Joint Injury in Young Adults and Risk for Subsequent Knee and Hip Osteoarthritis Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. Activity Increase Despite Arthritis (AÏDA): phase II randomised controlled trial of an active management booklet for hip and knee osteoarthritis in primary care. Moving to maintain function in knee osteoarthritis: evidence from the osteoarthritis initiative. The factor subdimensions of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) help to specify hip and knee osteoarthritis. a prospective evaluation and validation study. The effects of a health educational and exercise program for older adults with osteoarthritis for the hip or knee. Effects of activity strategy training on pain and physical activity in older adults with knee or hip osteoarthritis: a pilot study. Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: a population-based prospective cohort study. Effects of a tailored activity pacing intervention on pain and fatigue for adults with osteoarthritis. Effectiveness of Manual Physical Therapy and Exercise in Osteoarthritis of the Knee Effectiveness of hip abductor strengthening on health status, strength, endurance and six minute walk test in participants with medial compartment symptomatic knee osteoarthritis. Adherence to a Web-Based Physical Activity Intervention for Patients With Knee and/or Hip Osteoarthritis: A Mixed Method Study A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans Aquatic Physical Therapy for Hip and Knee Osteoarthritis: Results of a Single-Blind Randomized Controlled Trial Long-term exercise therapy resolves ethnic differences in baseline health status in older adults with knee osteoarthritis. Physical activity and self-reported, physician-diagnosed osteoarthritis: is physical activity a risk factor? Activity Increase Despite Arthritis (AÏDA): design of a Phase II randomised controlled trial evaluating an active management booklet for hip and knee osteoarthritis [ISRCTN24554946] Which patientswith osteoarthritis of hip and/or knee benefit most from behavioral graded activity? Effectiveness and efficiency of an 11-week exercise intervention for patients with hip or knee osteoarthritis: a protocol for a controlled study in the context of health services research Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis: a cluster-randomised trial. Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials Associations of radiological osteoarthritis of the hip and knee with locomotor disability in the Rotterdam Study Factors affecting the prevalence of osteoarthritis in healthy middle-aged women: data from the longitudinal Melbourne Women's Midlife Health Project.
Osteoarthritis is a major contributor to functional impairment and reduced independence in older adults ( 1 - 4 ) . It is the leading cause of arthritis in the United States , affecting an estimated 21 million persons ( 5 ) , and has substantial economic impact ( 6 , 7 ) . History of an injury to a joint , particularly at the knee and hip , is associated with an increased risk for osteoarthritis in cross-sectional and casecontrol studies ( 8 - 11 ) . Such studies , however , may overestimate this relation because persons with symptomatic osteoarthritis may be more likely to recall a past injury or to interpret early symptoms of osteoarthritis as indicative of joint injury . A prospect i ve cohort study can address this weakness by determining exposure status before the outcome develops . To date , prospect i ve studies have examined the relation between history of joint injury and osteoarthritis in middle-aged persons and senior citizens ( 12 , 13 ) , but not in young adults . However , many athletic injuries occur in high school and college . In addition , joint trauma may be a more common cause of osteoarthritis than has been previously recognized ( 14 ) . We performed a prospect i ve cohort study of 1321 young adults to examine the risk for knee and hip osteoarthritis associated with joint injury during young adult life . Methods Study Participants The Johns Hopkins Precursors Study was design ed by the late Caroline Bedell Thomas , MD , to identify precursors of the aging process ( 15 ) . A total of 1337 medical students , members of the graduating classes of 1948 through 1964 at the Johns Hopkins University School of Medicine in Baltimore , Maryl and , enrolled in the study . The cohort was 91 % male and 97 % white ; the mean age was 22 years . At entry , participants underwent a st and ard history and examination , including  assessment of musculoskeletal disorders , history of trauma , level of physical activity , and measurement of weight and height . Body mass index was calculated as weight in kilograms divided by height in meters squared . In addition , participants were asked to categorize their level of physical training during the past month as none , little , moderate , or much , as described elsewhere ( 16 ) . Since graduation , participants have been followed prospect ively with annual self-administered question naires to detect incident disease and to up date risk factor status over time . At the time that baseline data were collected , it was not customary to obtain informed consent . After establishment of the Joint Committee on Clinical Investigation at Johns Hopkins , the follow-up protocol was review ed and approved . Assessment of Injury Injury was defined as a report of trauma to the knee or hip joint , including internal derangement and fracture . During the baseline assessment , knee and hip injuries that occurred before graduation from medical school and the year of their occurrence were recorded . Postgraduation injuries were assessed by annual morbidity question naires . During every 5-year follow-up period , at least 86 % of the living participants responded at least once to the question naires . Injuries were assigned diagnosis codes according to the International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) ( 17 ) . Diagnoses included torn meniscus ( code 836.2 ) ; torn knee ligament ( code 844.9 ) ; tibial fracture ( code 823.8 ) ; femoral fracture ( code 821.01 ) ; fibular fracture ( code 823.81 ) ; patellar fracture ( code 822 ) ; broken leg , site not otherwise specified ( code 827.0 ) ; knee injury , not otherwise specified ( code 959.7 ) ; gunshot wound ( code 891 ) ; hemarthrosis ( code 844.9 ) ; shin splints ( code 844.9 ) ; and hip dislocation ( code 836.5 ) . Incidence of Osteoarthritis The methods used to determine osteoarthritis incidence in this cohort have been described elsewhere ( 18 ) . Briefly , all participants were mailed annual morbidity question naires . Before 1985 , respondents were queried about the development of physical and musculoskeletal disorders . Since 1985 , follow-up morbidity question naires have contained the specific question , Have you ever had arthritis ? and have asked those who respond affirmatively to provide the type of arthritis , year of onset , and treatment received . An event of osteoarthritis was defined as the self-report of osteoarthritis or degenerative arthritis in response to the question naire . The incidence date was determined by the reported year of osteoarthritis onset . Two rheumatologists review ed each report of osteoarthritis , assigned ICD-9-CM codes ( 17 ) to the most specific arthritis site reported by the respondent , and excluded inflammatory arthritides . For this analysis , only osteoarthritis at the knee ( code 715.96 ) and hip ( code 715.95 ) were included as outcomes . In 1995 , all surviving participants who had previously reported osteoarthritis were mailed a more detailed question naire . They were asked , Have you had pain in or around the knee , including back of the knee , on most days for at least 1 month ? and Have you had pain in or around either hip joint , including the buttock , groin , and side of upper thigh , on most days for at least 1 month ? These symptom-related questions were used to screen for knee and hip osteoarthritis , respectively , in the National Health and Nutrition Examination Survey ( NHANES ) ( 19 ) . Respondents were also asked whether they had undergone  radiographic evaluation of their knees and hips  and whether radiography revealed osteophytes , joint space narrowing , subchondral cysts , or bony sclerosis ( the radiographic hallmarks of osteoarthritis ) ( 20 ) . Statistical Analysis The association between baseline characteristics and injury status was assessed by using the Student t-test for continuous variables and the chi-square test for