spinal stenosis.METHODS: PubMed, Medline, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched up until 25/01/2020 for clinical practice guidelines on the management of lumbar spinal stenosis with a systematic process to generate recommendations and were publicly available.RESULTS: Ten guidelines were included, with a total of 76 recommendations for the treatment of lumbar spinal stenosis. Only 4 of the 10 guidelines were of satisfactory methodological quality according to the AGREE II instrument. Around three-quarters of recommendations (72.4%) were presented with poor evidence, with the remaining 21 presenting (27.6%) fair evidence. No recommendation presented good evidence. Recommendations were made on four types of interventions: surgery, injections, medications, and other nonsurgical treatments, with supporting evidence similar for all four treatment types. Positive recommendations were more common for injections (12/13=92.3%) and surgery (10/15=66%) than for nonsurgical treatments (6/21=28.6%) or medications (1/27=3.75%).CONCLUSIONS: Ten guidelines on the management of lumbar spinal stenosis were identified in the systematic review, but only four were of adequate methodological quality. While the evidence underpinning the various types of interventions was similar, guidelines tended to endorse surgery and injections but not nonsurgical interventions and medicines. These results support the need for greater rigor and inclusion of steps to minimize bias in the production of guidelines.

Osteoarthritis (OA) is a leading cause of disability. Clinical practice guidelines recommend education on OA management, exercise, and weight control. However, many people with OA do not receive this recommended OA care. Some health care professionals (HCPs) lack the knowledge and skills to deliver recommended OA care. This article presents a framework to guide the development and evaluation of education and training for HCPs in the delivery of evidence-based OA care including: (1) Overarching principles for education and training; (2) Core capabilities for the delivery of best evidence OA care; (3) Theories of learning and preferences for delivery; (4) Evaluation of education and training.

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

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.

Improving the health and well-being of people with osteoarthritis (OA) requires effective action beyond health service delivery. Integration of the different contexts and settings in which people live, work, and socialize, also known as the social determinants of health (SDH), with health care has the potential to provide additional benefits to health and well-being outcomes compared with traditional OA care. This article explores how SDH can impact the lives of people with OA, how SDH intersect at different stages of OA progression, and opportunities for integrating SDH factors to address the onset and management of OA across the life course.

To determine factors associated with hospital admissions from ED presentations for low back pain (LBP).This was a retrospective analysis of 147 ED centres in New South Wales (NSW), Australia, between 2005 and 2014. Data were accessed from the NSW Emergency Department Data Collection to determine patients who attended ED and whether or not they were admitted to hospital.There were 1 388 078 ED visits for LBP across 147 different ED centres between 2005 and 2014. Between 2005 and 2013, hospital admission rates from ED visits for LBP increased annually by 5.1% (95% confidence interval [CI] 3.9-6.4) from 477 per 100 000 in 2005 to 730 per 100 000 in 2013. Patients who were under injured workers' insurance (i.e. workers compensation insurance) had significantly lower odds (odds ratio [OR] 0.42, 95% CI 0.40-0.43) of being admitted to hospital for LBP compared with those not on injured workers' insurance. Patients living in the highest socioeconomic areas were also more likely to be admitted to hospital from an ED visit, compared with those from the lowest socioeconomic areas (OR 1.26, 95% CI 1.24-1.29).Rates of hospitalisation following attendance to ED for LBP increased annually by 5% between 2005 and 2013. Hospital admission rates were lower among patients from the lowest socioeconomic areas or under injured workers' compensation insurance.

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

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

HIGHLIGHTS • A text message intervention was developed to support recovery from low back pain. • An iterative process with clinicians, researchers, and consumers was conducted. • This study offers scientific support for the elaboration of future interventions., Objective To develop a bank of text messages for a lifestyle-based self-management intervention for people with low back pain (LBP). Design Iterative development process. Setting Community and primary care. Participants Fifteen researchers, clinicians, and consumer representatives participated in the concept and initial content development phase. Twelve experts (researchers and clinicians) and 12 consumers participated in the experts and consumers review phase. Full study sample of participants was N=39. Interventions Not applicable. Main Outcome Measures We first conducted two 2-hour workshops to identify important domains for people with LBP, sources of content, appropriate volume, and timing of the messages. The messages were then drafted by a team of writers. Second, we invited expert researchers and clinicians to review and score the messages using a 5-item psychometric scale according to (1) the appropriateness of the content and (2) the likelihood of clinical effectiveness and to provide written feedback. Messages scoring ≤8 out of 10 points would be modified accordingly. Consumers were invited to review the messages and score them using a 5-item psychometric scale according to the utility of the content, the understanding of the content, and language acceptability and to provide feedback. Messages scoring ≤12 out of 15 points would be improved. Results Exercise, education, mood, sleep, use of care, and medication domains were identified and 82 domain-specific evidence-based messages were written. Messages received a mean score of 8.3 out of 10 points by experts. Twenty-nine messages were modified accordingly. The mean score of the messages based on consumers feedback was of 12.5 out of 15 points. Thirty-six messages were improved. Conclusions We developed a bank of text messages for an evidence-based self-management intervention using a theory-based, iterative, codesign process with researchers, consumers, and clinicians. This article provides scientific support for future development of text message interventions within the pain field.

Objectives: The primary objective was to examine baseline patient activation as a prognostic factor for changes in pain and function following participation in an osteoarthritis management program. The secondary objective was to examine other prognostic factors from existing literature (e.g. employment, functional performance, depression, comorbidities). Method: One-hundred-and-eleven participants with knee osteoarthritis were assessed at 0-, 12- and 26-weeks in this prospective clinical cohort. Demographic variables, timed-up-and-go (TUG), patient activation measure (PAM-13), Depression Anxiety Stress Scale and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were collected. Multivariable linear regression examined relationships between prognostic factors and pain and function at 12- and 26-weeks. Results: Complete 12- and 26-week data were available for 89 and 74 participants respectively, 66 ​% female, 66.8 (SD 10.0) years, 74 ​% unemployed, 66 ​% finished high school or higher, 12 ​% on joint arthroplasty waitlists. Baseline PAM-13 scores were not associated with changes in pain or function at 12- or 26-weeks. Employment status (β ​= ​9.17 (95 ​% CI 2.11, 16.24), p ​= ​0.01) and TUG (β ​= ​−1.20 (95 ​% CI -1.91, −0.49), p ​

