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1. Acta Biomed. 2005 Dec;76(3):152-6.

Recovery of physical function and patient's satisfaction after total hipreplacement (THR) surgery supported by a tailored guide-book.

Fortina M, Carta S, Gambera D, Crainz E, Ferrata P, Maniscalco P.

Department of Orthopaedics and Traumatology, University Hospital of Siena, Siena,Italy. [email protected]

BACKGROUND AND AIM OF THE WORK: The purpose of this prospective study was to givea customized guide, describing the hospitalization period and the postoperativeexercise program, to patients scheduled for total hip arthroplasty (THA) and toshow its effectiveness on functional recovery and on patient's satisfaction with the rehabilitation care and with the in-hospital discharge planning aftersurgery.METHODS: This trial included 365 consecutive subjects with osteoarthritis whounderwent THA at the Orthopaedic and Traumatology Clinic of Siena (Italy). TheHarris Hip Score (HHS), a disease specific measure, was determined before andafter surgery. Postoperative evaluations, associated with a Satisfaction

Questionnaire, were carried out at the time of discharge and after 3 months.RESULTS: The overall satisfaction level was very high, both at discharge(81+/-28) and at follow-up (90+/-17). The HHS results showed a significant (p< or=0.05) improvement over time in patients with higher scores 3 months aftersurgery in comparison with baseline.CONCLUSIONS: Patients reported high levels of satisfaction at the 3 monthpostoperative follow-up and good levels at discharge. After surgery, the highest improvements were shown in bodly pain and physical function scores. The currentstudy showed that a customized guide was well accepted by patients with THA andsatisfie their need of information. It was also effective in improving patient's

satisfaction and early recovery of physical function after surgery.

PMID: 16676564 [PubMed - indexed for MEDLINE]

2. Acta Reumatol Port. 2011 Jul-Sep;36(3):268-81.

Physiotherapy in hip and knee osteoarthritis: development of a practice guidelineconcerning initial assessment, treatment and evaluation.

Peter WF, Jansen MJ, Hurkmans EJ, Bloo H, Dekker J, Dilling RG, Hilberdink W,Kersten-Smit C, de Rooij M, Veenhof C, Vermeulen HM, de Vos RJ, Schoones JW,

Vliet Vlieland TP; Guideline Steering Committee - Hip and Knee Osteoarthritis.

Department of Rheumatology, Leiden University Medical Center, The [email protected]

BACKGROUND: An update of a Dutch physiotherapy practice guideline in Hip and KneeOsteoarthritis (HKOA) was made, based on current evidence and best practice.METHODS: A guideline steering committee, comprising 10 expert physiotherapists,selected topics concerning the guideline chapters: initial assessment, treatment



and evaluation. With respect to treatment a systematic literature search wasperformed using various databases, and the evidence was graded (1-4). For theinitial assessment and evaluation mainly review papers and textbooks were used.Based on evidence and expert opinion, recommendations were formulated. A firstdraft of the guideline was reviewed by 17 experts from different professionalbackgrounds. A second draft was field-tested by 45 physiotherapists.RESULTS: In total 11 topics were selected. For the initial assessment, threerecommendations were formulated, pertaining to history taking, red flags, andformulating treatment goals. Concerning treatment, 7 recommendations wereformulated; (supervised) exercise therapy, education and self managementinterventions, a combination of exercise and manual therapy, postoperativeexercise therapy and taping of the patella were recommended. Balneotherapy andhydrotherapy in HKOA, and thermotherapy, TENS, and Continuous Passive Motion inknee OA were neither recommended nor discouraged. Massage therapy, ultrasound,electrotherapy, electromagnetic field, Low Level Laser Therapy, preoperativephysiotherapy and education could not be recommended. For the evaluation oftreatment goals the following measurement instruments were recommended: Lequesne index, Western Ontario and McMaster Universities osteoarthritis index, Hipdisability and Osteoarthritis Outcome Score and Knee injury and OsteoarthritisOutcome Score, 6-minute walktest, Timed Up and Go test, Patient SpecificComplaint list, Visual Analoge Scale for pain, Intermittent and ConstantOsteoArthritis Pain Questionnaire, goniometry, Medical Research Council for

strength, handheld dynamometer.CONCLUSIONS: This update of a Dutch physiotherapy practice guideline on HKOAincluded 11 recommendations on the initial assessment, treatment and evaluation. The implementation of the guideline in clinical practice needs furtherevaluation.


3. Am Fam Physician. 2010 Feb 15;81(4):444.

Osteoarthritis of the hip.

Scott D.

King's College Medical School, London, United Kingdom.

Comment inAm Fam Physician. 2011 Feb 15;83(4):352.


4. Ann R Coll Surg Engl. 2008 Jul;90(5):406-11. doi: 10.1308/003588408X285900.

The benefit of modified rehabilitation and minimally invasive techniques in totalhip replacement.

Lilikakis AK, Gillespie B, Villar RN.

Cambridge Hip and Knee Unit, BUPA Cambridge Lea Hospital, Impington, Cambridge,UK. [email protected]

INTRODUCTION: We wished to assess if an intensive rehabilitation regimen alone,



or one combined with modified anaesthetic and surgical techniques, can change thespeed of rehabilitation or the length of hospital stay after total hipreplacement.PATIENTS AND METHODS: We compared 44 patients who had followed a traditional carepathway, with 38 patients who had rehabilitated under a new rehabilitationprotocol, with 40 patients who had also received modified, minimally invasivetechniques. The speed of rehabilitation was measured in terms of three specificmilestones accomplished on the day after surgery.RESULTS: We found a statistically significant improvement in the day aftersurgery each activity was possible. The length of hospital stay was reduced from 6.5 days to 5.4 days to 4.1 days, a difference which was also statisticallysignificant.CONCLUSIONS: The data support the view that a new rehabilitation protocol alonecan reduce the length of hospital stay and hasten rehabilitation. The combinationof modified anaesthetic and minimally invasive surgical techniques with the newrehabilitation regimen can further improve short-term outcome after total hipreplacement.

PMCID: PMC2645750PMID: 18634739 [PubMed - indexed for MEDLINE]

5. Ann Rheum Dis. 2013 Jul;72(7):1125-35. doi: 10.1136/annrheumdis-2012-202745.Epub2013 Apr 17.

EULAR recommendations for the non-pharmacological core management of hip and kneeosteoarthritis.

Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG,Doherty M, Geenen R, Hammond A, Kjeken I, Lohmander LS, Lund H, Mallen CD, NavaT, Oliver S, Pavelka K, Pitsillidou I, da Silva JA, de la Torre J, Zanoli G,

Vliet Vlieland TP; European League Against Rheumatism (EULAR).National Resource Center for Rehabilitation in Rheumatology, DiakonhjemmetHospital, Oslo, Norway. [email protected]

The objective was to develop evidence -based recommendations and a research andeducational agenda for the non-pharmacological management of hip and kneeosteoarthritis (OA). The multidisciplinary task force comprised 21 experts:nurses, occupational therapists, physiotherapists, rheumatologists, orthopaedicsurgeons, general practitioner, psychologist, dietician, clinical epidemiologist and patient representatives. After a preliminary literature review, a first task

force meeting and five Delphi rounds, provisional recommendations were formulatedin order to perform a systematic review. A literature search of Medline and eightother databases was performed up to February 2012. Evidence was graded incategories I-IV and agreement with the recommendations was determined throughscores from 0 (total disagreement) to 10 (total agreement). Eleven evidence-basedrecommendations for the non-pharmacological core management of hip and knee OAwere developed, concerning the following nine topics: assessment, general



approach, patient information and education, lifestyle changes, exercise, weight loss, assistive technology and adaptations, footwear and work. The average level of agreement ranged between 8.0 and 9.1. The proposed research agenda included anoverall need for more research into non-pharmacological interventions for hip OA,moderators to optimise individualised treatment, healthy lifestyle with economic evaluation and long-term follow-up, and the prevention and reduction of workdisability. Proposed educational activities included the required skills toteach, initiate and establish lifestyle changes. The 11 recommendations provideguidance on the delivery of non-pharmacological interventions to people with hip or knee OA. More research and educational activities are needed, particularly in the area of lifestyle changes.


6. Ann Rheum Dis. 2007 Feb;66(2):215-21. Epub 2006 Jul 31.

The cost effectiveness of behavioural graded activity in patients withosteoarthritis of hip and/or knee.

CoupÃ© VM, Veenhof C, van Tulder MW, Dekker J, Bijlsma JW, Van den Ende CH.

Department of Clinical Epidemiology and Biostatistics, VU Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands. [email protected]

OBJECTIVE: To evaluate whether exercise treatment based on behavioural gradedactivity comprising booster sessions is a cost-effective treatment for patientswith osteoarthritis of the hip and/or knee compared with usual care.METHODS: An economic evaluation from a societal perspective was carried out

alongside a randomised trial involving 200 patients with osteoarthritis of thehip and/or knee. Outcome measures were pain, physical functioning, self-perceivedchange and quality of life, assessed at baseline, 13, 39 and 65 weeks. Costs weremeasured using cost diaries for the entire follow-up period of 65 weeks. Cost andeffect differences were estimated using multilevel analysis. Uncertainty aroundthe cost-effectiveness ratios was estimated by bootstrapping and graphicallyrepresented on cost-effectiveness planes.RESULTS: 97 patients received behavioural graded activity, and 103 patientsreceived usual care. At 65 weeks, no differences were found between the twogroups in improvement with respect to baseline on any of the outcome measures.

The mean (95% confidence interval) difference in total costs between the groupswas -euro773 (-euro2360 to euro772)--that is, behavioural graded activityresulted in less cost but this difference was non-significant. As effectdifferences were small, a large incremental cost-effectiveness ratio of euro51,385 per quality adjusted life year was found for graded activity versus usual care.CONCLUSIONS: This study provides no evidence that behavioural graded activity is either more effective or less costly than usual care. Yielding similar results t



ousual care, behavioural graded activity seems an acceptable method for treatingpatients with osteoarthritis of the hip and/or knee.


7. Ann Rheum Dis. 2004 Jun;63(6):703-8.

Management of osteoarthritis (OA) with an unsupervised home based exerciseprogramme and/or patient administered assessment tools. A cluster randomisedcontrolled trial with a 2x2 factorial design.

Ravaud P, Giraudeau B, Logeart I, Larguier JS, Rolland D, Treves R,Euller-Ziegler L, Bannwarth B, Dougados M.

DÃ©partement d'EpidÃ©miologie et de Biostatistique, HÃ´pital Bichat, FacultÃ© XavierBichat, UniversitÃ© Paris 7, Paris et INSERM U444, Paris, France.

Comment inAnn Rheum Dis. 2005 Jan;64(1):170; author reply 170-1.Aust J Physiother. 2004;50(4):260.

BACKGROUND: Diary recording of pain and disabling activities in osteoarthritis(OA) is widely recommended, but, to our knowledge, its impact on symptoms has notbeen investigated. Exercise programmes have been shown to be effective whenpatients are closely supervised by nurses or physiotherapists; however, data are lacking on the efficacy of an unsupervised home based exercise regimen inpatients with OA.OBJECTIVES: To evaluate the clinical efficacy of patient administered assessment tools and an unsupervised home based exercise programme alone or in combinationin patients with OA.METHODS: The study was a 24 week, open cluster randomised controlled trial with

afactorial design. Rheumatologists (n = 867) were assigned to four groupsaccording to the treatment given: standardised tools (ST; n = 220), exercises(EX; n = 213), both tools and exercises (ST+EX; n = 213), or usual care (n =221). Each rheumatologist was to enroll four patients who met the AmericanCollege of Rheumatology criteria for OA (three with knee OA, one with hip OA)."Tools" consisted of weekly recording of pain and disabling activities in adiary. A home based exercise programme was performed daily at least four timesper week with the aid of videotape and booklet. In addition to exercise andassessment, all patients received 12.5 mg or 25 mg of the non-steroidalanti-inflammatory drug rofecoxib once daily. Outcome variables were: pain(measured on a visual analogue scale, 0-100); Western Ontario and McMasterUniversities Osteoarthritis Index, function subscale (0-100); and patient

assessment of the quality of care (0-100).RESULTS: Overall, 2957 patients with OA (2216 knee, 741 hip) were included. After24 weeks, both pain and function improved in the ST, EX, ST+EX, and usual caregroups (mean (SD) -17 (27), -20 (29), -15 (27), -19 (29); and -11 (19), -12 (19),-10 (19), -11 (20), respectively), without significant differences betweengroups. However, patients in the EX and ST+EX groups were more likely to agreethat their rheumatologist had done his best to preserve their functional andphysical activities.



CONCLUSION: Although patients' assessments favoured the exercise programme,results from this study failed to demonstrate a short term symptomatic effect of the two non-pharmacological treatments (weekly recording of condition andexercise) in patients with OA concurrently receiving nonsteroidalanti-inflammatory drugs.


8. Ann Rheum Dis. 2003 Dec;62(12):1162-7.

Does hydrotherapy improve strength and physical function in patients withosteoarthritis--a randomised controlled trial comparing a gym based and ahydrotherapy based strengthening programme.

Foley A, Halbert J, Hewitt T, Crotty M.

Flinders University Department of Rehabilitation and Aged Care, RepatriationGeneral Hospital, South Australia.

