M. van der Leeden

Proprioception in knee osteoarthritis: a narrative review

OBJECTIVE To give an overview of the literature on knee proprioception in knee osteoarthritis (OA) patients. METHOD A literature search was performed and reviewed using the narrative approach. RESULTS (1) Three presumed functions of knee proprioception have been described in the literature: protection against excessive movements, stabilization during static postures, and coordination of movements. (2) Proprioceptive accuracy can be measured in different ways; correlations between these methods are low. (3) Proprioceptive accuracy in knee OA patients seems to be impaired when compared to age-matched healthy controls. Unilateral knee OA patients may have impaired proprioceptive accuracy in both knees. (4) Causes of impaired proprioceptive accuracy in knee OA remain unknown. (5) There is currently no evidence for a role of impaired proprioceptive accuracy in the onset or progression of radiographic osteoarthritis (ROA). (6) Impaired proprioceptive accuracy could be a risk factor for progression (but not for onset) of both knee pain and activity limitations in knee OA patients. (7) Exercise therapy seems to be effective in improving proprioceptive accuracy in knee OA patients. CONCLUSIONS Recent literature has shown that proprioceptive accuracy may play an important role in knee OA. However, this role needs to be further clarified. A new measurement protocol for knee proprioception needs to be developed. Systematic reviews focusing on the relationship between impaired proprioceptive accuracy, knee pain and activity limitations and on the effect of interventions (in particular exercise therapy) on proprioceptive accuracy in knee OA are required. Future studies focusing on causes of impaired proprioceptive accuracy in knee OA patients are also needed, taking into account that also the non-symptomatic knee may have proprioceptive impairments. Such future studies may also provide knowledge of mechanism underlying the impact of impaired proprioceptive accuracy on knee pain and activity limitations.

Determinants of range of joint motion in patients with early symptomatic osteoarthritis of the hip and/or knee: an exploratory study in the CHECK cohort

OBJECTIVE Reduced range of motion (ROM) is supposed to be a characteristic feature of osteoarthritis (OA). Because little is known about determinants of ROM, the objective of the present study was to explore the association between demographic, articular, and clinical factors and ROM in patients with early symptomatic knee and/or hip OA. DESIGN Baseline data of 598 participants of the Cohort Hip and Cohort Knee (CHECK) study were used in this cross-sectional study. METHODS Separate analyses were performed for participants with knee and participants with hip symptoms. Active knee flexion, and hip internal rotation, external rotation, flexion, adduction, and abduction were assessed using a goniometer. Participants underwent a standardised physical and radiographic examination, and completed a questionnaire. Exploratory regression analyses were performed to explore the association between ROM and demographic [i.e., age, gender, body mass index (BMI)], articular [i.e., osteophytosis, joint space narrowing (JSN)], and clinical (i.e., pain, stiffness) factors. RESULTS In patients with early symptomatic knee OA, osteophytosis, bony enlargement, crepitus, pain, and higher BMI were associated with lower knee flexion. JSN was associated with lower ROM in all planes of motion. In addition, osteophytosis, flattening of the femoral head, femoral buttressing, pain, morning stiffness, male gender, and higher BMI were found to be associated with lower hip ROM in two planes of motion. CONCLUSION Features of articular degeneration are associated with lower knee ROM and lower hip ROM in patients with early OA. Pain, stiffness, higher BMI, and male gender are associated with lower ROM as well.

Improvement in upper leg muscle strength underlies beneficial effects of exercise therapy in knee osteoarthritis: secondary analysis from a randomised controlled trial