The number of placebo surgical trials on musculoskeletal conditions is increasing, but little is known about the quality of their design and methods. This review aimed to (1) assess the level of placebo fidelity (ie, degree to which the placebo control mimicked the index procedure) in placebo trials of musculoskeletal surgery, (2) describe the trials' methodological features using the adapted Applying Surgical Placebo in Randomised Evaluations (ASPIRE) checklist, and (3) describe each trial's characteristics. We searched 4 electronic databases from inception until February 18, 2021, for randomised trials of surgery that included a placebo control for any musculoskeletal condition. Protocols and full text were used to assess placebo fidelity (categorised as minimal, low, or high fidelity). The adapted 26-item ASPIRE checklist was also completed on each trial. PROSPERO registration number: CRD42021202131. A total of 30,697 studies were identified in the search, and 22 placebo-controlled surgical trials of 2045 patients included. Thirteen trials (59%) included a high-fidelity placebo control, 7 (32%) used low fidelity, and 2 (9%) minimal fidelity. According to the ASPIRE checklist, included trials had good reporting of the "rationale and ethics" (68% overall) and "design" sections (42%), but few provided enough information on the "conduct" (13%) and "interpretation and translation" (11%) of the placebo trials. Most trials sufficiently reported their rationale and ethics, but interpretation and translation are areas for improvement, including greater stakeholder involvement. Most trials used a high-fidelity placebo procedure suggesting an emphasis on blinding and controlling for nonspecific effects.

Summary Objective The RADIANT study aimed to investigate the efficacy and safety of a complementary medicine supplement combination in people with hand osteoarthritis (HOA). Method This was an internet-based, double-blind, randomised, placebo-controlled trial. Participants aged over 40 years with symptomatic HOA with radiographic confirmation (Kellgren Lawrence grade ≥ 2) throughout Australia were recruited and randomly assigned (1:1) to receive either a supplement combination composed of Boswellia serrata extract 250 mg/day, pine bark extract 100 mg/day, methylsulfonylmethane 1,500 mg/day and curcumin 168 mg/day or placebo for 12 weeks. The primary outcome was change in hand pain assessed using a visual analogue scale (VAS 0–100) from baseline to week 12. A range of secondary outcomes and additional measures were recorded. Adverse events were monitored weekly. Results One hundred and six participants were included with mean age 65.6 years and 81% were women. 45% of the participants were graded as KLG 4, 40% KLG three and 39 (37%) had erosive OA. There was no significant difference in pain VAS reduction between groups. The adjusted between group difference in means (95%CI) was 5.34 (−2.39 to 13.07). Five participants (10%) in the supplement combination group discontinued study treatment due to AE vs four participants (7%) in the placebo group. Conclusion There were no significant differences in symptomatic relief between the two groups over 12 weeks. These findings do not support the use of the supplement combination for treating hand pain in people with HOA. Registration Prospectively registered (Australian New Zealand Clinical Trials Registry ACTRN12619000835145, 31/05/2019).

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. Various core and adjunctive therapies are available for osteoarthritis (OA) that can have beneficial effects on the well-being of the individual; however, challenges remain in implementing best-evidence, high-value care.

Background The Patient Activation Measure (PAM-13) was developed using Rasch analysis to assess knowledge, skills and confidence in the management of one’s health. Previous studies report positive relationships between PAM-13 scores, self-management behaviours and longitudinal health outcomes in adults with chronic disease. There is little extant measurement property evidence for the use of PAM-13 in specific osteoarthritis (OA) populations. This study tested measurement properties of the PAM-13 in people living with hip and knee OA. Methods Item response frequency analysis was conducted. Rasch analysis evaluated the fit of the PAM-13 data to the Rasch model. Model-data fit was evaluated using infit and outfit statistics; person/item reliability and person separation indices were computed. Unidimensionality was evaluated using Principal Components Analysis of Rasch residuals and the data were assessed for item redundancy. Differential Item Functioning (DIF) examined bias in respondent subgroups and correlations tested relationships between PAM-13 and other patient-reported outcomes. Results Two-hundred-and-seventeen PAM-13 surveys were completed; there were no missing responses, floor or ceiling effects. Person and item reliability were acceptable (0.98 and 0.87 respectively) with good separation (person separation index 2.58). Unidimensionality was evaluated, with 49.4% of the variance explained by the first eigenvector. There was evidence of potential local response-dependence. The Rasch fit statistics were acceptable (except for item-2). There were some issues identified with targeting of the PAM-13 items to people with higher ability and the item difficulty order was different to that proposed in original cohorts. Significant DIF was identified for sex and educational level for a small number of items. PAM-13 scores were moderately correlated with depressive symptoms on the Depression Anxiety Stress Scale and Assessment of Quality of Life-6D. There were small correlations between PAM-13 and Knee injury and Osteoarthritis Outcome Score pain and activities of daily living scores. Conclusions This study provides some evidence of adequate person and item reliability, unidimensionality, and construct validity to support the use of PAM-13 to measure patient activation in people living with hip and knee OA. Possible limitations regarding targeting, different item difficulty order, DIF and local response dependence should be investigated in future research.

Knowledge of patellofemoral osteoarthritis (OA) pain trajectories is vital to helping clinicians and patients make shared disease-specific decisions regarding treatment options and coping strategies.To describe the pain trajectories of people living with patellofemoral OA who present to a chronic care management program, and to explore baseline characteristics associated with different trajectories.In this prospective longitudinal cohort study, 88 participants who presented to a chronic care management program reported their worst pain over the previous week at baseline and at 6, 12, 18, and 26 weeks using a 10-cm visual analog scale. Trajectories (classes) were identified using latent class growth analysis. Demographics, pain, physical performance, strength, quality of life, mental health, and lower limb/foot structural measures obtained at baseline were assessed for association with trajectory class membership.Individuals in class 1 (28%) exhibited high, persistent pain from baseline (7.8 ± 1.7 cm), which continued over time (P = .52). Class 2 (57%) displayed moderate baseline pain (4.8 ± 1.8 cm), which also remained persistent (P = .97). Individuals in class 3 (15%) showed low, improving pain (baseline pain, 2.6 ± 1.2 cm) over time (P = .017). At baseline, poor Knee injury and Osteoarthritis Outcome Score (KOOS) scores, local and proximal sensitivity to pressure, and lower knee extensor strength were associated with increased odds of following the high-pain trajectory (range [95% confidence interval], 1.03 [1.00, 1.07] to 16.24 [2.53, 104.34]).Distinct pain trajectories appear to exist in people with patellofemoral OA presenting to a chronic care management program. Baseline variables may be useful for identifying individuals at risk of poorer prognosis. Larger studies are needed to confirm the efficacy of this finding.Prognosis, level 2b. J Orthop Sports Phys Ther 2019;49(1):5-16. Epub 12 Sep 2018. doi:10.2519/jospt.2019.8354.

