Hans Lund

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

The objective was to develop evidence -based recommendations and a research and educational agenda for the non-pharmacological management of hip and knee osteoarthritis (OA). The multidisciplinary task force comprised 21 experts: nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedic surgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task force meeting and five Delphi rounds, provisional recommendations were formulated in order to perform a systematic review. A literature search of Medline and eight other databases was performed up to February 2012. Evidence was graded in categories I–IV and agreement with the recommendations was determined through scores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-based recommendations for the non-pharmacological core management of hip and knee OA were developed, concerning the following nine topics: assessment, general approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included an overall need for more research into non-pharmacological interventions for hip OA, moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of work disability. Proposed educational activities included the required skills to teach, initiate and establish lifestyle changes. The 11 recommendations provide guidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.

Impact of Exercise Type and Dose on Pain and Disability in Knee Osteoarthritis: A Systematic Review and Meta-Regression Analysis of Randomized Controlled Trials

To identify the optimal exercise program, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient‐reported disability in knee osteoarthritis (OA).

Impact of exercise type and dose on pain and disability in knee osteoarthritis

To identify the optimal exercise program, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient‐reported disability in knee osteoarthritis (OA).

A RANDOMIZED CONTROLLED TRIAL OF AQUATIC AND LAND-BASED EXERCISE IN PATIENTS WITH KNEE OSTEOARTHRITIS*

OBJECTIVE To compare the efficacy of aquatic exercise and a land-based exercise programme vs control in patients with knee osteoarthritis. METHODS Primary outcome was change in pain, and in addition Knee Injury and Osteoarthritis Outcome Score questionnaire (KOOS). Standing balance and strength was also measured after and at 3-month follow-up. Seventy-nine patients (62 women), with a mean age of 68 years (age range 40-89 years) were randomized to aquatic exercise (n = 27), land-based exercise (n = 25) or control (n = 27). RESULTS No effect was observed immediately after exercise cessation (8 weeks). At 3-month follow-up a reduction in pain was observed only in the land-based exercise group compared with control (-8.1 mm, (95% confidence interval -15.4 to -0.4; p = 0.039), but no differences between groups were observed for KOOS; and no improvement following aquatic exercise. Eleven patients reported adverse events (i.e. discomfort) in land-based exercise, while only 3 reported adverse events in the aquatic exercise. CONCLUSION Only land-based exercise showed some improvement in pain and muscle strength compared with the control group, while no clinical benefits were detectable after aquatic exercise compared with the control group. However, aquatic exercise has significantly less adverse effects compared with a land-based programme.

Effect of whole body vibration exercise on muscle strength and proprioception in females with knee osteoarthritis

The purpose of this study was to assess the effect of whole body vibration (WBV) exercise on muscle strength and proprioception in female patients with osteoarthritis in the knee (knee-OA). A single blinded, randomised, controlled trial was performed in an outpatient clinic on 52 female patients diagnosed with knee-OA (mean age 60.4 years+/-9.6). They were randomly assigned to one of 3 groups: 1. WBV-exercise on a stable platform (VibM; n=17 (mean age, 61.5+/-9.2)), WBV-exercise on a balance board (VibF; n=18 (mean age, 58.7+/-11.0)), or control group (Con; n=18 (mean age, 61.1+/-8.5)). The WBV groups trained twice a week for 8 weeks, with a progressively increasing intensity. The WBV groups performed unloaded static WBV exercise. The following were measured: knee muscle strength (extension/flexion) and proprioception (threshold for detection of passive movement (TDPM)). Self-reported disease status was measured using WOMAC. It was found that muscle strength increased significantly (p<0.001) in VibM compared to Con. Isometric knee-extension significantly increased (p=0.021) in VibM compared to Con. TDPM was significantly improved (p=0.033) in VibF compared to Con, while there was a tendency (p=0.051) for VibM to perform better compared to Con. There were no effects in the self-reported disease status measures. This study showed that the WBV-exercise regime on a stable platform (VibM) yielded increased muscle strength, while the WBV-exercise on a balance board (VibF) showed improved TDPM. The WBV-exercise is a time-saving and safe method for rehabilitation of women with knee-OA.

Relationships between the fibromyalgia impact questionnaire, tender point count, and muscle strength in female patients with fibromyalgia: A cohort study

OBJECTIVE To test the hypothesis that fibromyalgia (FM) patients with reduced lower extremity strength are more symptomatic and tender than FM patients with normal muscle strength. METHODS A total of 840 FM patients and 122 healthy subjects were evaluated between 1998 and 2005. All of the patients completed version 1 of the Fibromyalgia Impact Questionnaire (FIQ) and were assessed for tender points and knee muscle strength. All subjects underwent bilateral isokinetic knee muscle strength testing in flexion and extension. Normative knee muscle strength values were calculated from the healthy subjects, and the FM cohort was divided in 2 groups: 1) patients with normal muscle strength and 2) patients with low muscle strength (2 SDs below normal). The clinical characteristics of these 2 groups were compared. RESULTS Significantly reduced knee muscle strength was found in 52% of the patients. There were no clinically significant differences between patients with low versus normal muscle strength. There were no clinically significant correlations between total FIQ score, tender point count, and muscle strength. Only 4.6% of the FIQ scores and 5.1% of the tender point counts were explained by muscle strength. CONCLUSION Significantly reduced knee muscle strength was found in more than half of the patients. Patients with subnormal muscle strength were not more symptomatic or tender than patients with normal muscle strength. There were no clinically significant correlations between FIQ, tender point count, and muscle strength; therefore, reduced knee muscle strength appears to be a common objective abnormality in FM that is independent of measurements of disease activity. The implication of this finding in regard to the clinical assessment of FM needs further study.

