Dina L. Jones

The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition.

The AAOS Evidence-Based Guideline on Treatment of Osteoarthritis of the Knee, 2nd Edition, includes only less-invasive alternatives to knee replacement. This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. ### Conservative Treatments: Recommendations 1-6 #### RECOMMENDATION 1 We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines. Strength of Recommendation: Strong #### RECOMMENDATION 2 We suggest weight loss for patients with symptomatic osteoarthritis of the knee and a BMI ≥25. Strength of Recommendation: Moderate #### RECOMMENDATION 3A We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of …

Helical computed tomography alone compared with plain radiographs with adjunct computed tomography to evaluate the cervical spine after high-energy trauma.

BACKGROUND Current literature supports the use of the three-view plain-radiograph series supplemented, when necessary, with helical computed tomography to evaluate the cervical spine in patients who have sustained trauma injury. The purpose of this study was to determine if helical computed tomography alone can be used to evaluate the cervical spine for acute osseous injury following high-energy trauma, thus eliminating the need to make radiographs. METHODS Patients were prospectively evaluated with helical computed tomography scanning of the cervical spine and standard three-view plain radiography. At a later date, the plain radiographs and computed tomography scans were independently reviewed by two radiologists who were blinded to both the initial interpretation and the interpretation of the corresponding study. The radiologists documented whether the plain radiographs were adequate and whether they showed an acute process. The findings in the study were compared with the initial findings and, when necessary, with the discharge summaries to determine if an injury had been identified. The accuracy of the plain radiographs, of the plain radiographs that had been deemed adequate, and of helical computed tomography used alone was ascertained. RESULTS Plain radiographs and helical computed tomography scans were made for 407 patients, and traumatic injuries were identified in fifty-eight of them. Plain radiographs alone were adequate for 194 (48%) of the 407 patients. Plain radiographs had a sensitivity of 45%, a specificity of 97%, a positive predictive value of 74%, and a negative predictive value of 91%. Adequate plain radiographs had a sensitivity of 52%, a specificity of 98%, a positive predictive value of 81%, and a negative predictive value of 93%. Helical computed tomography had a sensitivity and specificity of 98%, a positive predictive value of 89%, and a negative predictive value of >99%. The sensitivity, positive predictive value, and negative predictive value of adequate plain radiographs differed significantly from those of helical computed tomography alone (p < 0.001). Twelve (48%) of twenty-five adequate plain radiographs of patients in whom an injury had been identified on computed tomography missed that injury. Helical computed tomography alone missed one (2%) of the fifty-eight injuries. CONCLUSIONS Although helical computed tomography has a limited ability to detect pure ligamentous injury, it can be safely used without plain radiographs to evaluate the cervical spine for osseous abnormalities such as fractures and dislocations after high-energy trauma.

Effects of community-deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases: a meta-analysis.

To use the meta‐analytic approach to determine the effects of community‐deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases (AORD).

Exercise and global well-being in community-dwelling adults with fibromyalgia: a systematic review with meta-analysis.

BackgroundExercise has been recommended for improving global-well being in adults with fibromyalgia. However, no meta-analysis has determined the effects of exercise on global well-being using a single instrument and when analyzed separately according to intention-to-treat and per-protocol analyses. The purpose of this study was to fill that gap.MethodsStudies were derived from six electronic sources, cross-referencing from retrieved studies and expert review. Dual selection of randomized controlled exercise training studies published between January 1, 1980 and January 1, 2008 and in which global well-being was assessed using the Fibromyalgia Impact Questionnaire (FIQ) were included. Dual abstraction of data for study, subject and exercise program characteristics as well as assessment of changes in global well-being using the total score from the FIQ was conducted. Risk of bias was assessed using the Cochrane bias assessment tool. Random-effects models and Hedges standardized effect size (g) were used to pool results according to per-protocol and intention-to-treat analyses.ResultsOf 1,025 studies screened, 7 representing 5 per-protocol and 5 intention-to-treat outcomes in 473 (280 exercise, 193 control) primarily female (99%) participants 18-73 years of age were included. Small, statistically significant improvements in global well-being were observed for per-protocol (g and 95% confidence interval, -0.39, -0.69 to -0.08) and intention-to-treat (-0.34, -0.53 to -0.14) analyses. No statistically significant within-group heterogeneity was found (per-protocol, Qw = 6.04, p = 0.20, I2 = 33.8%; intention-to-treat, Qw = 3.19, p = 0.53, I2 = 0%) and no between-group differences for per-protocol and intention-to-treat outcomes were observed (Qb = 0.07, p = 0.80). Changes were equivalent to improvements of 8.2% for per-protocol analyses and 7.3% for intention-to-treat analyses.ConclusionsThe results of this study suggest that exercise improves global well-being in community-dwelling women with fibromyalgia. However, additional research on this topic is needed, including research in men as well as optimal exercise programs for improving global well-being in adults.