Background Online support groups (OSGs) are one way for people with chronic diseases, their family or friends, and health professionals to communicate, gain information, and provide social support. As the number of peer-to-peer OSGs for chronic musculoskeletal conditions grows, it is important to gain insight into the different designs of groups available, who is accessing them, if and how they may be effective, and what strategies are being used to implement or increase consumer engagement. Objective The objectives of this systematic review of people with musculoskeletal conditions were to (1) describe the design features (functions, usage options, moderation, and expert input) of peer-to-peer OSGs, (2) describe the characteristics of the individuals using peer-to-peer OSGs, (3) synthesize the evidence on outcomes of participation, and (4) identify strategies used in the delivery and maintenance of OSGs. Methods A search comprising terms related to the population (people with musculoskeletal disorders) and the intervention (peer-to-peer OSGs) was conducted in 6 databases. Results were filtered from 1990 (internet inception) to February 2019. Studies identified in the search were screened according to predefined eligibility criteria using a 2-step process. Quantitative studies were appraised by 2 reviewers using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Qualitative studies were appraised by 2 different reviewers using the Critical Appraisal Skills Programme checklist. Extracted data were synthesized narratively. Results We examined 21 studies with low to moderate risk of bias. Of these studies, 13 studies included OSGs hosted on public platforms, 11 studies examined OSGs that were conducted in English, and 6 studies used moderators or peer leaders to facilitate engagement. Studies either reported the number of OSG members (n=1985 across all studies) or the number of posts (range: 223-200,000). The majority of OSG members were females who were not full-time employees and with varied levels of education. There were no randomized controlled trials measuring the efficacy of OSGs. Qualitative and quantitative studies identified empowerment, social support, self-management behavior, and health literacy as primary constructs to measure OSG efficacy. Neutral or marginal improvement was reported in these constructs. Sharing experiences and a greater level of engagement appeared to have an important influence on OSGs efficacy. The extent to which members posted on the website influenced engagement. Conclusions Across a diverse range of designs, languages, included features, and delivery platforms, peer-to-peer OSGs for chronic musculoskeletal conditions attract predominantly female participants of all ages and education levels. The level of participation of a member appears to be related to their perceived benefit, health literacy, and empowerment. Future studies are needed to identify which design and maintenance strategies have superior efficacy and whether there are concomitant improvements in health outcomes for people with chronic musculoskeletal conditions resulting from participation in OSGs. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42018090326; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018090326

Purpose: There is growing international interest in the implementation of structured osteoarthritis management programs (OAMPs) to deliver best evidence osteoarthritis (OA) care. A consortium of researchers, clinicians and consumers concerned with optimising implementation of OAMPs have established the ‘Joint Effort’ Initiative (the Initiative), endorsed by the Osteoarthritis Research Society International (OARSI) in 2018. A priority action of the Initiative is to evaluate the outcomes and implementation of existing OAMPs.Marked differences between existing international OAMP models include treatments offered, settings and mode of delivery, intensity, duration and health disciplines involved. There is some evidence of effectiveness from randomised controlled trials (RCTs) and longitudinal cohort studies reporting outcomes from OAMPS in different real-world settings, however, this research is still in its infancy. The effects of different OAMP models have not been compared head-to-head and given the prohibitive costs and logistics associated with comparing OAMP models in RCTs, it is unlikely that these trials will take place. Instead, we will leverage research efforts and costs that have already been spent by combining data from existing cohort studies to compare the outcomes of different OAMP models.We aim to combine Individual Patient Data (IPD) from the existing international OAMP cohorts and use meta-analytic techniques to address the following objectives: 1) Compare the short-, medium- and long-term changes in pain, physical function, body weight, Quality of Life, fear of movement and goal achievement between different OAMPs. 2) Determine the short-, medium- and long-term overall effects of OAMPs on pain and physical function for people with knee and hip OA. 3) Examine the characteristics of OAMP participants who achieved/ did not achieve the Patient Acceptable Symptom State (PASS), OMERACT-OARSI responder criteria, and completers vs dropouts. 4) Describe the implementation evaluation outcomes of OAMPsMethods: We will use de-identified IPD from nine existing OAMP clinical cohorts from Australia, Norway, Sweden, Netherlands, UK, New Zealand and USA. Clinical cohorts will be eligible if they are derived from a hip/knee OAMP in a real-world setting with the following components: i) personalised OA care; ii) package of care with reassessment and progression; iii) minimum of two core treatments of education, exercise, and/or weight-loss, and; iv) optional adjunctive treatments. We will include both published and unpublished data.Based on scoping work on the outcomes measures and time points currently collected by each OAMP, our primary outcomes will be the difference in pain (numerical rating scale 0-10) and function (Western Ontario and McMasters Osteoarthritis Index function score (WOMAC)), at 12-weeks. Secondary outcomes will be changes in pain and function at 26- and 52-weeks. Other secondary outcomes at 12-, 26- and 52- weeks will be changes in: body weight; quality of life (EuroQol, Short Form 12); disease specific measures (Knee Injury and Osteoarthritis Outcome score, Hip Disability and Osteoarthritis Outcome score, WOMAC); functional performance (30-second chair stand test, six-minute walk test); fear of movement; and patient satisfaction. We will report against the PASS, OMERACT-OARSI definition of responders/non-responders and examine implementation outcomes where available including the Osteoarthritis Quality Indicator Questionnaire, uptake, reach and fidelity.The IPD will be harmonised and aggregated to create one large dataset. We will use descriptive statistics to compare the characteristics of participants across OAMPs. We will take a two-step approach to IPD meta-analytic techniques. First, we will estimate the change in outcomes for each OAMP (pain, function and other outcomes) with multivariable regression modelling. Second, we will weight and pool estimates using random-effects methods to determine the overall effects on pain and function, account for differences in effects across studies and examine prognostic effects and interactions of characteristics (e.g. baseline symptomatic severity, functional performance) of participants who achieved/did not achieve the PASS, OMERACT OARSI responder criteria and those who completed/dropped out of the OAMPs.Results: This study has received ethical approval from the NSLHD Human Research Ethics Committee (Australia). Ethical approval for use of other cohort data is being sought by researchers in their respective countries. We have performed extensive work with the stakeholders involved to identify appropriate co-collected outcomes and will collaborate with the OA Trial Bank to store and collate the cohort data, the first database of its kind.Conclusions: This project will be the first to compare patient and implementation outcomes across international OAMPs. It will address a priority of the Initiative and make recommendations on the “optimal” OAMP model/s to use.

