WOMAC Function Research Articles

Physical examination findings and their relationship with performance-based function in adults with knee osteoarthritis.

BackgroundMany physical examination (PE) maneuvers exist to assess knee function, none of which are specific to knee osteoarthritis (KOA). The Osteoarthritis Research Society International also recommends the use of six functional performance measures to assess function in adults with KOA. While earlier studies have examined the relationship between PE findings and self-reported function or PE findings and select performance tests in adults with knee pain and KOA, few have examined the all three types of measures. This cross-sectional study specifically examines the relationships between results of PE findings, functional performance tests and self-reported function in adults with symptomatic KOA.MethodsWe used baseline PE data from a prospective randomized controlled trial in 87 participants aged ≥40 years with symptomatic and radiographic KOA. The PE performed by three experienced physical therapists included: muscle assessment, function and special tests. Participants also completed functional performance tests and the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Multivariate linear regression identified contributions of PE findings towards functional performance and WOMAC scores, adjusting for age and gender.ResultsParticipants’ mean age was 60.4 years (SD = 10.5), mean disease duration was 8.4 years (SD = 10.1) and 27 participants had varus knee alignment. Mean WOMAC pain and function scores were 211 (SD = 113) and 709 (SD = 394), respectively. Weakness was present in major hip and knee muscles. Seventy-nine participants had a positive Ely’s, 65 a positive Waldron and 49 a positive Grind. Mean 6-min walk was 404 m (SD = 83) and mean Berg Balance was 53 (SD = 4). Regression analysis identified positive findings on 5 special tests (P < 0.05) as indicative of poorer 6 min walk. Positive Apley’s was associated (P < 0.05) with slower 20 m walk and a positive Ober with poorer balance scores (P < 0.05).ConclusionsDiminished hip muscle strength and flexibility, and patella dysfunction were prevalent in these adults with symptomatic KOA. Results of functional performance tests suggest balance and walking ability are impaired and are associated with PE findings of muscle length imbalance, hip muscle weakness and patella dysfunction. None of the PE measures were associated with self-reported function. Therefore, performance-based test results may be more useful in informing rehabilitation interventions.

Effects of sulfur bath on hip osteoarthritis: a randomized, controlled, single-blind, follow-up trial: a pilot study.

The effects of balneotherapy were evaluated in patients with osteoarthritis of the hip. This randomized, controlled, investigator-blinded study enrolled outpatients with hip osteoarthritis according to ACR criteria. In addition to home exercise therapy, one patient group received balneotherapy for 3weeks on 15 occasions. The mineral water used in this study is one of the mineral waters with the highest sulfide ion content (13.2mg/L) in Hungary. The control group received exercise therapy alone. The WOMAC Likert 3.1 index and the EQ-5D quality of life self-administered questionnaire were completed three times during the study: prior to first treatment, at the end of the 3-week treatment course, and 12weeks later. The main endpoint was achievement of Minimal Clinically Important Improvement (MCII) at 12weeks, defined as ≥7.9 points in a normalized WOMAC function score. The intention to treat analysis included 20 controls and 21 balneotherapy patients. At 12weeks, 17 (81%) balneotherapy group patients had Minimal Clinically Important Improvement and 6 (30%) of controls (p = 0.001). Comparing the results of the two groups at the end of treatment, there was a significant difference in the WOMAC stiffness score only, whereas after 12weeks, the WOMAC pain, stiffness, function, and total scores also showed a significant difference in favor of the balneotherapy group. The difference between the two groups was significant after 12weeks in point of EQVAS score, too. The results of our study suggest that the combination of balneotherapy and exercise therapy achieves more sustained improvement of joint function and decreases in pain than exercise therapy alone.

Effect of Body Mass Index and Psychosocial Traits on Total Knee Replacement Costs in Patients with Osteoarthritis.

