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Background. Integrating physical therapy sessions and an online application (e-Exercise) might support people with hip osteoarthritis (OA), knee OA, or both (hip/knee OA) in taking an active role in the management of their chronic condition and may reduce the number of physical therapy sessions. Objective. The objective of this study was to investigate the short- and long-term effectiveness of e-Exercise compared to usual physical therapy in people with hip/knee OA. Design. The design was a prospective, single-blind, multicenter, superiority, cluster-randomized controlled trial. Setting. The setting included 143 primary care physical therapist practices. Participants. The participants were 208 people who had hip/knee OA and were 40 to 80 years of age. Intervention. e-Exercise is a 3-month intervention in which about 5 face-to-face physical therapy sessions were integrated with an online application consisting of graded activity, exercise, and information modules. Usual physical therapy was conducted according to the Dutch physical therapy guidelines on hip and knee OA. Measurements. Primary outcomes, measured at baseline after 3 and 12 months, were physical functioning and free-living physical activity. Secondary outcome measures were pain, tiredness, quality of life, self-efficacy, and the number of physical therapy sessions. Results. The e-Exercise group (n = 109) received, on average, 5 face-to-face sessions; the usual physical therapy group (n = 99) received 12. No significant differences in primary outcomes between the e-Exercise group and the usual physical therapy group were found. Within-group analyses for both groups showed a significant improvement in physical functioning. After 3 months, participants in the e-Exercise group reported an increase in physical activity; however, no objectively measured differences in physical activity were found. With respect to secondary outcomes, after 12 months, sedentary behavior significantly increased in the e-Exercise group compared with the usual physical therapy group. In both groups, there were significant improvements for pain, tiredness, quality of life, and self-efficacy. Limitations. The response rate at 12 months was 65%. Conclusions. The blended intervention, e-Exercise, was not more effective than usual physical therapy in people with hip/knee OA., Osteoarthritis (OA) is the most common chronic condition of the joints. (1) Prevalence of this rheumatic disease increases with age and mostly affects the hip and knee. Based on radiographic [...]

Background and Purpose. One-time physical therapist consultation, prior to possible referral for physical therapy intervention, may enhance the quality of patient care, particularly if the referring physician is uncertain as to whether intervention by a physical therapist will be beneficial. The purpose of this study was to describe the use of consultation by a group of primary care physicians (PCPs) who could refer patients for a one-time consultation. Subjects and Methods. A 7-month observational study was conducted in the Netherlands with 59 pairs of randomly selected PCPs and physical therapists practicing in primary health care. Data were collected for the PCPs, the physical therapists, and the patients. Self-administered questionnaires (completed at the start and at the completion of the study), consultation request and report forms, and treatment referral records from health insurance agencies were used to obtain data. National reference data on patients referred by PCPs for intervention by a physical therapist were used to compare the data of patients referred by PCPs for a one-time consultation. The number and nature of consultation requests were determined as well as patient characteristics. The PCPs' satisfaction with the outcome and process of a one-time consultation and its impact on PCPs' management decisions also were described. Results. The number of referrals for a one-time consultation was 352 (X = 5.9 per PCP, SD = 5.4, range = 0-20), resulting in a mean referral rate of 4.7 per 1,000 patients (SD = 4.6). Characteristics of patients referred for a one-time consultation differed from national reference data of patients referred by their PCP for intervention by a physical therapist. Discussion and Conclusion. The results show that PCPs used the opportunity for a one-time physical therapist consultation and were satisfied with the outcome and process of consultation. The findings suggest that a one-time consultation is an appropriate and beneficial component of PCPs' patient management process. [Hendriks EJM, Kerssens JJ, Dekker J, et al. One-time physical therapist consultation in primary health care. Phys Ther. 2003;83:918-931.] Key Words: Communication, Cooperation, Physical therapist consultation, Primary health care., In the Netherlands, as in many other countries, primary care physicians (PCPs), also called "general practitioners" or "family doctors," occupy a pivotal position in the provision of care. (1-3) Their [...]

Background and Purpose. The purposes of this study were to describe the use of ultrasound by Dutch physical therapists and to address the question of whether this use is what would be considered correct. Subjects and Methods. Physical therapists in the Dutch primary health care system gathered data on 17,201 patients, addressing reasons for referral, treatment goals (in terms of impairments and disabilities), and physical therapy interventions. Patients treated with ultrasound (n= 3,959) were compared with a reference group of patients who were not treated with ultrasound (n= 13,242). Results. Physical therapists applied ultrasound for soft tissue injuries of recent onset, mainly aiming to reduce pain and swelling. Ultrasound was used in all phases of treatment and was not restricted to the first 3 weeks of treatment. Ultrasound was combined relatively infrequently with exercise and relatively frequently with massage. Conclusion and Discussion. Regarding the indications for referral and treatment goals chosen, the actual use of ultrasound corresponds to assumptions about expected use. The timing of its application and the combination with other forms of therapy do not correspond in all aspects to the assumptions made. [Roebroeck ME, Dekker J, Oostendorp RAB. The use of therapeutic ultrasound by physical therapists in Dutch primary health care. Phys Ther. 1998;78:470-478.], Key Words: Appropriate are, ICIDH, Physical theraphy, Survey research, Ultrasound. Ultrasound is an intervention that is frequently used by physical therapists. In the northeastern United States, 64% of physical therapists [...]