The burden of non-communicable diseases, such as osteoarthritis (OA), continues to increase for individuals and society. Regrettably, in many instances, healthcare professionals fail to manage OA optimally. There is growing disparity between the strength of evidence supporting interventions for OA and the frequency of their use in practice. Physical activity and exercise, weight management and education are key management components supported by evidence yet lack appropriate implementation. Furthermore, a recognition that treatment earlier in the disease process may halt progression or reverse structural changes has not been translated into clinical practice. We have largely failed to put pathways and procedures in place that promote a proactive approach to facilitate better outcomes in OA. This paper aims to highlight areas of evidence-based practical management that could improve patient outcomes if used more effectively.

Background Osteoarthritis (OA) is a major problem globally. First-line management comprises education and self-management strategies. Online support groups may be a low-cost method of facilitating self-management. Objective The aim of this randomized controlled pilot study is to evaluate the feasibility of the study design and implementation of an evidence-informed, expert-moderated, peer-to-peer online support group (My Knee Community) for people with knee OA. The impacts on psychological determinants of self-management, selected self-management behaviors, and health outcomes were secondary investigations. Methods This mixed methods study evaluated study feasibility (participant recruitment, retention, and costs), experimental intervention feasibility (acceptability and fidelity to the proposed design, including perceived benefit, satisfaction, and member engagement), psychological determinants (eg, self-efficacy and social support), behavioral measures, health outcomes, and harms. Of a total of 186, 63 (33.9%) participants (41/63, 65% experimental and 22/63, 35% control) with self-reported knee OA were recruited from 186 volunteers. Experimental group participants were provided membership to My Knee Community, which already had existing nonstudy members, and were recommended a web-based education resource (My Joint Pain). The control group received the My Joint Pain website recommendation only. Participants were not blinded to their group allocation or the study interventions. Participant-reported data were collected remotely using web-based questionnaires. A total of 10 experimental group participants also participated in semistructured interviews. The transcribed interview data and all forum posts by the study participants were thematically analyzed. Results Study feasibility was supported by acceptable levels of retention; however, there were low levels of engagement with the support group by participants: 15% (6/41) of participants did not log in at all; the median number of times visited was 4 times per participant; only 29% (12/41) of participants posted, and there were relatively low levels of activity overall on the forum. This affected the results for satisfaction (overall mean 5.9/10, SD 2.7) and perceived benefit (17/31, 55%: yes). There were no differences among groups for quantitative outcomes. The themes discussed in the interviews were connections and support, information and advice, and barriers and facilitators. Qualitative data suggest that there is potential for people to derive benefit from connecting with others with knee OA by receiving support and assisting with unmet informational needs. Conclusions Although a large-scale study is feasible, the intervention implementation was considered unsatisfactory because of low levels of activity and engagement by members. We recommend that expectations about the support group need to be made clear from the outset. Additionally, the platform design needs to be more engaging and rewarding, and membership should only be offered to people willing to share their personal stories and who are interested in learning from the experiences of others. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12619001230145; http://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377958

Importance Most clinical guidelines do not recommend platelet-rich plasma (PRP) for knee osteoarthritis (OA) because of lack of high-quality evidence on efficacy for symptoms and joint structure, but the guidelines emphasize the need for rigorous studies. Despite this, use of PRP in knee OA is increasing. Objective To evaluate the effects of intra-articular PRP injections on symptoms and joint structure in patients with symptomatic mild to moderate radiographic medial knee OA. Design, setting, and participants This randomized, 2-group, placebo-controlled, participant-, injector-, and assessor-blinded clinical trial enrolled community-based participants (n = 288) aged 50 years or older with symptomatic medial knee OA (Kellgren and Lawrence grade 2 or 3) in Sydney and Melbourne, Australia, from August 24, 2017, to July 5, 2019. The 12-month follow-up was completed on July 22, 2020. Interventions Interventions involved 3 intra-articular injections at weekly intervals of either leukocyte-poor PRP using a commercially available product (n = 144 participants) or saline placebo (n = 144 participants). Main outcomes and measures The 2 primary outcomes were 12-month change in overall average knee pain scores (11-point scale; range, 0-10, with higher scores indicating worse pain; minimum clinically important difference of 1.8) and percentage change in medial tibial cartilage volume as assessed by magnetic resonance imaging (MRI). Thirty-one secondary outcomes (25 symptom related and 6 MRI assessed; minimum clinically important difference not known) evaluated pain, function, quality of life, global change, and joint structures at 2-month and/or 12-month follow-up. Results Among 288 patients who were randomized (mean age, 61.9 [SD, 6.5] years; 169 [59%] women), 269 (93%) completed the trial. In both groups, 140 participants (97%) received all 3 injections. After 12 months, treatment with PRP vs placebo injection resulted in a mean change in knee pain scores of -2.1 vs -1.8 points, respectively (difference, -0.4 [95% CI, -0.9 to 0.2] points; P = .17). The mean change in medial tibial cartilage volume was -1.4% vs -1.2%, respectively (difference, -0.2% [95% CI, -1.9% to 1.5%]; P = .81). Of 31 prespecified secondary outcomes, 29 showed no significant between-group differences. Conclusions and relevance Among patients with symptomatic mild to moderate radiographic knee OA, intra-articular injection of PRP, compared with injection of saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months. These findings do not support use of PRP for the management of knee OA. Trial registration Australian New Zealand Clinical Trials Registry Identifier: ACTRN12617000853347.