categorical variables . These data are presented both for the entire cohort and separately by sex . Injury was the independent variable in the survival analysis ; age was the time variable . Knee and hip osteoarthritis were examined as separate outcomes . The relation of a joint injury at baseline to the incidence of osteoarthritis was examined by using KaplanMeier analysis ( 21 ) . The log-rank statistic was used to test whether the cumulative incidence of osteoarthritis differed according to injury status at cohort entry ( 22 ) . In addition , Cox proportional-hazards analysis was used to estimate the independent risk for osteoarthritis associated with a joint injury . Cox models were constructed for injury status at cohort entry and over follow-up , modeled as a time-dependent covariate . We adjusted for age at graduation , sex , body mass index , and level of physical activity , each of which was determined at baseline , to evaluate for possible confounding . In this cohort , body mass index at enrollment was more predictive of future osteoarthritis than average or most recent body mass index during follow-up ( 18 ) . These analyses were performed for all reported events of knee and hip osteoarthritis and for cases confirmed by both characteristic symptoms and radiographic findings . Hazard ratios are reported as relative risks with 95 % CIs . Statistical significance was defined as an level equal to 0.05 using a two-tailed test . We conducted a sensitivity analysis to assess the potential effect of an omitted covariate on the association between joint injury and subsequent osteoarthritis . Role of the Funding Sources The funding sources did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the study for publication . Results At graduation from medical school , the average age of the 1216 men and 121 women in the cohort was 26 years . Our analysis is based on events reported through 30 November 1995 and represents a median follow-up of 36 years . Information at baseline or during follow-up was available for 1321 participants , who form the basis of our longitudinal analysis . At the end of follow-up in 1995 , the mean age of the cohort SD was 61.4 8.9 years . Overall , 141 participants had a joint injury ( knee alone [ n = 111 ] , hip alone [ n = 16 ] , or injuries at both sites [ n = 14 ] ) before or after graduation . Table 1 shows the baseline characteristics of the cohort according to injury status at the end of follow-up . Proportions of men and women with joint injury were similar ( P > 0.2 , chi-square test ) . Participants were generally lean , 49 % were physically active , and 54 % smoked cigarettes . Men who had a joint injury were heavier at baseline than men who were injury-free , but both groups of men were similar in age , level of physical activity , and smoking status . Women with injury were , on average , 2 years older at baseline than those without injury . Table 1 . Baseline Characteristics of 1321 Men and Women according to Joint Injury at Cohort Entry or during Follow-up At baseline , 47 men ( 3.9 % ) reported a knee injury and 12 men ( 1.0 % ) reported a hip injury . The mean age at which the injuries occurred was 16 years . Knee injuries included 10 tibial fractures , 3 fibular fractures , 4 femoral fractures , 2 patellar fractures , and 9 otherwise unspecified leg fractures . In addition , 8 men incurred trauma result ing in torn knee cartilage , 2 had torn knee ligaments , 2 had knee injuries result ing from gunshot wounds , 1 had traumatic hemarthrosis , 1 had joint dislocation , 1 had shin splints , and 4 had otherwise unspecified knee injuries . Of men with a knee injury , 4 reported that they were injured while playing football , 2 each reported that they were injured while playing basketball or participating in athletics , and 1 each reported that he was injured while horseback riding , bicycling , skiing , playing volleyball , wrestling , playing baseball , or playing tennis . Knee trauma also result ed from motor vehicle accidents ( n =3 ) and falls ( n = 2 ) . At baseline , 4 of the 121 women ( 3.3 % ) had a history of knee injuries and 1 ( 0.8 % ) had a history of hip injuries . Sixty-two men and 7 women developed knee osteoarthritis , and 27 men and 5 women developed hip osteoarthritis . The mean SD ages at onset of AIM This paper reports a study of the effects of aquatic exercise on physical fitness ( flexibility , strength and aerobic fitness ) , self-reported physical functioning and pain in adults with osteoarthritis of the hip or knee . BACKGROUND Osteoarthritis is a common cause of disability and a primary reason for hip and knee joint replacement . Exercise is important for preventing and /or managing the functional limitations associated with joint disease . Aquatic exercise is thought to be beneficial and is often recommended for people with osteoarthritis ; however , few studies have examined the effects on people with osteoarthritis , and these have yielded inconsistent results . METHODS A two-group r and omized controlled trial with a convenience sample was used . Participants were recruited from community sources and r and omly assigned to a 12-week aquatic programme or a non-exercise control condition . Data for 38 participants were collected at baseline , week 6 , and week 12 during 2003 and 2004 . Instruments were a st and ard plastic goniometer , a h and held dynamometer , the 6-minute walk test , the multidimensional Health Assessment Question naire , and a visual analogue scale for pain . RESULTS Repeated measures analysis of variance showed that aquatic exercise statistically significantly improved knee and hip flexibility , strength and aerobic fitness , but had no effect on self-reported physical functioning and pain . The exercise adherence rate was 81.7 % , and no exercise-related adverse effect was observed or reported . CONCLUSIONS Beneficial short-term effects of aquatic exercise were found in adults with osteoarthritis of the hip or knee . Although the programme may not offer pain relief or self-reported improvements in physical functioning , results suggest that aquatic exercise does not worsen the joint condition or result in injury . Nurses engaging in disease management and health promotion for these patients should consider recommending or implementing aquatic classes for patients BACKGROUND The Hip & Knee Book : Helping you cope with osteoarthritis was developed to change disadvantageous beliefs and encourage physical activity in people with hip or knee osteoarthritis . AIM To assess the feasibility of conducting a definitive r and omised controlled trial ( RCT ) of this evidence -based booklet in people with hip or knee osteoarthritis . DESIGN Phase II feasibility r and omised controlled trial ( RCT ) . METHOD Computerised search es of patients ' record data bases identified people with osteoarthritis of the hip or knee , who were invited to participate in the RCT comparing the new booklet with a control booklet . Outcomes were measured at baseline , 1 month , and 3 months , and included : beliefs about hip and knee pain , exercise , and fear avoidance ; level of physical activity ; and health service use . RESULTS The trial methods were feasible in terms of recruitment , r and omisation , and follow-up , but most participants recruited had longst and ing established symptoms . After one and 3 months , there was a small relative improvement in illness , exercise , and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group ( n = 59 ) compared with the control group ( n = 60 ) , which provides some proof of principle for using these outcomes in future trials . CONCLUSION This feasibility study provided proof of principle for testing The Hip & Knee Book in a larger definitive RCT OBJECTIVES To investigate the association between baseline physical activity and 1-year functional performance in adults with knee osteoarthritis ( OA ) . DESIGN Prospect i ve cohort study of knee OA development and progression with 1-year follow-up . SETTING Community . PARTICIPANTS Osteoarthritis Initiative public data on adults with knee OA ( n=2274 ; age , 45 - 79y ) who participated in functional performance assessment s ( timed 20-m walk and chair st and test ) at baseline and 1-year follow-up . INTERVENTIONS Not applicable . MAIN OUTCOME MEASURE A good 1-year performance outcome ( separately defined for walk time and chair st and measures ) was improvement from baseline quintile or maintenance in the best quintile . RESULTS Almost 2 in 5 persons with radiographic knee OA improved or maintained high performance at 1 year .  