OBJECTIVES Although exercise therapy is effective for reducing pain and activity limitations in patients with knee osteoarthritis (OA), the underlying mechanisms are unclear. This study aimed to evaluate if improvements in neuromuscular factors (i.e. upper leg muscle strength and knee proprioception) underlie the beneficial effects of exercise therapy in patients with knee OA. DESIGN Secondary analyses from a randomised controlled trial, with measurements at baseline, 6 weeks, 12 weeks and 38 weeks. SETTING Rehabilitation centre. PARTICIPANTS One hundred and fifty-nine patients diagnosed with knee OA. INTERVENTION Exercise therapy. MAIN OUTCOME MEASURES Changes in pain [numeric rating scale (NRS)] and activity limitations [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function subscale and get-up-and-go test] during the study period. Independent variables were changes in upper leg muscle strength and knee joint proprioception (i.e. motion sense) during the study period. Longitudinal regression analyses (generalised estimating equation) were performed to analyse associations between changes in upper leg muscle strength and knee proprioception with changes in pain and activity limitations. RESULTS Improved muscle strength was significantly associated with reductions in NRS pain {B coefficient -2.5 [95% confidence interval (CI) -3.7 to -1.4], meaning that every change of 1 unit of strength was linked to a change of -2.5 units of pain}, WOMAC physical function (-8.8, 95% CI -13.4 to -4.2) and get-up-and-go test (-1.7, 95% CI -2.4 to -1.0). Improved proprioception was not significantly associated with better outcomes of exercise therapy (P>0.05). CONCLUSIONS Upper leg muscle strengthening is one of the mechanisms underlying the beneficial effects of exercise therapy in patients with knee OA.

Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes

OBJECTIVES To evaluate the feasibility and outcomes of early enforced mobilisation following surgery for gastrointestinal cancer. DESIGN Feasibility study with a separate-sample pre-post-test design. SETTING Surgical gastrointestinal ward. PARTICIPANTS Patients with various types of gastrointestinal cancer, before and after implementation of postoperative enforced mobilisation (n=55 and n=61, respectively). INTERVENTION The enforced mobilisation protocol included structured mobilisation by a nurse and walking supervised by a physiotherapist, starting within 24hours of surgery. MAIN OUTCOME MEASURES The enforced mobilisation protocol was deemed to be feasible if at least 50% of patients were able to walk the scheduled distance on postoperative day 1. Pre- and postimplementation differences in postoperative pulmonary complications (PPCs), length of hospital stay (LOS) and re-admission rate were analysed using regression analyses, adjusting for relevant co-variables. RESULTS In the various surgical groups, between 48% and 56% of patients were able to walk the scheduled distance on postoperative day 1, which was regarded as feasible. However, none of the patients who had undergone oesophageal resection were able to walk on postoperative day 1. Excluding these patients from the analyses, a significant decrease in PPCs was found (odds ratio 0.08, 95% confidence interval 0.010 to 0.71, P=0.023) following implementation of enforced mobilisation. Differences in LOS and re-admission rate were not significant. CONCLUSIONS Early enforced mobilisation seems to be feasible in patients following surgery for gastrointestinal cancer, except for those undergoing oesophageal resection. The occurrence of PPCs was reduced after implementation of enforced mobilisation. Further research is needed to confirm these results.

Fatigue in patients with chronic widespread pain participating in multidisciplinary rehabilitation treatment: a prospective cohort study

Abstract Purpose: To explore the associations between (improvement in) fatigue and (improvement in) clinical and cognitive factors in patients with chronic widespread pain (CWP), participating in multidisciplinary rehabilitation treatment. Methods: Data were used from baseline, 6 and 18 months of follow-up during a prospective cohort study of 120 CWP patients who completed multidisciplinary rehabilitation treatment. Cross-sectional and longitudinal relationships were analyzed between fatigue, clinical (i.e. pain, interference of pain and depression) and pain related cognitive factors (i.e. negative emotional cognitions, active cognitive coping, and control and chronicity beliefs). Results: Higher levels of pain, interference of pain, depression, negative emotional cognitions, and negative control and chronicity beliefs were associated with a higher level of fatigue. Improvement in depression was related to improvement in fatigue. Conclusions: In CWP patients, worse clinical status, and dysfunctional pain-related cognitions are associated with a higher level of fatigue. Our results suggest that improvement in depression might be a mechanism of improvement in fatigue. Furthermore, improvement in fatigue seems to be independent of improvement in pain related cognitions. Targeting fatigue in multidisciplinary pain treatment may need specific strategies. Implications for Rehabilitation Improvement in depression may be a mechanism of change to improve the level of fatigue in CWP. Improvement in dysfunctional (pain related) cognitions seems to be independent of improvement in fatigue. Targeting fatigue in multidisciplinary treatment may need specific strategies (e.g. additional interventions focusing on reducing fatigue and specific attention to improvement of sleep).