ObjectiveTo investigate the efficacy and safety of dietary supplements for patients with osteoarthritis.DesignAn intervention systematic review with random effects meta-analysis and meta-regression.Data sourcesMEDLINE, EMBASE, Cochrane Register of Controlled Trials, Allied and Complementary Medicine and Cumulative Index to Nursing and Allied Health Literature were searched from inception to April 2017.Study eligibility criteriaRandomised controlled trials comparing oral supplements with placebo for hand, hip or knee osteoarthritis.ResultsOf 20 supplements investigated in 69 eligible studies, 7 (collagen hydrolysate, passion fruit peel extract, Curcuma longa extract, Boswellia serrata extract, curcumin, pycnogenol and L-carnitine) demonstrated large (effect size >0.80) and clinically important effects for pain reduction at short term. Another six (undenatured type II collagen, avocado soybean unsaponifiables, methylsulfonylmethane, diacerein, glucosamine and chondroitin) revealed statistically significant improvements on pain, but were of unclear clinical importance. Only green-lipped mussel extract and undenatured type II collagen had clinically important effects on pain at medium term. No supplements were identified with clinically important effects on pain reduction at long term. Similar results were found for physical function. Chondroitin demonstrated statistically significant, but not clinically important structural improvement (effect size −0.30, –0.42 to −0.17). There were no differences between supplements and placebo for safety outcomes, except for diacerein. The Grading of Recommendations Assessment, Development and Evaluation suggested a wide range of quality evidence from very low to high.ConclusionsThe overall analysis including all trials showed that supplements provided moderate and clinically meaningful treatment effects on pain and function in patients with hand, hip or knee osteoarthritis at short term, although the quality of evidence was very low. Some supplements with a limited number of studies and participants suggested large treatment effects, while widely used supplements such as glucosamine and chondroitin were either ineffective or showed small and arguably clinically unimportant treatment effects. Supplements had no clinically important effects on pain and function at medium-term and long-term follow-ups.

Aim To compare the musculoskeletal (MSK) physical examination skills, knowledge acquisition and performance of first-year medical students trained by MSK specialist tutors to students trained by non-MSK specialist tutors, after a 6-week MSK physical examination tutorial program. Methods Twenty-first year medical students took part in the study. They were recruited into two groups, according to their exposure to either an MSK specialist or a non-MSK specialist tutor during their 6-week MSK training block. Knowledge acquisition was measured via a pre- and post-training objective structured clinical examination (OSCE). We assessed students’ self-belief and confidence levels regarding their newly acquired skills via a questionnaire. Independent t tests were used to examine mean group differences of OSCE scores and perceived level of confidence. Results Both groups demonstrated a significant improvement (3.9 and 3.8 points, respectively, on an eight-point scale for shoulder assessment, P < 0.01, 3.3 and 3.5, respectively, on a five-point scale for spine assessment, P < 0.01) in OSCE scores compared to baseline after completing the 6-week MSK physical examination tutorial program. There was no between-group difference in the OSCE scores from pre- to post-training (P = 0.92 for shoulder, P = 0.66 for spine) or for perceived level of confidence in performing a basic MSK examination after training (P = 0.91). Conclusion Students exposed to MSK specialist tutors did not demonstrate increased skill levels or knowledge in the area of MSK physical examination compared to those receiving the same training under the supervision of non-MSK specialist tutors. Both student groups demonstrated improvement.

BACKGROUND Studies of walking in those with femoroacetabular impingement syndrome have found altered pelvis and hip biomechanics. But a whole body, time-contiuous, assessment of biomechanical parameters has not been reported. Additionally, larger cam morphology has been associated with more pain, faster progression to end-stage osteoarthritis and increased cartilage damage but differences in walking biomechanics between large compared to small cam morphologies have not been assessed. RESEARCH QUESTION Are trunk, pelvis and lower limb biomechanics different between healthy pain-free controls and individuals with FAI syndrome and are those biomechanics different between those with larger, compared to smaller, cam morphologies? METHODS Twenty four pain-free controls were compared against 41 participants with FAI syndrome who were stratified into two groups according to their maximum alpha angle. Participants underwent three-dimensional motion capture during walking. Trunk, pelvis, and lower limb biomechanics were compared between groups using statistical parametric mapping corrected for walking speed and pain. RESULTS Compared to pain-free controls, participants with FAI syndrome walked with more trunk anterior tilt (mean difference 7.6°, p < 0.001) as well as less pelvic rise (3°, p < 0.001), hip abduction (-4.6°, p < 0.05) and external rotation (-6.5°, p < 0.05). They also had lower hip flexion (-0.06Nm⋅kg-1, p < 0.05), abduction (-0.07Nm⋅kg-1, p < 0.05) and ankle plantarflexion moments (-0.19Nm⋅kg-1, p < 0.001). These biomechanical differences occurred throughout the gait cycle. There were no differences in walking biomechanics according to cam morphology size. SIGNIFICANCE Results do not support the hypothesis that larger cam morphology is associated with larger differences in walking biomechanics but did demonstrate general differences in trunk, pelvis and lower limb biomechanics between those with FAI sydrome and pain-free controls. Altered external biomechanics are likely the result of complex sensory-motor strategy resulting from pain inhibition or impingement avoidance. Future studies should examine internal loading in those with FAI sydnrome.

Background Osteoarthritis (OA) is a chronic, disabling, and prevalent disorder. As there is no cure for OA, long-term self-management is paramount. Support groups (SGs) can facilitate self-management among people living with OA. Understanding preferences in design and features of SGs, including online SGs (OSGs), among people with OA can inform future development of SG interventions for this condition. Objective The objective of this study was to investigate health care– and health information–seeking behavior, digital literacy, and preferences for the design of SGs in people with OA. The study also explored the perceived barriers and enablers to being involved in OSGs. Methods An online survey study was conducted with a mixed method design (quantitative and qualitative). Individuals aged ≥45 years with knee, hip, or back pain for ≥3 months were recruited from an extant patient database of the Institute of Bone and Joint Research via email invitations. Quantitative elements of the survey included questions about sociodemographic background; health care– and health information–seeking behavior; digital literacy; and previous participation in, and preferences for, SGs and OSGs. Respondents were classified into 2 groups (Yes-SG and No-SG) based on previous participation or interest in an SG. Group differences were assessed with Chi-square tests (significance level set at 5%). Responses to free-text questions relating to preferences regarding OSG engagement were analyzed qualitatively using an inductive thematic analysis. Results A total of 415 people with OA completed the survey (300/415, 72.3% females; 252/415, 61.0% lived in a major city). The Yes-SG group included 307 (307/415, 73.9%) participants. Between the Yes-SG and No-SG groups, there were no differences in sociodemographic characteristics, health care– and health information–seeking behavior, and digital literacy. An online format was preferred by 126/259 (48.7%) of the Yes-SG group. Trained peer facilitators were preferred, and trustworthiness of advice and information were highly prioritized by the respondents. Qualitative analysis for OSG participation revealed 5 main themes. Lack of time and motivation were the main barriers identified. The main enablers were related to accessibility, enjoyment of the experience, and the content of the discussed information. Conclusions These findings highlight the preferences in design features and content of SGs and OSGs and may assist in the further development of such groups.