Physical activity  measured by the  Physical Activity Scale for the Elderly  ( PASE ) was significantly associated with good walk rate and chair st and outcomes ( odds ratio per 40 units PASE [ 95 % confidence interval]=1.13 [ 1.13 , 1.17 ] and 1.10 [ 1.05 , 1.15 ] , respectively ) , as were participation in sports/recreational activities ( 1.45 [ 1.23 , 1.71 ] and 1.29 [ 1.09 , 1.51 ] , respectively ) and lifestyle activities ( 1.11 [ 1.06 , 1.16 ] and 1.09 [ 1.04 , 1.14 ] , respectively ) . An independent protective relationship for these physical activity measures approached significance after adjusting for sociodemographic and health factors . Older adults reported the least baseline physical activity and least frequent good 1-year outcomes . CONCLUSIONS These findings support public health recommendations to be physically active in order to preserve function for persons with knee OA .  Physical activity messages should specifically target older adults whose low activity levels may jeopardize their ability to maintain functional performance OBJECTIVE To determine whether it is possible to specify different score patterns for hip and knee osteoarthritis ( OA ) , and to identify the degree of responsiveness and the validity of the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) factors , which are alternative health dimensions obtained by factor analysis of the WOMAC items . METHODS  WOMAC scales and WOMAC factors  were compared in a prospect i ve setting examining patients with hip and knee OA before and after rehabilitative inpatient intervention ( n = 317 ) . In a partial sample ( n = 103 ) , the validity of the WOMAC factors was determined by a global rating of their activities . RESULTS The WOMAC factor " ascending/descending " was significantly different for hip and knee OA in the health state before therapy ( score in hip 5.09 , in knee 6.59 ; p < 0.001 ) ; this was also true of the effect size after therapy ( hip 0.39 , knee 0.65 ; p = 0.012 ) . The WOMAC scales did not differ for the 2 conditions . The WOMAC factor " ascending/descending " was the most responsive dimension in knee OA ( effect size 0.65 ) , but in hip OA the WOMAC pain scale was most responsive ( effect size 0.55 ) . Most of the WOMAC factors correlated moderately ( r = 0.52 - 0.69 ) with the patient 's self-rating on the validation question naire . CONCLUSION The WOMAC factors are valid measures . Analyzing the WOMAC by the WOMAC factors facilitates and improves the differential relevance and accuracy of the WOMAC for specific conditions such as hip and knee OA OBJECTIVE Evaluation of a self-management program for patients with osteoarthritis ( OA ) of the hip or knee . The program , which consisted of 6 weekly sessions of 2 hours , included health education by a peer and physical exercises taught by a physical therapist . METHODS R and omized controlled trial . Inclusion criteria were diagnosis of OA of the hip or knee according to ACR clinical and radiographic criteria and age 55 to 75 years . EXCLUSION CRITERIA on waiting list for joint replacement . There were pretest , posttest , and followup ( 6 months ) assessment s. The experimental group consisted of 56 patients , the control group 49 . Outcome variables were pain , quality of life , activity restrictions , knowledge about OA , self-efficacy , body mass index ( BMI ) , and mobility measures . Attention was also paid to effects on health care utilization and lifestyle behavior . RESULTS Significant MANOVA group x time effects ( p < 0.05 , one-sided ) were found for pain , quality of life , strength of the left M. quadriceps , knowledge , self-efficacy , BMI , physically active lifestyle , and visits to the physical therapist . Most effects were moderate at posttest assessment and smaller at followup . No effects were found for range of motion and functional tasks . CONCLUSION The program was reasonably effective , but more attention should be paid to proactive followup interventions and to the selection of participants OBJECTIVE To examine effects of activity strategy training ( AST ) , a structured rehabilitation program taught by occupational therapists and design ed to teach adaptive strategies for symptom control and engagement in physical activity ( PA ) . METHODS A r and omized controlled pilot trial was conducted at 4 sites ( 3 senior housing facilities and 1 senior center ) in southeastern , lower Michigan . Fifty-four older adults with hip or knee osteoarthritis ( mean + /- SD age 75.3+/-7.1 years ) participated . At each site , older adults were r and omly assigned to 1 of 2 programs : exercise plus AST ( Ex + AST ) or exercise plus health education ( Ex + Ed ) . The programs involved 8 sessions over 4 weeks with 2 followup sessions over a 6-month period , and were conducted concurrently within each site . Pain , total PA and PA intensity ( measured objective ly by actigraphy and subjectively by the Community Healthy Activities Model Program for Seniors question naire ) , arthritis self-efficacy , and physical function were assessed at baseline and posttest . RESULTS At posttest , participants who received Ex + AST had significantly higher levels of objective peak PA ( P=0.02 ) compared with participants who received Ex + Ed . Although not statistically significant , participants in Ex + AST tended to have larger pain decreases , increased total objective and subjective PA , and increased physical function . No effects were found for arthritis self-efficacy . CONCLUSION Although participants were involved in identical exercise programs , participants who received AST tended to have larger increases in PA at posttest compared with participants who received health education . Future studies will be needed to examine larger sample s and long-term effects of AST OBJECTIVE To determine in a prospect i ve population -based cohort study relationships between different measures of body mass and the incidence of severe knee and hip osteoarthritis defined as arthroplasty of knee or hip due to osteoarthritis . MATERIAL S AND METHODS  Body mass index ( BMI ) , waist circumference , waist-hip ratio ( WHR ) , weight and percentage of body fat ( BF% )  were measured at baseline in 11,026 men and 16,934 women from the general population . The incidence of osteoarthritis over 11 years was monitored by linkage with the Swedish hospital discharge register . RESULTS 471 individuals had knee osteoarthritis and 551 had hip osteoarthritis . After adjustment for age , sex , smoking and physical activity , the relative risks ( RR ) of knee osteoarthritis ( fourth vs first quartile ) were 8.1 ( 95 % CI 5.3 to 12.4 ) for BMI , 6.7 ( 4.5 to 9.9 ) for waist circumference , 6.5 ( 4.6 to 9.43 ) for weight , 3.6 ( 2.6 to 5.0 ) for BF% and 2.2 ( 1.7 to 3.0 ) for WHR . Corresponding RR for hip osteoarthritis were 2.6 ( 2.0 to 3.4 ) for BMI , 3.0 ( 2.3 to 4.0 ) for weight , 2.5 ( 1.9 to 3.3 ) for waist , 1.3 ( 0.99 to 1.6 ) for WHR and 1.5 ( 1.2 to 2.0 ) for BF% . CONCLUSION All measures of overweight were associated with the incidence of knee osteoarthritis , with the strongest relative risk gradient observed for BMI . The incidence of hip osteoarthritis showed smaller but significant differences between normal weight and obesity . Our results support a major link between overweight and biomechanics in increasing the risk of knee and hip osteoarthritis in men and women OBJECTIVE We examined whether tailored activity pacing intervention was more effective at reducing pain and fatigue than general activity pacing intervention . METHOD Adults with knee or hip osteoarthritis ( N = 32 ) stratified by age and gender were r and omized to receive either tailored or general pacing intervention . Participants wore an accelerometer for 5 days that measured physical activity and allowed for repeated symptom assessment . Physical activity and symptom data were used to tailor activity pacing instruction . Outcomes at 10-week follow-up were pain ( Western Ontario and McMaster Universities Osteoarthritis Index ) and fatigue ( Brief Fatigue Inventory ) . RESULTS Compared with general intervention , the tailored group had less fatigue interference ( p = .02 ) and trended toward decreased fatigue severity ( p = .09 ) at 10-wk follow-up . No group differences were found in pain reduction . CONCLUSION Tailoring instruction on the basis of recent symptoms and physical activity may be a more effective symptom management approach than general instruction given the positive effects