The effectiveness of self‐management educational interventions for osteoarthritis of the knee Incorporating Novel Mobile Health Technologies Into Management of Knee Osteoarthritis in Patients Treated With Intra-Articular Hyaluronic Acid: Rationale and Protocol of a Randomized Controlled Trial Is there an evidence-based efficacy for the use of foot orthotics in knee and hip osteoarthritis? Elaboration of French clinical practice guidelines. The effect of prehabilitation exercise on strength and functioning after total knee arthroplasty. The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results. Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study. How Effective are Lateral Wedge Orthotics in Treating Medial Compartment Osteoarthritis of the Knee? A Systematic Review of the Recent Literature Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. Efficacy of periosteal stimulation therapy for the treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial. Occupational physical loading tasks and knee osteoarthritis: a review of the evidence. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). A home-based pedometer-driven walking program to increase physical activity in older adults with osteoarthritis of the knee: a preliminary study. A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care Manual for guided home exercises for osteoarthritis of the knee. Effects of quadriceps electrical stimulation program on clinical parameters in the patients with knee osteoarthritis Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis. Exercise for fall risk reduction in community-dwelling older adults: a systematic review. Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators? Community environmental factors are associated with disability in older adults with functional limitations: the MOST study. Effectiveness of an Internet-Delivered Exercise and Pain-Coping Skills Training Intervention for Persons With Chronic Knee Pain Comparative Effectiveness of Tai Chi Versus Physical Therapy for Knee Osteoarthritis
Background Osteoarthritis ( OA ) is a common cause of pain and disability , and is the most common form of arthritis in the Western world . The most common joint to be affected is the knee . Pain and functional disability are common symptoms , which can lead to reduced quality of life and increase the risk of further morbidity . Current treatment aims to educate patients about the management of OA , reduce pain , improve function , decrease disability and reduce the progression of the disease . Education with clients has been described as a set of planned educational activities design ed to improve patients ' health behaviours and /or health status . The purpose of self‐education is to maintain or improve health , or , in some cases , to slow deterioration by increasing participant 's perception of self efficacy defined as an ability to control or manage various aspects of OA . To date , there is no systematic review of the literature undertaken to identify the effectiveness of self‐management educational activities for osteoarthritis of the knee . Objective The objective of this systematic review is to evaluate the effectiveness of  self‐management educational interventions on function and quality of life for adult subjects with OA of the knee . Search strategy A comprehensive search strategy was undertaken on data bases available from University of South Australia from their inception to January 2007 . Selection criteria R and omised controlled trials or clinical controlled trials were sought which evaluated any self management interventions for osteoarthritis knee . Critical appraisal of study quality was undertaken using Joanna Briggs Institute critical appraisal instruments . Data extraction was via the Joanna Briggs Institute st and ard data extraction form for evidence of effectiveness , and Review Manager Software was used to calculate comparative statistics . Results Thirteen trials were included in the review . Trials were clinical ly and method ologically heterogeneous . Pooled results indicate evidence of a beneficial effect from  self management strategies with reducing pain ( SMD ‐0.25 , 95%CI ‐0.36 to ‐0.13 , 11 trials 1379 participants ) . There was no effect on physical function ( SMD 0.13 , 95%CI ‐0.33 to ‐0.08 , eight trials , 1156 subjects ) . No beneficial effects were found from self management interventions with improving quality of life . We also found the exercise component of self management ( four trials ) demonstrated a benefit with reducing pain , improving function and quality of life . Exercise also offered a benefit over no exercise  . Overall method ological quality was moderate . Discussion Pooled results indicate evidence of a beneficial effect from self management strategies with reducing pain and improving function . Significant heterogeneity was found between trials . This was controlled for in the analysis but may be explained by heterogeneity in both the intervention and control group . The exercise component of self management programmes appears to contribute a significant benefit . Conclusion There is encouraging evidence of a small benefit from exercise in self management programs . Clear guidelines can not be provided for practice regarding the exercise content due to heterogeneity but overall benefit suggests this component should be emphasized and implemented in primary care self management programmes Background Osteoarthritis ( OA ) of the knee is one of the leading causes of disability in the United States . One relatively new strategy that could be helpful in the management of OA is the use of mHealth technologies , as they can be used to increase physical activity and promote exercise , which are key components of knee OA management . Objective Currently , no published data on the use of a mHealth approach to comprehensively monitor physical activity in patients with OA are available , and similarly , no data on whether mHealth technologies can impact outcomes are available . Our objective is to evaluate the effectiveness of mHealth technology as part of a tailored , comprehensive management strategy for patients with knee OA . Methods The study will assess the impact of a smartphone app that integrates data from a wearable activity monitor ( thereby both encouraging changes in mobility as well as tracking them ) combined with education about the benefits of walking on patient mobility . The results from the intervention group will be compared with data from a control group of individuals who are given the same Arthritis Foundation literature regarding the benefits of walking and wearable activity monitors but who do not have access to the data from those monitors . Activity monitors will capture step count estimates and will compare those with patients ’ step goals , calories burned , and distance walked . Patients using the novel smartphone app will be able to enter information on their daily pain , mood , and sleep quality . The relationships among activity and pain , activity and mood , and sleep will be assessed , as will patient satisfaction with and adherence to the mobile app . Results We present information on an upcoming trial that will prospect ively assess the ability of a mobile app to improve mobility for knee OA patients who are treated with intra-articular hyaluronic acid . Conclusions We anticipate the results of this study will support the concept that mHealth technologies provide continuous , real-time feedback to patients with OA on their overall level of activity for a more proactive , personalized approach to treatment that may help modify behavior and assist with self-management through treatment support in the form of motivational messages and reminders OBJECTIVE To develop clinical practice guidelines for the use of foot orthotics ( FO ) in the treatment of knee and hip osteoarthritis . METHOD The SOFMER ( French Physical Medicine and Rehabilitation Society ) methodology , associating a systematic review of the literature , input from every day clinical practice and external review by a multidisciplinary expert committee , was used . The selected analysis criteria were  pain , disability , medications used and X-ray evolution of osteoarthritis .  