Objectives Dietary supplements are increasingly used by people with osteoarthritis. Boswellia serrata extract, curcumin, pine bark extract and methylsulfonylmethane have been identified as having the largest effects for symptomatic relief in a systematic review. It is important to understand whether any pharmacokinetic interactions are among the major constituents of these supplements so as to provide information when considering the combination use of these supplements. The aim of this study was to investigate the pharmacokinetics of the constituents alone and in combination. Methods This study was a randomized, open-label, single-dose, four-treatment, four-period, crossover study with 1-week washout. The pharmacokinetics of the constituents of these supplements when dosed in combination with methylsulfonylmethane were compared to being administered alone. Plasma samples were obtained over 24 h from 16 healthy participants. Eight major constituents were analysed using a validated ultra-high-performance liquid chromatography–tandem mass spectrometry assay. Key findings The pharmacokinetics of each constituent was characterized, and there were no significant differences in the pharmacokinetic profiles of the constituents when administered as a combination, relative to the constituents when administered alone (P > 0.05). Conclusions These data suggest that interactions between the major constituents of this supplement combination are unlikely and therefore could be investigated to manage patients with osteoarthritis without significant concerns for possible pharmacokinetic interactions.

BACKGROUND Online support groups (OSGs) are one way for people with chronic diseases, their family or friends, and health professionals to communicate, gain information, and provide social support. As the number of peer-to-peer OSGs for chronic musculoskeletal conditions grows, it is important to gain insight into the different designs of groups available, who is accessing them, if and how they may be effective, and what strategies are being used to implement or increase consumer engagement. OBJECTIVE The objectives of this systematic review of people with musculoskeletal conditions were to (1) describe the design features (functions, usage options, moderation, and expert input) of peer-to-peer OSGs, (2) describe the characteristics of the individuals using peer-to-peer OSGs, (3) synthesize the evidence on outcomes of participation, and (4) identify strategies used in the delivery and maintenance of OSGs. METHODS A search comprising terms related to the population (people with musculoskeletal disorders) and the intervention (peer-to-peer OSGs) was conducted in 6 databases. Results were filtered from 1990 (internet inception) to February 2019. Studies identified in the search were screened according to predefined eligibility criteria using a 2-step process. Quantitative studies were appraised by 2 reviewers using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Qualitative studies were appraised by 2 different reviewers using the Critical Appraisal Skills Programme checklist. Extracted data were synthesized narratively. RESULTS We examined 21 studies with low to moderate risk of bias. Of these studies, 13 studies included OSGs hosted on public platforms, 11 studies examined OSGs that were conducted in English, and 6 studies used moderators or peer leaders to facilitate engagement. Studies either reported the number of OSG members (n=1985 across all studies) or the number of posts (range: 223-200,000). The majority of OSG members were females who were not full-time employees and with varied levels of education. There were no randomized controlled trials measuring the efficacy of OSGs. Qualitative and quantitative studies identified empowerment, social support, self-management behavior, and health literacy as primary constructs to measure OSG efficacy. Neutral or marginal improvement was reported in these constructs. Sharing experiences and a greater level of engagement appeared to have an important influence on OSGs efficacy. The extent to which members posted on the website influenced engagement. CONCLUSIONS Across a diverse range of designs, languages, included features, and delivery platforms, peer-to-peer OSGs for chronic musculoskeletal conditions attract predominantly female participants of all ages and education levels. The level of participation of a member appears to be related to their perceived benefit, health literacy, and empowerment. Future studies are needed to identify which design and maintenance strategies have superior efficacy and whether there are concomitant improvements in health outcomes for people with chronic musculoskeletal conditions resulting from participation in OSGs. CLINICALTRIAL PROSPERO International Prospective Register of Systematic Reviews CRD42018090326; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018090326

Background Placebo-controlled trials are an important tool when assessing the efficacy of spinal surgical procedures. The most common spinal surgical procedure in older adults is decompression for lumbar spinal stenosis. Before conducting a placebo-surgical trial on decompression surgery, an investigation of patients’ willingness to participate in a placebo-controlled trial of decompression surgery and barriers to participation were explored. Materials An online survey. Methods Descriptive analyses of demographic and clinical data, and participants' willingness to participate in a placebo-surgical trial. Logistic regression was used to examine potential predictors of willingness to participate. Two independent researchers performed a coded framework analysis of patients’ barriers to participation. Results 68 patients were invited and 63 participants completed the survey (91.3% response, mean (SD) age 69.5 (10.9) years, 52% females), 71% suffered from moderate to very severe pain. Ten participants (15.9%) were willing to participate in a placebo-controlled trial. Being married was associated with decreased odds of participating (OR: 0.2; 95% CI, 0.05 to 0.8; P = 0.03), while the main barriers were a lack of information about the procedure, reassurance of a positive outcome with participation, and concerns about the risks and benefits of placebo surgery. Conclusions A minority of patients with lumbar spinal stenosis were willing to participate in a placebo-controlled trial of surgery. The identified barriers indicate that educating eligible patients about: the need for placebo-surgical trials, the personal risks and benefits of participation, and the importance and potential benefits of placebo trials to others, may be crucial to ensure adequate recruitment into the placebo-controlled surgical trial. Conclusions should be read cautiously however, given the small sample size present in this study.