Background and Purpose. The physical therapy management of patients with pain often lacks a theoretical or conceptual basis. The purpose of this study was to compare treatments of patients with back and knee pain with a treatment framework (conceptual model) that we developed. This framework emphasizes physiological recovery, or reduction of impairments (eg, reduction of swelling), followed by emphasis on the reduction of disabilities. Expectations were derived concerning treatment goals and interventions in the course of treatment. Subjects. Patients with back pain (n=1,085) and patients with knee trauma (n=416) were treated by 83 Dutch physical therapists. Methods. Survey data were gathered on impairments and disabilities and on treatment goals and interventions. Results. For both groups of patients, two out of a maximum of eight treatment goals were directed at alleviating impairments in accordance with the framework. Goals directed toward the alleviation of disabilities did not show a similar relationship to the framework. For two treatment goals, the course of treatment was in accordance with the framework for both groups of patients. Conclusion and Discussion. The framework is only partially reflected in Dutch physical therapist practice. The use of such a framework, however, may be a helpful tool in gaining more insight into physical therapy in daily practice. [van Baar ME, Dekker J, Bosveld W. A survey of physical therapy goals and interventions for patients with back and knee pain. Phys Ther. 1998;78:33-42.], Key Words: Intervention, Pain, Physical therapy, Survey research. Physical therapists are increasingly discussing the importance of studying the relationship between diagnoses and treatment.[1-3] Recently, it was shown that diagnostic categories [...]

Background and Purpose. The diagnosis made by a physical therapist gives direction to the selection of therapeutic interventions. Therefore, in an investigation, specific relationships between diagnoses and therapeutic interventions are expected. This study was designed to test whether such relationships exists. Subjects and Methods. Data on diagnosis, treatment goals, and interventions were gathered on 8,714 patients by 74 physical therapists. The diagnosis and treatment goals were defined in terms of impairments and disabilities. Results. Specific relationships were found to exist between those impairments and disabilities that were chosen as a basis for forming treatment goals and the application of interventions. These relationships are particularly marked at the impairment level. Conclusion and Discussion. It is concluded that the diagnostic categories validly predict which interventions are applied and that the selection of interventions depends on which treatment goals are pursued [Dekker J, van Baar ME, Curfs EC, Kerssens JJ. Diagnosis and treatment in physical therapy an investigation of their relationship Phys Ther 1993,73 568-5801.], The need for studies on the diagnoses made by physical therapists and the relationship of these diagnoses to treatment has only recently been recognized.[1-3] Although physical therapists evaluate their patients' [...]

The current approach to the management of emotions in patients with cancer is "distress screening and referral for the provision of psychosocial care." Although this approach may have certain beneficial effects, screening and referral programs have shown a limited effect on patient psychological well-being. We argue that this limited effect is due to a mismatch between patient needs and the provision of care, and that a fundamental reconceptualization of the clinical management of emotions in patients with cancer is needed. We describe the rationale and characteristics of "emotional support and case finding" as the approach to the management of emotions in patients with cancer. The two main principles of the approach are: (1) Emotional support: (a) The treating team, consisting of doctors, nurses, and allied health staff, is responsive to the emotional needs of patients with cancer and provides emotional support. (b) The treating team provides information on external sources of emotional support. (2) Case finding: The treating team identifies patients in need of mental health care by means of case finding, and provides a referral to mental health care as indicated. We present a novel perspective on how to organize the clinical management of emotions in patients with cancer. This is intended to contribute to a fruitful discussion and to inform an innovative research agenda on how to manage emotions in patients with cancer.

Pain interference and pain behavior are highly relevant outcomes in patients with rheumatoid arthritis (RA). The Patient‐Reported Outcomes Measurement Information System (PROMIS) is a universally applicable set of item banks measuring patient‐reported health, and if applied as computerized adaptive tests (CATs), more efficiently and precisely than current instruments. The objective was to study the psychometric properties of the Dutch‐Flemish PROMIS pain interference (PROMIS‐PI) and the PROMIS pain behavior (PROMIS‐PB) item banks in patients with RA. A total of 2,029 patients with RA completed the full PROMIS‐PI (version 1.1, 40 items), and 1,554 patients completed the full PROMIS‐PB (version 1.1, 39 items). The following psychometric properties were studied: unidimensionality, local dependence, monotonicity and graded response model (GRM) fit, cross‐cultural validity (differential item functioning [DIF] for language [Dutch versus Flemish]), other forms of measurement invariance, construct validity, reliability, and floor and ceiling effects. The PROMIS‐PI and PROMIS‐PB banks were sufficiently unidimensional (Omega‐hierarchical [Omega‐H] 0.99, 0.95, and explained common variance 0.95, 0.78, respectively), had negligible local dependence (0.3–1.4% of item pairs), good monotonicity (H 0.75, 0.46), and a good GRM model fit (no misfitting items). Furthermore, both item banks showed good cross‐cultural validity (no DIF for language), measurement invariance (no DIF for age, sex, administration mode, and disease activity), good construct validity (all hypotheses met), high reliability (>0.90 in the range of patients with RA), and an absence of floor and ceiling effects (0% minimum or maximum score, respectively). Both PROMIS‐PI and PROMIS‐PB banks showed good psychometric properties in patients with RA and can be used as CATs in research and clinical practice.