A Hierarchy of Patient-Reported Outcomes for Meta-Analysis of Knee Osteoarthritis Trials: Empirical Evidence from a Survey of High Impact Journals

Objectives. To develop a prioritised list based on responsiveness for extracting patient-reported outcomes (PROs) measuring pain and disability for performing meta-analyses in knee osteoarthritis (OA). Methods. A systematic search was conducted in 20 highest impact factor general and rheumatology journals chosen a priori. Eligible studies were randomised controlled trials, using two or more PROs measuring pain and/or disability. Results. A literature search identified 402 publications and 38 trials were included, resulting in 54 randomised comparisons. Thirty-five trials had sufficient data on pain and 15 trials on disability. The WOMAC “pain” and “function” subscales were the most responsive composite scores. The following list was developed. Pain: (1) WOMAC “pain” subscale, (2) pain during activity (VAS), (3) pain during walking (VAS), (4) general knee pain (VAS), (5) pain at rest (VAS), (6) other composite pain scales, and (7) other single item measures. Disability: (1) WOMAC “function” subscale, (2) SF-36 “physical function” subscale, (3) SF-36 (Physical composite score), and (4) Other composite disability scores. Conclusions. As choosing the PRO most favourable for the intervention from individual trials can lead to biased estimates, using a prioritised list as developed in this study is recommended to reduce risk of biased selection of PROs in meta-analyses.

Effect of static stretching of quadriceps and hamstring muscles on knee joint position sense

Objectives: To evaluate if a stretch regimen consisting of three 30 second stretches would alter joint position sense (JPS). Methods: A blinded, randomised, cross over design with a washout time of 24 hours was used with 20 healthy volunteers. JPS was estimated from the ability to reproduce the same position in one knee (target versus estimated angle) expressed as the difference between target and estimated angle (constant error, CE). Measurements were repeated three times in a sitting and a prone position on the dominant leg measured before and immediately after the static stretch. The static stretch consisted of a 30 second stretch followed by a 30 second pause, repeated three times. Results: At baseline, the mean (SD) CE was −2.71 (3.57)° in the sitting position. No difference (p  =  0.99) in CE between stretching and control was observed (0.00; 95% confidence interval −0.98 to 0.99). At baseline, the CE was −3.28 (4.81)° in the prone position. No difference (p  =  0.89) in CE between stretching and control was observed (0.12; 95% confidence interval −1.52 to 1.76). Conclusion: A static stretch regimen had no effect on JPS in healthy volunteers.

Low levels of physical activity in patients with severe mental illness

Abstract Background: Physical inactivity is an independent risk factor for cardiovascular diseases and Type 2 diabetes, both being highly prevalent in patients with severe mental illness. Though physical activity has become an important issue in psychiatric treatment and rehabilitation in the past decade, systematic evaluations of physical activity level in psychiatric populations could be more disseminated. Aim: The primary aim of the study was to investigate the physical activity level of psychiatric patients in comparison with healthy controls. Methods: Patients with severe mental illness (n =47) and a group of healthy controls (n =28) matched on sex and age reported their physical activity level using the Physical Activity Scale (PAS). PAS was administered as an interview in relation to patients and as a questionnaire in relation to healthy controls. Results: Patients had statistically significant lower levels of physical activity compared with healthy controls (P <0.0001) and the level of physical activity among patients was hazardously low. Conclusion: The study confirmed previous studies and clinical experience that patients with severe mental illness are physically inactive and emphasize the importance of physical activity in psychiatric treatment and rehabilitation. The PAS is an applicable and relevant method for evaluating physical activity levels in psychiatric patients.

Differences between questionnaire- and interview-based measures of activities of daily living (ADL) ability and their association with observed ADL ability in women with rheumatoid arthritis, knee osteoarthritis, and fibromyalgia

Objectives: Although self-report based on questionnaire is the common method to obtain information about activities of daily living (ADL) ability in rheumatic diseases, little is known about the relationship between measures of ADL ability based on questionnaire, interview, and observation. The present study examined whether measures of self-reported ADL ability based on questionnaire and interview yielded different results, determined whether the magnitude of the difference varied among women with rheumatoid arthritis (RA), knee osteoarthritis (OA), and fibromyalgia (FM), and investigated the relationships between self-reported and observed ADL ability. Method: The 47 ADL tasks of the ADL taxonomy were used to evaluate self-reported ADL ability based on questionnaire (ADL-Q) and interview (ADL-I), and the Assessment of Motor and Process Skills (AMPS) was used to obtain measures of observed ADL ability. Results: Participants across diagnostic groups reported significantly more ADL ability based on the ADL-Q than on the ADL-I. Moderate correlations were found between the ADL-Q and ADL-I ability measures. Although low to moderate correlations were seen between measures based on the AMPS ADL motor scale and the ADL-Q and ADL-I, respectively, correlations between measures based on AMPS ADL process scale and ADL-Q and ADL-I were generally low. Overall, there was no difference in how the measures based on the two modes of self-report related to the observed ADL ability measures. Conclusion: Measures of self-reported ADL ability based on either questionnaire or interview have limited relationship to each other or to observed performance of ADL tasks.