AIM To determine the impact of an osteoarthritis-specific multidisciplinary conservative care program (OACCP) on willingness for surgery (WFS) and to identify changes and factors in our cohort that influence and predict willingness for surgery. METHODS Consecutive OACCP participants with hip or knee OA, with WFS (willing, unsure or unwilling) data for at least two appointments were included. The proportions of unwilling versus willing/unsure patients at baseline and last appointment were compared using McNemar's test. Logistic regression was used to analyze baseline age, gender, main language, educational status, living situation, number of comorbidities, index joint, non-index joint osteoarthritis, completion of program, baseline and change in pain, function, depression, body mass index and 6-min walk test (6MWT) for association with changing WFS. RESULTS At baseline 203/409 were unwilling for surgery while by final appointment 234/409 were unwilling (P = 0.002). Of the 206 initially willing/unsure participants, 63/206 (30.6%) became unwilling by final appointment. Index joint, completion of program, baseline and change in pain, self-reported function and 6MWT were independently associated with becoming unwilling. Final model from multivariate logistic regression analysis regarding becoming unwilling included baseline pain (P < 0.001), change in pain (P < 0.001), completion of program (P < 0.001) and age (P = 0.004). CONCLUSION A conservative OA-specific treatment program that improves pain and function can reduce willingness for surgery among participants with hip or knee OA. The strongest determinants of this reduction in willingness were baseline and change in pain, completion of the program and participant age.

Objective To identify predictors of worsening symptoms and overall health of the treated hip or knee joint following 26 weeks of a nonsurgical chronic disease management program for hip and knee osteoarthritis (OA) and to examine the consistency of these predictors across 3 definitions of worsening. Methods This prospective cohort study followed 539 participants of the program for 26 weeks. The 3 definitions of worsening included symptomatic worsening based on change in the Western Ontario and McMaster Universities Osteoarthritis Index Global score (WOMAC-G) measuring pain, stiffness, and function; a transition scale that asked about overall health of the treated hip or knee joint; and a composite outcome including both. Multivariate logistic regression models were constructed for the 3 definitions of worsening. Results Complete data were available for 386 participants: mean age was 66.3 years, 69% were female, 85% reported knee joint pain as primary symptom (signal joint), 46% were waitlisted for total joint arthroplasty (TJA). TJA waitlist status, signal joint, 6-Minute Walk Test (6MWT), depressive symptoms, pain, and age were independently associated with at least 1 definition of worsening. TJA waitlist status and 6MWT remained in the multivariate models for the transition and composite definitions of worsening. Conclusion Participants reporting worsening on the transition scale did not consistently meet the WOMAC-G definition of worsening symptoms. TJA waitlist status was predictive of the composite definition of worsening, a trend apparent for the transition definition. However, variables that predict worsening remain largely unknown. Further research is required to direct comprehensive and targeted management of patients with hip and knee OA.

BACKGROUND CONTEXT Selecting a walking outcome measure for neurogenic claudication requires knowledge of its measurement properties. PURPOSE To systematically review and appraise the literature on the measurement properties of walking outcome measures for patients with neurogenic claudication. STUDY DESIGN A systematic review and meta-analysis. METHODS A systematic search was conducted on the following seven databases: PubMed, PsychINFO, Web of Science, Embase, CINAHL, MEDLINE, and Cochrane Central Register of Controlled Trials. Clinical studies that assessed a measurement property of a walking outcome measure for patients with neurogenic claudication were selected. The methodological quality of studies was assessed using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. Measurement property results were assessed using the adapted criteria from Terwee et al. (2007). RESULTS Twelve studies that evaluated 15 separate walking outcome measures were included. Out of the 12 studies included, half had poor methodological quality. Four measures had acceptable test-retest reliability: the self-paced walking test (intraclass correlation coefficient, or ICC was 0.98, 95% CI: 0.95–0.99), Physical Function Scale (PFS) (pooled analysis ICC = 0.79, 95% CI: 0.77–0.89), PFS walk item (ICC = 0.81, 95% CI: 0.68–0.89), and Oswestry Disability Index (ODI) walk item (ICC = 0.86, 95% CI: 0.76–0.92). Responsiveness was assessed on five walking outcome measures, and three had adequate responsiveness: the ODI walk item (Area under the Curve, or AUC, was 0.76, SD 0.15), Treadmill test (AUC = 0.70), and PFS (AUC = 0.77, SD 0.14). A meta-analysis demonstrated the PFS had adequate test retest reliability (pooled ICC = 0.79, 95% CI: 0.77–0.89) and internal consistency (pooled Cronbach's αlpha (α) = 0.84, 95% CI: 0.81–0.86), but not criterion validity (pooled correlation coefficient = -0.59, 95% CI: -0.71, -0.45). Measures that recorded adequate criterion validity were the ODI walk item (pooled correlation coefficient = -0.71, 95% CI: -0.80, -0.58), Treadmill test (pooled correlation coefficient = 0.86, 95% CI: 0.78–0.91), and self predicted walking item (pooled correlation coefficient = 0.74, 95% CI: 0.63–0.82). CONCLUSIONS The results of our systematic review demonstrated that high-quality studies that asses the measurement properties of walking outcome measures for patients with neurogenic claudication are lacking. There was only limited evidence available for each walking measure, which prevented any single outcome from being confirmed as the gold standard measure of neurogenic claudication. Clinicians and researchers are recommended to use the self-paced walking test and ODI walk item until further evidence is available. Future research should focus on producing high-quality studies with excellent methodology and larger sample sizes.

IntroductionHand osteoarthritis (HOA) is a highly prevalent disabling joint disease. The current management regimens are limited. Potentially as a consequence, many people turn to complementary and alternative medicines for symptomatic relief. A combination of two or more supplements is common in clinical practice; however, evidence for the efficacy of this approach is lacking. The aim of this study is to investigate the efficacy of a supplement combination for treating symptomatic HOA in comparison to placebo.Methods and analysisThe RADIANT study is an internet-based, parallel, superiority, double-blind, placebo-controlled, randomised, two-arm clinical trial. A participatory design is used to facilitate the study procedures. One hundred and six participants aged over 40 years with painful HOA and structural change on X-ray (Kellgren and Lawrence grade (KLG) ≥2) will be recruited from the community and randomly allocated to receive either a supplement combination composed of: (1) combined supplement containingBoswellia serrataextract, pine bark extract and methylsulfonylmethane and (2) curcumin or placebo for 12 weeks. The primary outcome will be 12-week change in hand pain on a visual analogue scale (VAS). Main secondary outcomes include adverse events, change in hand function, patient global assessment of disease activity and quality of life. A range of additional measures will be recorded, and an individual patient placebo response will be performed. The primary analysis will be conducted using an intention-to-treat approach. Adverse events will be monitored weekly throughout the study.Ethics and disseminationThis protocol has been approved by the University of Sydney Human Research Ethics Committee (HREC No. 2018/766). Dissemination will occur through conferences, social media, scientific publications and PhD thesis.Trial registration numberAustralian New Zealand Clinical Trials Registry (ACTRN12619000835145); Pre-results