The recommendations are classified according to the level of proof in Grade A , B or C according to the French National Agency for Health Accreditation and Evaluation ( NAHAE ) . RESULTS In medial knee osteoarthritis , foot pronation orthotics -- when there are no contraindications -- can be proposed for their symptomatic impact , especially in the decrease of NSAIDs consumption ( Grade B ) . To this day , there is no evidence of a structural or functional impact on osteoarthritis ( Grade B ) . Outside of this specific clinical framework , there is no vali date d indication for prescribing foot orthotics in the treatment of knee or hip OA ( Grade C ) . CONCLUSION It is necessary to have further r and omized controlled trials to better define the indication of Foot orthotics ( severity of knee OA , genu varum ) , test the efficacy of other orthoses such as cushioning FO . The long-term side effects , mainly on the external femorotibial compartment could also be assessed . A medical and economical assessment of FO prescriptions is also quite necessary OBJECTIVE The purpose of this study was to examine the effect of a preoperative exercise intervention on knee pain , functional ability , and quadriceps strength among patients with knee osteoarthritis before and after total knee arthroplasty ( TKA ) surgery . DESIGN A repeated- measures design was used to compare 2 groups over 4 data collection points . SETTING AND PATIENTS Community-dwelling subjects with osteoarthritis of the knee who were scheduled for a unilateral TKA were recruited from a single orthopedic surgeon 's office and were r and omized into control ( n = 28 ) or prehab groups ( n = 26 ) . INTERVENTIONS The control patients maintained usual care before their TKA . The exercisers performed prehabilitation exercises , which included resistance training , flexibility , and step training , 3 times per week before their TKA . OUTCOME MEASURES Knee pain , functional ability , quadriceps strength , and strength asymmetry were assessed at baseline ( T1 ) , at 1 week before the patients ' TKA ( T2 ) , and again at 1 ( T3 ) and 3 ( T4 ) months after TKA . RESULTS The exercisers improved their sit-to-st and performance at T2 , whereas the control group did not change their performance of functional tasks and had increased pain at T2 . At T3 the exercisers demonstrated improved sit-to-st and performance . The control patients at T3 exhibited decreases in pain , their 6-minute walk , surgical leg strength and an increase in their nonsurgical leg strength and leg strength asymmetry . At T4 the exercisers improved in their performance of 3 of the 4 functional tasks , decreased all of their pain measures , and increased their surgical and nonsurgical quadriceps strength . At T4 the control group improved their performance on 2 of the 4 functional tasks , decreased all of their pain measures , increased their nonsurgical leg strength , and exhibited greater leg strength asymmetry . CONCLUSION These findings appear to indicate the efficacy of prehabilitation among TKA patients and support the theory of prehabilitation Osteoarthritis ( OA ) of the knee leads to restrictions of physical activity and ability to perform activities of daily living . Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability . The Arthritis , Diet , and Activity Promotion Trial ( ADAPT ) was developed to test the efficacy of lifestyle behavioral changes on physical function , pain , and disability in obese , sedentary older adults with knee OA . This controlled trial r and omized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups : Healthy Lifestyle Control ; Dietary Weight Loss ; Structured Exercise ; or Combined Exercise and Dietary Weight Loss . The weight-loss goal for the diet groups was a 5 % loss at 18 months . The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory . Exercise training consisted of aerobic and strength training for 60 minutes , three times per week in a group and home-based setting . The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index . Other measurements included timed stair climb , distance walked in 6 minutes , strength , gait , knee pain , health-related quality of life , knee radiographs , body weight , dietary intake , and cost-effectiveness of the interventions . We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks . The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA OBJECTIVE The purpose s of this pilot study were to determine if a combined dietary and exercise intervention would result in significant weight loss in older obese adults with knee osteoarthritis , and to compare the effects of exercise plus dietary therapy with exercise alone on gait , strength , knee pain , biomarkers of cartilage degradation , and physical function . DESIGN Single-blind , two-arm , r and omized clinical trial conducted for 24 weeks . SETTING A university health and exercise science center . PARTICIPANTS Twenty-four community-dwelling obese older adults aged > or = 60 years , body mass index > or = 28 , knee pain , radiographic evidence of knee osteoarthritis , and self-reported physical disability . INTERVENTION R and omization into two groups : exercise and diet ( E&D ) and exercise alone ( E ) . Exercise consisted of a combined weight training and walking program for 1 hour three times per week . The dietary intervention included weekly sessions with a nutritionist utilizing cognitive-behavior modification to change dietary habits to reach a group goal of an average weight loss of 15 lb ( 6.8 kg ) over 6 months . MEASUREMENTS All measurements were conducted at baseline and 3 and 6 months , except for synovial fluid analysis , which was obtained only at baseline and 6 months . In addition , weight was measured weekly in the E&D group . Physical disability and knee pain were measured by self-report and physical performance was measured using the 6-minute walk and stair climb tasks . Biomechanical testing included kinetic and kinematic analysis of gait and isokinetic strength testing . Synovial fluid was analyzed for levels of total proteoglycan , keratan sulfate , and interleukin-1 beta . RESULTS Twenty-one of the 24 participants completed the study , with one dropout in the E&D group and two in the E group . The E&D group lost a mean of 18.8 lb ( 8.5 kg ) at 6 months compared with 4.0 lb ( 1.8 kg ) in the E group ( P = .01 ) . Significant improvements were noted in both groups in self-reported disability and knee pain intensity and frequency as well as in physical performance measures . However , no statistical differences were found between the two groups at 6 months in knee pain scores or self-reported performance measures of physical function . There was no difference in knee strength between the groups , with both groups showing modest improvements from baseline to 6 months . At 6 months , the E&D group had a significantly greater loading rate ( P = .03 ) and maximum braking force ( P = .01 ) during gait . There were no significant between-group differences in the other biomechanical measures . Synovial fluid sample s were obtainable at both baseline and 6 months in eight participants ( four per group ) . The level of keratan sulfate decreased similarly in both groups from an average baseline of 96.8 + /- 37.1 to 71.5 + /- 23 ng/microg total proteoglycan . The level of IL-1 decreased from 25.3 + /- 9.8 at baseline to 8.3 + /- 6.1 pg/mL. The decrease in IL-1 correlated with the change in pain frequency ( r = -0.77 , P = .043 ) . CONCLUSIONS Weight loss can be achieved and sustained over a 6-month period in a cohort of older obese persons with osteoarthritis of the knee through a dietary and exercise intervention . Both exercise and combined weight loss and exercise regimens lead to improvements in pain , disability , and performance . Moreover , the trends in the biomechanical data suggest that exercise combined with diet may have an additional benefit in improved gait compared with exercise alone . A larger study is indicated to determine if weight loss provides additional benefits to exercise alone in this patient population Lateral wedges were originally proposed to manage medial compartment osteoarthritis of the knee but recent review s suggest that lateral wedges do not affect disease progression . We performed a systematic review to analyse the recent literature and define how effective , if at all , lateral wedges are in the management of medial compartment osteoarthritis of the knee . The inclusion criteria were defined as any study published within the last decade , using a sample size of at least twenty patients , and investigating the effect of insoles or wedges on either unilateral or bilateral knee varus osteoarthritis . The st and ardised keyword term ‘ lateral*wedge*OR insole*OR orthotic * OR medial compartment OR varus OR osteoarthri * OR knee * ’ was used . We identified 10 studies that fitted our inclusion criteria . Although there is not enough evidence in the literature to prove that lateral wedge orthotics are an effective treatment for varus osteoarthritis of the knee  , there is some evidence to suggest that they do have some symptomatic effect .  