Lower Extremity Osteoarthritis Research Articles

FRI0581-HPR Falls Associated with Muscle Strength and Pain in Knee Osteoarthritis Patients with Self-Reported Knee Instability

BackgroundSubjects with knee osteoarthritis (OA) and self-reported knee instability have a higher fall incidence than healthy older adults1. Increased risk of falls might be associated with knee instability related factors:...

Evaluating the effects of anxiety disorder on physical and psychosocial measures for indigent patients with severe lower extremity osteoarthritis

Background: The purpose of this study was to evaluate the effects of anxiety disorder on preoperative physical and psychosocial measures for patients undergoing lower extremity total joint arthroplasty. It was hypothesized that patients with anxiety disorder would express higher levels of pain, worse function, and worse quality of life indices. Methods: Four hundred and four indigent patients undergoing total knee or hip arthroplasty were assessed for anxiety disorder. Patients with anxiety disorder (n=48) were compared with patients without anxiety disorder (n=356) at the univariate level for the Western Ontario and McMaster Universities (WOMAC) score, Knee Society Score, Harris Hip Score, and the Short Form- 36 (SF-36). Results: Twenty-eight (10.6%) of 265 patients who had total knee arthroplasty and 20 (14.4%) of 139 patients who had total hip arthroplasty met the criteria for anxiety disorder on the patient health questionnaire. Overall, 48 (11.9%) of 404 patients undergoing total knee or total hip arthroplasty met these criteria for anxiety disorder on the patient health questionnaire. Patients with anxiety disorder were significantly more likely to report greater levels of pain and stiffness along with lower levels of function and quality of life indices before surgery. Conclusions: The results of this study support the hypothesis that patients diagnosed with anxiety disorder before undergoing total knee arthroplasty or total hip arthroplasty would report poorer scores on physical and psychosocial measures before surgery. Recognizing how anxiety disorder relates to pain catastrophizing and fear avoidance factors may explain the mechanism for which psychological distress translates into poor function and greater pain.

Assessment of the Health-Related Quality of Life Impact of EUFLEXXA (1% Sodium Hyaluronate) Using Short Form 36 (SF-36) Data Collected in aRandomized Clinical Trial Evaluating Treatment of Osteoarthritis Knee Pain

Background: Outcome measurements of clinical trials such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) have provided disease specific data on lower extremity osteoarthritis (OA). The impact of the disease, condition, or treatment on the dimensions of functioning and well-being has been supplemented by the use of general health-related quality of life (HRQoL) instruments. Objective: To examine patients’ general HRQoL measures using the Short Form 36 (SF-36) from the 26-wk double-blind, randomized, saline (IA-SA)-controlled FLEXX Trial and the 26-wk open-label Extension Study, which evaluated efficacy and safety of intra-articular (IA) injections of a bioengineered hyaluronic acid (HA [BioHA]) for treatment of OA knee pain. Methods: HRQoL of participants treated with IA-BioHA in the FLEXX Trial was compared to patients’ baseline HRQoL and to United States population and OA norms using the SF-36v2.This study evaluated the durability of improvement in physical health related domains of the SF-36 observed at week 26 of the FLEXX Trial by assessing the physical functioning scores at week 52 for patients who received a second course of 3 weekly injections of IABioHA during the FLEXX Trial Extension Study. Results: Baseline SF-36 scores indicated significant physical limitations in patients enrolled in the FLEXX Trial relative to United States population and OA population norms. Changes between the SF-36 scores for IABioHA– treated patients at week 26 continued to improve following a repeat injection series through week 52, with a significantly lower bodily pain domain (P=0.014). Conclusions: Patients treated with IA-BioHA in the FLEXX Trial experienced significantly greater improvement in physical functioning and disability at 26 weeks as measured by the SF-36. A repeat injection series of IA-BioHA resulted in further improvement towards United States population norms in their physical ability with a significant reduction in bodily pain from the end of the FLEXX trial to the end of the Extension Study (week 52).