Exercise and Health-Related Quality of Life in Older Community-Dwelling Adults A Meta-Analysis of Randomized Controlled Trials

The authors used the meta-analytic approach to examine the effects of physical activity on health-related quality of life (HRQOL) in older community-dwelling adults. A random-effects model was used for all primary analyses. Of the 257 studies screened, 11 randomized controlled trials representing 13 groups and 617 men and women (324 physical activity, 293 control), all older than 50, were included. Overall, a significant (small to moderate) standardized effect size improvement was found for physical function as a result of physical activity (Hedgess g = 0.41, 95% confidence interval [CI] = 0.19, 0.64, p < .001). This was equivalent to a common language effect size of 62% and an odds ratio of 2.14 (95% CI = 1.42, 3.24). No significant differences were found for the other nine HRQOL outcomes. Although additional research is needed, results suggest that physical activity improves self-reported physical function, a component of HRQOL, in older community-dwelling adults.

Physical Activity and Older Adults: Expert Consensus for a New Research Agenda

PURPOSE This study sought to advance the state of knowledge regarding physical activity and aging by identifying areas of agreement among experts regarding topics that are well understood versus those that are in urgent need of continued research efforts. DESIGN AND METHODS We used a web-based survey with snowball sampling to identify 348 experts who were invited to complete a brief web-based survey. Responses were received from 38% of invited respondents. RESULTS Respondents reported that the efficacy and effectiveness of several types of physical activity were well understood but the dose-response relationship required for a health benefit was not. In general, more research is needed examining the effectiveness of programs on cognitive health outcomes and the impact of multiple risk factor programs. With respect to translation, more research is needed on how to maintain older adults in evidence-based programs and how to adapt programs for special populations. Researchers agreed that racial/ethnic minorities; persons with low socioeconomic status; and those with physical, intellectual, or mental health disability were substantially understudied. Finally, research on maintenance, implementation, and reach with respect to these populations was judged to be more urgently needed than research on efficacy and effectiveness. IMPLICATIONS A substantial amount of consensus was found across a national group of experts. These findings should be instrumental in forging a new research agenda in the area of aging and physical activity.

Efficacy and Effectiveness of Exercise on Tender Points in Adults with Fibromyalgia: A Meta-Analysis of Randomized Controlled Trials

Fibromyalgia is a major public health problem affecting an estimated 200 to 400 million people worldwide. The purpose of this study was to use the meta-analytic approach to determine the efficacy and effectiveness of randomized controlled exercise intervention trials (aerobic, strength training, or both) on tender points (TPs) in adults with fibromyalgia. Using random effects models and 95% confidence intervals (CI), a statistically significant reduction in TPs was observed based on per-protocol analyses (8 studies representing 322 participants) but not intention-to-treat analyses (5 studies representing 338 participants) (per-protocol, g, −0.68, 95% CI, −1.16, −0.20; intention-to-treat, g, −0.24, 95% CI, −0.62, 0.15). Changes were equivalent to relative reductions of 10.9% and 6.9%, respectively, for per-protocol and intention-to-treat analyses. It was concluded that exercise is efficacious for reducing TPs in women with FM. However, a need exists for additional well-designed and reported studies on this topic.

Differences between actual and expected leisure activities after total knee arthroplasty for osteoarthritis.