OBJECTIVE: To compare the effects of a hydrotherapy resistance exercise programme

with a gym based resistance exercise programme on strength and function in thetreatment of osteoarthritis (OA).DESIGN: Single blind, three arm, randomised controlled trial.SUBJECTS: 105 community living participants aged 50 years and over with clinical OA of the hip or knee.METHODS: Participants were randomised into one of three groups: hydrotherapy (n=35), gym (n = 35), or control (n = 35). The two exercising groups had threeexercise sessions a week for six weeks. At six weeks an independentphysiotherapist unaware of the treatment allocation performed all outcomeassessments (muscle strength dynamometry, six minute walk test, WOMAC OA Index,total drugs, SF-12 quality of life, Adelaide Activities Profile, and the

Arthritis Self-Efficacy Scale).RESULTS: In the gym group both left and right quadriceps significantly increased in strength compared with the control group, and right quadriceps strength wasalso significantly better than in the hydrotherapy group. The hydrotherapy group increased left quadriceps strength only at follow up, and this was significantly different from the control group. The hydrotherapy group was significantlydifferent from the control group for distance walked and the physical componentof the SF-12. The gym group was significantly different from the control groupfor walk speed and self efficacy satisfaction. Compliance rates were similar for

both exercise groups, with 84% of hydrotherapy and 75% of gym sessions attended. There were no differences in drug use between groups over the study period.CONCLUSION: Functional gains were achieved with both exercise programmes comparedwith the control group.




9. Ann Rheum Dis. 2001 Sep;60(9):834-40.

Responsiveness of the WOMAC osteoarthritis index as compared with the SF-36 inpatients with osteoarthritis of the legs undergoing a comprehensiverehabilitation intervention.

Angst F, Aeschlimann A, Steiner W, Stucki G.

Clinic of Rheumatology and Rehabilitation Zurzach, [email protected]

Comment inAnn Rheum Dis. 2002 Feb;61(2):182-3.

OBJECTIVE: To compare the responsiveness of the condition-specific WesternOntario and McMaster Universities osteoarthritis (OA) index (WOMAC) and thegeneric Short Form-36 (SF-36) in patients with OA of the legs undergoing acomprehensive inpatient rehabilitation intervention.METHODS: A prospective follow up study of consecutively referred inpatients of a rehabilitation clinic was made. The patients included fulfilled the AmericanCollege of Rheumatology criteria for knee or hip OA and underwent both passiveand, particularly, active physical therapy for three to four weeks.

Responsiveness assessment was performed using the standardised response mean(SRM), effect size, and Guyatt's responsiveness statistic between admission anddischarge (end of rehabilitation) and then again between admission and threemonths later. For pain and function the SRMs were stratified by sex and OA joint.Effects were tested by the t test and SRMs of different scales were compared bythe jack knife test.RESULTS: At the three month follow up, complete data were obtained for 223patients. In general, the three responsiveness statistics showed a similar order of responsiveness. For both instruments, the pain scales were more responsivethan the function scales. The responsiveness of the pain scale of bothinstruments was comparable (SRM=0.723 for WOMAC and SRM=0.528 for SF-36 at the

end of rehabilitation; SRM=0.377 for WOMAC and SRM=0.468 for SF-36 at the threemonth follow up). In the measurement of function, the WOMAC was significantlymore responsive than the SF-36 (SRMs, end of rehabilitation: 0.628 v 0.249; threemonth follow up: 0.235 v -0.001). Responsiveness tended to be higher in women andin knee OA than in men and hip OA.CONCLUSIONS: Both instruments, the WOMAC and the SF-36, capture improvement inpain in patients undergoing comprehensive inpatient rehabilitation intervention. Functional improvement can be detected better by the WOMAC than by the SF-36. Allthe other scales of both instruments were more weakly responsive.


10. Ann Rheum Dis. 2001 Dec;60(12):1123-30.

Effectiveness of exercise in patients with osteoarthritis of hip or knee: ninemonths' follow up.



van Baar ME, Dekker J, Oostendorp RA, Bijl D, Voorn TB, Bijlsma JW.

Netherlands Institute of Primary Health Care, Utrecht, The [email protected]

OBJECTIVE: To determine whether the effects of an exercise programme in patients with osteoarthritis of hip or knee are sustained at six and nine months' followup.METHODS: A randomised, single blind, clinical trial was conducted in a primarycare setting. Patients with osteoarthritis of hip or knee (ACR criteria) wereselected. Two intervention groups were compared. Both groups received treatmentfrom their general practitioner, including patient education and drug treatmentif necessary. The experimental group also received exercise treatment from aphysiotherapist in primary care. The treatment period was 12 weeks, with anensuing 24 week follow up. The main outcome measures were pain, drug use(non-steroidal anti-inflammatory drugs), and observed disability.RESULTS: 201 patients were randomly allocated to the exercise or control group,and 183 patients completed the trial. At 24 weeks exercise treatment wasassociated with a small to moderate effect on pain during the past week(difference in change between the two groups -11.5 (95% CI -19.7 to -3.3). At 36 weeks no differences were found between the groups.CONCLUSIONS: Beneficial effects of exercise decline over time and finally

disappear.PMCID: PMC1753453PMID: 11709454 [PubMed - indexed for MEDLINE]

11. Arthritis Res Ther. 2010;12(1):R25. doi: 10.1186/ar2932. Epub 2010 Feb 12.

Efficacy of a progressive walking program and glucosamine sulphatesupplementation on osteoarthritic symptoms of the hip and knee: a feasibilitytrial.

Ng NT, Heesch KC, Brown WJ.

The University of Queensland, School of Human Movement Studies, Blair Drive, StLucia Campus, Brisbane, Queensland 4072, Australia. [email protected]

INTRODUCTION: Management of osteoarthritis (OA) includes the use ofnon-pharmacological and pharmacological therapies. Although walking is commonlyrecommended for reducing pain and increasing physical function in people with OA,glucosamine sulphate has also been used to alleviate pain and slow theprogression of OA. This study evaluated the effects of a progressive walkingprogram and glucosamine sulphate intake on OA symptoms and physical activityparticipation in people with mild to moderate hip or knee OA.METHODS: Thirty-six low active participants (aged 42 to 73 years) were provided

with 1500 mg glucosamine sulphate per day for 6 weeks, after which they began a12-week progressive walking program, while continuing to take glucosamine. Theywere randomized to walk 3 or 5 days per week and given a pedometer to monitorstep counts. For both groups, step level of walking was gradually increased to3000 steps/day during the first 6 weeks of walking, and to 6000 steps/day for thenext 6 weeks. Primary outcomes included physical activity levels, physicalfunction (self-paced step test), and the WOMAC Osteoarthritis Index for pain,stiffness and physical function. Assessments were conducted at baseline and at6-, 12-, 18-, and 24-week follow-ups. The Mann Whitney Test was used to examine



differences in outcome measures between groups at each assessment, and theWilcoxon Signed Ranks Test was used to examine differences in outcome measuresbetween assessments.RESULTS: During the first 6 weeks of the study (glucosamine supplementationonly), physical activity levels, physical function, and total WOMAC scoresimproved (P < 0.05). Between the start of the walking program (Week 6) and thefinal follow-up (Week 24), further improvements were seen in these outcomes (P < 0.05) although most improvements were seen between Weeks 6 and 12. No significantdifferences were found between walking groups.CONCLUSIONS: In people with hip or knee OA, walking a minimum of 3000 steps(approximately 30 minutes), at least 3 days/week, in combination with glucosaminesulphate, may reduce OA symptoms. A more robust study with a larger sample isneeded to support these preliminary findings.TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN012607000159459.