Objectives: To investigate cartilage tissue turnover in response to a supervised 12-week exercise-related joint loading training program followed by a 6-month period of unsupervised training in patients with knee osteoarthritis (OA). To study the difference in cartilage tissue turnover between high- and low-resistance training. Method: Patients with knee OA were randomized into either high-intensity or low-intensity resistance supervised training (two sessions per week) for 3 months and unsupervised training for 6 months. Blood samples were collected before and after the supervised training period and after the follow-up period. Biomarkers huARGS, C2M, and PRO-C2, quantifying cartilage tissue turnover, were measured by ELISA. Changes in biomarker levels over time within and between groups were analyzed using linear mixed models with baseline values as covariates. Results: huARGS and C2M levels increased after training and at follow-up in both low- and high-intensity exercise groups. No changes were found in PRO-C2. The huARGS level in the high-intensity resistance training group increased significantly compared to the low-intensity resistance training group after resistance training (p= 0.029) and at follow-up (p= 0.003). Conclusion: Cartilage tissue turnover and cartilage degradation appear to increase in response to a 3-month exercise-related joint loading training program and at 6-month follow-up, with no evident difference in type II collagen formation. Aggrecan remodeling increased more with high-intensity resistance training than with low-intensity exercise.

To evaluate whether improvement of proprioception, pain, or dynamic knee instability mediates the effect of wearing a soft knee brace on activity limitations in patients with knee osteoarthritis (OA). We conducted an analysis of data for 44 patients with knee OA who were enrolled in a laboratory‐based trial evaluating the effect of wearing a commercially available soft knee brace. Activity limitations were assessed with the 10‐meter walk test and the Get Up and Go test. Knee joint proprioception was assessed by an active joint position sense test; pain was assessed on a numeric rating scale (NRS) (range 0–10); pressure pain threshold (PPT) was assessed with a hand‐held pressure algometer; dynamic knee instability was expressed by the perturbation response, i.e., a measure reflecting a deviation in mean knee varus–valgus angle after a controlled mechanical perturbation on a treadmill, with respect to level walking. Mediation analysis was conducted using the product of coefficients approach. Confidence intervals were calculated with a bootstrap procedure. A decrease in pain (scored on an NRS) and a decrease in dynamic knee instability mediated the effect of wearing a soft knee brace on the reduction of activity limitations (P< 0.05), while changes in proprioception and PPT did not mediate this effect (P> 0.05). This study shows that decreased pain and reduced dynamic knee instability are pathways by which wearing a soft knee brace decreases activity limitations in patients with knee OA.

As the population ages, the number of people with chronic diseases increases. Frequently, older people suffer from joint pain together with other chronic diseases, which can lead to decreased physical functioning. To investigate the associations of the changes in cognitive appraisals, coping strategies and pain with the change in physical functioning in older people, who have chronic pain and chronic diseases. Elderly persons (n= 407, mean age 77 years, and 62% female), with self-reported joint pain and at least two chronic diseases, filled in questionnaires about cognitive appraisals, coping strategies, pain intensity and physical functioning at baseline, at 6- and 18-month follow-ups. The associations of change in physical functioning with changes in cognitive appraisals, coping strategies and pain were modelled using generalized estimating equations (GEE). Increase in pain, in negative thinking about the consequences of pain, and in activity avoidance and decrease in self-efficacy beliefs were associated with a decline in physical functioning. Observed mean changes were small but large inter-individual variability was seen. This shows that cognitive appraisals and coping strategies are malleable. Statistical model of change clarifies the direction of longitudinal associations. The longitudinal findings suggest that joint pain, cognitive appraisals and coping strategies may determine physical functioning in older people who have chronic pain and comorbidity.

The aim of this study was to explore self-perceived care needs and determinants of identified needs in older adults with joint pain and comorbidity. This is a cross-sectional study using baseline data from a cohort study of older adults in the Netherlands (≥65 years) with joint pain and comorbidity (n= 407). We used the Camberwell Assessment of Need for the Elderly (CANE) to assess self-perceived care needs. Regression analyses were conducted to examine the associations between needs and sociodemographic factors (age, gender, partner status and educational level), physical factors (pain intensity, comorbidity, frailty and physical functioning) and psychosocial factors (anxiety, depression and social support). Older adults with joint pain and comorbidity reported on average 4.0 care needs out of 13 CANE items, of which 0.3 were unmet. High levels of environmental and physical needs were reported, such as needs with regard to physical illness (91%), household (61%) and mobility/falls (53%). However, most of these needs were met. Only few people reported psychosocial needs, but a large proportion of these needs was unmet, especially regarding company (66.7%) and daytime activities (37%). Psychosocial needs were more often present in frail participants (OR 2.40, 95% CI 1.25–4.61), and those with less perceived social support (OR 1.05, 95% CI 1.01–1.08) and more depressive symptoms (OR 1.17, 95% CI 1.07–1.26). Unmet needs are mainly present in the psychosocial domain. Specific attention targeted at these unmet needs may improve psychosocial well-being of older adults with joint pain and comorbidity.