Background Knee osteoarthritis (OA) causes substantial pain, physical dysfunction and impaired quality of life. There is no cure for knee OA, and for some people, the disease may involve progressive symptomatic and structural deterioration over time. Platelet-rich plasma (PRP) is a therapeutic agent that aims to address underlying biological processes responsible for OA pathogenesis. As such, it has the potential to improve both symptoms and joint structure. The aim of this clinical trial is to determine whether a series of injections of PRP into the knee joint will lead to a significantly greater reduction in knee pain, and less loss of medial tibial cartilage volume over 12 months when compared to a series of placebo saline injections in people with knee OA. Methods This will be a two-group, superiority, randomised, participant-, interventionist- and assessor-blinded, placebo-controlled trial. Two hundred and eighty-eight participants aged over 50 years with painful knee OA and mild to moderate structural change on x-ray (Kellgren and Lawrence grade 2 and 3) will be randomly allocated to receive either three PRP injections or three normal saline injections into the knee joint at weekly intervals. The primary outcomes will be 12-month change in average overall knee pain severity (numeric rating scale) and medial tibial cartilage volume (magnetic resonance imaging (MRI)). Secondary outcomes include additional measures of knee pain and other symptoms, function in daily living and sport and recreation, quality of life, participant-perceived global ratings of change, and other MRI structural outcomes including meniscal and cartilage morphology, synovitis, effusion, bone marrow lesions and cartilage defects. A range of additional measures will be recorded, and a separate health economic evaluation will be performed. Discussion The findings from this study will help determine whether PRP improves both clinical and structural knee OA outcomes over 12 months when compared to a series of placebo saline injections. Trial registration Australian New Zealand Clinical Trials Registry reference: ACTRN12617000853347. Prospectively registered 9th of June 2017. Electronic supplementary material The online version of this article (10.1186/s12891-018-2205-5) contains supplementary material, which is available to authorized users.

Objective Greater joint laxity and radial subluxation of the thumb metacarpal base have been shown to be risk factors for the development of trapeziometacarpal osteoarthritis in an asymptomatic and radiographically normal joint. Despite this, it is unknown whether joint laxity changes with disease progression from mild to severe osteoarthritis. This study aimed to investigate the relationship between joint laxity and osteoarthritis severity, using the trapeziometacarpal subluxation ratio as an indicator of joint laxity. Method Baseline data were used from the first 100 participants included in the COMBO (Efficacy of combined conservative therapies on clinical outcomes in base of thumb OA) trial. All participants had bilateral posteroanterior (PA) and Eaton stress view hand radiographs, as well as grip and tip-pinch strength measurements. The PA view was used to assess Kellgren-Lawrence and Eaton grades, and the Eaton stress view was used to assess the trapeziometacarpal joint subluxation ratios. Generalised estimating equations were utilized to account for the fact that hand data are paired, and within-person measurements are therefore not independent. Results Lower radial subluxation ratios were associated with higher Kellgren-Lawrence grades (B-coefficient -0.302; p-value 0.027), and lower grip strength scores (B-coefficient 2.06; p-value 0.006). Conclusions Radial subluxation ratios decreased with increasing disease severity, contrary to the progression from a normal joint to one with mild osteoarthritis, wherein higher joint laxity is a risk factor for disease. This may be explained by the mechanical stabilization provided by osteophytes and capsular changes in worsening osteoarthritis, as has been shown to be the case in the knee. Trial registration number ACTRN 12616000353493. Level of evidence III.

Introduction: Femoroacetabular impingement (FAI) syndrome is a common cause of hip pain in active young adults and a primary contributor to the future development of hip osteoarthritis. Diagnostic imaging is essential for identification of cam and/or pincer morphology in FAI syndrome, though precise diagnostic criteria remain elusive. Patient factors may require consideration, in conjunction with measures of bony morphology, to predict symptom-related consequences in FAI syndrome. This study aimed to determine the morphological parameter(s) and patient factor(s) associated with symptom severity in FAI syndrome. Methods: Ninety-nine participants diagnosed with FAI syndrome (symptoms, clinical examination, and imaging) received standardised plain radiographs and magnetic resonance scans of their affected hip. Alpha angle was measured in four reconstructed radial planes at 30° intervals from superior to anterior. Acetabular version, femoral version, lateral centre edge angle, femoral neck-shaft angle, and anterior centre edge angle were also measured from imaging. Participants completed the international Hip Outcome Tool–33 (iHOT–33) and the 11–point modified UCLA activity score. Univariate linear regression was used to assess the relationship between iHOT–33 score and each morphological parameter and patient factor (i.e. age, sex, body mass index, symptom duration, annual income, health care system) measured. Variables with p < 0.2 were used in a backward stepwise regression model to establish which, if any, were independent predictors of iHOT–33 score. Results: Participants (age 32.9 ± 10.5 years, 44 % female) had an average iHOT–33 score of 41.9 ± 18.8. Higher anterior centre edge angle was associated with a higher iHOT-33 score (p = 0.027). Lower income (p = 0.002) and lower modified UCLA activity score (p < 0.001) were associated with a lower iHOT-33 score. Female participants had worse iHOT–33 scores than males (mean difference –8.6 [95 %CI–1.2, –16.1], p = 0.026) and participants who accessed the public healthcare system had worse iHOT-33 scores than those who accessed the private healthcare system (mean difference –16.7 [95 %CI–9.7,–23.8], p < 0.001). After backwards stepwise elimination, anterior centre edge angle, modified UCLA activity score, sex, and health care system remained as independent predictors of the iHOT–33 score. Discussion: Abnormal bony hip morphology, which by definition is a cornerstone of FAI syndrome, may influence hip-related quality of life to a lesser extent than potentially modifiable factors like activity level. Anterior centre edge angle was the only measure of hip morphology associated with the iHOT–33 score, despite comprehensive bony morphological measurement. Longitudinal prospective investigations are required to establish whether the patient factors identified can predict subsequent structural deterioration in individuals with FAI syndrome.