Clinical and psychosocial attributes are associated with clinical outcomes after total knee replacement (TKR) surgery in patients with osteoarthritis (OA), but their relationship with TKR-related costs is less clear. Our objective was to evaluate the effect of clinical and psychosocial attributes on TKR costs. We conducted a 6-month prospective cohort study of patients with knee OA who underwent TKR. We examined baseline demographic, clinical [body mass index (BMI) and comorbidities], and psychosocial attributes (social support, locus of control, coping, depression, anxiety, stress, and self-efficacy); baseline and 6-month OA clinical outcomes [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function]; and 6-month direct and indirect TKR-related costs. Multiple regression was performed to identify determinants of TKR-related costs. We included 212 patients; 66% were women, 71% were white, and the mean age was 65.2 years. The mean baseline WOMAC pain score was 55 (SD 19) and WOMAC function score was 54 (SD 20). Mean total TKR-related costs were US$30,831 (SD $9893). Multivariate regression analyses showed that increasing BMI and anxiety levels and decreasing levels of positive social interactions were associated with increased costs. A lower cost scenario with a lower range of normal BMI (19.5), highest positive social interaction, and no anxiety predicted TKR costs to be $22,247. Predicted costs in obese patients (BMI 36) with lowest positive social interaction and highest anxiety were $58,447. Increased baseline BMI, anxiety, and poor social support lead to higher TKR-related costs in patients with knee OA. Preoperative interventions targeting these factors may reduce TKR-related costs, and therefore be cost-effective.

Porous tantalum uncemented acetabular components in revision total hip arthroplasty: a minimum ten-year clinical, radiological and quality of life outcome study.

Reconstruction of the acetabulum after failed total hip arthroplasty (THA) can be a surgical challenge in the presence of severe bone loss. We report the long-term survival of a porous tantalum revision acetabular component, its radiological appearance and quality of life outcomes. We reviewed the results of 46 patients who had undergone revision of a failed acetabular component with a Paprosky II or III bone defect and reconstruction with a hemispherical, tantalum acetabular component, supplementary screws and a cemented polyethylene liner. After a minimum follow-up of ten years (ten to 12), the survivorship of the porous tantalum acetabular component was 96%, with further revision of the acetabular component as the end point. The ten-year survivorship, with hip revision for any reason as the end point, was 92%. We noted excellent pain relief (mean Western Ontario and McMaster Universities Arthritis Index (WOMAC) score pain 92.6, (40 to 100)) and good functional outcomes (mean WOMAC function 90.3 (30.9 to 100), mean University of California Los Angeles activity scale 5 (2 to 10)) and generic quality of life measures (mean Short Form-12 (SF-12) physical component 48.3 (18.1 to 56.8), mean SF-12 mental component 56.7 (32.9 to 70.3)). Patient satisfaction with pain relief, function and return to recreational activities were excellent. Uncemented acetabular reconstruction using a tantalum acetabular component gives excellent clinical and quality of life outcomes at a minimum follow-up of ten years. Cite this article: Bone Joint J 2016;98-B:767-71.

Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study.

To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation. Investigator-blinded, randomized, placebo-controlled pilot study. Hospital, surgeon's office, participant's home. 82 persons undergoing TKR. Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments. Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale. Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group. Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.

Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis.

Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi–randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

Effect on Pain and Symptoms of Aspiration Before Hyaluronan Injection for Knee Osteoarthritis

The main objective of this study was to observe whether synovial fluid aspiration of the knee joint compared to no aspiration, before and after 5 weekly injections of intra-articular hyaluronan, provides an improvement in knee pain and physical function. Patients were randomized to an arthrocentesis group (n = 92) or a nonarthrocentesis group (n = 88). In the arthrocentesis group, knee joints were maximally aspirated before each hyaluronan administration. In the nonarthrocentesis group, synovial fluid was not removed. Hyaluronan was injected into the knee joints once a week for 5 weeks. Patients were followed up for 25 weeks. Outcome measures included patient pain (using the 100-mm visual analog scale [VAS] during a 50-foot walking test), Western Ontario McMaster University Osteoarthritis Index (WOMAC) function scores, and overall effectiveness evaluated by patients and investigators on a scale of 1 to 6. The arthrocentesis group showed significantly greater improvement from baseline to week 25 in VAS pain (P < 0.001) and WOMAC function scores (P < 0.001) than the nonarthrocentesis group. However, the differences of patient and investigator assessment of effectiveness did not achieve significance. Synovial fluid drainage before injection of intra-articular hyaluronan significantly improved VAS pain and WOMAC function scores in patients with knee osteoarthritis, however, the differences of patient and investigator assessment did not achieve significance.