We aimed to (i) evaluate the immediate effect of a soft knee brace on pain, activity limitations, self-reported knee instability, and self-reported knee confidence, and (ii) to assess the difference in effect between a non-tight and a tight soft brace in patients with knee osteoarthritis (OA). Forty-four patients with knee OA and self-reported knee instability participated in the single-session, laboratory, experimental study. A within-subject design was used, comparing a soft brace with no brace, and comparing a non-tight with a tight soft brace. The outcome measures were pain, self-reported knee instability and knee confidence during level and perturbed walking on the treadmill and activity limitations (10-m walk test and the get up and go (GUG) test). Linear mixed-effect model analysis for continuous outcomes and logistic generalized estimating equations for categorical outcomes were used to evaluate the effect of wearing a soft brace. Wearing a soft brace significantly reduced pain during level walking (B− 0.60, P= 0.001) and perturbed walking (B− 0.80, P< 0.001), reduced the time to complete the 10-m walk (B− 0.23, P< 0.001) and the GUG tests (B− 0.23, P= 0.004), reduced self-reported knee instability during level walking (OR 0.41, P= 0.002) and perturbed walking (OR 0.36, P< 0.001), and reduced lack of confidence in the knees during level walking (OR 0.45, P< 0.001) and perturbed walking (OR 0.56, P< 0.001), compared with not wearing a soft brace. There was no difference in effects between a non-tight and tight brace, except for the 10-m walk test. Wearing a tight brace significantly reduced the time to complete the 10-m walk test in comparison with wearing a non-tight brace (B− 0.11, P= 0.03). The results of this study indicate that a soft brace is an efficacious intervention targeting pain, activity limitations, self-reported knee instability, and knee confidence in the immediate term in patients with knee OA. Further studies are needed evaluating the mode of action based on exerted pressure, and on the generalization to functioning in daily life. trialregister.nl, NTR6363. Retrospectively registered on 15 May 2017.

To evaluate the efficacy on physical functioning and safety of tailored exercise therapy in patients with knee osteoarthritis (OA) and comorbidities. In a randomized controlled trial, 126 participants were included with a clinical diagnosis of knee OA and at least 1 of the following target comorbidities: coronary disease, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, or obesity (body mass index ≥30 kg/m2), with severity score ≥2 on the Cumulative Illness Rating Scale. The intervention group received a 20‐week, individualized, comorbidity‐adapted exercise program consisting of aerobic and strength training and training of daily activities. The control group received their current medical care for knee OA and were placed on a waiting list for exercise therapy. Primary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, subscale physical functioning (WOMAC‐pf), and the 6‐minute walk test (6MWT). Measurements were performed at baseline, after 20 weeks (directly posttreatment), and at 3 months posttreatment. Statistically significant physical functioning differences over time were found between the intervention and control group (WOMAC: B = −7.43 [95% confidence interval (95% CI) −9.99, −4.87], P< 0.001; and 6MWT: B = 34.16 [95% CI 17.68, 50.64], P< 0.001) in favor of the intervention group. At 3 months followup, the mean improvements in the intervention group were 33% on the WOMAC scale and 15% on the 6MWT. These improvements are of clinical relevance. No serious adverse events occurred during the intervention. This is the first study showing that tailored exercise therapy is efficacious in improving physical functioning and safe in patients with knee OA and severe comorbidities.

We introduced a stepped‐care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high‐quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS. We used data from a 2‐year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures. Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice. After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient‐tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis.

To establish the 3‐year outcome and course of physical functioning and spinal mobility impairments in patients routinely treated with tumor necrosis factor inhibitors (TNFi) and to find predictors of physical functioning and spinal mobility impairments. Ankylosing spondylitis (AS) patients eligible for TNFi were followed in a 3‐year prospective observational study. Prediction models were developed with linear mixed modeling. Bath Ankylosing Spondylitis Functional Index (BASFI) and Bath Ankylosing Spondylitis Metrology Index (BASMI) were used as outcome measures for physical functioning and spinal mobility. A total of 257 patients were included and treated with etanercept (n = 174) or adalimumab (n = 83). Physical functioning improved significantly during the first 6 months after the start of TNFi. The BASFI score decreased from mean ± SD 5.4 ± 2.4 to 3.3 ± 2.6 at 6 months, and stabilized thereafter (BASFI third year score mean ± SD 3.6 ± 2.5). The BASMI showed no significant changes over time. Lower baseline BASFI and BASMI scores predicted a better level of physical functioning and spinal mobility after 3 years of TNFi therapy. Other predictors for a better 3‐year outcome and course of physical functioning included absence of comorbidity, physical activity, younger age, and lower body mass index at baseline. Physical functioning in routinely TNFi‐treated AS patients improved up to 6 months and stabilized thereafter. Therefore, it would be better to extend the period of evaluation of TNFi treatment to 6 months rather than the 3 months currently used. The risk factors of long‐term physical functioning found in this study might help to identify patients at risk at an earlier stage and improve treatment strategy.