Fit and Strong! Plus: Design of a comparative effectiveness evaluation of a weight management program for older adults with osteoarthritis

Osteoarthritis (OA) is the most common chronic condition and principal cause of disability among older adults. The current obesity epidemic has contributed to this high prevalence rate. Fortunately both OA symptoms and obesity can be ameliorated through lifestyle modifications. Physical activity (PA) combined with weight management improves physical function among obese persons with knee OA but evidence-based interventions that combine PA and weight management are limited for this population. This paper describes a comparative effectiveness trial testing an evidence-based PA program for adults with lower extremity (LE) OA, Fit and Strong!, against an enhanced version that also addresses weight management based on the evidence-based Obesity Reduction Black Intervention Trial (ORBIT). Adult participants (n=400) with LE OA, age 60+, overweight/obese, and not meeting PA requirements of ≥150min per week, are randomized to one of the two programs. Both 8-week interventions meet 3 times per week and include 60min of strength, flexibility, and aerobic exercise instruction followed by 30min of education/group discussion. The Fit and Strong! education sessions focus on using PA to manage OA; whereas Fit and Strong! Plus addresses PA and weight loss management strategies. Maintenance of behavior change is reinforced in both groups during months 3–24 through telephone calls and mailed newsletters. Outcomes are assessed at baseline, and 2, 6, 12, 18, and 24months. Primary outcomes are dietary change at 2months followed by weight loss at 6months that is maintained at 24months. Secondary outcomes assess PA, physical performance, and anxiety/depression.

Total Joint Arthroplasty and Preoperative Low Back Pain

Lower extremity osteoarthritis with concomitant low-back pain (LBP) may obscure a clinician’s ability to properly evaluate the status of hip or knee osteoarthritis and subsequent total joint arthroplasty (TJA) candidacy. A prospective cohort study was conducted to determine prevalence and severity of preoperative LBP among TJA patients, and the effect of TJA on alleviating LBP. Preoperative moderate to worst imaginable LBP pain on the Oswestry Disability Index (ODI) was significantly higher among hips compared to knees (28.8% vs. 16.1%, P<0.0001). Compared to knees, hips also saw significant ODI improvement from preoperative to one-year postoperative. TJA candidates with considerable preoperative LBP should be counselled that TJA outcome may be impaired by the coexistence of spine disease, and that residual spine pain may continue following otherwise successful TJA.

Reasons Why Multimorbidity Increases the Risk of Participation Restriction in Older Adults With Lower Extremity Osteoarthritis: A Prospective Cohort Study in Primary Care

To determine why multimorbidity causes participation restriction in adults ages ≥50 years who consult primary care with lower extremity osteoarthritis (OA). This was a population-based prospective cohort study of 1,053 consulters for lower extremity OA who were free of participation restriction at baseline. Path analysis was used to test proposed mechanisms by examining for mediation of the association between multimorbidity at baseline, defined by self-report and consultation data separately, and incident participation restriction at 3 years by lower extremity pain severity, obesity, locomotor disability, and depression. Multimorbidity was associated with incident participation restriction (adjusted odds ratio [OR] 2.83, 95% confidence interval [95% CI] 2.03-3.94 for multimorbidity [self-report]; OR 1.59, 95% CI 1.15-2.21 for multimorbidity [consultation data]). The extent of mediation of the association of baseline multimorbidity, defined by self-report, and incident participation restriction was greater for severe lower extremity pain than obesity (standardized beta coefficients for indirect effect 0.032 [SE 0.015] and 0.020 [SE 0.019], respectively). The addition of depression and locomotor disability increased the amount of mediation (0.115 [SE 0.028]) and reduced the proportion explained by severe lower extremity pain (0.014 [SE 0.015]) and obesity (0.006 [SE 0.010]). Locomotor disability was the strongest mediator. The additional impact on participation in social and domestic life that multimorbidity places on individuals with lower extremity OA appears to be mediated through further restriction of locomotor disability, as well as through depression. The results suggest that the effect of multimorbidity on the daily lives of people with lower extremity OA will be ameliorated by active management of depression and locomotor disability.

Does Lower Extremity Osteoarthritis Exacerbate Risk Factors for Falls in Older Adults?

The risk of falling reportedly increases almost 2.5-times in those with lower extremity osteoarthritis (OA(LE)) compared with age-matched controls. However, the mechanisms underlying the increased risk are not clear. The risk factors for falls in people with OA(LE) found in the literature are mostly the same as the risk factors for people without OA(LE). It is hypothesized that risk factors for falls are exacerbated by OA(LE), such that these individuals are more likely to become dynamically unstable and, once this has occurred, are less able to perform an appropriate compensatory stepping response compared with people without OA(LE). To the extent that this is true, task-specific training targeting the compensatory step, which decreases falls in middle-aged and older women, should be effective for people with OA(LE). The purpose of the present review is to provide the rationale for the above hypothesis. Furthermore, the present authors present evidence that the fall risk of people with OA(LE) could be efficiently and effectively reduced using task-specific training previously shown to reduce falls in middle aged and older women.