on fatigue Arthritis has been identified as the most common cause of disability in the United States ( 1 , 2 ) . Thirty-three percent of persons 63 to 94 years of age are affected by osteoarthritis of the knee , which often limits the ability to rise from a chair , st and comfortably , walk , and use stairs ( 3 , 4 ) . Acetaminophen and nonsteroidal anti-inflammatory drugs ( NSAIDs ) are commonly used to treat osteoarthritis . Use of NSAIDs can lead to gastric complications , increased risk for hospitalization , and death ( 5 ) . Other treatment options for persons with osteoarthritis of the knee include physical therapy exercise and treatment programs , cortisone injections , and joint replacement surgery . Puett and Griffin ( 6 ) review ed 15 controlled trials of nonmedicinal , noninvasive therapies for hip and knee osteoarthritis from 1966 through 1993 ( 6 ) . The authors concluded that exercise reduces pain and improves function in patients with osteoarthritis of the knee , but the optimal exercise regimen has not been determined . Fitness walking , aerobic exercise , and strength training have all been reported to result in functional improvement in patients with osteoarthritis of the knee ( 6 - 12 ) . Unweighted treadmill walking has not been shown to decrease pain associated with osteoarthritis of the knee ( 13 ) . Other research ers ( 14 , 15 ) have concluded that exercise may benefit patients with osteoarthritis but advise that long-term studies are required to determine the appropriate amounts of exercise to avoid accelerating the underlying process of arthritis . Active and passive range-of-motion exercise is considered an important part of rehabilitation programs for patients with osteoarthritis ( 16 - 18 ) . Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function ( 19 ) . We evaluated the effectiveness of manual physical therapy for osteoarthritis of the knee , as applied by physical therapists with formal training in such an approach ( 20 ) . Our hypothesis was that physical therapy consisting of manual therapy to the knee , hip , ankle , and lumbar spine combined with range-of-motion , strengthening , and cardiovascular exercises would be more effective than placebo for improving function , decreasing pain and stiffness , and increasing the distance walked in 6 minutes . Methods Patients Eighty-three patients with osteoarthritis of the knee were r and omly assigned to receive treatment ( n=42 ; 15 men and 27 women [ mean age , 60 11 years ] ) or placebo ( n=41 ; 19 men and 22 women [ mean age , 62 10 years ] ) . All patients were referred by physicians to physical therapy for osteoarthritis of the knee . Physicians at the various clinics in the medical center who normally see patients with osteoarthritis of the knee were informed of the study so that appropriate referrals could be made . If the patients met our inclusion criteria , they were offered the opportunity to participate . The main inclusion criterion was a diagnosis of osteoarthritis of the knee based on fulfillment of one of the following clinical criteria developed by Altman and colleagues [ 21 ] : 1 ) knee pain , age 38 years or younger , and bony enlargement ; 2 ) knee pain , age 39 years or older , morning stiffness for more than 30 minutes , and bony enlargement ; 3 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and bony enlargement ; or 4 ) knee pain , crepitus on active motion , morning stiffness for more than 30 minutes , and age 38 years or older . Altman and colleagues found this criteria to be 89 % sensitive and 88 % specific ( 21 - 23 ) . Patients were required to be eligible for military health care , have had no surgical procedure on either lower extremity in the past 6 months , and have no physical impairment unrelated to the knee that would prevent safe participation in a timed 6-minute walk test or any other aspect of the study . Patients had to have sufficient English- language skills to comprehend all explanations and to complete the assessment tools . They were also required to live within a 1-hour drive of the physical therapy clinic . Patients who could not attend the required number of visits or had received a cortisone injection to the knee joint within the previous 30 days were not enrolled . Patients were instructed to keep taking any current medications and not to start taking new medications for osteoarthritis during the clinical treatment and 8-week follow-up . Therapy with any osteoarthritis medication must have been initiated at least 30 days before participation in the study . The study was approved by the institutional review board of Brooke Army Medical Center , Fort Sam Houston , Texas . All patients completed an informed consent form and were advised of the risks of the study , including increased symptoms , injuries from falls , and cardiovascular events . No external funding was received for this study . Procedure Patients who met the inclusion criteria were r and omly assigned to one of two groups . Blank folders were numbered from 1 to 100 and were given concealed codes for the group of assignment , determined by a r and om-number generator . When a patient was eligible and gave consent to participate , the treating therapist drew the next folder from the file , which determined the group of assignment . The treatment group received a combination of manual physical therapy and supervised exercise . The placebo group received ultrasound at a subtherapeutic intensity . Neither group was aware of the treatment that the other group was receiving . Demographic data collected for each patient included age , sex , occupation , height , weight , duration of symptoms , presence of symptoms in one or both knees , previous knee surgery , medications , and present activity level . Knee radiographs were obtained and read by a radiologist who assigned a radiographic severity rating for osteoarthritis ( 24 ) . Dependent variables measured in this study were the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) score ( 25 ) and distance covered during a timed 6-minute walk test . The WOMAC Osteoarthritis Index consists of 24 questions , each corresponding to a visual analogue scale . This test has been shown to be a reliable , valid , and responsive multidimensional outcome measure for evaluation of patients with osteoarthritis of the hip or knee ( 26 ) . The timed 6-minute walk test measures the distance a patient walks in 6 minutes and has been demonstrated to be a reliable measurement of functional exercise capacity ( 27 ) . All measurements of dependent variables were obtained by a trained research assistant who was blinded to group assignment . After research assistants obtained pretreatment values for the dependent variables , patients returned to the treating physical therapist for thorough st and ardized clinical examination of the knee , hip , ankle , and lumbar spine . Treatment was initiated according to group assignment . The treatment group received manual physical therapy as indicated by the results of the examination . The manual therapy treatment techniques , consisting of passive physiologic and accessory joint movements , muscle stretching , and soft-tissue mobilization , were applied primarily to the knee . The same treatments were also administered to the lumbar spine , hip , or ankle if these areas showed limitation in active or passive movement , were symptomatic , or were contributing to overall lower limb dysfunction ( 28 - 31 ) . A minimal pain level was not exceeded in any treatment . The treatment group also performed a closely supervised st and ardized knee exercise program at each of the eight treatment sessions . This program consisted of active range-of-motion exercises for the knee , muscle strengthening exercises for the hip and knee , muscle stretching for the lower limbs , and riding a stationary bike . All of the activities were mutually reinforcing , with repeated gentle challenges to the end ranges of movement . An outline of the exercise program is shown in the Appendix Figure . The physical therapist increased the number of strengthening exercise bouts and the stationary bike riding time on the basis of patient tolerance . The current literature provides efficient methods to produce the desired effects of increasing strength , flexibility , and range of motion ( 32 - 35 ) . At each session , the physical therapist examined the patient for adverse signs and symptoms , such as increased pain , joint effusion , and increased skin temperature over knee joints . These signs and