Gait variability and stability measures might be useful to assess gait quality changes after fall prevention programs. However, reliability of these measures appears limited. The objective of the present study was to assess the effects of measurement strategy in terms of numbers of subjects, measurement days and measurements per day on the power to detect relevant changes in gait variability and stability between conditions among healthy elderly. Sixteen healthy older participants [65.6 (SD 5.9) years], performed two walking trials on each of 2 days. Required numbers of subjects to obtain sufficient statistical power for comparisons between conditions within subjects (paired, repeated-measures designs) were calculated (with confidence intervals) for several gait measures and for different numbers of trials per day and for different numbers of measurement days. The numbers of subjects required to obtain sufficient statistical power in studies collecting data from one trial on 1 day in each of the two compared conditions ranged from 7 to 13 for large differences but highly correlated data between conditions, up to 78–192 for data with a small effect and low correlation. Low correlations between gait parameters in different conditions can be assumed and relatively small effects appear clinically meaningful. This implies that large numbers of subjects are generally needed. This study provides the analysis tools and underlying data for power analyses in studies using gait parameters as an outcome of interventions aiming to reduce fall risk.

To systematically summarize the literature on the course of pain in patients with knee osteoarthritis (OA), prognostic factors that predict deterioration of pain, the course of physical functioning, and prognostic factors that predict deterioration of physical functioning in persons with knee OA. A search was conducted in PubMed, CINAHL, Embase, Psych‐INFO, and SPORTDiscus up to January 2014. A meta‐analysis and a qualitative data synthesis were performed. Of the 58 studies included, 39 were of high quality. High heterogeneity across studies (I2>90%) and within study populations (reflected by large SDs of change scores) was found. Therefore, the course of pain and physical functioning was interpreted to be indistinct. We found strong evidence for a number of prognostic factors predicting deterioration in pain (e.g., higher knee pain at baseline, bilateral knee symptoms, and depressive symptoms). We also found strong evidence for a number of prognostic factors predicting deterioration in physical functioning (e.g., worsening in radiographic OA, worsening of knee pain, lower knee extension muscle strength, lower walking speed, and higher comorbidity count). Because of high heterogeneity across studies and within study populations, no conclusions can be drawn with regard to the course of pain and physical functioning. These findings support current research efforts to define subgroups or phenotypes within knee OA populations. Strong evidence was found for knee characteristics, clinical factors, and psychosocial factors as prognostics of deterioration of pain and physical functioning.

Background: After spinal cord injury (SCI), people are confronted with abrupt discontinuity in almost all areas of life, leading to questions on how to live a meaningful life again. Global meaning refers to basic ideas and goals that guide people in giving meaning to their lives, in specific situations. Little is known about global meaning relating to SCI and whether global meaning changes after SCI.Purpose: The purpose of this study was twofold: (i) to explore the content of global meaning of people with SCI, and (ii) to explore whether or not global meaning changes after SCI.Methods: In-depth semi-structured interviews were conducted with 16 people with SCI. Interviews were analyzed according to the method of grounded theory.Results: (i) Five aspects of global meaning were found: core values, relationships, worldview, identity and inner posture. (ii) Overall, little change in the content of global meaning was found after SCI; specific aspects of global meaning were foregrounded after SCI.Conclusion: Five aspects of global meaning were found in people with SCI. Global meaning seems hardly subject to change.

Severe pain in patients with knee osteoarthritis (OA) hampers the ability to exercise. A protocol for the standardized optimization of analgesics in combination with exercise therapy was developed. The purpose of this protocol was to reduce pain, thereby allowing the patient to participate in exercise therapy. The objective of the present study was to evaluate the feasibility and outcome of the protocol. Forty‐nine patients with knee OA and severe knee pain (numerical rating scale for pain ≥7) were included. Analgesics were prescribed following an incremental protocol. After 6 weeks, a 12‐week exercise therapy program was added. Information about analgesic use and exercise therapy content was recorded. Knee pain and activity limitations were assessed at baseline, after 6 weeks, and after 18 weeks. Statistically significant improvements in pain and activity limitations were found in intent‐to‐treat analysis after 6 weeks of analgesic use and after the intervention was completed. Mean improvements from baseline were 30% (P< 0.001) for pain and 17% (P< 0.001) for activity limitations after the intervention was completed. Seventy‐eight percent of the patients were able to exercise according to the protocol. In these patients, exercise therapy following 6 weeks of analgesic use resulted in a further improvement of activity limitations of 10% (P= 0.004). The combined intervention of standardized analgesic prescription and exercise therapy allows most patients with knee OA and severe pain to participate in exercise therapy, leading to reduction of pain and activity limitations. These promising results need to be confirmed in a randomized controlled trial.

To investigate patterns of physical activity in older adults with knee osteoarthritis (OA) compared to older adults without knee OA across 6 European countries. We expect country‐specific differences in the physical activity levels between persons with knee OA compared to persons without knee OA. A varying degree of physical activity levels across countries would express a facilitating or impeding influence of the social, environmental, and other contextual factors on a physically active lifestyle. Baseline cross‐sectional data from the European Project on Osteoarthritis were analyzed. In total, 2,551 participants from 6 European countries (Germany, Italy, The Netherlands, Spain, Sweden, and the UK) were included. Participants with knee OA were less likely to follow physical activity recommendations and had poorer overall physical activity profiles than those without knee OA (mean 62.9 versus 81.5 minutes/day, respectively; P= 0.015). The magnitude of this difference varied across countries. Detailed analysis showed that low physical activity levels in persons with knee OA could be attributed to less everyday walking time (odds ratio 1.31, 95% confidence interval 1.07–1.62). This study highlighted the fact that having knee OA is associated with a varying degree of physical activity patterns in different countries. This national variation implies that low levels of physical activity among persons with knee OA cannot be explained exclusively by individual or disease‐specific factors, but that social, environmental, and other contextual factors should also be taken into account.