Evaluating the effects of Somatization Disorder on self-reported measures of pain, function, disability and quality of life for patients with end-stage lower extremity osteoarthritis undergoing total joint arthroplasty

Somatization Disorder is a polysymptomatic disorder for which individuals report physical complaints that are unrelated to identifiable diseases or ailments. Often co-existing with depression and anxiety, symptoms of Somatization Disorder are highly prevalent in chronic pain populations and have been found to interfere with treatment. Prior research has shown that patients with general clinical psychopathology who undergo total joint arthroplasty (TJA) are more likely to have poorer outcomes following surgery compared to patients without clinical psychopathology.

Effects of physical exercise prescribed by a medical support team on elderly lower extremity osteoarthritis combined with metabolic syndrome and/or type 2 diabetes

The aims of the present study were to investigate the effectiveness of exercise intervention provided by a medical support team specializing in lifestyle-related diseases in the treatment of elderly lower extremity osteoarthritis and to examine the influence of bodyweight decrease on changes in the evaluation indexes. Participants were 61 patients (57 women and 4 men, aged 68.3 ± 9.6 years) with lower extremity osteoarthritis (109 total diseased joints) and either one or more of the following diseases: obesity, metabolic syndrome and type 2 diabetes. Indexes relating to metabolic diseases, orthopedic disorders, lifestyle activity level and health-related quality of life (HRQOL) were obtained before and after exercise intervention. The numbers of patients with obesity, metabolic syndrome, type 2 diabetes, gonarthrosis and coxarthrosis were 56, 49, 32, 56 and 9, respectively. The mean intervention period was 4.7 ± 1.6 months (2-10.8 months). Indexes relating to metabolic diseases and orthopedic disorders, activity level and HRQOL were all significantly improved after intervention (P < 0.05). Bodyweight decreased by 10.3% and showed a correlation with other evaluated items. Five explanatory variables were extracted through multiple regression analysis that bodyweight reduction rate was set as the criterion variable: changes of bodyweight, body mass index, percent body fat, glycated hemoglobin and total energy expenditure per bodyweight. The exercise intervention provided by our medical support team clearly improved indexes relating to metabolic diseases and orthopedic disorders. In addition, decreased bodyweight was related to improvements in metabolic factors, motor function and HRQOL.

A Randomized Controlled Trial to Investigate the Effects of Water-Based Exercise to Improve Falls Risk and Physical Function in Older Adults With Lower-Extremity Osteoarthritis

Hale LA, Waters D, Herbison P. A randomized controlled trial to investigate the effects of water-based exercise to improve falls risk and physical function in older adults with lower-extremity osteoarthritis. Objective To investigate the efficacy of a water-based exercise program specifically targeting balance to reduce falls risk and improve measures of balance and physical function in older adults with osteoarthritis (OA). Design Randomized controlled trial. Setting Community. Participants Persons (N=39; mean±SD age, 74±6y; 26 women) with mild to moderate OA and at risk for falling met study criteria, were measured at baseline, and were randomly assigned to the intervention (n=23) and control groups (n=16). Interventions Water-based program (12wk, twice weekly; intervention group) or a time-matched computer training program (control group). Main Outcome Measure The primary outcome was the short-form Physiological Profile Assessment (PPA). Secondary outcomes included the Step Test, Timed Up and Go Test, Western Ontario and McMaster Universities OA Index (Likert 3.0 version), Arthritis Impact Measurement Scales 2, and Activity-specific Balance Confidence Scale. Results No statistically significant between-group differences were found for any outcome measured (n=35; 4 lost to follow-up). Within-group analysis indicated that Step Test results improved significantly in both groups (mean change: control group, left leg, 2.07; 95% confidence interval, 3.19–.95; P=.002; intervention group, 2.14; 95% confidence interval, 3.20–1.08; P=.000). Two PPA item scores (reaction time, contrast sensitivity) improved significantly (86.83; 95% confidence interval, 9.86–163.79; P=.03; 1.43; 95% confidence interval, 2.35–.50; P=.005, respectively) in the control group, resulting in a lower falls risk score. Conclusions Water-based exercise did not reduce falls risk in our sample compared with attending a computer skills training class. Our study is, to our knowledge, the first to compare water-based exercise in this population with a control group that attended a time-dose–equivalent seated community-based activity. Whether gaining computer skills and going out into the community twice weekly is adequate stimulus to reduce falls risk in people with OA requires further investigation.