Exploratory secondary analyses of a cognitive-behavioral intervention for knee osteoarthritis demonstrate reduction in biomarkers of adipocyte inflammation

To investigate the effects of pain coping skills training (PCST) and a lifestyle behavioral weight management (BWM) program on inflammatory markers and biomarker associations with pain and function in the OA LIFE study. Serum samples were available from a subset (N=169) of the overweight or obese knee OA participants in the OA LIFE study that evaluated: PCST, BWM, combined PCST+BWM, or standard care (SC). Inflammatory markers (hsCRP, IL-1ra, IL-1β, IL-6, IL-8, TNF-α, TNFRI, TNFRII, and hyaluronic acid (HA)), and adipokines (leptin and adiponectin) were measured before and after the 24-week treatment period. Biomarkers were assessed for effects of treatment and for associations with change in weight, pain and disability (unadjusted and adjusted for age, race, sex, baseline body mass index (BMI), and baseline biomarker concentration). PCST+BWM was associated with significant reductions in hsCRP (P=0.0014), IL-6 (P=0.0075), and leptin (P=0.0001). After adjustment, there was a significant effect of PCST+BWM on changes in leptin (b=-0.19, P=0.01) and IL-6 (b=-0.25, P=0.02) relative to SC. Reductions in leptin and IL-6 were significantly correlated with reductions in weight, BMI and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain; reductions in IL-6 were correlated with improvements in WOMAC and Arthritis Impact Measurement Scales (AIMS) physical function. By mediation analyses, weight loss was responsible for 54% of the change in IL-6 and all of the change in leptin. OA-related inflammatory markers were reduced by a 24-week combined PCST+BWM intervention. This suggests that the inflammatory state can be successfully modified in the context of a readily instituted clinical intervention with a positive clinical outcome.

Association of mechanical factors with medial knee osteoarthritis: Across-sectional study from Matsudai Knee Osteoarthritis Survey.

Knee osteoarthritis (OA) is a multifactorial disease that is affected by mechanical factors. The aim of present study was to investigate the association between multiple mechanical factors and medial knee OA in a large epidemiological cohort. Six hundred and ninety-nine subjects (323 males and 376 females), participating in the Matsudai Knee Osteoarthritis Survey 2010, were included. Twelve mechanical factors were selected and their association with the radiographic grade of knee OA, the Western Ontario and McMaster University Index (WOMAC) pain score, and the WOMAC function score was evaluated. A logistic regression analysis identified varus thrust to be associated with the radiographic grade of knee OA in males (OR: 1.876, 95% CI: 1.332-2.663) and females (2.61, 1.922-3.542), the WOMAC pain score in males (1.997, 1.463-2.672), and the WOMAC function score in females (1.449, 1.12-1.874). Quadriceps muscle strength was associated with the radiographic OA grade in males (0.605, 0.399-0.917) and females (0.636, 0.469-0.863), the WOMAC pain score in females (0.537, 0.445-0.789), and the WOMAC function score in males (0.581, 0.44-0.766). The knee flexion angle was also associated with the radiographic OA grade in males (0.344, 0.19-0.621) and females (0.121, 0.022-0.653), and the WOMAC pain score in males (0.287, 0.156-0.53) and females (0.537, 0.336-0.859). Obesity was associated with the radiographic OA grade in males (1.543, 1.041-2.287) and females (1.589, 1.176-2.146), the WOMAC pain score in female (2.017, 1.517-2.68). Femolo-tibial angle had no significant association with the radiographic knee OA grade or with the WOMAC pain and function scores. Among patients with medial knee OA, dynamic mechanical factors, such as varus thrust, quadriceps muscle strength, and range of motion were more likely to be associated with the radiographic grade of knee OA and to be the WOMAC pain and function scores, compared to static mechanical factors.

