# Exercise as it relates to Disease/The effect of the GLA:D program on individuals with hip or knee osteoarthritis

The following critical appraisal analyses: 'Good Life with Osteoarthritis in Denmark (GLA:D)' by Skou and Roos (2017).

## What is the background to this research?

Osteoarthritis is the most common degenerative joint disorder, affecting the articular cartilage and underlying bone in joints. The high prevalence of osteoarthritis is correlated to older age, 65 years and above. However, predisposition to osteoarthritis can also occur from lifestyle factors, genetics and comorbidities. Pain in the affected joint is commonly present in patients with osteoarthritis. Due to this, patients are less likely to exercise and more likely to develop comorbidities such as obesity. This ultimately increases the risk of undergoing surgical interventions such as menisectomys. Patients may also experience impaired quality of life due to joint pain and restrictions in daily activities. Due to these outcomes, Good Life with osteoArthritis: Demark (GLA:D) aims to educate and provide neuromuscular exercise programs for osteoarthritic populations. The GLA:D program strongly serves as a first-line intervention strategy to prehabilitate patients, and reduce the likelihood of undergoing surgical interventions through exercise.
GLA:D was introduced in 2013 in Denmark. Since the program is relatively new it currently requires data analysis from participants, to examine the validity and reliability of the program. This research article consists of randomised control trials for osteoarthritic patients in GLA:D programs. As a meta-analysis, the research article can systematically evaluate data over a larger cohort to assess the effectiveness of the GLA:D program in clinical practice. This is essential to reducing unnecessary surgical interventions and promoting prehabilitation through the GLA:D program.

## Where is the research from?

The research was published through BMC Musculoskeletal Disorders. BMC uses submission guidelines for all proposed articles and has developed into a reputable platform over the last 20 years. The authors Skou and Roos both have strong research connections in the physiotherapy industry, and have collaborated and aided in the publications of many previous articles in the field. Both authors are based in Denmark, placing them at the frontier for the GLA:D program. No conflict of interests is present. However, it is relevant to acknowledge that both authors of the research article have extensive track records in the field. Due to this, the authors have been involved in the majority of the supporting evidence. This may impact the reliability of the evidence due to possible bias from the authors.

## What kind of research was this?

The following research article is a meta-analysis of GLA:D programs. This study attains greater evidence through systematically reviewing randomised control trials.
The meta-analysis consists of:
* 50 randomised control trials for knee osteoarthritis.
* 10 randomised control trials for hip osteoarthritis.

## What did the research involve?

Certified physiotherapists for the GLA:D program must follow strict clinical guidelines and practices when implementing the intervention. Due to this, the randomised control trials used in the study were uniform in their methodology. Participants were required to complete educational (3 sessions over two weeks) and neuromuscular components (2 sessions per week for 6 weeks) as part of the GLA:D program for a minimum of 8 weeks. Participants completed physical function tests taken at baseline, 3 and 12 months (30-second chair stand test and 40m fast-paced walk test) as objective measures for the program. The meta-analysis compiles this data to assess the aims of the GLA:D program. These aims include reduced pain, number of patients taking pain killers, and patients on sick leave. Along with improved physical activity, physical function and quality of life. The study also investigates access to health care, since participation requires a qualified physiotherapist who has completed the GLA:D education course.
The research article uses the visual analogue scale (VAS), along with quality of life questionnaires; Knee Injury and Osteoarthritis Outcome Score (KOOS) and Hip Disability and Osteoarthritis Outcome Score (HOOS). VAS was used to assess pain intensity at baseline, 3 and 12 months. This tool has been supported as effective in clinical practice for patients with osteoarthritis. KOOS and HOOS tests assess quality of life, pain intensity, and functional tests capacity (30-second chair stand test, 40m fast-paced walk test). Assessing maintained physical activity and medication usage during and post GLA:D is also supported in literature. Using the 30-second chair stand test and 40m fast-paced walk test as physical function tests proposed by the Osteoarthritis Research Society International (OARSI), is also supported in literature. Limitations to the methodology include having the majority of the meta-analysis based on knee osteoarthritis compared to hip osteoarthritis. This affects the interpretation of the results due to the skewed data. 74% of participants were female, therefore, data may not be accurate when interpreting for male populations. Participant numbers reduced for the 12 month compared to the 3 month follow up at 68% and 84% respectively. Therefore, final results are affected due to the limited data.