symptoms of osteoarthritis had to be stable or decreasing before manual therapy or exercise was progressed . Patients exercised in a painless or minimally painful manner . If any post-treatment or exercise soreness lasted more than a few hours , the regimen was decreased accordingly for that patient . The placebo group received treatment by the physical therapist that consisted of subtherapeutic ultrasound for 10 minutes at an intensity of 0.1 W/cm2 and 10 % pulsed mode ( lowest setting and greatest cycle interruption ) to the area of knee symptoms . The placebo group received the same subjective and h and s-on objective reevaluation before and after each session as the treatment group . The amount of time directly spent with the treating therapist was approximately 30 minutes for both groups . The treatment group required an additional 30 to 45 minutes to perform their exercises in the clinic . Both groups were treated twice weekly for 4 weeks , for a total of eight clinic treatments . Patients in the treatment group also performed the same exercises at home , except for the closed-chain strengthening exercises , on the days on which they were not treated in the physical therapy clinic . They also walked at home each day at a comfortable pace and distance . The treating physical therapist instructed each patient in the performance of the exercises and provided a detailed h and out containing instructions and photographs of the exercises . Each patient maintained a home exercise BACKGROUND AND OBJECTIVES Decreased activity of hip abductor musculature has been suggested as a contributing factor for the disease progression in participants with symptomatic knee osteoarthritis ( OA ) . In this study , the effectiveness of 6 weeks isolated hip abductor strengthening on WOMAC , 6 minute walk test and hip strength and endurance in participants with symptomatic medial compartment knee OA were studied . MATERIAL AND METHOD Thirty persons with medial compartment knee OA were r and omized to hip abductor strengthening group ( n = 15 )  and conventional group ( n = 15 ) . Both the groups received intervention for 5 times per week for 6 weeks . 6 minute walk test , health status ( WOMAC ) , hip strength ( by modified syphgmomanometer ) and hip endurance ( number of repetitions ) were assessed at baseline and post intervention . The dependent variables were analyzed using 2 × 2 ANOVA , with repeated measurement as second factor to determine the effects of the intervention on each outcome variable . RESULTS Significant group-by-time interactions were observed for each variable of interest . Post hoc testing revealed that all the outcome measures improved significantly in the hip abductor strengthening group following the 6-week intervention than the control group . CONCLUSION The incorporation of hip-strengthening exercises may be considered along with conventional exercises when design ing a rehabilitation program for persons with knee OA Background Web-based interventions show promise in promoting a healthy lifestyle , but their effectiveness is hampered by high rates of nonusage . Predictors and reasons for (non)usage are not well known . Identifying which factors are related to usage contributes to the recognition of subgroups who benefit most from Web-based interventions and to the development of new strategies to increase usage . Objective The aim of this mixed methods study was to explore patient , intervention , and study characteristics that facilitate or impede usage of a Web-based physical activity intervention for patients with knee and /or hip osteoarthritis . Methods This study is part of a r and omized controlled trial that investigated the effects of Web-based physical activity intervention .  A total of 199 participants between 50 - 75 years of age with knee and /or hip osteoarthritis were r and omly assigned to a Web-based intervention ( n=100 ) or a waiting list ( n=99 ) . This mixed methods study used only data from the individuals allocated to the intervention group . Patients were defined as users if they completed at least 6 out of 9 modules .  Logistic regression analyses with a stepwise backward selection procedure were executed to build a multivariate prediction usage model . For the qualitative part , semistructured interviews were conducted . Both inductive and deductive analyses were used to identify patterns in reported reasons for nonusage . Results Of the 100 participants who received a password and username , 46 completed 6 modules or more . Multivariate regression analyses revealed that higher age ( OR 0.94 , P=.08 ) and the presence of a comorbidity ( OR 0.33 , P=.02 ) predicted nonusage . The sensitivity analysis indicated that the model was robust to changes in the usage parameter . Results from the interviews showed that a lack of personal guidance , insufficient motivation , presence of physical problems , and low mood were reasons for nonusage . In addition , the absence of human involvement was viewed as a disadvantage and it negatively impacted program usage . Factors that influenced usage positively were trust in the program , its reliability , functionality of the intervention , social support from family or friends , and commitment to the research team . Conclusions In this mixed methods study , we found patient , intervention , and study factors that were important in the usage and nonusage of a Web-based PA intervention for patients with knee and /or hip osteoarthritis . Although the self-guided components offer several advantages , particularly in relation to costs , reach , and access , we found that older patients and participants with a comorbid condition need a more personal approach . For these groups the integration of Web-based interventions in a health care environment seems to be promising . Trial Registration The Netherl and s National Trial Register ( NTR ) : NTR2483 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=2483 ( Archived by Webcite at http://www.webcitation.org/67NqS6Beq ) Context Despite their established benefit in patients with osteoarthritis , many treatment strategies are underused . Contribution In this r and omized trial , providing treatment recommendations to physicians in addition to telephone-based support to patients with knee or hip osteoarthritis result ed in modest improvements in physical function . Caution The relative contributions of the physician- and patient-based interventions to the observed improvement could not be assessed . Implication A combined physician and patient intervention may be beneficial in patients with knee or hip osteoarthritis . Osteoarthritis is one of the most common chronic health conditions and a leading cause of pain and disability ( 15 ) . Its prevalence is increasing , and this trend is expected to continue ( 6 , 7 ) . In addition to the substantial toll at the individual level ( 8) , osteoarthritis is placing an increasing burden on health care systems ( 9 , 10 ) . Evidence -based guidelines indicate that adequate management of hip and knee osteoarthritis requires both behavioral and clinical strategies ( 1114 ) .  Physical activity  and  weight management  are key behavioral strategies for managing hip and knee osteoarthritis , but most adults with osteoarthritis are physically inactive or overweight ( 15 , 16 ) . Similarly , despite strong evidence supporting several clinical strategies , such as joint injections , physical therapy , and pain medications , some of these treatments are underused , and studies have shown low rates of adherence to osteoarthritis quality indicators ( 1720 ) . Improvement in osteoarthritis management is needed at both the patient and provider levels . The purpose of our study was to examine a combined patient and provider intervention for management of osteoarthritis in primary care . Methods The Institutional Review Board of the Department of Veterans Affairs ( VA ) Medical Center in Durham , North Carolina , approved this study . Detailed methods have been published previously ( 21 ) . Study Design This was a cluster r and omized , controlled trial , with primary care providers ( PCPs ) assigned to an osteoarthritis intervention group or a usual care control group . R and omization was computer-generated , maintained by the study statistician , and stratified on the basis of the providers ' volume of female patients ( < 15 % vs. 15 % ) . We aim ed to enroll 10 patient participants ( 5 white and 5 nonwhite ) from each of 30 PCPs . Providers assigned to the osteoarthritis intervention group