Post‐traumatic osteoarthritis: Improved understanding and opportunities for early intervention

Even with current treatments of acute joint injuries, more than 40% of people who suffer significant ligament or meniscus tears, or articular surface injuries, will develop osteoarthritis (OA). Correspondingly, 12% or more of all patients with lower extremity OA have a history of joint injury. Recent research suggests that acute joint damage that occurs at the time of an injury initiates a sequence of events that can lead to progressive articular surface damage. New molecular interventions, combined with evolving surgical methods, aim to minimize or prevent progressive tissue damage triggered by joint injury. Seizing the potential for progress in the treatment of joint injuries to forestall OA will depend on advances in (1) quantitative methods of assessing the injury severity, including both structural damage and biologic responses, (2) understanding of the pathogenesis of post-traumatic OA, taking into account potential interactions among the different tissues and the role of post-traumatic incongruity and instability, and (3) application of engineering and molecular research to develop new methods of treating injured joints. This paper highlights recent advances in understanding of the structural damage and the acute biological response following joint injury, and it identifies important directions for future research.

Lower limb osteoarthritis: biomechanical alterations and implications for therapy

To review the role of biomechanics in the pathogenesis of lower-extremity osteoarthritis and recent advances in biomechanically active intervention strategies for osteoarthritis. The conventional approach to treating knee osteoarthritis with analgesics and physical therapy has not been shown to alter the natural history of the disease, suggesting that novel strategies are necessary. Progression of lower-extremity osteoarthritis is mediated by aberrant biomechanics, which can be assessed using gait analyses and validated markers of dynamic knee loading such as the peak adduction moment (AddM) and adduction angular impulse (AddImp). Recognition of the mechanical component of osteoarthritis progression has led to intervention strategies that seek to reduce functional loads at the knee, and thereby, potentially, to palliate pain and retard disease progression. Biomechanically active interventions have been demonstrated to reduce dynamic loading of the knees in patients with osteoarthritis, and are potentially promising strategies to treat symptoms as well as to alter disease progression in osteoarthritis.

Complications for Racial and Ethnic Minority Groups After Total Hip and Knee Replacement

Total hip and knee replacement reduces disability associated with lower extremity osteoarthritis. It has been shown that racial and ethnic minority groups underutilize these procedures; however, little information exists on postoperative outcomes for ethnic minorities. We conducted a systematic review of the literature to compile population-based or multicenter studies on early postoperative outcomes after total hip and knee replacement in racial and ethnic minorities. Nine studies met the inclusion criteria. Among the nine eligible studies, four examined total knee replacement, three examined total hip replacement, and two examined both. Two studies investigated mortality after total knee replacement, and one found that blacks had an increased risk of mortality. Three studies investigated infection after total knee replacement; all found an increased risk in blacks and Hispanics. Four studies examined non-infection-related complications after total knee replacement, and all four found that nonwhites had an increased risk of complications. Two studies investigated mortality after total hip replacement; one of these found that, for primary hip replacement, blacks had an increased risk of mortality. There is a paucity of research on outcomes after orthopaedic procedures for racial and ethnic minority groups. On the basis of the available literature, racial and ethnic minority groups appear to have a higher risk for early complications (those occurring within ninety days), particularly joint infection, after total knee replacement and perhaps a higher risk of mortality after total hip replacement.

Fit and Strong!: bolstering maintenance of physical activity among older adults with lower-extremity osteoarthritis.

