Laurianne Loew

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.

Background and Purpose The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m2). Data Sources Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro. Study Selection The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications. Data Extraction An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel. Data Synthesis Recommendations were graded based on the strength of evidence (A, B, C, C+, D, D+, or D−) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit. Limitations Further research is needed, as more than half of the trials were of low methodological quality. Conclusions This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.

OBJECTIVE To update the Evidence-Based Clinical Practice Guidelines (EBCPGs) on aerobic walking programs for the management of osteoarthritis (OA) of the knee. DATA SOURCES A literature search was conducted using the electronic databases MEDLINE, PubMed, and the Cochrane Library for all studies related to aerobic walking programs for OA from 1966 until February 2011. STUDY SELECTION The literature search found 719 potential records, and 10 full-text articles were included according to the selection criteria. The Ottawa Methods Group established the inclusion and exclusion criteria regarding the characteristics of the population, by selecting adults of 40 years old and older who were diagnosed with OA of the knee. DATA EXTRACTION Two reviewers independently extracted important information from each selected study using standardized data extraction forms, such as the interventions, comparisons, outcomes, time period of the effect measured, and study design. The statistical analysis was reported using the Cochrane collaboration methods. An improvement of 15% or more relative to a control group contributes to the achievement of a statistically significant and clinically relevant progress. A specific grading system for recommendations, created by the Ottawa Panel, used a level system (level I for randomized controlled studies and level II for nonrandomized articles). The strength of the evidence of the recommendations was graded using a system with letters: A, B, C+, C, D, D+, or D-. DATA SYNTHESIS Evidence from 7 high-quality studies demonstrated that facility, hospital, and home-based aerobic walking programs with other therapies are effective interventions in the shorter term for the management of patients with OA to improve stiffness, strength, mobility, and endurance. CONCLUSIONS The greatest improvements were found in pain, quality of life, and functional status (grades A, B, or C+). A common limitation inherent to the EBCPGs is the heterogeneity of studies included with regards to the characteristics of the population, the interventions, the comparators, the outcomes, the period of time, and the study design. It is strongly recommended to use the Cochrane Risk of Bias Summary assessment to evaluate the methodologic quality of the studies and to consider avenues for future research on how aerobic walking programs would be beneficial in the management of OA of the hip.

A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument.

Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

Ottawa panel evidence-based clinical practice guidelines on therapeutic massage for neck pain

OBJECTIVE To update evidence-based clinical practice guideline (EBCPG) on the use of massage compared to a control or other treatments for adults (>18 years) suffering from sub-acute and chronic neck pain. METHODS A literature search was performed from January 1, 1948 to December 31, 2010 for relevant articles. The Ottawa Panel created inclusion criteria focusing on high methodological quality and grading methods. Recommendations were assigned a grade (A, B, C, C+, D, D+, D-) based on strength of evidence. RESULTS A total of 45 recommendations from ten articles were developed including 8 positive recommendations (6 grade A and 2 grade C+) and 23 neutral recommendations (12 grade C and 11 grade D). DISCUSSION Therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain. CONCLUSION The Ottawa Panel was able to demonstrate that the massage interventions are effective for relieving immediate post-treatment neck pain symptoms, but data is insufficient for long-term effects.

A systematic critical appraisal of non-pharmacological management of rheumatoid arthritis with Appraisal of Guidelines for Research and Evaluation II.

Clinical practice guidelines (CPGs) have been developed to summarize evidence about the management of rheumatoid arthritis (RA) and facilitate the uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of this review was to assess the quality of CPGS on non-pharmacological management of RA with a standardized and validated instrument - the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and summarize the key recommendations from these CPGs. Scientific literature databases from 2001 to 2013 were systematically searched and a total of 13 CPGs for RA was identified. Only a minority of AGREE II domains were effectively addressed by the CPGS. Scope and purpose was effectively addressed in 10 out of 13 CPGs, stakeholder involvement in 11 CPGs, rigor of development in 6 CPGs, clarity/presentation in 9 CPGs, editorial independence in 1 CPGs, and applicability in none of the CPGs. The overall quality of the included CPGs according to the 7-point AGREE II scoring system was 4.8±1.04. Patient education/self-management, aerobic, dynamic and stretching exercises were the commonly recommended for the non-pharmacological management of RA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. CPGs creators should use the AGREE II criteria when developing guidelines. Innovative and effective methods of CPGs implementation to users are needed to ultimately enhance the quality of life of arthritic individuals. In addition, it was difficult to establish between strongly recommended, recommended and weakly recommended, as there is no consensus between the strength of the recommendations between the appraised CPGs.

Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis

Objectives: The primary objective is to identify effective land-based therapeutic exercise interventions and provide evidence-based recommendations for managing hip osteoarthritis. A secondary objective is to develop an Ottawa Panel evidence-based clinical practice guideline for hip osteoarthritis. Methods: The search strategy and modified selection criteria from a Cochrane review were used. Studies included hip osteoarthritis patients in comparative controlled trials with therapeutic exercise interventions. An Expert Panel arrived at a Delphi survey consensus to endorse the recommendations. The Ottawa Panel hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) considered the study design (level I: randomized controlled trial and level II: controlled clinical trial), statistical significance (p < 0.5), and clinical importance (⩾15% improvement). Results: Four high-quality studies were included, which demonstrated that variations of strength training, stretching, and flexibility exercises are generally effective for improving the management of hip osteoarthritis. Strength training exercises displayed the greatest improvements for pain (Grade A), disability (Grades A and C+), physical function (Grade A), stiffness (Grade A), and range of motion (Grade A) within a short time period (8–24 weeks). Stretching also greatly improved physical function (Grade A), and flexibility exercises improved pain (Grade A), range of motion (Grade A), physical function (Grade A), and stiffness (Grade C+). Conclusion: The Ottawa Panel recommends land-based therapeutic exercise, notably strength training, for management of hip osteoarthritis in reducing pain, stiffness and self-reported disability, and improving physical function and range of motion.

People getting a grip on arthritis II: An innovative strategy to implement clinical practice guidelines for rheumatoid arthritis and osteoarthritis patients through Facebook

Objective: The purpose of the study is to determine if an updated online evidence-based educational programme delivered through Facebook is effective in improving the knowledge, skills, and self-efficacy of patients with arthritis in relation to evidence-based self-management rehabilitation interventions for osteoarthritis (OA) and rheumatoid arthritis (RA). Methods: Adult patients (>18 years old) with self-reported OA or RA were eligible for the study. One-hundred-and-ten participants were recruited from the general public and different arthritis patient organizations throughout Canada. Eleven participants were selected to participate in focus groups to select effective self-management strategies for OA and RA according to level of implementation burden. Ninety-nine participants were then selected to participate in the online Facebook intervention which included a ‘group’ web page providing case-based video clips on how to apply the selected self-management interventions. Over a three-month period participants were asked to complete three online questionnaires regarding their previous knowledge, intention to use/actual use of the self-management strategies, self-efficacy and confidence in managing their condition. Results: Knowledge acquisition scores improved among OA and RA participants with a mean difference of 1.8 (p < 0.01) when compared from baseline to immediate post-intervention. At three months post-intervention, almost all self-management strategies were successful with participants following through on their intention to use the self-management strategies; however, statistically significant results were only demonstrated for ‘aquatic jogging’ (p < 0.05) and ‘yoga’ (p < 0.05) among OA participants, and ‘aquatic therapy’ (p < 0.01) among RA participants. Self-efficacy was maintained from immediate post-intervention to three months follow-up, and confidence improved as the study progressed. Conclusions: This online programme can provide patient organization representatives with the opportunity to learn about and integrate evidence-based self-management strategies for OA and RA in their daily lives, to increase their awareness of useful community resources, and support their efforts to disseminate the information to others with arthritis.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs

Objective: To identify effective strengthening exercise programs and provide rehabilitation teams and patients with updated, high-quality recommendations concerning traditional land-based exercises for knee osteoarthritis. Methods: A systematic search and adapted selection criteria included comparative controlled trials with strengthening exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+ or D-) was based on statistical significance (p < 0.5) and clinical importance (⩾15% improvement). Results: The 26 high-quality studies identified demonstrated that various strengthening exercise programs with/without other types of therapeutic exercises are generally effective for improving knee osteoarthritis management within a six-month period. Strengthening exercise programs demonstrated a significant improvement for pain relief (four Grade A, ten Grade B, two Grade C+), physical function (four Grade A, eight Grade B) and quality of life (three Grade B). Strengthening in combination with other types of exercises (coordination, balance, functional) showed a significant improvement in pain relief (three Grade A, 11 Grade B, eight Grade C+), physical function (two Grade A, four Grade B, three Grade C+) and quality of life (one Grade A, one Grade C+). Conclusion: There are a variety of choices for strengthening exercise programs with positive recommendations for healthcare professionals and knee osteoarthritis patients. There is a need to develop combined behavioral and muscle-strengthening strategies to improve long-term maintenance of regular strengthening exercise programs.

People getting a grip on arthritis: A knowledge transfer strategy to empower patients with rheumatoid arthritis and osteoarthritis

Objective: The purpose of this study was twofold. First, to help people with arthritis become aware of and utilize Rheumatoid Arthritis (RA) and Osteoarthritis (OA) Clinical Practice Guidelines (CPGs) as they relate to self-management strategies. Second, to evaluate the impact of specific Knowledge Translation (KT) activities on CPG uptake. More specifically, investigators were interested in: (1) participant acquisition of knowledge, skills, and self-efficacy regarding the uptake of CPGs; (2) participant intention and actual use of CPGs; (3) whether participants trained to become educators shared new CPG knowledge with other people who have RA or OA; and (4) the effect of press media in promoting CPGs to the general public. Methods: Workshop 1 (WS1) was delivered by a multidisciplinary faculty. Selected participants from WS1 were then trained to become educators of pertinent CPGs and deliver the same content to a second group of patients in Workshop 2 (WS2). Questionnaires to measure the four aforementioned interests in KT were administered pre- and post- workshop as well as three months post-workshop. Results: Acquisition of new knowledge by workshop participants (n = 49) was found for Transcutaneous Electrical Nerve Stimulation (TENS), Tai Chi, and insoles and footwear, although not for weight management, aerobic walking, and strengthening exercises. Immediately post-workshop, participants in WS1 (M = 7.96, SD = 1.89) and WS2 (M = 7.16, SD = 1.46) had comparatively similar self-efficacy levels regarding symptom management. No statistically-significant changes were found for online general public participants. Conclusion: An intensive evidence-based educational programme focused on training CPG educators appears to be an effective method of KT for patients with RA and OA. Similar KT activities would be employed again but with greater attention to use of media strategies.

The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part one: introduction, and mind-body exercise programs*

Objective: To identify effective mind-body exercise programs and provide clinicians and patients with updated, high-quality recommendations concerning non-traditional land-based exercises for knee osteoarthritis. Methods: A systematic search and adapted selection criteria included comparative controlled trials with mind-body exercise programs for patients with knee osteoarthritis. A panel of experts reached consensus on the recommendations using a Delphi survey. A hierarchical alphabetical grading system (A, B, C+, C, D, D+, D-) was used, based on statistical significance (P < 0.5) and clinical importance (⩾15% improvement). Results: The four high-quality studies identified demonstrated that various mind-body exercise programs are promising for improving the management of knee osteoarthritis. Hatha Yoga demonstrated significant improvement for pain relief (Grade B) and physical function (Grade C+). Tai Chi Qigong demonstrated significant improvement for quality of life (Grade B), pain relief (Grade C+) and physical function (Grade C+). Sun style Tai Chi gave significant improvement for pain relief (Grade B) and physical function (Grade B). Conclusion: Mind-body exercises are promising approaches to reduce pain, as well as to improve physical function and quality of life for individuals with knee osteoarthritis.