This prospective cohort study determined the type, frequency, intensity, and duration of actual vs expected leisure activity among a cohort undergoing total knee arthroplasty. Data on actual and expected participation in 36 leisure activities were collected preoperatively and at 12 months in 90 patients with knee osteoarthritis. Despite high expectations, there were statistically and clinically significant differences between actual and expected activity at 12 months suggesting that expectations may not have been fulfilled. The differences were equivalent to walking 14 less miles per week than expected, which is more than the amount of activity recommended in national physical activity guidelines. Perhaps an educational intervention could be implemented to help patients establish appropriate and realistic leisure activity expectations before surgery.

Measuring Health in Patients With Cervical and Lumbosacral Spinal Disorders : Is the 12-Item Short-Form Health Survey a Valid Alternative for the 36-Item Short-Form Health Survey?

OBJECTIVES To determine the convergent validity of the 12-Item Short-Form Health Survey, version 2 (SF-12v2), with 36-Item Short-Form Health Survey, version 2 (SF-36v2), in patients with spinal disorders, and to determine other key factors that might further explain the variances between the 2 surveys. DESIGN Cross-sectional study. SETTING Orthopedic ambulatory care. PARTICIPANTS Eligible participants (N=98; 24 with cervical, 74 with lumbosacral disorders) who were aged 18 years and older, scheduled to undergo spinal surgery, and completed the SF-36v2. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES SF-36v2 and SF-12v2 (extracted from the SF-36v2). RESULTS The 2 summary scores, physical and mental component scores (r range, .88-.97), and most of the scale scores (r range, .81-.99) correlated strongly between the SF-12v2 and SF-36v2, except for the general health score (cervical group, r=.69; lumbosacral group, r=.76). Stepwise linear regression analyses showed the SF-12v2 general health scores (cervical: beta=.61, P<.001; lumbosacral: beta=.68, P<.001) and the level of comorbidities (cervical: beta=-.37, P=.014; lumbosacral: beta=-.18, P=.039) were significant predictors of the SF-36v2 general health score in both groups, whereas age (beta=.32, P<.001) and smoking history (beta=-.22, P=.005) were additional predictors in the lumbosacral group. CONCLUSIONS SF-12v2 is a practical and valid alternative for the SF-36v2 in measuring health of patients with cervical or lumbosacral spinal disorders. The validity of the SF-12v2 general health score interpretation is further improved when the level of comorbidities, age, and smoking history are taken into consideration.

A Public Health Perspective on Physical Activity After Total Hip or Knee Arthroplasty for Osteoarthritis

Abstract Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are common treatments for osteoarthritis (OA) with good-to-excellent outcomes. As the US population ages, rates of OA and THA/TKA will continue to rise. People with OA and THA/TKA are less active than those without arthritis or arthrosplasty, respectively. With the numerous documented health benefits obtained from physical activity, it is imperative from a public health perspective that patients are sufficiently active to maintain health after surgery. Increasing moderate-intensity physical activity is a safe, efficacious, and cost-effective mechanism for improving health and reducing health care costs in this population. The return to leisure/sporting activities after THA/TKA is not as well studied as other aspects of functional recovery. In particular, no evidence-based guidelines for physical activity after THA/TKA are available. Most recommendations have been derived from cross-sectional surveys of orthopedic surgeons. Based on the literature, the general consensus for recommendations appears to be to: 1) return to low- to moderate-intensity activities and no-, low-, or intermediate-impact activities within 3 to 6 months postoperatively, 2) discourage high-impact activities, 3) avoid high-contact athletic activities, and 4) educate rather than dissuade patients from resuming leisure/sporting activities. Sports medicine physicians are in an ideal position to counsel patients in regard to leading active lifestyles. The physician can evaluate and treat any remaining functional limitations postoperatively, as well as prescribe the appropriate dose (ie, type, intensity, frequency, and duration) of physical activity. The 2008 Physical Activity Guidelines for Americans can help guide physicians in prescribing the appropriate dose of activity. Finally, physicians can refer patients to evidence-based, community-delivered group exercise and/or behavioral change interventions that are approved by the Centers for Disease Control and Prevention for people with arthritis.