Comorbidity, Obesity, and Exercise Therapy in Patients with Knee and Hip Osteoarthritis

Comorbidity and overweight are highly prevalent in patients with knee and hip osteoarthritis. This chapter addresses comorbidity and overweight in osteoarthritis, and adaptations of exercise therapy required because of comorbidity and overweight.

AB1158-HPR The Avoidance Model in Knee and Hip Osteoarthritis: A Systematic Review of the Evidence

Background The avoidance model explains how behavioral mechanisms may lead to activity limitations in patients with osteoarthritis (OA) of the knee or hip. According to this model, the patient with OA experiences pain during activities. This leads to the expectation that renewed activity will cause greater pain, resulting in avoidance of activities. Avoidance of activities results in physical decline, most notably muscle weakness. Muscle weakness leads to an increase in activity limitations. In addition, it is hypothesized that psychological distress enhances the tendency to avoid activities, leading to muscle weakness and activity limitations. Objectives To review the scientific evidence for the validity of the avoidance model in patients with knee and hip OA. Methods A literature search was conducted in four electronic databases. Selection criteria included: knee or hip OA or pain; examination of consecutive components of the avoidance model; observational study; original research report. The methodological quality of the selected articles was assessed, and qualitative data synthesis identified levels of evidence. Results Sixty studies were included. In patients with knee OA, strong evidence was found that avoidance of activities is associated with activity limitations via muscle weakness (mediation by muscle weakness); strong evidence was found for an association between muscle weakness and activity limitations; and weak evidence was found that pain and psychological distress are associated with muscle weakness via avoidance (mediation by avoidance). In patients with hip OA, weak evidence was found for mediation by muscle weakness; and strong evidence was found for an association between muscle weakness and activity limitations. Conclusions In patients with knee OA, the association between avoidance of activities and activity limitations is for a substantial part explained by muscle weakness. In both patients with knee OA and patients with hip OA, muscle weakness is associated with activity limitations. These results emphasize the importance of muscle strength in maintenance of activities. More research is needed on the consecutive associations between pain or psychological distress, avoidance of activities and muscle weakness, and to confirm causal relationships. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1191

FRI0408 Body mass index and depression are independently associated with knee pain and activity limitations in knee osteoarthritis: Results from the AMS-OA cohort

Background Body mass index (BMI) and depression are positively associated with each other (Rosemann et al. 2008), and positively associated with pain and activity limitations in knee osteoarthritis (OA) patients (Dekker et al. 2009). There is growing evidence that metabolic factors are involved in both the development of overweight and depression (McIntyre et al. 2007). This raises the question whether BMI and depression are related to knee pain and activity limitations independently of each other. Objectives To establish if BMI and depression are independently associated with knee pain and activity limitations in knee OA patients. Methods A cross-sectional study was conducted in a sample of 304 participants with knee OA from the Amsterdam Osteoarthritis Cohort. All patients fulfilled the American College of Rheumatology (ACR) clinical criteria for knee OA. Depression was measured with the Hospital Anxiety and Depression Scale. Pain was measured with a numeric rating scale for knee pain during the last week, and activity limitations were measured with the Western Ontario and McMaster Universities Osteoarthritis Index and the timed get up and go test. Multivariable regression analyses were performed with BMI and depression as independent variables, and pain and activity limitations as dependent variables. Regression models with only BMI or only depression as independent variable were compared with regression models with both BMI and depression as independent variables. All analyses were adjusted for age, gender, civil status, educational level and comorbidity count. Results BMI and depression were independently associated with knee pain. After adjustment for each other the regression coefficients (Bs) of BMI and depression changed with 20.5% and 16.4% respectively, and were still significantly associated with knee pain (p≤0.01). BMI and depression were independently associated with both self-reported and performance-based activity limitations (p≤0.01). After adjustment for each other the Bs of BMI and depression changed with 10.3% and 27.9% in the analyses with self-reported activity limitations as dependent variable, and with 4.7% and 40.6% in the analysis with performance-based activity limitations as dependent variable. Conclusions The association between overweight and knee pain and activity limitations is not explained by depression, and the association between depression and knee pain and activity limitations is not explained by overweight. Both BMI and depression are independently associated with knee pain and activity limitations. As a consequence, in treating patients with knee OA, overweight and depression should both be targeted. Disclosure of Interest None Declared