Association of mechanical factors with medial knee osteoarthritis: A cross-sectional study from Matsudai Knee Osteoarthritis Survey

Abstract Background Knee osteoarthritis (OA) is a multifactorial disease that is affected by mechanical factors. The aim of present study was to investigate the association between multiple mechanical factors and medial knee OA in a large epidemiological cohort. Methods Six hundred and ninety-nine subjects (323 males and 376 females), participating in the Matsudai Knee Osteoarthritis Survey 2010, were included. Twelve mechanical factors were selected and their association with the radiographic grade of knee OA, the Western Ontario and McMaster University Index (WOMAC) pain score, and the WOMAC function score was evaluated. Results A logistic regression analysis identified varus thrust to be associated with the radiographic grade of knee OA in males (OR: 1.876, 95% CI: 1.332–2.663) and females (2.61, 1.922–3.542), the WOMAC pain score in males (1.997, 1.463–2.672), and the WOMAC function score in females (1.449, 1.12–1.874). Quadriceps muscle strength was associated with the radiographic OA grade in males (0.605, 0.399–0.917) and females (0.636, 0.469–0.863), the WOMAC pain score in females (0.537, 0.445–0.789), and the WOMAC function score in males (0.581, 0.44–0.766). The knee flexion angle was also associated with the radiographic OA grade in males (0.344, 0.19–0.621) and females (0.121, 0.022–0.653), and the WOMAC pain score in males (0.287, 0.156–0.53) and females (0.537, 0.336–0.859). Obesity was associated with the radiographic OA grade in males (1.543, 1.041–2.287) and females (1.589, 1.176–2.146), the WOMAC pain score in female (2.017, 1.517–2.68). Femolo-tibial angle had no significant association with the radiographic knee OA grade or with the WOMAC pain and function scores. Conclusion Among patients with medial knee OA, dynamic mechanical factors, such as varus thrust, quadriceps muscle strength, and range of motion were more likely to be associated with the radiographic grade of knee OA and to be the WOMAC pain and function scores, compared to static mechanical factors.

Telephone coaching to enhance a physiotherapist-prescribed home-based physical activity program for knee osteoarthritis: A randomised clinical trial

Purpose: Physical activity and exercise are recommended by osteoarthritis (OA) clinical and general health guidelines. Amongst people with OA, physical activity levels are low, there is a global under-utilisation of exercise, and benefits are generally not sustained because adherence is typically suboptimal and declines over time. Health coaching, often delivered by telephone, is increasingly used for chronic disease self-management. It aims to improve patient adherence to treatment recommendations and facilitate health behavior change. Aim: To investigate whether telephone coaching improves effectiveness of a physiotherapist-prescribed home-based physical activity and exercise program for knee OA. Methods: Design: Randomised controlled trial. Participants: 168 inactive adults aged ≥50 with knee pain and clinically-diagnosed knee OA were recruited from the community. Eighty-four participants were randomly allocated to Coaching (27M, 57F; age 61.1±6.9 years; mass 89.0±19.5 kgs) and 84 to Control (35M, 49F; 63.4±7.8 years, 87.5±22.0 kgs). Intervention: All participants received 5x30 minute face-to-face consultations with a physiotherapist over 6 months for education, prescription of a home exercise program (4–6 lower limb strengthening exercises, 3 times per week) and physical activity advice. Coaching participants also received 6–12 telephone coaching sessions by clinicians trained in health coaching for physical activity and exercise behaviour change support. Outcomes: Measures were assessed at baseline, 6, 12 and 18 months. Primary outcomes were average knee pain over the past week assessed using an 11-point numeric rating scale (NRS; 0-10) and physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; 0-68) at 6 months. Secondary outcomes included these measures at 12 and 18 months, NRS walking pain, WOMAC pain score, quality-of-life (AQoL-6D) and physical activity assessed by the Physical Activity Scale for the Elderly (PASE), Active Australia Survey, 7 day activity monitor and perceived change (7-point Likert scale). Exercise adherence was assessed every 3 months. Statistical analysis: The study was powered to detect a minimum clinically important difference (MCID) in NRS pain of 1.8 and in WOMAC function of 6 non-normalized units with standard deviations of 2.2 and 11.6 respectively. Analyses were by intention-to-treat with multiple imputation for missing data. The mean (95% confidence interval) difference in change (baseline minus follow-up) between groups was estimated using a linear mixed model including random effects for physiotherapists and telephone coaches and baseline outcome score as a covariate. Results: 142 (85%), 136 (81%) and 128 (76%) participants completed 6, 12 and 18 month measurements, respectively, with completion rates comparable between groups. Most participants attended all 5 physiotherapy sessions with the mean (SD) being 4.4 (1.2) for coaching and 4.3 (1.4) for control (p>0.05). The mean (SD) number of telephone coaching sessions was 5.4 (2.0). Change in NRS pain (mean difference 0.4 units; 95%CI −0.4 to 1.3) or WOMAC function (1.8; 95%CI −1.9 to 5.5) did not differ between groups at 6 months, with both showing clinically relevant improvements. Most secondary outcomes related to physical activity and exercise behaviour favoured coaching at 6 months (PASE, mean difference −28.3; 95%CI −54.9 to −1.8; Home exercise completion, mean difference 14%, 95%CI 4 to 24; Self-rated exercise adherence on NRS, mean difference 1.7, 95%CI 0.8 to 2.6; Global increase in physical activity, Odds ratio 2.1; 95%CI 1.0 to 4.4) but generally not at 12 or 18 months. There were no between-group differences in most other secondary outcomes. Adverse events were mild (mostly transient increased knee pain), similar between groups and reported by approximately one-third of participants during the intervention, but were infrequent during follow-up. Co-intervention use was also similar across groups. Conclusions: Addition of telephone coaching did not augment pain and function benefits of a physiotherapist-prescribed physical activity and exercise program, although physical activity levels and adherence to home exercise were generally increased in the short-term. Our study provides novel information about the effects of telephone coaching and extends the limited research in telephone coaching for OA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Does a new implant design with more physiological kinematics provide better results after knee arthroplasty?