received the provider intervention , and their enrolled patient participants received the patient intervention . Patient participants in both groups continued with any usual medical care recommended by their providers . Because all patient participants were enrolled at the Durham VA Medical Center , usual care could include any of the st and ard treatments for osteoarthritis given by a PCP as well as referral to other providers or specialists . Provider and patient participants in the usual care group received no additional intervention during the study . Participants and Recruitment Primary care providers in the Ambulatory Care Service of the Durham VA Medical Center , with patient panels large enough to be likely to enroll 10 participants , were invited to participate . Patients were eligible if they had hip osteoarthritis ( based on radiographic evidence in the electronic medical record [ EMR ] ) , knee osteoarthritis ( based on radiographic evidence in the EMR or clinical criteria from the American College of Rheumatology [ 22 ] ) , or both , along with self-reported joint symptoms ( pain , aching , stiffness or swelling in or around a hip or knee joint with arthritis ) that were present on most days during the past month or for which the patient had used pain medications on most days during the past month ( 23 ) . Participants also had to be overweight ( body mass index [ BMI ] 25 kg/m2 ) and not currently adhering to physical activity recommendations from the U.S. Department of Health and Human Services ( 24 ) . Exclusion criteria are summarized in the Appendix Table . Potential participants were identified from the Durham VA Medical Center EMR , mailed an introductory letter , and called for a screening interview . Eligible patients completed consent and baseline assessment s at the Durham VA Medical Center and were subsequently informed of their group assignment by telephone . Study team members involved in screening and consent were blinded to r and omization . Potential patient participants were blinded to their PCP 's group assignment until after the baseline assessment s. Appendix Table . Exclusion Criteria Interventions Patient Intervention This was a 12-month intervention focusing on physical activity , weight management , and cognitive behavioral pain management strategies ( 21 ) . Telephone calls were scheduled twice per month for the first 6 months and monthly for the last 6 months and were delivered by a counselor with training in osteoarthritis and behavior change . Goal setting and action planning were major components of the intervention . The counselor used motivational interviewing strategies throughout the intervention ( 21 , 25 , 26 ) . Patient participants were given written educational material s corresponding to intervention topics , an exercise video for patients with osteoarthritis , and an audio CD of relaxation exercises . Provider Intervention This intervention involved delivery of the following patient-specific osteoarthritis treatment recommendations to PCPs , based on published treatment guidelines ( 13 , 14 , 27 ) : refer to a physical therapist , refer for an evaluation for a knee brace , refer to MOVE ! ( the VA system 's weight management program that includes physical activity counseling [ 28 ] ) , perform or refer for an intra-articular injection , recommend a topical nonsteroidal anti-inflammatory drug ( NSAID ) or capsaicin , add a gastroprotective agent or remove an NSAID , discuss the possibility of a new or alternate pain medication , or refer to an orthopedic evaluation for joint replacement surgery . We developed algorithms ( Appendix ) to determine when each treatment option might be reasonable for a PCP to consider for a patient ( 21 ) . Study team members collected all information needed to complete the algorithm for each patient participant during baseline assessment s. Patient-specific recommendations were delivered to PCPs via the EMR as a progress note requiring an electronic signature . The study team monitored upcoming visits for participants in the osteoarthritis intervention group , and recommendations were delivered to PCPs about 1 week before the participants ' first routine visit after enrollment . The recommendations remained available to PCPs within the EMR , but no further communications were transmitted to osteoarthritis intervention providers . Outcome Measures Baseline and 12-month follow-up measures were completed in person , except for 36 participants who could not return to the Durham VA Medical Center at 12 months but completed some measures via telephone . The primary outcome was also assessed via telephone at 6 months . Outcomes assessors were blinded to r and omization . Participants were reimbursed $ 25 and $ 10 for completing in-person and telephone assessment s , respectively . Primary Outcome The primary outcome measure was total score on the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) , a self-reported measure of lower extremity pain ( 5 items ) , stiffness ( 2 items ) , and function ( 17 items ) in the previous 2 weeks ( 2931 ) . All items are rated on a 5-point Likert scale ranging from none to extreme ; total scores range from 0 to 96 , with higher scores indicating worse symptoms and function . Secondary Outcomes We examined the WOMAC pain and function subscales separately . We also administered the Short Physical Performance Battery ( SPPB ) ( 32 ) , a commonly used performance measure in older adults that includes 3 tests of balance , a timed 8-foot walk , and 5 chair st and s. The total score ranges from 0 ( worst performance ) to 12 ( best performance ) . Depressive symptoms were assessed with the Patient Health Question naire-8 ( 33 ) , with scores ranging from 0 to 24 . Process Measures We collected additional process measures related to behaviors or outcomes intermediate to changes in symptoms or function . Self-reported physical activity was measured with the Community Healthy Activities Model Program for Seniors ( CHAMPS ) ( 34 , 35 ) , which assesses the frequency and duration of light to vigorous activities in the previous 4 weeks ; we report the weekly frequency and duration of all exercise as well as moderate- or higher-intensity exercise . CHAMPS has established testretest reliability and association with accelerometer-based physical activity among older adults ( 36 ) . Body mass index was calculated using measured height and weight ; when 12-month follow-up measures were administered via telephone , weight was self-reported . For all patient participants , we used the Durham VA Medical Center EMR to examine osteoarthritis-related referrals from PCPs and participants ' actual visits for physical therapy , evaluations for knee braces , joint injections , MOVE ! , and orthopedic consultation during the study . We assessed changes in oral and topical pain medication  by participant self-reports . For oral pain medications , we defined new use during the study as either no pain medication use at baseline but some use at follow-up or use of a different pain medication at follow-up than at baseline . For topical creams , we defined new users as those who reported using any type at follow-up but not at baseline . We acknowledge that use of new oral or topical pain medications may not necessarily have led to better pain control . We also report proportions of osteoarthritis intervention participants whose PCP received each treatment recommendation from the study team and , among those , proportions who had referrals and visits for those treatments . Participant Characteristics We collected patient participantreported information on age , sex , Background and Purpose Aquatic physical therapy is frequently used in the management of patients with hip and knee osteoarthritis ( OA ) , yet there is little research establishing its efficacy for this population . The purpose of this study was to evaluate the effects of aquatic physical therapy on hip or knee OA . Subjects A total of 71 volunteers with symptomatic hip OA or knee OA participated in this study . Methods The study was design ed as a r and omized controlled trial in which participants r and omly received 6 weeks of aquatic physical therapy or no aquatic physical therapy . Outcome measures included pain , physical function , physical activity levels , quality of life , and muscle strength . Results The intervention result ed in less pain and joint stiffness and greater physical function , quality of life , and hip muscle strength . Totals of 72 % and 75 % of participants