12. Arthritis Res Ther. 2009;11(3):R98. doi: 10.1186/ar2743. Epub 2009 Jun 25.

Exercise therapy for the management of osteoarthritis of the hip joint: asystematic review.

McNair PJ, Simmonds MA, Boocock MG, Larmer PJ.

Health and Rehabilitation Research Centre, Auckland University of Technology,Private Bag 92006, Auckland 1020, New Zealand. [email protected]

INTRODUCTION: Recent guidelines pertaining to exercise for individuals withosteoarthritis have been released. These guidelines have been based primarily on studies of knee-joint osteoarthritis. The current study was focused on the hipjoint, which has different biomechanical features and risk factors for

osteoarthritis and has received much less attention in the literature. Thepurpose was to conduct a systematic review of the literature to evaluate theexercise programs used in intervention studies focused solely on hip-jointosteoarthritis, to decide whether their exercise regimens met the new guidelines,and to determine the level of support for exercise-therapy interventions in themanagement of hip-joint osteoarthritis.METHODS: A systematic literature search of 14 electronic databases was undertakento identify interventions that used exercise therapy as a treatment modality for hip osteoarthritis. The quality of each article was critically appraised andgraded according to standardized methodologic approaches. A 'pattern-of-evidence

'approach was used to determine the overall level of evidence in support ofexercise-therapy interventions for treating hip osteoarthritis.RESULTS: More than 4,000 articles were identified, of which 338 were consideredsuitable for abstract review. Of these, only 6 intervention studies met theinclusion criteria. Few well-designed studies specifically investigated the useof exercise-therapy management on hip-joint osteoarthritis. Insufficient evidencewas found to suggest that exercise therapy can be an effective short-termmanagement approach for reducing pain levels, improving joint function and the



quality of life.CONCLUSIONS: Limited information was available on which conclusions regarding theefficacy of exercise could be clearly based. No studies met the level of exerciserecommended for individuals with osteoarthritis. High-quality trials are needed, and further consideration should be given to establishing the optimal exercisesand exposure levels necessary for achieving long-term gains in the management of osteoarthritis of the hip.


13. Arthritis Rheum. 2008 Sep 15;59(9):1221-8. doi: 10.1002/art.24010.

Effect of therapeutic exercise for hip osteoarthritis pain: results of ameta-analysis.

HernÃ¡ndez-Molina G, Reichenbach S, Zhang B, Lavalley M, Felson DT.

Boston University, Boston, Massachusetts, USA.

Comment inEvid Based Med. 2009 Apr;14(2):41.

OBJECTIVE: Recommendations for lower extremity osteoarthritis (OA) and exercisehave been primarily based on knee studies. To provide more targetedrecommendations for the hip, we gathered evidence for the efficacy of exercisefor hip OA from randomized controlled trials.METHODS: 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 painrelief in hip OA. Two reviewers independently performed the data extraction andcontacted the authors when necessary. Effect sizes (ES) of treatment versus

control and the I(2) statistic to assess heterogeneity across trials werecalculated. Trial data were combined using a random-effects meta-analysis.RESULTS: Nine trials met the inclusion criteria (1,234 subjects), 7 of whichcombined hip and knee OA; therefore, we contacted the authors who provided thedata on hip OA patients. In comparing exercise treatment versus control, we founda 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%) amongtrials. Heterogeneity was caused by 1 trial consisting of an exerciseintervention that was not administered in person. Removing this study left 8trials (n = 493) with similar exercise strategy (specialized hands-on exercisetraining, 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).CONCLUSION: Therapeutic exercise, especially with an element of strengthening, isan efficacious treatment for hip OA.




14. Arthritis Rheum. 2008 Oct 15;59(10):1480-7. doi: 10.1002/art.24105.

Effects of activity strategy training on pain and physical activity in olderadults with knee or hip osteoarthritis: a pilot study.

Murphy SL, Strasburg DM, Lyden AK, Smith DM, Koliba JF, Dadabhoy DP, Wallis SM.

University of Michigan, Ann Arbor, MI, USA. [email protected]

OBJECTIVE: To examine effects of activity strategy training (AST), a structuredrehabilitation program taught by occupational therapists and designed to teachadaptive strategies for symptom control and engagement in physical activity (PA).METHODS: A randomized controlled pilot trial was conducted at 4 sites (3 seniorhousing facilities and 1 senior center) in southeastern, lower Michigan.Fifty-four older adults with hip or knee osteoarthritis (mean +/- SD age75.3+/-7.1 years) participated. At each site, older adults were randomly assignedto 1 of 2 programs: exercise plus AST (Ex + AST) or exercise plus healtheducation (Ex + Ed). The programs involved 8 sessions over 4 weeks with 2followup sessions over a 6-month period, and were conducted concurrently withineach site. Pain, total PA and PA intensity (measured objectively by actigraphyand subjectively by the Community Healthy Activities Model Program for Seniorsquestionnaire), arthritis self-efficacy, and physical function were assessed at

baseline and posttest.RESULTS: At posttest, participants who received Ex + AST had significantly higherlevels of objective peak PA (P=0.02) compared with participants who received Ex+Ed. Although not statistically significant, participants in Ex + AST tended tohave larger pain decreases, increased total objective and subjective PA, andincreased physical function. No effects were found for arthritis self-efficacy.CONCLUSION: Although participants were involved in identical exercise programs,participants who received AST tended to have larger increases in PA at posttestcompared with participants who received health education. Future studies will be needed to examine larger samples and long-term effects of AST.


15. Arthritis Rheum. 2008 Feb 15;59(2):247-54. doi: 10.1002/art.23332.

Cost-effectiveness of intensive exercise therapy directly following hospitaldischarge in patients with arthritis: results of a randomized controlled clinicaltrial.

Bulthuis Y, Mohammad S, Braakman-Jansen LM, Drossaers-Bakker KW, van de Laar MA.

Institute for Behavioral Research, University of Twente, Enschede, TheNetherlands.