BackgroundImproved knee kinematics is one of the major goals to obtain better satisfaction after total knee arthroplasty. This study examined whether a guided motion knee design improves functional outcome and satisfaction as compared to a conventional design. MethodsIn a retrospective manner, from January 2005 to December 2008, patients with two different kinematic TKA designs were enrolled. The 150 patients were divided into two groups: guided motion group (77) with kinematic design (Journey) and control group (73) with no kinematic design (LCS). All the patients had the same surgical technique and postoperative protocols. The functional and radiographic results were interpreted with the Hospital for Special Surgery (HSS) knee score and WOMAC score. ResultsAfter a mean follow-up of 84.2months, the guided motion group had higher mean postoperative range of motion (p=0.022), functional status in the WOMAC function subscale (p=0.002), but had higher residual pain in the WOMAC pain subscale (p=0.018 and p=0.013) and higher iliotibial band syndrome incidence (6.6% vs 0%; p=0.02). There were no significant differences in HSS score between the two groups. No differences were seen between groups in patient satisfaction in the WOMAC total score (p=0.46) and survival rate. ConclusionThe guided motion design can improve functional status according to WOMAC but not to HSS knee scores. Poorer pain scores and no higher patient satisfaction were observed with this kinematic design.

Predictors of Subjective Outcome After Medial Unicompartmental Knee Arthroplasty

BackgroundUnexplainable pain after medial unicompartmental knee arthroplasty (UKA) remains a leading cause for revision surgery. Therefore, the aim of this study is to identify the patient-specific variables that may influence subjective outcomes after medial UKA to optimize results. MethodsRetrospectively, we analyzed 104 consecutive medial UKA patients. The evaluated parameters consisted of age, body mass index, gender, preoperative radiographic severity of the various knee compartments, and preoperative and postoperative mechanical axis alignments. ResultsAt an average of 2.3-year follow-up, our data demonstrate that body mass index, gender, and preoperative severity among the various knee compartments do not influence Western Ontario and McMaster Universities Arthritis Index (WOMAC) results. Preoperatively, patients aged <65 years had inferior WOMAC stiffness (4.6 vs 2.9, P = .001), pain (9.7 vs 7.6, P = .041), and total (37.2 vs 47.6, P = .028) scores vs patients aged ≥65 years. Postoperatively, only the difference on the WOMAC stiffness subscale remained significant between both age groups, in favor of patients aged ≥65 years (1.0 vs 1.5, P = .035). A postoperative varus mechanical axis alignment of 1°-4° correlated to significantly superior WOMAC pain (P = .03), function (P = .04), and total (P = .04) scores compared to a varus of ≤1° or ≥4°. ConclusionOur data suggest that greater pain relief can be expected in patients aged <65 years and that a postoperative lower limb alignment of 1°-4° varus should be pursued. Taking these factors into consideration will help to maximize clinical outcomes, fulfill patient expectations after medial UKA, and subsequently minimize revision rates.