Patients with early osteoarthritis and higher BMI may benefit to a greater extent than those with a greater extent of degenerative changes and lower BMI . The literature is unclear as to what the optimal duration for the use of lateral wedges is , but does support the prolonged use of the wedges as the benefits at one month are maintained at one year . Future studies should be r and omised controlled trials with a large sample size with long follow-up , and use objective clinical , biomechanical and radiological outcome measures OBJECTIVE This 8 week r and omized , double blind clinical trial compared the effect of a combined home based progressive exercise program and treatment with the nonsteroidal medication oxaprozin to treatment with oxaprozin alone on pain and physical functioning in older community dwelling patients with unilateral knee osteoarthritis ( OA ) . METHODS Efficacy variables measured before and after 8 weeks included ( 1 ) pain using the Western Ontario McMaster ( WOMAC ) pain , physical disability , and stiffness subscales and a 10 point visual analog scale ( VAS ) before and after self-paced walking ( SPW ) and stepping ( SPS ) functional tasks ; ( 2 ) physical function using the time to complete a self-paced 40 m walk ( SPW ) and 20 cycles of 2 steps ( SPS ) : ( 3 ) physical activity level using the Physical Activity Scale for Elderly ( PASE ) ; ( 4 ) clinical measures of knee functioning ( range of motion ) .  One hundred seventy-nine men and women ( mean age 74 + /- 6 yrs ) with radiographic evidence of mild/moderate medial compartment OA were r and omized to either a progressive home based knee exercise program ( n = 88 ) or a control program ( n = 89 ) . All patients were given oxaprozin 1,200 mg per os daily . RESULTS We observed significant reduction from baseline in activity related pain ( VAS ) ; and improvement in SPW and SPS test time , passive range of motion , and PASE after 8 weeks in both groups . These changes were significantly greater ( p < 0.05 ) in the exercise versus sham group . CONCLUSION Addition of a progressive exercise program to nonsteroidal antiinflammatory therapy in patients with knee OA can improve measures of activity and activity related pain more than medication alone OBJECTIVES To examine the efficacy of periosteal stimulation therapy ( PST , osteopuncture ) for the treatment of  chronic pain associated with advanced knee osteoarthritis . DESIGN R and omized , controlled clinical trial . SETTING Outpatient pain clinic . PARTICIPANTS Eighty-eight community-dwelling older adults with moderate knee pain or greater for 3 months or longer and Kellgren-Lawrence ( K-L ) grade 2 through 4 radiographic severity ( 80 % had K-L 4 ) . INTERVENTION Participants were r and omized to receive PST or control PST once a week for 6 weeks . MEASUREMENTS Pain severity and self-reported function ( Western Ontario and McMasters University Osteoarthritis Index ( WOMAC ) ) and physical performance ( Short Physical Performance Battery ( SPPB ) ) were assessed at baseline , after the last PST session ( post ) , and 3 months later ( follow-up ) . Pain severity was also assessed monthly using the multidimensional pain inventory short form . RESULTS Pain was reduced significantly more in the PST group than in the control PST group at post ( P=.003 ; mean WOMAC pain subscale baseline 9.4 vs 6.4 ) and 1 month later ( P<.001 ) , but by 2 months , pain levels had regressed to pre-intervention levels . The group-by-time interaction for the WOMAC function scale was significant at post ( P=.04 ) but not at follow-up ( P=.63 ) . No significant group differences were found for the SPPB . Neither analgesic use nor global improvement differed between groups . There were four treatment dropouts . CONCLUSION PST affords short-term modest pain reduction for older adults with advanced knee OA . Future research should test the effectiveness of booster treatments in sustaining analgesic benefits and of combining PST with therapeutic exercise in ameliorating disability risk UNLABELLED Purpose : To perform a systematic review with best evidence synthesis examining the literature on the relationship between occupational loading tasks and  knee osteoarthritis ( OA ) . METHODS Two data bases were search ed to identify articles published between 1946 and April , 2011 . Eligible studies were those that ( 1 ) included adults reporting on their employment history ; ( 2 ) measured individuals ' exposure to work-related activities with heavy loading in the knee joint ; and ( 3 ) identified presence of knee OA ( determined by X-ray ) , cartilage defects associated with knee OA ( identified by magnetic resonance imaging ) , or joint replacement surgery . RESULTS A total of 32 articles from 31 studies met the inclusion criteria . We found moderate evidence that combined heavy lifting and kneeling is a risk factor for knee OA , with odds ratios ( OR ) varying from 1.8 to 7.9 , and limited evidence for heavy lifting ( OR=1.4 - 7.3 ) , kneeling ( OR=1.5 - 6.9 ) , stair climbing ( OR=1.6 - 5.1 ) , and occupational groups ( OR=1.4 - 4.7 ) as risk factors . When examined by sex , moderate level evidence of knee OA was found in men ; however , the evidence in women was limited . CONCLUSIONS Further high- quality prospect i ve studies are warranted to provide further evidence on the role of occupational loading tasks in knee OA , particularly in women OBJECTIVE To determine the effects of structured exercise programs on  self-reported disability in older adults with knee osteoarthritis . SETTING AND DESIGN A r and omized , single-blind clinical trial lasting 18 months conducted at 2 academic medical centers . PARTICIPANTS A total of 439 community-dwelling adults , aged 60 years or older , with radiographically evident knee osteoarthritis , pain , and self-reported physical disability .  INTERVENTIONS An aerobic exercise program , a resistance exercise program , and a health education program . MAIN OUTCOME MEASURES The primary outcome was self-reported disability score ( range , 1 - 5 ) . The secondary outcomes were knee pain score ( range , 1 - 6 ) , performance measures of physical function , x-ray score , aerobic capacity , and knee muscle strength . RESULTS A total of 365 ( 83 % ) participants completed the trial . Overall compliance with the exercise prescription was 68 % in the aerobic training group and 70 % in the resistance training group . Postr and omization , participants in the aerobic exercise group had a 10 % lower adjusted mean ( + /- SE ) score on the physical disability question naire ( 1.71 + /- 0.03 vs 1.90 + /- 0.04 units ; P<.001 ) , a 12 % lower score on the knee pain question naire ( 2.1 + /- 0.05 vs 2.4 + /- 0.05 units ; P=.001 ) , and performed better ( mean [ + /- SE ] ) on the 6-minute walk test ( 1507 + /- 16 vs 1349 + /- 16 ft ; P<.001 ) , mean ( + /-SE ) time to climb and descend stairs ( 12.7 + /- 0.4 vs 13.9 + /- 0.4 seconds ; P=.05 ) , time to lift and carry 10 pounds ( 9.1 + /- 0.2 vs 10.0 + /- 0.1 seconds ; P<.001 ) , and mean ( + /-SE ) time to get in and out of a car ( 8.7 + /- 0.3 vs 10.6 + /- 0.3 seconds ; P<.001 ) than the health education group . The resistance exercise group had an 8 % lower score on the physical disability question naire ( 1.74 + /- 0.04 vs 1.90 + /- 0.03 units ; P=.003 ) , 8 % lower pain score ( 2.2 + /- 0.06 vs 2.4 + /- 0.05 units ; P=.02 ) , greater distance on the 6-minute walk ( 1406 + /- 17 vs 1349 + /- 16 ft ; P=.02 ) , faster times on the lifting and carrying task ( 9.3 + /- 0.1 vs 10.0 + /- 0.16 seconds ; P=.001 ) , and the car task ( 9.0 + /- 0.3 vs 10.6 + /- 0.3 seconds ; P=.003 ) than the health education group . There were no differences in x-ray scores between either exercise group and the health education group . CONCLUSIONS Older disabled persons with osteoarthritis of the knee had modest improvements in measures of disability , physical performance , and pain from participating in either an aerobic or a resistance exercise program . These data suggest that exercise should be prescribed as part of the treatment for knee osteoarthritis OBJECTIVES To determine whether a home-based pedometer-driven walking program with arthritis self-management education ( Walk + ) would increase physical activity , muscle strength , and functional performance in older adults with osteoarthritis ( OA ) of the knee as opposed to arthritis self-management education alone ( EDU ) . DESIGN A r and omized two-by-three ( group-by-time ) design with