OBJECTIVE: To estimate the cost-utility and cost-effectiveness of a 3-weekintensive exercise training (IET) program directly following hospital dischargein patients with rheumatic diseases.METHODS: Patients with arthritis who were admitted to the hospital because of adisease activity flare or for elective hip or knee arthroplasty were randomlyassigned to either the IET group or usual care (UC) group. Followup lasted 1



year. Quality-adjusted life years (QALYs) were derived from Short Form 6D scores and a visual analog scale (VAS) rating personal health. Function-related outcome was measured using the Health Assessment Questionnaire, the McMaster TorontoArthritis (MACTAR) Patient Preference Disability Questionnaire, and the EscolaPaulista de Medicina Range of Motion scale (EPMROM). Costs were reported from asocietal perspective. Differences in costs and incremental cost-effectivenessratios (ICERs) were estimated.RESULTS: Data from 85 patients (50 IET and 35 UC) could be used forhealth-economic analysis. VAS personal health-based QALYs were in favor of IET.Function-related outcome showed statistically significant improvements in favorof IET over the first 6 months, according to the MACTAR (P < 0.05) and the EPMROM(P < 0.01). At 1-year followup, IET was euro718 less per patient. The ICER showeda reduction in mean total costs per QALY. In 70% of cases the intervention wascost-saving.CONCLUSION: IET results in better quality of life at lower costs after 1 year.Thus, IET is the dominant strategy compared with UC. This highlights the need forimplementation of IET after hospital discharge in patients with arthritis.


16. Arthritis Rheum. 2007 Oct 15;57(7):1245-53.

Long-term effectiveness of exercise therapy in patients with osteoarthritis ofthe hip or knee: a systematic review.

Pisters MF, Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG,Dekker J.

Netherlands Institute for Health Services Research, Utrecht, The [email protected]

OBJECTIVE: 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.METHODS: We conducted an extensive literature search in PubMed, EMBase, CINAHL,SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Bothrandomized clinical trials and controlled clinical trials on the long-termeffectiveness of exercise therapy were included. The followup assessments were atleast 6 months after treatment ended. Methodologic quality was independentlyassessed by 2 reviewers. Effect estimates were calculated and a best evidencesynthesis was performed based on design, methodologic quality, and statistical

significance of findings.RESULTS: Five high-quality and 6 low-quality randomized clinical trials wereincluded. Strong evidence was found for no long-term effectiveness on pain andself-reported physical function, moderate evidence for long-term effectiveness onpatient global assessment of effectiveness, and conflicting evidence for observedphysical function. For exercise programs with additional booster sessions,moderate evidence was found for long-term effectiveness on pain, self-reportedphysical function, and observed physical function.



CONCLUSION: The positive posttreatment effects of exercise therapy on pain andphysical function in patients with OA of the hip and/or knee are not sustained inthe long term. Long-term effectiveness was only found for patient globalassessment of effectiveness. However, additional booster sessions after thetreatment period positively influenced maintenance of beneficial posttreatmenteffects on pain and physical function in the long term.


17. Arthritis Rheum. 2007 Apr 15;57(3):407-14.

Physical activity for osteoarthritis management: a randomized controlled clinicaltrial evaluating hydrotherapy or Tai Chi classes.

Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J.

The George Institute for International Health, University of Sydney, Sydney,Australia. [email protected]

Comment inAust J Physiother. 2008;54(2):143.

OBJECTIVE: To determine whether Tai Chi or hydrotherapy classes for individualswith chronic symptomatic hip or knee osteoarthritis (OA) result in measurableclinical benefits.METHODS: A randomized controlled trial was conducted among 152 older persons withchronic symptomatic hip or knee OA. Participants were randomly allocated for 12weeks to hydrotherapy classes (n = 55), Tai Chi classes (n = 56), or a waitinglist control group (n = 41). Outcomes were assessed 12 and 24 weeks afterrandomization and included pain and physical function (Western Ontario andMcMaster Universities Osteoarthritis Index), general health status (MedicalOutcomes Study Short Form 12 Health Survey [SF-12], version 2), psychologicalwell-being, and physical performance (Up and Go test, 50-foot walk time, timed

stair climb).RESULTS: At 12 weeks, compared with controls, participants allocated tohydrotherapy classes demonstrated mean improvements (95% confidence interval) of 6.5 (0.4, 12.7) and 10.5 (3.6, 14.5) for pain and physical function scores (range0-100), respectively, whereas participants allocated to Tai Chi classesdemonstrated improvements of 5.2 (-0.8, 11.1) and 9.7 (2.8, 16.7), respectively. Both class allocations achieved significant improvements in the SF-12 physicalcomponent summary score, but only allocation to hydrotherapy achieved significantimprovements in the physical performance measures. All significant improvements

were sustained at 24 weeks. In this almost exclusively white sample, classattendance was higher for hydrotherapy, with 81% attending at least half of theavailable 24 classes, compared with 61% for Tai Chi.CONCLUSION: Access to either hydrotherapy or Tai Chi classes can provide largeand sustained improvements in physical function for many older, sedentaryindividuals with chronic hip or knee OA.




18. Arthritis Rheum. 2006 Oct 15;55(5):700-8.

Effect of preoperative exercise on measures of functional status in men and womenundergoing total hip and knee arthroplasty.

Rooks DS, Huang J, Bierbaum BE, Bolus SA, Rubano J, Connolly CE, Alpert S,Iversen MD, Katz JN.

New England Baptist Hospital, Beth Israel Deaconess Medical Center, and HarvardMedical School, Boston, MA 02215, USA. [email protected]

OBJECTIVE: To evaluate the effect of a short preoperative exercise interventionon the functional status, pain, and muscle strength of patients before and after total joint arthroplasty.METHODS: A total of 108 men and women scheduled for total hip arthroplasty (THA) or total knee arthroplasty (TKA) were randomized to a 6-week exercise oreducation (control) intervention immediately prior to surgery. We assessedoutcomes through questionnaires and performance measures. Analyses examineddifferences between groups over the preoperative and immediate postoperativeperiods and at 8 and 26 weeks postsurgery.RESULTS: Among THA patients, the exercise intervention was associated with

improvements in preoperative Western Ontario and McMaster UniversitiesOsteoarthritis Index function score (improvement of 2.2 in exercisers versusdecline of 3.9 in controls; P = 0.02) and Short Form 36 physical function score(decline of 0.4 in exercisers versus decline of 14.3 in controls; P = 0.003). No significant differences were seen in TKA patients. Exercise participationincreased muscle strength preoperatively (18% in THA patients and 20% in TKApatients), whereas the control patients had essentially no change in strength (P > 0.05 for exercise versus education in both THA and TKA groups). Exerciseparticipation prior to total joint arthroplasty substantially reduced the risk ofdischarge to a rehabilitation facility in THA and TKA patients (adjusted odds

ratio 0.27, 95% confidence interval 0.074-0.998). The intervention had no effectson outcomes 8 and 26 weeks postoperatively.CONCLUSION: A 6-week presurgical exercise program can safely improve preoperativefunctional status and muscle strength levels in persons undergoing THA.Additionally, exercise participation prior to total joint arthroplastydramatically reduces the odds of inpatient rehabilitation.


19. Arthritis Rheum. 2006 Dec 15;55(6):925-34.

Effectiveness of behavioral graded activity in patients with osteoarthritis ofthe hip and/or knee: A randomized clinical trial.