reported improvements in pain and function , respectively , compared with only 17 % ( each ) of control participants . Benefits were maintained 6 weeks after the completion of physical therapy , with 84 % of participants continuing independently . Discussion and Conclusion Compared with no intervention , a 6-week program of aquatic physical therapy result ed in significantly less pain and improved physical function , strength , and quality of life . It is unclear whether the benefits were attributable to intervention effects or a placebo response OBJECTIVES To determine whether ethnicity was associated with baseline and 18-month health status within a merged sample of older adults with knee osteoarthritis ( OA ) from the Fitness Arthritis in Seniors Trial and the Arthritis , Diet , and Activity Promotion Trial . DESIGN Cross-sectional and prospect i ve study . SETTING Center-based exercise therapy at two universities . PARTICIPANTS A total of 584 African-American ( n=143 ) and Caucasian-American ( n=441 ) adults aged 60 and older with knee OA were examined for baseline and 18-month health status . MEASUREMENTS Six-minute-walk distance , 36-item Short Form General Health Scale ( SF-36 GHS ) , and Physical Functioning Question naire index score . Ethnicity was obtained via self-report . RESULTS Analyses of covariance testing the effect of ethnicity , adjusted for demographic and health status covariates , revealed significant effects for ethnicity upon baseline 6-minute-walk distance and SF-36 GHS , with Caucasian Americans reporting better scores ( P=.001 ) , although these differences were not significant after 18 months of exercise therapy . CONCLUSION Ethnicity and baseline function are important factors that should not be overlooked in knee OA research involving exercise interventions . Moreover , not only should physical activity be recommended to improve functional outcomes , it may also be a useful strategy in reducing health disparities This prospect i ve study evaluated regular physical activity and  self-reported physician-diagnosed osteoarthritis of the knee and /or hip joints among 16,961 people , ages 20 - 87 , examined at the Cooper Clinic between 1970 and 1995 . Among those aged 50 years and older , osteoarthritis incidence was higher among women ( 7.0 per 1000 person-years ) than among men ( 4.9 per 1000 person-years , P = 0.001 ) , while among those under 50 years of age , osteoarthritis incidence was similar between men ( 2.6 ) and women ( 2.7 ) . High levels of physical activity  ( running 20 or more miles per week ) were associated with osteoarthritis among men under age 50 after controlling for body mass index , smoking , and use of alcohol or caffeine ( hazard ratio = 2.4 , 95 % CI : 1.5 , 3.9 ) , while no relationship was suggested among women or older men . These findings support the conclusion that high levels of physical activity  may be a risk factor for symptomatic osteoarthritis among men under age 50 Background Hip and knee osteoarthritis is a common cause of pain and disability , which can be improved by exercise interventions . However , regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement . The best method of encouraging increased activity in this patient group is not known . A booklet has been developed for patients with hip or knee osteoarthritis . It focuses on changing disadvantageous beliefs and encouraging increased physical activity . Methods / Design This paper describes the design of a Phase II r and omised controlled trial ( RCT ) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs , and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour . A computerised search of four general medical practice patients ' record data bases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months . A r and om sample of 120 will be invited to participate in the RCT comparing the new booklet  with a control booklet , and we expect 100 to return final question naires . This trial will assess the feasibility of recruitment and r and omisation , the suitability of the control intervention and outcome measurement tools , and will provide an estimate of effect size . Outcomes will include beliefs about hip and knee pain , beliefs about exercise , fear avoidance , level of physical activity , health status and health service costs . They will be measured at baseline , one month and three months . Discussion We discuss the merits of testing effectiveness in a phase II trial , in terms of intermediate outcome measures , whilst testing the processes for a larger definitive trial . We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial . Trial registration Current Controlled Trials IS RCT Our objective was to investigate whether behavioral grade d activity ( BGA ) has particular benefit in specific subgroups of osteoarthritis ( OA ) patients . Two hundred participants with OA of hip or knee , or both ( clinical American College of Rheumatology , ACR , criteria ) participated in a r and omized clinical trial on the efficacy of BGA compared to treatment according to the Dutch physiotherapy guideline ( usual care ; UC ) . Changes in pain ( Visual Analog Scale , VAS ) , physical functioning ( Western Ontario and McMaster Universities Osteoarthritis Index , WOMAC , and McMaster Toronto Arthritis Question naire , MACTAR ) , and patient global assessment were compared for specific subgroups . Subgroups were assigned by the median split method and were analyzed using analysis of covariance . Beneficial effects of BGA were found for patients with a relatively low level of physical functioning ( p?0.03 ) . Furthermore , beneficial effects of BGA  in patients with a low level of internal locus of control were marginally significant ( p = .05 ) . Patients with a relatively low level of physical functioning  benefit more from BGA compared to UC . Compared to UC , BGA is the preferred treatment option in patients with a low level of physical functioning Background Osteoarthritis is the most common reason for pain in older adults , and the individual and economic burden of this disease is immense . The chronic character of osteoarthritis requires a long-term therapeutic treatment . In this regard life-style interventions such as physical exercises that can be carried out by the patient himself are recommended as first line treatment . There is evidence for the short-term benefit of exercise therapy in terms of pain reduction and physical functioning . Nonetheless research agendas highlight the need for multifaceted interventions that incorporate exercise strategies into patient care . Studies should be conducted with appropriate sample sizes and should allow statements on long-term effects as well as cost-utility and safety . These open questions are under the scope of this study . Methods / design This is a controlled study in the context of health services research . The study population consists of n = 1400 subjects with hip or knee osteoarthritis . The  intervention group will be recruited from participants of a country-wide health insurance offer for people with hip or knee osteoarthritis . Potential participants for the control group ( ratio 10:1 ( control vs. intervention ) will be filtered out from the insurance data base according to pre-defined matching criteria and asked by letter for their participation . The final statistical twins from the responders ( 1:1 ) will be determined via propensity score matching . The progressive training intervention comprises 8 supervised group sessions , supplemented by home exercises ( 2/week over 11 weeks ) . Exercises include mobilization , strengthening and training of postural control . Primary outcomes are pain and function measured with the WOMAC Index immediately after the intervention period . Among other things , health related quality of life , self-efficacy , cost utility and safety will be evaluated as secondary outcomes . Participants will be followed up 6 , 12 and 24 month after baseline . Discussion Results of this trial will document the effects of clinical as well as economic outcomes in a regular health care setting on the basis of a large sample size . As such , results of this trial might have great impact on future implementations of group- and home-based exercises in hip or knee osteoarthritis . Trail registration German Clinical Trial Register DRKS00009251 . Registered 10 September 2015 QUESTION Does behavioural grade d activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee ? DESIGN Analysis of secondary outcomes of a cluster-r and omised