participants assigned to  Walk + ( n = 17 , mean age + /- st and ard deviation = 69.6 + /- 6.7 ) or EDU ( n = 17 , age = 70.8 + /- 4.7 ) . SETTING Community located in the Baltimore-Washington area . PARTICIPANTS Thirty-four community-dwelling adults , aged 60 and older with symptomatic knee OA and self-reported functional impairment . INTERVENTIONS Both groups received 12 hours of the Arthritis Self-Management program over 12 weeks and were followed for an additional 12 weeks . In addition , the Walk + group received individualized instruction in the use of a pedometer , with the goal of increasing their step count by 30 % of their baseline step count . MEASUREMENTS The outcome measures were physical activity ( daily step counts and total activity vector magnitude as measured by a pedometer and Tritrac-R3D accelerometer ) , quadriceps femoris strength ( isometric peak torque ) , and functional performance tasks ( 100-foot walk-turn-walk , timed stair climb , timed chair rise , and pain status ) . RESULTS Daily steps walked showed a significant group-by-time interaction ( P = .04 ) after controlling for age . From baseline to completion of training , a 23 % increase in daily steps occurred in the Walk + group and a 15 % decrease in the EDU group . Although steps increased in the Walk + group , total activity vector magnitude was maintained , suggesting a more efficient gait . The Walk + group became quicker than the EDU group in the normal-pace walk-turn-walk ( P = .04 ) . An isometric strength gain of 21 % postintervention was seen in the Walk + group , compared with a loss of 3.5 % in the EDU group . CONCLUSION In older adults with symptomatic knee OA , Walk + appears to increase walking , with improvements in muscle strength and walking performance . The use of a home-based pedometer-driven program to increase physical activity , strength , and function in this population warrants further research 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 , Osteoarthritis is a leading cause of pain and disability ( 13 ) . Already a leading chronic health condition in primary care setting s ( 4 ) , osteoarthritis will become increasingly prevalent ( 58 ) . Treatment involves a combination of behavioral , pharmacologic , and other clinical therapies ( 911 ) ; therefore , both patients and health care providers play key roles in effective management . However , studies have identified gaps in the use of key behavioral strategies , including physical activity and weight management ( 1214 ) , as well as low use of some recommended clinical therapies ( 1520 ) . These studies emphasize the need to improve the use of evidence -based osteoarthritis therapies . It is not known whether interventions focused on health care providers or patients may be more effective for improving osteoarthritis management and outcomes . Most previous osteoarthritis interventions occurred at the patient level , with little attempt to effect provider- or system-level changes . We previously reported that among a group of patients with osteoarthritis receiving care at a single Veterans Affairs medical center ( VAMC ) , a combined patient and provider intervention result ed in statistically significant , modest improvements in physical function ( 21 ) . This study extends this research area by separately examining patient-level , health care providerlevel , and combined osteoarthritis interventions in several primary care clinics . Methods The Institutional Review Board of Duke University Medical Center approved this study . Methods were published previously ( 22 ) . Owing to our lack of awareness , the study was registered at Clinical Trials.gov 15 days after the first participant was enrolled , which met institutional requirements but not the International Committee of Medical Journal Editors ' requirement of registration before participant enrollment . Only 1 participant was enrolled , and no analyses were done before registration . Study Setting and Design This study was conducted within the Duke Primary Care Research Consortium . Ten primary care clinics were r and omly assigned to provider intervention or control conditions , and patients within those clinics were assigned to patient intervention or control , result ing in 4 study groups : patient intervention , provider intervention , patientprovider intervention , and usual care . R and omization schedules for clinics and patients were computer generated by the statistician . Clinic r and omizations were paired on the basis of type ( family or internal medicine ) as well as similarities in practice size ( numbers of patients and providers ) and rural versus urban location ; 1 clinic in each pair was assigned to the provider intervention and 1 to the provider control group . Patient r and omizations were stratified by race ( white vs. nonwhite ) and sex . All participants continued with usual care for osteoarthritis as recommended by their providers , with no restrictions . Participants and Recruitment All primary care providers ( PCPs ) at the study clinics were invited to participate ; only 2 declined . Patients were eligible if they had osteoarthritis of the hip ( based on radiographic evidence in the electronic medical record [ EMR ] ) or knee ( based on radiographic evidence in the EMR or satisfaction of American College of Rheumatology clinical criteria [ 23 ] ) , along with self-reported joint symptoms ( pain , aching , stiffness , or swelling in or around a hip or knee joint with arthritis that was present or for which the patient used pain medications on most days during the past month ) ( 24 ) . Participants had to be overweight ( body mass index [ BMI ] 25 kg/m2 ) and not currently meeting U.S. Department of Health and Human Services physical activity recommendations ( 150 minutes of aerobic activity and 2 sessions of muscle strengthening activity weekly ) ( 25 ) . Exclusion criteria are summarized in Appendix Table 1 . Potential participants were identified from the EMR , were mailed an introductory letter , and were called for screening . Eligible patients gave consent , completed baseline assessment s , and were informed of their r and omization assignment by the study coordinator via telephone . Appendix Table 1 . Exclusion Criteria Interventions Patient Behavioral Intervention for Osteoarthritis The intervention took place over 12 months and focused on physical activity , weight management , and cognitive behavioral strategies for managing  pain  ( 22 ) . Telephone calls were scheduled twice per month for the first 6 months , then 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 intervention components . Motivational interviewing strategies were used throughout the intervention ( 22 , 26 , 27 ) . Participants were given written educational material s , an exercise video , and an audio CD of relaxation exercises . Provider Intervention The study team delivered the following patient-specific osteoarthritis treatment recommendations to PCPs , based on treatment guidelines ( 11 , 28 , 29 ) : refer to physical therapist , refer for evaluation for knee brace , refer to weight management program , refer to physical activity program , perform or refer for intra-articular injection , recommend topical nonsteroidal anti-inflammatory drug or capsaicin , add gastroprotective agent or remove nonsteroidal anti-inflammatory drug in patients at high risk for peptic ulcer disease , discuss new or alternate pain medication , and refer to orthopedic evaluation for joint replacement surgery . We developed algorithms based on patient data ( Appendix Table 2 ) regarding when each treatment option would be reasonable for a PCP to consider for a patient ( 22 ) . However , decisions regarding whether to recommend these treatments to patients were at the discretion of the PCPs . The study team monitored upcoming visits for provider intervention participants , and recommendations were delivered only once per participant , before the first routine visit after enrollment . Most recommendations were delivered via the Duke EMR , but 22 were delivered via secure e-mail during an EMR transition . Appendix Table 2 . Provider Intervention Recommendations and Algorithms Outcome Measures The primary and secondary analyses include measures at baseline through 12 months . Analyses of maintenance effects ( 18 and 24 months ) will be presented separately . All outcomes ( including osteoarthritis treatment use ) were assessed in person at baseline and 12 months , except for 48 participants who could not return at 12 months but completed some measures via telephone . The primary outcome also was assessed via telephone at 