Veenhof C, KÃ¶ke AJ, Dekker J, Oostendorp RA, Bijlsma JW, van Tulder MW, van denEnde CH.




Comment inNat Clin Pract Rheumatol. 2007 Jun;3(6):322-3.

OBJECTIVE: To determine the effectiveness of a behavioral graded activity program(BGA) compared with usual care (UC; exercise therapy and advice) according to theDutch guidelines for physiotherapy in patients with osteoarthritis (OA) of thehip and/or knee. The BGA intervention is intended to increase activity in thelong term and consists of an exercise program with booster sessions, usingoperant treatment principles.METHODS: We conducted a cluster randomized trial involving 200 patients with hip and/or knee OA. Primary outcome measures were pain (visual analog scale [VAS] andWestern Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), physicalfunction (WOMAC), and patient global assessment, assessed at weeks 0, 13, 39, and65. Secondary outcome measures comprised tiredness (VAS), patient-orientedphysical function (McMaster Toronto Arthritis Patient Preference DisabilityQuestionnaire [MACTAR]), 5-meter walking time, muscle strength, and range ofmotion. Data were analyzed according to intent-to-treat principle.RESULTS: Both treatments showed short-term and long-term beneficial within-group

effects. The mean differences between the 2 groups for pain and functional statuswere not statistically significant. Significant differences in favor of BGA were found for the MACTAR functional scale and 5-meter walking test at week 65.CONCLUSION: Because both interventions resulted in beneficial long-term effects, the superiority of BGA over UC has not been demonstrated. Therefore, BGA seems tobe an acceptable method to treat patients with hip and/or knee OA, withequivalent results compared with UC.


20. Arthritis Rheum. 2005 Jun 15;53(3):375-82.

Influence of various recruitment strategies on the study population and outcomeof a randomized controlled trial involving patients with osteoarthritis of thehip or knee.

Veenhof C, Dekker J, Bijlsma JW, van den Ende CH.


OBJECTIVE: To examine the effect of 2 different recruitment methods on thecharacteristics of participants with osteoarthritis (OA) of the hip or knee andon the efficacy of an exercise program.METHODS: In a clinical trial on the effectiveness of exercise therapy in OA ofthe hip or knee, 2 groups of patients were recruited: one group through referralsby physiotherapists (PT group, n = 110) and one group invited by newspaperarticles (NP group, n = 90). At baseline, demographic, clinical, and psychosocial



data were collected and compared between the 2 groups using chi-square andStudent's t-tests. After 13 weeks of exercise therapy and followup assessments atweeks 39 and 65, the main outcome measures (pain, physical function, and globalperceived effect) were assessed and compared by multiple regression analysis.RESULTS: The NP group reported less pain and tiredness at baseline, although morejoints were affected with osteoarthritis. The PT group scored higher on the scale'powerful-others' of locus of control. After adjusting for baseline differences, the effect of treatment after 13, 39, and 65 weeks was comparable for both groupsfor all outcome measures.CONCLUSION: Recruitment method affects clinical characteristics and physicalfunctioning of patients recruited for the study. A mix of recruitment strategies does not seem to affect treatment outcome, on the condition that adjustments are made for baseline differences.


21. Arthritis Rheum. 2004 Oct 15;51(5):722-9.Comparison of manual therapy and exercise therapy in osteoarthritis of the hip:arandomized clinical trial.

Hoeksma HL, Dekker J, Ronday HK, Heering A, van der Lubbe N, Vel C, Breedveld FC,van den Ende CH.

Leyenburg Hospital, The Hague, The Netherlands. [email protected]

OBJECTIVE: To determine the effectiveness of a manual therapy program compared

with an exercise therapy program in patients with osteoarthritis (OA) of the hip.METHODS: A single-blind, randomized clinical trial of 109 hip OA patients wascarried out in the outpatient clinic for physical therapy of a large hospital.The manual therapy program focused on specific manipulations and mobilization of the hip joint. The exercise therapy program focused on active exercises toimprove muscle function and joint motion. The treatment period was 5 weeks (9sessions). The primary outcome was general perceived improvement after treatment.Secondary outcomes included pain, hip function, walking speed, range of motion,and quality of life.RESULTS: Of 109 patients included in the study, 56 were allocated to manual

therapy and 53 to exercise therapy. No major differences were found on baselinecharacteristics between groups. Success rates (primary outcome) after 5 weekswere 81% in the manual therapy group and 50% in the exercise group (odds ratio1.92, 95% confidence interval 1.30, 2.60). Furthermore, patients in the manualtherapy group had significantly better outcomes on pain, stiffness, hip function,and range of motion. Effects of manual therapy on the improvement of pain, hipfunction, and range of motion endured after 29 weeks.CONCLUSION: The effect of the manual therapy program on hip function is superior



to the exercise therapy program in patients with OA of the hip.


22. Arthritis Rheum. 1999 Jul;42(7):1361-9.

Effectiveness of exercise therapy in patients with osteoarthritis of the hip orknee: a systematic review of randomized clinical trials.

van Baar ME, Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW.

Netherlands Institute of Primary Health Care, Utrecht.

OBJECTIVE: To review the effectiveness of exercise therapy in patients withosteoarthritis (OA) of the hip or knee.METHODS: A computerized literature search of Medline, Embase, and Cinahl wascarried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain,self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials wassystematically assessed by independent reviewers. Effect sizes and power

estimates were calculated. A best evidence synthesis was conducted, weighting thestudies with respect to their validity and power.RESULTS: Six of the 11 assessed trials satisfied at least 50% of the validitycriteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain,small beneficial effects on both disability outcome measures, andmoderate-to-great beneficial effects according to patient's global assessment of effect.CONCLUSION: There is evidence of beneficial effects of exercise therapy in

patients with OA of the hip or knee. However, the small number of good studiesrestricts drawing firm conclusions.


23. BMC Fam Pract. 2013 Mar 11;14:33. doi: 10.1186/1471-2296-14-33.

Agreement of general practitioners with the guideline-based stepped-care strategyfor patients with osteoarthritis of the hip or knee: a cross-sectional study.

Smink AJ, Bierma-Zeinstra SM, Dekker J, Vliet Vlieland TP, Bijlsma JW, Swierstra

BA, Kortland JH, Voorn TB, van den Ende CH, Schers HJ.