Objective.To investigate the longterm association of a wide range of comorbidities with physical and mental functioning in patients with rheumatoid arthritis (RA).Methods.Longitudinal data over a period of 11 years were collected from 882 patients with RA. Somatic comorbidity and comorbid depression were measured at baseline, with a questionnaire including 20 chronic diseases and with the Center for Epidemiologic Depression Scale, respectively. Physical functioning was measured at 5 timepoints with a disease-specific measure [Health Assessment Questionnaire (HAQ)] and a generic measure [physical scales of the Medical Outcomes Study Short Form-36 (SF-36)]. Mental functioning was measured with the mental scales of the SF-36. To determine the association of baseline-specific comorbidities with functioning over time, we performed longitudinal analyses.Results.At baseline, 72% percent of the patients were women, mean age ± SD was 59.3 ± 14.8 years, median RA disease duration was 5.0 years, and 68% had ≥ 1 comorbid condition. The effect of comorbid conditions was more apparent when physical functioning was measured with SF-36, a disease-generic measure, compared with the HAQ, a disease-specific measure. Circulatory conditions and depression were associated (p < 0.05) with worse physical functioning according to the HAQ. Respiratory conditions, musculoskeletal conditions, cancer, and depression were associated (p < 0.05) with worse physical functioning according to the SF-36. Respiratory conditions and depression were associated with worse mental functioning.Conclusion.Patients with specific comorbid conditions have an increased risk of low functioning in the long term. Targeted attention for these specific comorbid conditions by clinicians is recommended.

Objective.To examine whether different groups of fatigue trajectories can be identified among patients with early symptomatic osteoarthritis (OA) of the knee or hip, to describe the level of fatigue severity within each of these fatigue groups, and to investigate the involvement of age, sex, use of medication, comorbidity, and OA severity in relation to group membership.Methods.Six years of followup data on fatigue (Medical Outcomes Study Short Form-36 Vitality scale) came from the Cohort Hip and Cohort Knee (CHECK) cohort. Growth mixture modeling was applied to identify distinct fatigue trajectories as well as to take into account the effects of the patient characteristics.Results.Three fatigue trajectories were identified: low fatigue, low-to-high fatigue, and high fatigue. Latter trajectories showed considerable overlap from years 2 to 6, but differed in some patient characteristics in comparison with each other and in comparison with the low fatigue group. Comorbidity, medication use, and sex were significantly associated with the identified trajectories. Women, individuals with a comorbid disease, and those who used medication were more likely to follow a high fatigue trajectory.Conclusion.These findings suggest heterogeneous development of fatigue in the early OA population associated with varying patient characteristics. Further, this study shows that a considerable number of patients with OA already experience elevated levels of fatigue at an early stage of OA. While these findings need to be replicated, the identification of these trajectories with differing patient characteristics may warrant tailored psychosocial interventions for patients with elevated levels of fatigue.

Objective.Vitamin D deficiency, which is common among elderly people, has been linked to muscle weakness. In patients with knee osteoarthritis (OA), the association between muscle strength and serum 25-hydroxy Vitamin D [25(OH)D] level has not been studied comprehensively. The aim of our study was to examine the association between serum 25(OH)D level and muscle strength in patients with knee OA.Methods.Data of the Amsterdam Osteoarthritis cohort from 319 participants with knee OA were used in a cross-sectional study. Serum 25(OH)D level (nmol/l) was measured by a competitive electrochemiluminescence method. Muscle strength (nm/kg) of the upper leg was measured isokinetically. Univariable and multivariable linear regression analyses were used to calculate the association between serum 25(OH)D level and muscle strength.Results.Serum 25(OH)D level was significantly associated with muscle strength (B = 0.036, 95% CI 0.017–0.054, p < 0.001), adjusted for season of blood collection. After adding body mass index (BMI) to the model, this association was no longer significant (B = 0.011, 95% CI −0.007 to 0.029, p = 0.214). Alcohol consumption, number of comorbidities, and sex were subsequently added and changed the model slightly. Without BMI, this model showed a significant association between serum 25(OH)D level and muscle strength (B = 0.029, 95% CI 0.014–0.043, p < 0.001).Conclusion.The observed association between a low serum 25(OH)D level and muscle weakness in patients with knee OA is attenuated by BMI. Further studies are needed to explain the associations among Vitamin D level, muscle strength, and adiposity in patients with knee OA.

Objective.(1) To select a limited number of performance-based tests that are reliable, show improvement in physical functioning after tumor necrosis factor inhibitor (TNFi) therapy in patients with ankylosing spondylitis (AS), and generate information equivalent to the full set of tests, and (2) are feasible for use in daily clinical practice.Methods.Eight performance-based tests were evaluated. To eliminate redundant testing, the tests that showed adequate reliability, the highest standardized response mean (SRM), and the largest proportion of patients with an improved performance-based physical functioning were selected. The selected tests were combined into a new criterion for improvement in physical functioning (AS Performance-based Improvement; ASPI). The number and percentage of improved patients identified with the ASPI and identified with the full set of performance tests were compared.Results.Reliability for all tests was adequate to excellent (ICC 0.73–0.96). The tests for bending, putting on socks, and getting up from the floor had the highest SRM (0.52–0.74) and showed the largest proportion of improved patients after TNFi therapy. The combination of these 3 tests was feasible in daily clinical practice and showed improved physical functioning after TNFi therapy in 67% of the patients.Conclusion.The 3 selected tests are recommended for use in daily practice because they generate information comparable to the full set. They are reliable and feasible, and the combination of these tests showed improved physical functioning after TNFi therapy in 67% of the patients. Evaluation of physical functioning might be improved by adding these tests to other AS outcome measures.