6 months . Outcomes assessors were blind to r and omization . Participants were reimbursed $ 25 and $ 10 for in-person and phone assessment s , respectively . Primary Outcomes The primary outcome was the 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 past 2 weeks ( 3032 ) . All items are rated on a 5-point Likert scale ranging from none to extreme ( total range , 0 to 96 ; higher scores indicate worse symptoms and function ) . Secondary Outcomes We examined WOMAC pain and function subscales separately . We also administered the Short Physical Performance Battery ( 33 ) , which 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 8-item Patient Health Question naire ( PHQ-8 ) ( 34 ) , with scores ranging from 0 to 24 . Physical Activity and BMI Several exploratory measures were collected ( 22 ) ; here , we focus on physical activity and BMI , because they assess core patient intervention components . Self-reported physical activity was measured with the Community Healthy Activities Model Program for Seniors ( CHAMPS ) ( 35 , 36 ) ; we report the weekly frequency and duration of all exercise , as well as moderate- or higher-intensity exercise , during the past 4 weeks . Height and weight were measured to calculate BMI ; when 12-month follow-up measures were administered via telephone , weight was self-reported . Osteoarthritis Treatment Use and Recommendations We describe the proportions of participants who reported receiving the following treatments during the study period : physical therapy for knee or hip osteoarthritis , new knee brace use , joint injections , a change in oral pain medications , new use of topical creams , and joint replacement surgery . We assessed osteoarthritis treatment use via self-report , because the EMR would not capture care received outside the Duke system . For the provider intervention groups , we also report the proportions of participants for whom each treatment recommendation was given to the PCP by the study team . Data regarding recommendations or referrals given to patients by PCPs were not collected . Participant Characteristics We collected patient-reported characteristics , including age , sex , race/ethnicity ( white vs. nonwhite ) , household financial situation ( with inadequate income meaning just enough or not enough to meet basic expenses ) , education level , marital status , work status ( employed or student vs. other ) , disabled ( positive response to disabled in the work status question ) , general self-rated health ( excellent , very good , or good vs. fair or poor ) , and duration of osteoarthritis symptoms . Adverse Events At each study encounter , we inquired about hip and knee injuries or surgeries . We noted other adverse events that participants reported to the study team during regular contact or that were discovered during study -related EMR review . Sample Size The estimated sample size of 140 participants per group ( 56 per clinic ) was based on detecting a 15 % improvement in WOMAC scores at 12 months for either of 2 primary hypotheses , with 80 % power and a type I error rate of 0.05 . Sample size calculations were based on methods for appropriate INTRODUCTION Physiotherapy is one of the most important components of therapy for osteoarthritis of the knee . The objective of this prospect i ve case series was to assess the efficiency of a guidance manual for patients with osteoarthritis of the knee in relation to pain , range of movement , muscle strength and function , active goniometry , manual strength test and function . METHODS Thirty-eight adults with osteoarthritis of the knee ( > or= 45 years old ) who were referred to the physiotherapy service at the university hospital ( Santa Casa de Misericórdia de São Paulo ) were studied . Patients received guidance for the practice of specific physical exercises and a manual with instructions on how to perform the exercises at home . They were evaluated for pain , range of movement , muscle strength and function . These evaluations were performed before they received the manual and three months later . Patients were seen monthly regarding improvements in their exercising abilities . RESULTS The program was effective for improving muscle strength , controlling pain , maintaining range of movement of the knee joint , and reducing functional incapacity . DISCUSSION A review of the literature showed that there are numerous clinical benefits to the regular practice of physical therapy exercises by patients with osteoarthritis of the knee(s ) in a program with appropriate guidance . This study shows that this guidance can be attained at home with the use of a proper manual . CONCLUSIONS Even when performed at home without constant supervision , the use of the printed manual for orientation makes the exercises for osteoarthritis of the knee beneficial The aim of this study was to evaluate the effects of electrical stimulation program on pain , disability , and quadriceps strength in the patients with knee osteoarthritis . Fifty women diagnosed as knee osteoarthritis were r and omized into two groups as electrical stimulation and biofeedback-assisted isometric exercises . Both of the programs were performed 5 days a week , for a duration of 4 weeks . Outcome measures for pain were visual analogue scale pain score and Western Ontario McMaster osteoarthritis index ( WOMAC ) pain score . Disability and stiffness were assessed with WOMAC physical function and stiffness score . One repetition maximum ( RM ) and 10 RM were used for measuring quadriceps strength . In addition , 50 m walking time and 10 steps stairs climbing up-down time were evaluated . Both groups showed significant improvements in pain , physical function , and stiffness scores after the therapy . There were statistically significant improvements in 50 m walking time and 10 steps stairs climbing up-down time and 1 RM and 10 RM values indicating the improvement in muscle strength . In addition , there were no significant differences between the groups after the therapy . We conclude that electrical stimulation treatment was as effective as exercise in knee osteoarthritis and electrical stimulation treatment can be suggested especially for the patients who have difficulty in or contraindications to perform an exercise program 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 prevention of disability in activities of daily living ( ADL ) may prolong older persons ' autonomy ( older persons are defined in this study as those aged > or = 60 years ) . However , proved preventive strategies for ADL disability are lacking . A sedentary lifestyle is an important cause of disability . This study examines whether an exercise program can prevent ADL disability . METHODS A 2-center , r and omized , single-blind , controlled trial was conducted in which participants were assigned to an aerobic exercise program , a resistance exercise program , or an attention control group .  Of the 439 community-dwelling persons aged 60 years or older with knee osteoarthritis originally recruited , the 250 participants initially free of ADL disability were used for this study .  Incident ADL disability , defined as developing difficulty in transferring from a bed to a chair , eating , dressing , using the toilet , or bathing , was assessed quarterly during 18 months of follow-up . RESULTS The cumulative incidence of ADL disability was lower in the exercise groups ( 37.1 % ) than in the attention control group ( 52.5 % ) ( P = .02 ) . After adjustment for demographics and baseline physical function , the relative risk of incident ADL disability for assignment to exercise was 0.57 ( 95 % confidence interval , 0.38 - 0.85 ; P = .006 ) . Both exercise programs prevented ADL disability ; the relative risks were 0.60 ( 95 % confidence interval , 0.38 - 0.97 ; P = .04 ) for resistance exercise and 0.53 ( 95 % confidence interval , 0.33 - 0.85 ; P = .009 ) for aerobic exercise . The lowest ADL disability risks were found for participants with the highest compliance to exercise . CONCLUSIONS Aerobic and resistance exercise may reduce the incidence of ADL disability in older persons with knee osteoarthritis .  