Department of Rheumatology, Sint Maartenskliniek, PO box 9011, 6500 GM Nijmegen, The Netherlands. [email protected]

BACKGROUND: To improve the management of hip or knee osteoarthritis (OA), amultidisciplinary guideline-based stepped-care strategy (SCS) withrecommendations regarding the appropriate non-surgical treatment modalities and



optimal sequence for care has been developed. Implementation of this SCS in thegeneral practice may be hampered by the negative attitude of generalpractitioners (GPs) towards the strategy. In order to develop a tailoredimplementation plan, we assessed the GPs' views regarding specificrecommendations in the SCS and their working procedures with regard to OA.METHODS: A survey was conducted among a random sample of Dutch GPs. Questionsincluded the GP's demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCSrecommendations. In particular, we assessed GP's views regarding theeffectiveness of 14 recommended and non-recommended treatment modalities.Furthermore, we calculated their agreement with 7 statements based on the SCSrecommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs' agreement with the SCSrecommendations.RESULTS: Four hundred fifty-six GPs (37%) aged 30-65 years, of whom 278 males(61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-SteroidalAnti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articularinjections, education, lifestyle advice, acetaminophen, and tramadol) wereconsidered effective by the majority of the GPs (varying between 95-60%). Themean agreement score, based on a 5-point scale, with the recommendationsregarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance

in GPs' agreement could be explained by the GPs' attitudes regarding theeffectiveness of the recommended and non-recommended non-surgical treatmentmodalities and the type of practice.CONCLUSION: In general, GPs support the recommendations in the SCS. Therefore, weexpect that their attitudes will not impede a successful implementation ingeneral practice. Our results provide several starting points on which to focusimplementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identifyfactors that contribute substantially to GPs' attitudes regarding the SCSrecommendations regarding the sequence for care.


24. BMC Fam Pract. 2009 Sep 4;10:62. doi: 10.1186/1471-2296-10-62.

Activity Increase Despite Arthritis (AIDA): design of a Phase II randomisedcontrolled trial evaluating an active management booklet for hip and kneeosteoarthritis [ISRCTN24554946].

Williams NH, Amoakwa E, Burton K, Hendry M, Belcher J, Lewis R, Hood K, Jones J, Bennett P, Edwards RT, Neal RD, Andrew G, Wilkinson C.

Department of Primary Care and Public Health, Cardiff University, School ofMedicine, North Wales Clinical School, Gwenfro Units 6-7, Wrexham TechnologyPark, LL13 7YP, UK. [email protected]

BACKGROUND: Hip and knee osteoarthritis is a common cause of pain and disability,which can be improved by exercise interventions. However, regular exercise isuncommon in this group because the low physical activity level in the generalpopulation is probably reduced even further by pain related fear of movement. Th



ebest method of encouraging increased activity in this patient group is not known.A booklet has been developed for patients with hip or knee osteoarthritis. Itfocuses on changing disadvantageous beliefs and encouraging increased physicalactivity.METHODS/DESIGN: This paper describes the design of a Phase II randomisedcontrolled trial (RCT) to test the effectiveness of this new booklet for patientswith hip and knee osteoarthritis in influencing illness and treatment beliefs,and to assess the feasibility of conducting a larger definitive RCT in terms ofhealth status and exercise behaviour. A computerised search of four generalmedical practice patients' record databases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelvemonths. A random sample of 120 will be invited to participate in the RCTcomparing the new booklet with a control booklet, and we expect 100 to returnfinal questionnaires. This trial will assess the feasibility of recruitment andrandomisation, the suitability of the control intervention and outcomemeasurement tools, and will provide an estimate of effect size. Outcomes willinclude beliefs about hip and knee pain, beliefs about exercise, fear avoidance, level of physical activity, health status and health service costs. They will be

measured at baseline, one month and three months.DISCUSSION: We discuss the merits of testing effectiveness in a phase II trial,in terms of intermediate outcome measures, whilst testing the processes for alarger definitive trial. We also discuss the advantages and disadvantages oftesting the psychometric properties of the primary outcome measures concurrently with the trial.TRIAL REGISTRATION: Current Controlled Trials ISRCTN24554946.


25. BMC Musculoskelet Disord. 2013 Jan 14;14:21. doi: 10.1186/1471-2474-14-21.The effect of education and supervised exercise vs. education alone on the timeto total hip replacement in patients with severe hip osteoarthritis. A randomizedclinical trial protocol.

Jensen C, Roos EM, KjÃ¦rsgaard-Andersen P, Overgaard S.

Orthopedic Research Unit, Dept, of Orthopedic Surgery and Traumatology, OdenseUniversity Hospital, 29, Sdr, Boulevard, DK-5000, Odense C, [email protected]

BACKGROUND: The age- and gender-specific incidence of total hip replacementsurgery has increased over the last two decades in all age groups. Recent studiesindicate that non-surgical interventions are effective in reducing pain anddisability, even at later stages of the disease when joint replacement isconsidered. We hypothesize that the time to hip replacement can be postponed inpatients with severe hip osteoarthritis following participation in a patienteducation and supervised exercise program when compared to patients receivingpatient education alone.METHODS/DESIGN: A prospective, blinded, parallel-group multi-center trial (2



sites), with balanced randomization [1:1]. Patients with hip osteoarthritis andan indication for hip replacement surgery, aged 40 years and above, will beconsecutively recruited and randomized into two treatment groups. The activetreatment group will receive 3 months of supervised exercise consisting of 12sessions of individualized, goal-based neuromuscular training, and 12 sessions ofintensive resistance training plus patient education (3 sessions). The controlgroup will receive only patient education (3 sessions). The primary end-point forassessing the effectiveness of the intervention is 12 months after baseline.However, follow-ups will also be performed once a year for at least 5 years. The primary outcome measure is the time to hip replacement surgery measured on aKaplain-Meier survival curve from time of inclusion. Secondary outcome measuresare the five subscales of the Hip disability and Osteoarthritis Outcome Score,physical activity level (UCLA activity score), and patient's global perceivedeffect. Other measures include pain after exercise, joint-specific adverseevents, exercise adherence, general health status (EQ-5D-5L), mechanical musclestrength and performance in physical tests. A cost-effectiveness analysis willalso be performed.DISCUSSION: To our knowledge, this is the first randomized clinical trialcomparing a patient education plus supervised exercise program to patienteducation alone in hip osteoarthritis patients with an indication for surgery on

the time to total hip replacement.TRIAL REGISTRATION: NCT01697241.


26. BMC Musculoskelet Disord. 2012 Feb 21;13:26. doi: 10.1186/1471-2474-13-26.

Reliability and validity of the Physical Activity Scale for the Elderly (PASE) inpatients with hip osteoarthritis.