Is There a Threshold for Stiffness Complaints Following TKA on the WOMAC Stiffness Subscale?

Stiffness complaints after total knee arthroplasty (TKA) are frequent, yet poorly understood and can be challenging for surgeons to address. The WOMAC stiffness subscale is a widely used measure of stiffness and can serve as a simple screening tool for complaints. We aimed to identify a threshold for stiffness complaints on the WOMAC stiffness subscale and investigate its overlap with range of motion (ROM) in TKA patients. TKA patients were enrolled preoperatively and followed for 6months. At follow-up, patients reported their ROM, completed the WOMAC stiffness subscale (range 1-8 with 8 continuous stiffness) and indicated whether they experienced more stiffness than expected. To identify a threshold for complaints, we compared patients' WOMAC stiffness scores to when they experienced more stiffness than expected, visually, and statistically. We also mapped ROM limitations at 6months to WOMAC stiffness scores. Finally, we determined if baseline characteristics were associated with stiffness complaints. Two hundred and forty-six TKA patients were enrolled preoperatively with 82% follow-up rate at 6months. Our results showed that patients with a WOMAC stiffness score = 3+ were significantly more likely to experience more stiffness than expected. Patients reporting full ROM (54%) reported a wide range of WOMAC stiffness subscale scores (1-6). Baseline WOMAC pain and function scores were the only factors associated with stiffness complaints. ROM is a poor surrogate of patient-reported stiffness, and the patients' perception of "stiffness" is clearly more complex than just ROM. We identified a WOMAC threshold that could potentially easily serve this purpose.

Randomised controlled trial to evaluate a physiotherapy-led functional exercise programme after total hip replacement

BackgroundAt present, there is an insufficient evidence base to evaluate the effectiveness of physiotherapy following total hip replacement (THR). This study evaluated the effectiveness of a physiotherapy-supervised functional exercise programme between 12 and 18 weeks following THR. These time-points coincide with increased functional demand in patients. DesignAdequately powered assessor-blinded randomised controlled trial. SettingPatients were recruited at a pre-operative assessment clinic and randomised following surgery. ParticipantsSixty-three subjects were randomised to either the usual care group (control, n=31) or the functional exercise+usual care group (n=32). InterventionsPatients in the functional exercise group attended a physiotherapy-supervised functional exercise class twice weekly from 12 to 18 weeks following THR. Patients in the control group followed the usual care protocol with no exercise intervention. Main outcome measurementThe main outcome measurement tool was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and the secondary outcomes included walking speed, hip abduction dynamometry, Short Form 12 physical and mental health scores, and visual analogue pain scale score. ResultsAt 18 weeks post surgery, WOMAC function and walking speed improved significantly more in the functional exercise group [mean difference −4.0, 95% confidence interval (CI) −7.0 to 1.0 (P<0.01); mean difference 21.9m, 95% CI 0.60 to 43.3 (P<0.04)] than the control group, but there was no significant difference in hip abductor strength. ConclusionThis study demonstrated that patients who undertake a physiotherapy-led functional exercise programme between 12 and 18 weeks after THR may gain significant functional improvement compared with patients receiving usual care.Clinical trial registration number NCT01683201.

A randomized controlled clinical and radiological trial about outcomes of navigation-assisted TKA compared to conventional TKA: long-term follow-up.