Exercise may be an effective strategy for preventing ADL disability and , consequently , may prolong older persons ' autonomy PURPOSE To evaluate the influence of exercise on falls and fall risk reduction  in community-dwelling older adults and to present an up date d synthesis of outcome measures for the assessment of fall risk in community-dwelling older adults . METHOD A systematic review was performed , considering English- language articles published from 2000 to 2006 and accessible through MEDLINE , CINAHL , PEDro , EMBASE , and /or AMED . Included were r and omized controlled clinical trials ( RCTs ) that used an exercise or physical activity intervention and involved participants over age 50 . Screening and method ological quality for internal validity were conducted by two independent review ers . RESULTS The search retrieved 156 abstract s ; 22 articles met the internal validity criteria . Both individualized and group exercise programmes were found to be effective in reducing falls and fall risk . The optimal type , frequency , and dose of exercise to achieve a positive effect have not been determined . A variety of outcome measures have been used to measure fall risk , especially for balance . CONCLUSIONS Falls and fall risk can be reduced with exercise interventions in the community-dwelling elderly , although the most effective exercise variables are unknown . Future studies in population s with comorbidities known to increase fall risk will help determine optimal , condition-specific fall-prevention programmes . Poor balance is a key risk factor for falls ; therefore , the best measure of this variable should be selected when evaluating patients at risk of falling Objective : To determine the additional prognostic value of clinical history , physical examination and x-ray findings to a previously derived simple generic model ( age , body mass index , anxiety and pain severity ) in a cohort of older adults with knee pain . Methods : Prospect i ve cohort study in community-dwelling adults in North Staffordshire . 621 participants ( aged ⩾50 years ) reporting knee pain who attended a research clinic at recruitment and were followed up by postal question naire at 18 months . Poor functional outcome was measured by the Physical Functioning Scale of the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) at 18-month follow-up defined in 60 % of participants . Results : Three clinical history variables ( bilateral knee pain , duration of morning stiffness and inactivity gelling ) were independently associated with poor outcome . The addition of the “ clinical history ” model to the “ generic ” model led to a statistical improvement in model fit ( likelihood ratio ( LR ) = 24.84 , p = 0.001 ) . Two physical examination variables ( knee tender point count and single-leg balance ) were independently associated with poor outcome but did not lead to a significant improvement when added to the “ clinical history and generic ” model ( LR = 6.34 , p = 0.50 ) . Functional outcome was significantly associated with severity of knee radiographic osteoarthritis ( OA ) , but did not lead to any improvement in fit when added to the “ generic , clinical history and physical examination ” model ( LR = 1.86 , p = 0.39 ) . Conclusions : Clinical history , physical examination and severity of radiographic knee OA are of limited value over generic factors when trying to predict which older adults with knee pain will experience progressive or persistent functional difficulties BACKGROUND There is limited evidence supporting the hypothesized environment-disability link . The objectives of this study were to ( a ) identify the prevalence of community mobility barriers and transportation facilitators and ( b ) examine whether barriers and facilitators were associated with disability among older adults with functional limitations . METHODS Four hundred and thirty-five participants aged 65 + years old with functional limitations were recruited from the Multicenter Osteoarthritis Study , a prospect i ve study of community-dwelling adults with or at risk of developing symptomatic knee osteoarthritis . Presence of community barriers and facilitators was ascertained by the Home and Community Environment survey . Two domains of disability , ( a ) daily activity limitation ( DAL ) and ( b ) daily activity frequency ( DAF ) , were assessed with the Late-Life Disability Instrument . Covariates included age , gender , education , race , comorbidity , body mass index , knee pain , and functional limitation . Multivariable logistic regression was used to examine adjusted associations of community factors with presence of DAL and DAF . RESULTS Approximately one third of the participants lived in a community with high mobility barriers and low transportation facilitators .  High mobility barriers was associated with greater odds of DAL ( odds ratio [ OR ] = 2.0 , 95 % confidence interval [ CI ] 1.2 - 3.1 ) after adjusting for covariates , and high transportation facilitators was associated with lower odds of DAL ( OR = 0.5 , 95 % CI 0.3 - 0.8 ) but not with DAF in adjusted models . CONCLUSION People with functional limitations who live in communities that were more restrictive felt more limited in doing daily activities but did not perform these daily activities any less frequently Osteoarthritis is the leading cause of persistent knee pain , affecting around one quarter of adults ( 1 , 2 ) , and is a major contributor to global disability ( 3 ) . Knee osteoarthritis causes loss of function , reduced quality of life , and psychological disability ( 4 ) . It has no cure and , given the aging population and increasing obesity rates , disease burden is rapidly increasing ( 5 , 6 ) . The urgent need for effective and accessible models of health service delivery that can be provided on a population level has been recognized as a research priority by key stakeholders ( 7 ) . Such models should take a biopsychosocial approach ; emphasize nondrug , nonsurgical treatment ; and foster self-management , of which appropriate educational information is a core component ( 8) . Exercise has well-established benefits for pain and function in persons with knee osteoarthritis ( 911 ) and is recommended by clinical guidelines as the cornerstone of conservative management ( 12 ) . It is often prescribed by a health professional and can be performed effectively at home ( 9 ) . Evidence also supports  pain-coping skills training ( PCST ) , an approach based on cognitive behavioral principles , to target psychological factors , such as low self-efficacy , poor pain coping , and pain catastrophizing , that are common in persons with chronic pain ( 13 , 14 ) . However , for many , accessing specialist clinicians to prescribe and supervise these treatments may be difficult due to cost , transport issues , or geographic location , particularly in regional and rural areas where services may be limited or nonexistent ( 15 , 16 ) . The Internet is a time-efficient and convenient method to deliver health interventions with broad reach ( 17 , 18 ) . Educational material is often accessed online by persons with chronic pain ( 19 ) . Remotely delivered physiotherapy and exercise can benefit persons with knee pain and osteoarthritis ( 2022 ) and those who have undergone knee joint replacement , albeit often using sophisticated technology ( 23 ) . An Internet-based interactive PCST program ( PainCOACH ) , design ed to translate key therapeutic elements of clinician-delivered face-to-face PCST ( 24 ) , showed improved outcomes in persons with hip or knee osteoarthritis ( 25 ) . An online intervention combining these treatments aligns with a biopsychosocial approach to chronic disease management ( 8) but has not been investigated in this patient population . This study aim ed to evaluate the effectiveness of an innovative Internet-based intervention combining physiotherapist-prescribed home exercise delivered via videoconferencing ( Skype [ Microsoft ] ) and automated PCST in addition to educational material in persons with chronic knee pain . Our primary hypothesis was that the intervention would reduce pain and improve physical function after 3 months compared with educational material only . Supplement . Study Protocol Methods Design Overview We conducted a parallel , 2-group pragmatic r and omized , controlled trial . The protocol has been published ( 26 ) . The trial was prospect ively registered with the Australian New Zeal and Clinical Trials Registry ( ACTRN12614000243617 ) . Initial registration erroneously listed the Depression , Anxiety and Stress Scale ( DASS-21 ) as a secondary outcome rather than an eligibility screening tool . We amended the registry after enrolling 16 participants but before collecting follow-up data . No interim analyses were performed . The Institutional Human Ethics Committee approved the trial , and participants provided informed consent . Recruitment occurred from March 2014 to May 2015 , with follow-up completed in February 2016 . Participants and physiotherapists were unblinded to group allocation and were aware of the alternative treatment components , but study hypotheses were not disclosed to participants . The statistician was blinded . A nested health economic evaluation and a qualitative study exploring patients ' and physiotherapists ' experiences will be published separately . Setting and Participants We recruited community-dwelling participants from Australia via print , radio , and social media advertisements and our data base .  