Objective.We aimed to evaluate the associations between knee muscle strength (MS) and falls, controlling for knee joint proprioception, varus-valgus knee joint laxity, and knee pain, among patients with knee osteoarthritis (OA) reporting knee instability.Methods.A sample of 301 subjects (203 women, 98 men, 35–82 yrs) with established knee OA and self-reported knee instability was studied. The occurrence of at least 1 fall in the previous 3 months was assessed by questionnaire. Maximum knee extension and flexion strength were measured isokinetically. Additionally, proprioception, varus-valgus laxity, and pain were assessed. Student t tests were used to assess differences between subgroups. The association of muscle strength and falls was calculated using univariate and multivariate logistic regression analysis.Results.Over 10% of the subjects (31 out of 301) reported a fall in the previous 3 months. High knee extension muscle strength (crude OR 0.3, 95% CI 0.1–0.8, p = 0.022) and high knee flexion muscle strength (crude OR 0.2, 95% CI 0.0–1.0, p = 0.048) were associated with a lower risk of falls. Proprioception and laxity did not confound this relationship. After adjusting for pain, extensor strength had an adjusted OR of 0.5 (95% CI 0.2–1.4, p = 0.212) for falls and flexor strength had an adjusted OR of 0.4 (95% CI 0.1–2.3, p = 0.312).Conclusion.High knee extension and flexion muscle strength decreased the risk of falls in patients with knee OA and self-reported knee instability. After considering the effect of pain, there was insufficient statistical power to detect an association between muscle strength and falls, which might be because of the low number of subjects who fell (n = 31).

ObjectiveTo determine the effect of patient exercise adherence within the prescribed physical therapy treatment period and after physical therapy discharge on patient outcomes of pain, physical function, and patient selfperceived effect in individuals with osteoarthritis OA of the hip andor knee.MethodsWe performed a prospective observational followup study in which 150 patients with OA of the hip andor knee receiving exercise therapy were followed for 60 months. Data were obtained from a randomized controlled trial, with assessments at baseline and 3, 15, and 60 months of followup. The association between exercise adherence and patient outcomes of pain, physical function, and selfperceived effect was examined using generalized estimating equations analyses.ResultsAdherence to recommended home exercises and being more physically active were significantly associated with better treatment outcomes of pain, selfreported physical function, physical performance, and selfperceived effect. The association between adherence and outcome was consistent over time. Adherence to home activities was only associated with better selfperceived effect.ConclusionBetter adherence to recommended home exercises as well as being more physically active improves the longterm effectiveness of exercise therapy in patients with OA of the hip andor knee. Both within and after the treatment period, better adherence is associated with better patient outcomes of pain, physical function, and selfperceived effect. Since exercise adherence declines over time, future research should focus on how exercise behavior can be stimulated and maintained in the long term.

Does behavioural graded activity result in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hip or knee?

Interobserver reliability study.

Dropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by χ2tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P< 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.

To summarize recent studies on risk factors for functional decline (i.e. worsening of pain and activity limitations) in osteoarthritis of the hip or knee; after a long period of neglect, information on risk factors for functional decline has markedly improved in recent years.

ObjectiveTo study the relationship between 4 components of physical activity and the 12year incidence of clinical knee osteoarthritis OA among older adults.MethodsLongitudinal data from 1,678 men and women, ages 55–85 years, were collected in the Longitudinal Aging Study Amsterdam. Incident clinical knee OA was defined by an algorithm using selfreport and general practitioner data. Physical activity was assessed by a validated questionnaire from which 4 physical activity component scores were created: muscle strength, intensity, mechanical strain, and turning actions. Cox proportional hazards models were conducted to examine the relationship between these scores and incident knee OA and reported as hazard ratios HRs with 95 confidence intervals 95 CIs.ResultsDuring 12 years of followup, 463 respondents 28 developed clinical knee OA. A high mechanical strain score HR 1.43, 95 CI 1.15–1.77 and a low muscle strength score HR 1.30, 95 CI 1.01–1.68 were associated with an increased risk of knee OA after adjustment for age, sex, region of living, education, lifetime physical work demands, lifetime general physical activity, body mass index, current total physical activity level, and depression. No association was observed in the intensity and turning actions components. The results were similar for men and women, and for obese and nonobese respondents.ConclusionOlder adults who perform low muscle strength activities or activities causing high mechanical strain had an increased risk of clinical knee OA. These results suggest that specific components of physical activity may influence the development of knee OA.

•Current evidence showed that exercise therapy is a cost-effective treatment in knee OA.•Our stratified approach of exercise therapy did not appear to be cost-effective compared to usual exercise therapy.•Policy-makers should decide whether stratified exercise therapy can be implemented.