Well balanced knees with good alignment are essential for a well-functioning TKA with long survival of its implants. This prospective randomized study comparing navigation-assisted TKA and conventional TKA reported the clinical and radiological outcomes at a follow-up of 9years. The purpose of this study was to compare the clinical and radiological outcomes for patients who underwent navigation-assisted TKA or conventional TKA after long-term follow-up. A total of 80 patients (88 knees) were available for physical and radiological examination 9years after TKA. Clinical outcomes were evaluated using HSS, WOMAC, and KS function and pain scores. And radiological outcomes of the component loosening and its survivorship during 9-year follow-up were also evaluated. There were no significant differences in the field of clinical outcomes between the two groups. In terms of radiological outcomes, the navigation group had fewer alignment outliers (7.3 vs 20%, p=0.006). Although the clinical outcomes showed no differences between the two groups, the survival rate was slightly better in the navigation group than in the conventional group without statistical significance (best-case scenario 100 vs 95.3%, n.s., worst-case scenario 95.6 vs 88.4%, n.s.). Navigation-assisted TKA produced better alignment outcomes and better survival rates than conventional instruments although some of the differences were not statistically significant. I.

Moxibustion is an Alternative in Treating Knee Osteoarthritis: The Evidence From Systematic Review and Meta-Analysis.

Knee osteoarthritis (KOA) is a common disorder in elderly. There is no known cure for KOA, and thus therapeutic strategies of alleviating symptoms are increasingly emphasized. Moxibustion has been widely used to treat KOA; however, results are inconclusive. The aim of our study is to critically reassess the effects of moxibustion on KOA.We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedical Literature database (CBM) through 25 November 2015. Two independent reviewers selected studies and abstracted information, as well as assessed the risk of bias using Cochrane risk of bias tool. The random-effects meta-analyses were performed based on abstracted data.We initially captured 163 citations and added 4 records through checking review. After critical appraisal, 13 RCTs were included. Meta-analyses indicated that moxibustion is not statistically different from oral drug in improving the response rate (MD = 1.09; 95% CI = 1.00, 1.20; P = 0.05), alleviating pain and improving physical function. Our meta-analysis also found that moxibustion is superior to usual care and sham moxibustion in reducing WOMAC score (MD = 7.56; 95% CI = 4.11, 11.00; P = 0.00), pain and function, as well as increasing QoL. Moreover, most AEs caused by moxibustion can heal without medical care.We concluded that moxibustion treatment is equal to the oral drugs and intra-articular injections and may be an alternative in treating patients with KOA.

Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomised controlled trials

ObjectivesThe clinical impact of preoperative physiotherapy on recovery after joint replacement remains controversial. This systematic review aimed to assess the clinical impact of prehabilitation before joint replacement.DesignWe searched PubMed, Embase...

A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial.

Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused. To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes. Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740). Department of Veterans Affairs Medical Center in Durham, North Carolina. 30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis. The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record. The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes. At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ. The study was conducted in a single Veterans Affairs medical center. The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis. Department of Veterans Affairs, Health Services Research and Development Service.

Efficacy of intra-articular hyaluronic acid injections and exercise-based rehabilitation programme, administered as isolated or integrated therapeutic regimens for the treatment of knee osteoarthritis.

To assess the efficacy of intra-articular hyaluronic acid (HA) injections and exercise-based rehabilitation (EBR) programme, administered as isolated or integrated for the treatment of knee osteoarthritis. One hundred sixty-five patients affected by moderate degrees of knee OA were randomly divided into three groups. Group 1 (HA) underwent three HA injections (one every 2weeks); group 2 (EBR) underwent 20 treatment sessions in a month of an individualized programme; and group 3 (HA+EBR) received both treatments simultaneously. Primary outcome was the Italian version of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index; secondary outcome was the evaluation of active range of movement (AROM). All patients were evaluated before and 1, 3 and 6months after treatment. Significance was set at p<0.05. Two patients in each group were lost to follow-up. No adverse events occurred. All groups experienced improvements at 1-month follow-up. No further improvements could be detected within groups over time. At 1-month follow-up, WOMAC pain subscale showed significant improvement in group 3 compared to group 1 (p=0.043). WOMAC pain, stiffness and function subscales showed that group 2 significantly worsened between 1 and 6months after treatment (p=0.004, p=0.026 and p=0.025, respectively). AROM revealed no significant differences between and within groups over time. Intra-articular HA injections and individualized rehabilitation programmes administered in isolation or in combination are effective in improving knee function and pain relief. The combined treatment showed the greatest pain relief at 1-month follow-up compared to either in isolation. Compared to the previous studies, this is the first study, which proposed an EBR programme tailored to the compartment of the knee joint most involved in the degenerative process. I.