Eligibility was confirmed using an online survey followed by a telephone interview .  Inclusion criteria were age 50 years or older , knee pain for more than 3 months and on most days of the previous month , knee pain during walking ( score of 4 on an 11-point numerical rating scale [ NRS ] , with terminal descriptors of no pain and worst pain possible ) in the previous week , mild to moderate physical dysfunction ( score > 20 out of 68 on the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index [ WOMAC ] ) , and an active e-mail account and a computer with Internet access . Exclusion criteria were joint replacement in the symptomatic knee , awaiting joint replacement surgery , intra-articular corticosteroid injection or knee surgery in the previous 6 months or planned joint surgery in the subsequent 9 months , treatment for knee pain or participation in a strengthening exercise or PCST program in the previous 6 months , systemic arthritic condition , neurologic condition affecting the lower limb or limiting exercise , pain at another site that was worse than knee pain or limited exercise , and high-level depression ( score > 21 on the depression subscale of the DASS-21 [ 27 ] ) . R and omization and Interventions Computer-generated r and omization was conducted by r and om permuted blocks of size 2 to 8 stratified by sex and residence ( metropolitan or regional/rural ) . The r and omization schedule was prepared by an independent biostatistician and concealed from the research er enrolling participants in sequentially numbered , opaque , sealed envelopes . Intervention Participants received 3 Internet-delivered treatments . The first was educational material about exercise and physical activity , pain management , emotions , healthy eating , complementary therapies , and medications ( www.arthritisaustralia.com.au ) . Participants were encouraged to access the material at their leisure . The second was an interactive automated PCST program ( PainCOACH ) ( 24 , 25 ) . Participants were asked to complete eight 35- to 45-minute modules ( 1 per week commencing in week 1 ) and practice pain-coping skills daily ( Appendix Table 1 ) . These skills included progressive relaxation , activityrest cycling , scheduling pleasant activities , changing negative thoughts , pleasant imagery and distraction techniques , and problem solving . The third was 7 Skype sessions with a physiotherapist over 12 weeks ( in weeks 2 , 3 , 4 , 6 , 8 , 10 , and 12 ) . Sessions lasted 45 minutes in weeks 2 and 12 and 30 minutes in the other weeks . Physiotherapists were allocated to participants on the basis of availability , and the same physiotherapist undertook all consultations with any given participant . The physiotherapist performed a brief assessment and prescribed a lower-limbstrengthening home exercise program to be performed 3 times per week ( 26 , 28 ) ( Appendix Table 2 ) . Exercise progression was provided by varying the exercises , repetitions , load , or difficulty to approximate a 10-repetition maximum level and a self-rated effort level of at least 5 out of 10 ( hard ) on a modified Borg Rating of Perceived Exertion scale ( 29 ) . Participants were provided with instructions , video demonstrations , and equipment ( such as resistance b and s and ankle weights ) . They also were encouraged to increase physical activity levels , received written information about how to do so , and were given the option of using a pedometer for motivation ( provided at no cost ) . Appendix Table 1 . Summary of the Internet-Based PainCOACH Content * Appendix Table 2 . Home Exercise Program Protocol * Generic e-mail reminders to complete PainCOACH modules were sent weekly during the first 8 weeks . At week 11 and at monthly intervals from week 13 , participants received e-mails encouraging them to review the final module , revisit useful or meaningful modules , and continue home exercise and pain-coping skills practice .  Eight physiotherapists ( 4 men ) with an average of 16 years ( range , 3 to 28 years ) of clinical musculoskeletal experience were trained to deliver the exercise component . Physiotherapists attended a 1-day training course conducted by the research ers and were given an exercise manual . They also were provided with an overview of PainCOACH and were asked to encourage participants to complete modules and practice skills . Regular telephone and Skype meetings between the physiotherapists and the research ers were held to discuss implementation of the intervention . A brief video showing a mock physiotherapy session is provided in the Supplement Video . Control The control group received access to the same online educational material as the intervention group . Outcomes and Follow-up Participants completed measurements online at baseline , 3 months ( primary time point ) , and 9 months . They received a $ 50AUD gift voucher for completing all question naires . The primary outcomes were valid and reliable self-reported measures of pain and physical function that are recommended for knee osteoarthritis clinical trials ( 30 ) . Overall average pain during walking over the previous week was measured with an NRS , with terminal descriptors of no pain ( score of 0 ) and worst pain possible ( score of 10 ) and a minimum clinical ly important difference ( MCID ) of 1.8 units ( 31 ) . Difficulty with physical function over the previous 48 hours was measured with the WOMAC ( Likert version 3.1 ) physical function subscale ( 32 ) , with total scores ranging from 0 ( no dysfunction ) to 68 ( maximum dysfunction ) and an MCID of 6 units ( 33 ) . Secondary outcomes included knee pain over the previous 48 hours , measured using the WOMAC pain subscale ( 32 ) ( scores range from 0 [ no pain ] to 20 [ maximum pain ] ) ; global change overall , in pain , and in physical function , measured using 7-point Likert scales with terminal descriptors of much worse to much better ( measured at 3 and 9 months ) ; health-related quality of life , Knee osteoarthritis is a major age-related public health problem and a leading cause of long-term pain and disability ( 1 , 2 ) . No effective medical treatments for the disease currently exist . Nonsteroidal anti-inflammatory drugs ( NSAIDs ) and acetaminophen are commonly used to treat osteoarthritis but often fail to relieve symptoms and may cause serious adverse effects ( 3 ) . Physical therapy , a globally recommended element of the st and ard care regimen for knee osteoarthritis , produces moderate benefits for pain and physical functioning , but data on psychological well-being and durability effects are limited ( 4 , 5 ) . Identifying new and effective treatments for patients with knee osteoarthritis is an urgent clinical and public health priority . Tai Chi is a multicomponent traditional Chinese mindbody practice that combines meditation with slow , gentle , graceful movements ; deep diaphragmatic breathing ; and relaxation ( 6 ) . Previous studies have indicated that Tai Chi can reduce pain and improve physical and psychological health among patients with chronic rheumatic disorders , such as rheumatoid arthritis and fibromyalgia ( 713 ) . In our previous r and omized trial , participants with knee osteoarthritis who completed 12 weeks of  Tai Chi showed greater improvements in pain , physical function , depression , and health status compared with an attention control group ( 12 ) . A 2013 up date d meta- analysis of 7 studies that included 348 participants with osteoarthritis showed significant reductions in pain and improvements in physical function after 8 to 24 weeks of Tai Chi training compared with a waiting list , attention control , or usual physical activity ( 14 ) . Those prior trials suggested that Tai Chi could provide a practical exercise regimen with an integrative mindbody approach to manage knee osteoarthritis . The physical component provides exercise benefits that are consistent with recommendations for knee osteoarthritis ( physical function , balance , and muscle strength ) ( 15 ) , and the mind component promotes psychological well-being , life satisfaction , and improved perceptions of health ( 9 , 16 ) . To date , however , no r and omized trials have directly