To compare the impact of negotiated vs. mainstreamed follow-up with telephone reinforcement (TR) on maintenance of physical activity (PA) after Fit and Strong! ended. A multisite comparative effectiveness trial with repeated measures. Single group random effects analyses showed significant improvements at 2, 6, 12, and 18 months on PA maintenance, lower-extremity (LE) pain and stiffness, LE function, sit-stand, 6-minute distance walk, and anxiety/depression. Analyses by follow-up condition showed persons in the negotiated with TR group maintained a 21% increase in caloric expenditures over baseline at 18 months, with lesser benefits seen in the negotiated-only, mainstreamed-with-TR, and mainstreamed-only groups. Significant benefits of telephone dose were also seen on LE joint stiffness, pain, and function as well as anxiety and anxiety/depression. The negotiated follow-up contract that Fit and Strong! uses, bolstered by TR, is associated with enhanced long-term PA maintenance and health outcomes.

A computer-adaptive disability instrument for lower extremity osteoarthritis research demonstrated promising breadth, precision, and reliability

Objective To develop and evaluate a prototype measure (OA-DISABILITY-CAT) for osteoarthritis research using item response theory (IRT) and computer-adaptive test (CAT) methodologies. Study Design and Setting We constructed an item bank consisting of 33 activities commonly affected by lower extremity (LE) osteoarthritis. A sample of 323 adults with LE osteoarthritis reported their degree of limitation in performing everyday activities, and completed the Health Assessment Questionnaire-II (HAQ-II). We used confirmatory factor analyses to assess scale unidimensionality and IRT methods to calibrate the items and examine the fit of the data. Using CAT simulation analyses, we examined the performance of OA-DISABILITY-CATs of different lengths compared with the full-item bank and the HAQ-II. Results One distinct disability domain was identified. The 10-item OA-DISABILITY-CAT demonstrated a high degree of accuracy compared with the full-item bank ( r = 0.99). The item bank and the HAQ-II scales covered a similar estimated scoring range. In terms of reliability, 95% of OA-DISABILITY reliability estimates were over 0.83 vs. 0.60 for the HAQ-II. Except at the highest scores, the 10-item OA-DISABILITY-CAT demonstrated superior precision to the HAQ-II. Conclusion The prototype OA-DISABILITY-CAT demonstrated promising measurement properties compared with the HAQ-II, and is recommended for use in LE osteoarthritis research.

Effect of therapeutic exercise for hip osteoarthritis pain: Results of a meta‐analysis

Recommendations for lower extremity osteoarthritis (OA) and exercise have been primarily based on knee studies. To provide more targeted recommendations for the hip, we gathered evidence for the efficacy of exercise for hip OA from randomized controlled trials. A bibliographic search identified trials that were randomized, controlled, completed by >or=60% of subjects, and involved an exercise group (strengthening and/or aerobic) versus a non exercise control group for pain relief in hip OA. Two reviewers independently performed the data extraction and contacted the authors when necessary. Effect sizes (ES) of treatment versus control and the I(2) statistic to assess heterogeneity across trials were calculated. Trial data were combined using a random-effects meta-analysis. Nine trials met the inclusion criteria (1,234 subjects), 7 of which combined hip and knee OA; therefore, we contacted the authors who provided the data on hip OA patients. In comparing exercise treatment versus control, we found a beneficial effect of exercise with an ES of -0.38 (95% confidence interval [95% CI] -0.68, -0.08; P = 0.01), but with high heterogeneity (I(2) = 75%) among trials. Heterogeneity was caused by 1 trial consisting of an exercise intervention that was not administered in person. Removing this study left 8 trials (n = 493) with similar exercise strategy (specialized hands-on exercise training, all of which included at least some element of muscle strengthening), and demonstrated exercise benefit with an ES of -0.46 (95% CI -0.64, -0.28; P < 0.0001). Therapeutic exercise, especially with an element of strengthening, is an efficacious treatment for hip OA.

The impact of momentary pain and fatigue on physical activity in women with osteoarthritis

To examine the daily life patterns of both pain and fatigue symptoms and objective physical activity (using ambulatory monitoring) in women with symptomatic lower extremity osteoarthritis (OA), and to evaluate how momentary symptoms impact physical activity levels. Sixty women age >or=55 years (40 with knee or hip OA and 20 matched controls) participated in an observational study involving 2 laboratory visits and a 5-day home data collection period. During the home period physical activity levels were assessed continuously, and symptoms were inputted 6 times a day into an enhanced accelerometer at prespecified time points. In the OA group as compared with the control group over the 5-day period, average physical activity was significantly lower (P = 0.02) and peak physical activity tended to be lower (P = 0.06). Although pain and fatigue overall were of moderate severity in this cohort, fatigue escalated throughout each day. In a hierarchical linear model, fatigue was most strongly associated with physical activity (beta = -30.1, P < 0.0001). Pain was more weakly associated with physical activity and in the direction opposite to what was hypothesized (beta = 16.9, P = 0.04). Momentary reports of fatigue negatively predicted physical activity levels and were much more strongly related to physical activity than momentary pain. In order to help women with knee or hip OA manage symptoms and become more physically active, it may be important to emphasize fatigue management.