ObjectiveTo evaluate the prevalence and 8year course of forefoot impairments and walking disability in patients with rheumatoid arthritis RA.MethodsA total of 848 patients with recentonset RA from 1995 through the present were included. The patients were assessed annually. Pain and swelling of the metatarsophalangeal MTP joints, erosions and joint space narrowing of the MTP joints and first interphalangeal joints, and the Health Assessment Questionnaire walking subscale were analyzed using descriptive and correlational techniques.ResultsPain and swelling of ≥1 MTP joint was present in 70 of patients at baseline, decreasing to ∼40–50 after 2 years. The forefoot erosion score was ≥1 in 19 of the patients at baseline, and the prevalence of forefoot erosion increased to ∼60 after 8 years, during which the mean forefoot erosion score increased from 1.3 to 7.9. At least mild walking disability was present in 57 of patients at baseline, stabilizing at ∼40 after 1 year.ConclusionThe prevalence rates for pain and swelling of the MTP joints and walking disability are initially high and then stabilize, but the prevalence and severity of forefoot joint damage increase during an 8year course of RA. The findings of this study quantitatively emphasize the importance of forefoot involvement in patients with RA.

ObjectiveTo compose an inventory of instruments that have been described to measure foot function i.e., pressure andor gait parameters, foot pain, and footrelated disability in rheumatoid arthritis RA, and to investigate the clinimetric quality of these measures.MethodsA systematic search was conducted in Medline, CINAHL, EMBase, and Sportdiscus. Standardized criteria, extended with levels of evidence, were applied to assess the quality of the clinimetric studies and the properties i.e., reliability, validity, and responsiveness of the described instruments.ResultsA variety of measurement instruments were identified. Only 16 instruments have been studied for their measurement properties in RA patients: 7 for assessing foot function, 3 for measuring footrelated disability, and 6 for measuring both foot pain and footrelated disability. Thirteen instruments were rated for reliability, of which 10 were rated positively on different levels of evidence. No positive rating for absolute measurement error was applicable for any of the tests. Internal consistency was reported for 7 instruments; 3 assigned a positive rating. For 2 instruments, Rasch analysis was used to assess the methodologic quality. A positive rating was reported for goodnessoffit only, not for item calibration. Seven instruments were rated for construct validity, and 3 assigned a positive rating. Only 2 instruments were rated positively for responsiveness.ConclusionThis review offers a basis for choosing the most appropriate instruments for measuring foot function, foot pain, and footrelated disability in RA patients, both for clinical practice and for research. Further research on the quality of these measures is urgently needed.

Samenvatting: In deze studie is geïnventariseerd hoeveel verpleeghuisbewoners fysiotherapie ontvangen, en welke factoren een rol spelen bij het inzetten van een behandeling. Van een aselecte steekproef van 600 verpleeghuisbewoners uit 15 verpleeghuizen,opgenomen voor revalidatie of langdurige zorg,werden gegevens verzameld door middel van interviews met verpleeghuisartsen en fysiotherapeuten. Gemiddeld kreeg 69% van de bewoners fysiotherapie, maar dit percentage verschilde tussen verpleeghuizen. Dit verschil werd vooral verklaard door het beschikbare aantal fysiotherapeuten. Bewoners opgenomen voor revalidatie en bewoners van een somatische afdeling hebben de meeste kans op fysiotherapie. Dit suggereert een potentieel ondergebruik van fysiotherapie voor bewoners met cognitieve problemen die langdurige zorg nodig hebben.

OBJECTIVE: To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint. Design Cost effectiveness study alongside a single blind randomised controlled trial. Setting Memory clinic, day clinic of a geriatrics department, and participants’ homes. Patients 135 patients aged ≥65 with mild to moderate dementia living in the community and their primary care givers. Intervention 10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision. MAIN OUTCOME MEASURES: Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures. RESULTS: The intervention cost €1183 (£848, $1738) (95% confidence interval €1128 (£808, $1657) to €1239 (£888, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were €1748 (£1279, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9). CONCLUSIONS: Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.

To determine the long‐term effectiveness (≥6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee.We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long‐term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings.Five high‐quality and 6 low‐quality randomized clinical trials were included. Strong evidence was found for no long‐term effectiveness on pain and self‐reported physical function, moderate evidence for long‐term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long‐term effectiveness on pain, self‐reported physical function, and observed physical function.The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long‐term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term.

To determine the effectiveness of a behavioral graded activity program (BGA) compared with usual care (UC; exercise therapy and advice) according to the Dutch guidelines for physiotherapy in patients with osteoarthritis (OA) of the hip and/or knee. The BGA intervention is intended to increase activity in the long term and consists of an exercise program with booster sessions, using operant treatment principles.We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physical function (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and 65. Secondary outcome measures comprised tiredness (VAS), patient‐oriented physical function (McMaster Toronto Arthritis Patient Preference Disability Questionnaire [MACTAR]), 5‐meter walking time, muscle strength, and range of motion. Data were analyzed according to intent‐to‐treat principle.Both treatments showed short‐term and long‐term beneficial within‐group effects. The mean differences between the 2 groups for pain and functional status were not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5‐meter walking test at week 65.Because both interventions resulted in beneficial long‐term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems to be an acceptable method to treat patients with hip and/or knee OA, with equivalent results compared with UC.