compared Tai Chi and st and ard care treatments . The primary goal of this study was to compare the effectiveness of  Tai Chi  versus a physical therapy regimen among a large sample of patients with symptomatic and radiographic knee osteoarthritis who were seen in the clinical setting and followed for 12 months . Supplement . Study Protocol Methods Design Overview This 52-week , single-blind , r and omized , comparative effectiveness trial recruited participants with symptomatic and radiographic knee osteoarthritis . Patients were r and omly assigned to either Tai Chi ( 2 times per week for 12 weeks ) or physical therapy in a clinical setting ( 2 times per week for 6 weeks , followed by 6 weeks of rigorously monitored home exercise ) . Details of the trial design and conduct have been published ( 17 ) and registered at Clinical Trials.gov ( NCT01258985 ) . The study was approved by the Tufts Health Sciences Institutional Review Board and overseen by an independent data and safety monitoring board . Setting and Participants The trial was conducted at Tufts Medical Center in Boston , Massachusetts , between October 2010 and September 2014 . Participants were recruited through multimodal strategies , including print advertisements , online media , a booth at a senior exposition , and a clinical patient data base . We obtained informed consent before baseline assessment s for eligibility . We enrolled persons aged 40 years or older who met American College of Rheumatology criteria for symptomatic knee osteoarthritis and had radiographic evidence of tibiofemoral or patellofemoral osteoarthritis ( defined as the presence of a definite osteophyte in the tibiofemoral compartment and /or the patellofemoral compartment , as assessed on st and ing anteriorposterior and lateral or sunrise views ) ( 18 ) . All participants were required to have a score of 40 or greater on at least 1 of the 5 questions in the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) pain subscale ( range of 0 to 100 , with higher scores indicating greater pain ) at baseline . A study rheumatologist ( W.H. ) confirmed eligibility of applicants . We excluded persons who had participated in Tai Chi or physical therapy in the past year ; those with current serious medical conditions , such as dementia , symptomatic heart or vascular disease , or recent stroke , that would limit full participation ; those with intra-articular steroid or intra-articular hyaluronic acid injections in the past 3 or 6 months or reconstructive surgery before baseline screening on the most severely affected knee ; and those with a score less than 24 on the Mini-Mental State Examination ( 19 ) . Participants who satisfied eligibility criteria were offered enrollment . R and omization Participants were r and omly assigned in a 1:1 ratio to Tai Chi or physical therapy after the baseline evaluation . R and omization was done in 9 consecutive cycles , comprising about 20 participants each . Within each block of patients r and omly assigned in each cycle , those assigned to Tai Chi were further r and omly assigned to 1 of 3 instructors so that each instructor treated 1 group every 3 blocks . This design allowed for assessment of instructor-level effects . Pseudor and om numbers were generated in advance by the statistician ( C.S. ) using the R statistical package ( 20 ) . Assignments were concealed in sealed , opaque envelopes with date and signature labels . The study coordinator opened the consecutive envelopes individually after obtaining consent and confirming eligibility . Research study nurses , physical function assessors , and sponsor personnel were blinded to the treatment assignments during enrollment . The blinded assessors did not have access to the data until data collection was complete . Interventions Tai Chi and physical therapy ran concurrently to minimize seasonal influences on disease activity . We encouraged participants to maintain routine activities but refrain from new exercises outside the study . Both groups received educational information about the importance of physical activity and home practice . We tracked reasons for missed sessions and asked participants to complete daily logs indicating duration of practice . Participants were encouraged to integrate at least 30 minutes of Tai Chi or physical therapy into their daily routine throughout follow-up . Attendance was monitored during each in-person session by using attendance forms and sign-in sheets . Study staff made monthly calls to monitor adherence throughout the 1-year follow-up . Tai Chi The 60-minute Tai Chi sessions occurred twice per week for 12 weeks . We recruited 3 experienced Tai Chi instructors from the greater Boston area . We developed a st and ardized classical Yang style Tai Chi protocol for knee osteoarthritis that was based on the literature ( 13 ) . Before study initiation , the principal investigator ( C.W. ) and the Tai Chi master ( R.R. , who was also 1 of the 3 instructors ) review ed the concepts of knee osteoarthritis and trained the other instructors ( 17 , 21 ) . In the first session , participants received printed material s on  Tai Chi principles , practice techniques , and safety pre caution s. The instructor explained mindbody exercise theory and procedures . Subsequent sessions started with a warm-up and a review of Tai Chi principles and movement , breathing techniques , and relaxation methods . Participants were instructed to practice Tai Chi at home for at least 20 minutes per day . The principal investigator monitored all sessions by regularly review ing video recordings and providing feedback throughout the study . After completing the 12-week intervention ( 24 sessions ) , participants were instructed to continue Tai Chi practice for 52 weeks with the aid of provided homework material s. Physical Therapy The physical therapy protocol followed U.S. guidelines for knee osteoarthritis treatment ( 15 ) and consisted of two 30-minute outpatient sessions per week for 6 weeks . Before enrollment , the supervising physical therapist ( M.I. ) trained the 3 physical therapists . She observed evaluations and interventions during each treatment cycle to ensure consistency in documentation and provided feedback for program progression ( 17 ) . Depending on the diagnostic findings in the initial musculoskeletal examination , the therapist targeted physical therapy regimens to address specific treatment goals developed collaboratively with the participant . At each session , the physical therapist examined the participant for adverse signs and symptoms before proceeding with manual therapy or exercise . Patients were encouraged to also perform exercises at home . After 6 weeks , participants were instructed to continue exercises in 30-minute sessions 4 times per week for 6 weeks . These were monitored weekly by telephone by using st and ardized forms to ascertain frequency , exercises completed , adverse events , and adherence . Outcomes and Follow-up Knee osteoarthritis outcomes , which were measured at baseline and 12 , 24 , and 52 weeks , were drawn from the core set recommended by the Osteoarthritis Research Society International ( OARSI ) and focused on pain , physical function , and patients ' overall assessment of their disease severity ( 22 ) . Primary Outcome The primary outcome was the change in WOMAC pain subscale score between baseline and 12 weeks . The WOMAC is a vali date d , self-administered visual analogue scale design ed specifically to evaluate osteoarthritis symptoms ( 23 ) . Secondary Outcomes Secondary outcomes were measured at baseline and 12 , 24 , and 52 weeks and included WOMAC physical function and stiffness scores , Patient Global Assessment score , Beck Depression Inventory-II score ( 24 ) , scores on the physical and mental components of the 36-item Short Form Health Survey ( SF-36 ) ( 25 ) , Arthritis Self-Efficacy Scale score ( 26 ) , and results of the 6-minute walk test ( 27 ) and the
Several individual RCTs demonstrated clinical ly important improvements in pain and disability with aerobic exercise .
Other PT interventions demonstrated no sustained benefit .
Individual RCTs showed similar benefits with aerobic , aquatic , and strengthening exercise .
Adverse events were uncommon and did not deter participants from continuing treatment .
Low-strength evidence suggested that only a few PT interventions were effective .
BACKGROUND Osteoarthritis is a leading cause of disability .
Nonsurgical treatment is a key first step .
PURPOSE Systematic literature review of physical therapy ( PT ) interventions for community-dwelling adults with knee osteoarthritis .