## What were the basic results?

The study found that:
* Pain intensity decreased after 3 months for both hip and knee osteoarthritic patients.
* The use of pain medication significantly decreased for both hip and knee osteoarthritic patients. Risk of taking pain medication also decreased.
* Patients improved on the 30-second chair stand test and 40m fast-paced walk test after 3 months.
* Patients improved on maintaining physical activity (at least 30 minutes of light to moderate daily exercise) after 3 months.
* Patients improved on KOOS and HOOS questionnaire ratings after 3 months.
* Reductions in sick leave were statistically significant from baseline to 12 months.
The data was interpreted using crude and adjusted means, standard deviations, 95% confidence intervals and p values. Result interpretation occurred with both exercise and surgical intervention patients. Further interpretation occurred with only exercise intervention patients. Positive publication bias is evident in the research article. Data on 12 month follow up, though started as not statistically significant was not included in the final results. If included it could hinder overall results and reliability of the program.

## What conclusions can we take from this research?

The GLA:D program supports reductions in pain, patients taking pain killers and sick leave. Along with improvements in physical function, physical activity and quality of life. The program also serves to reduce comorbidities through exercise. Further research into the impact of the GLA:D program on surgical prevention, would have strengthened the research articles expected outcomes of the program as a preventative intervention. Additional implications include that improvements in pain, physical function and physical activity were only significant in the short term of the program. Therefore, further study into the program and follow up measures needs to occur to ensure patients experience long term benefits of the GLA:D program.

## Practical advice

Although this is developing research, it has potential as a prehabilitation intervention in hip and knee osteoarthritic populations. Patients may be referred by an orthopaedic surgeon or consult physiotherapists independently to participate in the GLA:D program. Only after approval from a physiotherapist can a patient participate in the GLA:D program. During the program, patients are encouraged to engage in at least 30 minutes of daily exercise, for instance going for a walk. For further information talk to your general practitioner or physiotherapist regarding the GLA:D program.

## Further information/resources

Further information on the GLA:D program, support groups and facilitators can be found below:
* 'GLA:D Australia'
* 'GLA:D Australia Locations'
* 'GLA:D'
* 'GLA:D PROGRAM FOR HIP AND KNEE OA'

## References

* 1 2 3 4 Moskowitz RW. The burden of osteoarthritis: clinical and quality-of-life issues. The American journal of managed care. 2009 Sep 1;15(8 Suppl):S223-9.
* ↑ Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. The Lancet. 2019 Apr 27;393(10182):1745-59.
* 1 2 Coggon D, Reading I, Croft P, McLaren M, Barrett D, Cooper C. Knee osteoarthritis and obesity. International journal of obesity. 2001 May;25(5):622-7.
* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA: D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC musculoskeletal disorders. 2017 Dec;18(1):1-3.
* ↑ BioMed Central. BMC Musculoskeletal Disorders: About [Internet]. Texas (US): BioMed Central; c2021 [cited 2021 Sep 1]. Available from: https://bmcmusculoskeletdisord.biomedcentral.com/about
* ↑ Mahir L, Belhaj K, Zahi S, Azanmasso H, Lmidmani F, El Fatimi A. Impact of knee osteoarthritis on the quality of life. Annals of physical and rehabilitation medicine. 2016 Sep 1;59:e159.
* ↑ Klässbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scandinavian journal of rheumatology. 2003 Jan 1;32(1):46-51.
* 1 2 Davis AM, Kennedy D, Wong R, Robarts S, Skou ST, McGlasson R, Li LC, Roos E. Cross-cultural adaptation and implementation of Good Life with osteoarthritis in Denmark (GLA: D™): group education and exercise for hip and knee osteoarthritis is feasible in Canada. Osteoarthritis and cartilage. 2018 Feb 1;26(2):211-9.
* ↑ Roos EM, Grønne DT, Skou ST, Zywiel MG, McGlasson R, Barton CJ, Kemp JL, Crossley KM, Davis AM. Immediate outcomes following the GLA: D® program in Denmark, Canada and Australia. A longitudinal analysis including 28,370 patients with symptomatic knee or hip osteoarthritis. Osteoarthritis and Cartilage. 2021 Apr 1;29(4):502-6.