Measuring activity pacing in women with lower-extremity osteoarthritis: a pilot study.

We examined how women with osteoarthritis naturally use activity pacing and how pacing relates to symptoms and physical activity within daily routines. Thirty women with knee or hip osteoarthritis (mean age = 63.8 +/- 6.9) wore an actigraph accelerometer and repeatedly reported activity pacing, pain, and fatigue. Using the median split, symptom patterns were compared for low and high pacers. The relationship between activity pacing and physical activity was also examined. Activity pacing was low (1.4 +/- 0.9); pain and fatigue were mild (1.0 +/- 0.7 and 1.1 +/- 0.7, respectively). When compared with low pacers, high pacers had more severe, escalating symptoms. Activity pacing was related to lower physical activity (beta = -28.14, SE = 6.24), t(586) = -4.51, p = .0001. CONCLUSION. Pain, fatigue, and activity pacing use varied depending on average activity pacing level. High pacers may benefit from interventions to manage daily symptoms.

The history of falls and the association of the timed up and go test to falls and near-falls in older adults with hip osteoarthritis

BackgroundFalling accounts for a significant number of hospital and long-term care admissions in older adults. Many adults with the combination of advancing age and functional decline associated with lower extremity osteoarthritis (OA), are at an even greater risk. The purpose of this study was to describe fall and near-fall history, location, circumstances and injuries from falls in a community-dwelling population of adults over aged 65 with hip OA and to determine the ability of the timed up and go test (TUG) to classify fallers and near-fallers.MethodA retrospective observational study of 106 older men and women with hip pain for six months or longer, meeting a clinical criteria for the presence of hip OA at one or both hips. An interview for fall and near-fall history and administration of the TUG were administered on one occasion.ResultsForty-five percent of the sample had at least one fall in the past year, seventy-seven percent reported occasional or frequent near-falls. The majority of falls occurred during ambulation and ascending or descending steps. Forty percent experienced an injury from the fall. The TUG was not associated with history of falls, but was associated with near-falls. Higher TUG scores occurred for those who were older, less mobile, and with greater number of co-morbidities.ConclusionA high percentage of older adults with hip OA experience falls and near-falls which may be attributed to gait impairments related to hip OA. The TUG could be a useful screening instrument to predict those who have frequent near-falls, and thus might be useful in predicting risk of future falls in this population.

Long-Term Impact of Fit and Strong! on Older Adults With Osteoarthritis

We present final outcomes from the multiple-component Fit and Strong! intervention for older adults with lower extremity osteoarthritis. A randomized controlled trial compared the effects of this exercise and behavior-change program followed by home-based reinforcement (n=115) with a wait list control (n=100) at 2, 6, and 12 months. Fit and Strong! combined flexibility, aerobic walking, and resistance training with education and group problem solving to enhance self-efficacy for exercise and maintenance of physical activity. All participants developed individualized plans for long-term maintenance. Relative to controls, treatment participants experienced statistically significant improvements in self-efficacy for exercise (p=.001), minutes of exercise per week (p=.000), and lower extremity stiffness (p=.018) at 2 months. These benefits were maintained at 6 months and were accompanied by increased self-efficacy for adherence to exercise over time (p=.001), reduced pain (p=.040), and a marginally significant increase in self-efficacy for arthritis pain management (p=.052). Despite a substantially smaller sample size at 12 months, significant treatment-group effects were maintained on self-efficacy for exercise (p=.006) and minutes of exercise per week (p=.001), accompanied by marginally significant reductions in lower extremity stiffness (p=.056) and pain (p=.066). No adverse health effects were seen. Effect sizes for self-efficacy for exercise and for maintenance of physical activity were 0.798 and 0.713, and 0.905 and 0.669, respectively, in the treatment group at 6 and 12 months. This consistent pattern of benefits indicates that this low-cost intervention is efficacious for older adults with lower extremity osteoarthritis.