trial with concealed allocation , assessor blinding , and intention-to-treat analysis . PARTICIPANTS Two hundred patients with hip and /or knee osteoarthritis . INTERVENTION Experimental group received 18 sessions of behavioural grade d activity over 12 weeks and up to 7 booster sessions over the next year . The control group received 18 sessions of usual care over 12 weeks according to the Dutch physiotherapy guideline . OUTCOME MEASURES Exercise adherence was measured using a question naire and physical activity was measured using the SQUASH question naire at baseline , 13 , and 65 weeks . RESULTS Adherence to recommended exercises was significantly higher in the experimental group than in the control group at 13 weeks ( OR 4.3 , 95 % CI 2.1 to 9.0 ) and at 65 weeks ( OR 3.0 , 95 % CI 1.5 to 6.0 ) . Significantly more of the experimental than the control group met the recommendations for physical activity at 13 weeks ( OR 5.3 , 95 % CI 1.9 to 14.8 ) and at 65 weeks ( OR 2.9 , 95 % CI 1.2 to 6.7 ) . CONCLUSION Behavioural grade d activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee , both in the short- and long-term . TRIAL REGISTRATION NCT00522106 Background Osteoarthritis ( OA ) of the hip and knee are among the most common chronic conditions , result ing in substantial pain and functional limitations . Adequate management of OA requires a combination of medical and behavioral strategies . However , some recommended therapies are under-utilized in clinical setting s , and the majority of patients with hip and knee OA are overweight and physically inactive . Consequently , interventions at the provider-level and patient-level both have potential for improving outcomes . This manuscript describes two ongoing r and omized clinical trials being conducted in two different health care systems , examining patient-based and provider-based interventions for managing hip and knee OA in primary care . Methods / Design One study is being conducted within the Department of Veterans Affairs ( VA ) health care system and will compare a Combined Patient and Provider intervention relative to usual care  among n = 300 patients ( 10 from each of 30 primary care providers ) . Another study is being conducted within the Duke Primary Care Research Consortium and will compare Patient Only , Provider Only , and Combined ( Patient + Provider ) interventions relative to usual care  among n = 560 patients across 10 clinics . Participants in these studies have clinical and / or radiographic evidence of hip or knee osteoarthritis , are overweight , and do not meet current physical activity guidelines . The 12-month , telephone-based patient intervention focuses on physical activity , weight management , and cognitive behavioral pain management . The provider intervention involves provision of patient-specific recommendations for care ( e.g. , referral to physical therapy , knee brace , joint injection ) , based on evidence -based guidelines . Outcomes are collected at baseline , 6-months , and 12-months . The primary outcome is the Western Ontario and McMasters Universities Osteoarthritis Index ( self-reported pain , stiffness , and function ) , and secondary outcomes are the Short Physical Performance Test Protocol ( objective physical function ) and the Patient Health Question naire-8 ( depressive symptoms ) . Cost effectiveness of the interventions will also be assessed . Discussion Results of these two studies will further our underst and ing of the most effective strategies for improving hip and knee OA outcomes in primary care setting s . Trial registration NCT01130740 ( VA ) ; NCT 01435109 ( NIH OBJECTIVE To assess the contribution of radiological osteoarthritis of the hips and knees to disabilities in the activities of daily living related to lower limb function . METHODS During a home interview 1156 men and 1739 women , r and omly chosen from the source population of all independently living residents aged 55 years and over living in a district of Rotterdam ( the Rotterdam Study ) were asked about locomotor disability by six questions of the Health Assessment Question naire ( HAQ ) and about pain in the hips and knees in the past month . Radiographs of hips and knees were scored according to the Kellgren grading system for osteoarthritis . RESULTS The prevalence of locomotor disability , defined as at least some difficulty with three or more out of six lower limb functions , was 20.2 % for men and 31.9 % for women ;  hip pain was present in 8.3 % of the men and 16.6 % of the women ; knee pain in 12.6 % of the men and 22.3 % of the women . The prevalence of radiological osteoarthritis grade 2 + of the hip was 14.1 % for men and 15.9 % for women , and of the knee 16.3 % and 29.1 % respectively . The odds ratio ( OR ) ( 95 % confidence intervals ) of hip radiological osteoarthritis for locomotor disability adjusted for age and all other variables was for men : 1.4 ( 0.9 , 2.1 ) and for women : 2.2 ( 1.6 , 2.9 ) . The ORs of knee radiological osteoarthritis adjusted for age and all other variables were 1.1 ( 0.9 , 2.1 ) and 1.4 ( 1.1 , 1.8 ) respectively . Severe radiological osteoarthritis ( grade 3 + ) was stronger associated . The ORs of pain in the hips or knees and morning stiffness were much higher ( between 2.7 and 5.5 for men and between 2.1 and 5.1 for women ) . CONCLUSIONS Radiological osteoarthritis of the hip and knee are only weak independent predictors of  locomotor disability in women , and not at all independently associated with locomotor disability in men . Age , pain of the hips and knees , and morning stiffness seem to be the most important independent determinants of locomotor disability The prevalence of  osteoarthritis ( OA )  is greater in women then men . Weight , a factor strongly associated with osteoarthritis , is significantly increased over the menopausal transition . Despite the high prevalence of osteoarthritis , a disabling disease with limited treatment options , there is a paucity of studies in women . The longitudinal phase of the Melbourne Women 's Midlife Health Project , is a population -based prospect i ve study of 438 Australian born women who have been followed annually over 11 years . 257 ( 59 % ) of these women remained in longitudinal assessment at 11th year of follow-up and 224 of these women agreed to undergo X-rays of their knees and h and s. In this study , X-rays were scored for evidence of osteoarthritis using a vali date d scale , by two investigators who were blinded to question naire results . Information on hormone therapy use , physical activity , smoking , BMI and age were obtained by both self-administered and face-to-face question naires . Results showed that one hundred and twenty-eight women ( 56 % ) had evidence of radiological OA . Forty-nine ( 21.6 % ) had evidence of radiological knee OA . One hundred and one ( 44.5 % ) had evidence of radiological h and OA . Compared to baseline , at 11th year of follow-up participants had put on weight ( 4 kg range -14 to 25 kg ) and a larger proportion ( 25 % vs. 40 % ) reported exercising frequently ( P = 0.005 ) . Physical activity and BMI were associated with higher prevalence of osteoarthritis in the final year of follow-up . Smoking was associated with a lower prevalence of radiological knee OA . The prevalence was 61 % among never smokers compared to only 39 % among those who smoked ( P < 0.05 ) . Total OA was associated with never having used hormone therapy ( odds ratio 2.7 ; CI 1.1 - 6.9 ) . There was a trend for increasing level of physical activity at ages 20 - 29 to be associated with an increased risk of knee OA ( P value 0.03 for trend ) . In conclusion increasing age , BMI and history of more frequent physical activity in younger years were risk factors for radiological knee OA . In contrast , smoking appeared to be associated with less knee OA . Never having used hormone therapy was a risk factor for radiological h and and knee OA . Further work will be needed to determine whether modification of these factors can prevent the development of OA
Social ( e.g. support from spouse ( n = 141 ) ) and environment ( outdoor temperature ( n = 38 ) ) factors were identified as possible factors that influence physical activity .
Conclusion : Demographic , physical , social , psychological and environmental factors are all important correlates for physical activity for people with knee or hip osteoarthritis .
Objective : To determine the factors associated with physical activity participation in adults with hip or knee osteoarthritis .