Svege I, Kolle E, Risberg MA.Norwegian Research Center for Active Rehabilitation, Department of Orthopedics,Oslo University Hospital, Norway. [email protected]

BACKGROUND: Physical activity (PA) is beneficial in reducing pain and improvingfunction in lower limb osteoarthritis (OA), and is recommended as a first linetreatment. Self-administered questionnaires are used to assess PA, but knowledge about reliability and validity of these PA questionnaires are limited, inparticular for patients with OA. The purpose of this study was to evaluate thereliability and validity of the Physical Activity Scale for the Elderly (PASE) in

patients with hip OA.METHODS: Forty patients with hip OA (20 men and 20 women, mean age 61.3 Â± 10years) were included. For test-retest reliability PASE was administered twicewith a mean time between tests of 9 Â± 4 days. Intraclass correlation coefficient(ICC), standard error of measurement (SEM) and minimal detectable change (MDC)were calculated for the total score and for the particular items assessingdifferent PA intensity levels. In addition a Bland-Altman analysis for the total PASE score was performed. Construct validity was evaluated by comparing the PASE



results with the Actigraph GT1M accelerometer and the International PhysicalActivity Questionnaire (IPAQ), using the Spearman rank correlation coefficient.RESULTS: ICC for the total PASE score was 0.78, with relatively large error ofmeasurement; SEM = 31 and MDC = 87. ICC for the intensity items was 0.20 formoderate PA intensity, 0.46 for light PA intensity and to 0.68 for vigorous PAintensity. The Spearman rank correlation coefficient between the Actigraph GT1Mtotal counts per minute and the total PASE score was 0.30 (p = 0.089), andranging from 0.20-0.38 for the different PA intensity categories. The Spearmanrank correlation between IPAQ and PASE was 0.61 (p = 0.001) for the total scores.CONCLUSIONS: In patients with hip OA the test-retest reliability of the totalPASE score was moderate, with acceptable ICC, but with large measurement errors. The construct validity of the PASE was poor when compared to the Actigraph GT1Maccelerometer. Test-retest reliability and construct validity revealed that thePASE was unable to assess PA intensity levels. PASE is not recommended as a validtool to examine PA level for patients with hip OA.


27. BMC Musculoskelet Disord. 2011 Oct 12;12:232. doi: 10.1186/1471-2474-12-232.

Cost-effectiveness of exercise therapy versus general practitioner care forosteoarthritis of the hip: design of a randomised clinical trial.

van Es PP, Luijsterburg PA, Dekker J, Koopmanschap MA, Bohnen AM, Verhaar JA,Koes BW, Bierma-Zeinstra SM.

Erasmus MC, University Medical Center, Department of General Practice, PO Box2040, 3000 CA Rotterdam, the Netherlands. [email protected]

BACKGROUND: Osteoarthritis (OA) is the most common joint disease, causing painand functional impairments. According to international guidelines, exercisetherapy has a short-term effect in reducing pain/functional impairments in knee

OA and is therefore also generally recommended for hip OA. Because of its highprevalence and clinical implications, OA is associated with considerable(healthcare) costs. However, studies evaluating cost-effectiveness of commonexercise therapy in hip OA are lacking. Therefore, this randomised controlledtrial is designed to investigate the cost-effectiveness of exercise therapy inconjunction with the general practitioner's (GP) care, compared to GP care alone,for patients with hip OA.METHODS/DESIGN: Patients aged â¥ 45 years with OA of the hip, who consulted the GPduring the past year for hip complaints and who comply with the American College of Rheumatology criteria, are included. Patients are randomly assigned to either

exercise therapy in addition to GP care, or to GP care alone. Exercise therapyconsists of (maximally) 12 treatment sessions with a physiotherapist, and homeexercises. These are followed by three additional treatment sessions in the 5th, 7th and 9th month after the first treatment session. GP care consists of usualcare for hip OA, such as general advice or prescribing pain medication. Primaryoutcomes are hip pain and hip-related activity limitations (measured with the Hipdisability Osteoarthritis Outcome Score [HOOS]), direct costs, and productivitycosts (measured with the PROductivity and DISease Questionnaire). These



parameters are measured at baseline, at 6 weeks, and at 3, 6, 9 and 12 monthsfollow-up. To detect a 25% clinical difference in the HOOS pain score, with apower of 80% and an alpha 5%, 210 patients are required. Data are analysedaccording to the intention-to-treat principle. Effectiveness is evaluated usinglinear regression models with repeated measurements. An incrementalcost-effectiveness analysis and an incremental cost-utility analysis will also beperformed.DISCUSSION: The results of this trial will provide insight into thecost-effectiveness of adding exercise therapy to GPs' care in the treatment of OAof the hip. This trial is registered in the Dutch trial registryhttp://www.trialregister.nl: trial number NTR1462.


28. BMC Musculoskelet Disord. 2011 Nov 24;12:270. doi: 10.1186/1471-2474-12-270.

Efficacy of conservative treatment regimes for hip osteoarthritis--evaluation of the therapeutic exercise regime "Hip School": a protocol for a randomised,controlled trial.

Krauss I, Steinhilber B, Haupt G, Miller R, Grau S, Janssen P.

Medical Clinic, Department of Sports Medicine, University of Tuebingen, Germany. [email protected]

BACKGROUND: Hip osteoarthritis (hip OA) is a disease with a major impact on both national economy and the patients themselves. Patients suffer from pain andfunctional impairment in activities of daily life which are associated with adecrease in quality of life. Conservative therapeutic interventions such asphysical exercises aim at reducing pain and increasing function and

health-related quality of life. However, there is only silver level evidence for efficacy of land-based physical exercise in the treatment of hip OA. The purpose of this randomized controlled trial is to determine whether the specific 12-week exercise regime "Hip School" can decrease bodily pain and improve physicalfunction and life quality in subjects with hip osteoarthritis.METHODS/DESIGN: 217 participants with hip OA, confirmed using the clinical score of the American College of Rheumatology, are recruited from the community andrandomly allocated to one of the following groups: (1) exercise regime "HipSchool", n = 70; (2) Non-intervention control group, n = 70; (3) "Sham"

ultrasound group, n = 70; (4) Ultrasound group, n = 7. The exercise regimecombines group exercises (1/week, 60-90') and home-based exercises (2/week,30-40'). Sham ultrasound and ultrasound are given once a week, 15'. Measures are taken directly prior to (M1) and after (M2) the 12-week intervention period. Two follow-ups are conducted by phone 16 and 40 weeks after the intervention period. The primary outcome measure is the change in the subscale bodily pain of the SF36



from M1 to M2. Secondary outcomes comprise the WOMAC score, SF36, isometricstrength of hip muscles, spatial-temporal and discrete measures derived fromclinical gait analysis, and the length of the centre of force path in differentstanding tasks. An intension-to-treat analysis will be performed usingmultivariate statistics (group Ã time).DISCUSSION: Results from this trial will contribute to the evidence regarding theeffect of a hip-specific exercise regime on physical function, pain, andhealth-related quality of life in patients with hip osteoarthritis.TRIAL REGISTRATION: German Clinical Trial Register DRKS00000651.


29. BMC Musculoskelet Disord. 2011 May 4;12:88. doi: 10.1186/1471-2474-12-88.

Non-surgical treatment of hip osteoarthritis. Hip school, with or without theaddition of manual therapy, in comparison to a minimal control intervention:protocol for a three-armed randomized clinical trial.

Poulsen E, Christensen HW, Roos EM, Vach W, Overgaard S, Hartvigsen J.

Institute of Sports Science and Clinical Biomechanics, University of Southern

Denmark, Denmark. [email protected]: Hip osteoarthritis is a common and chronic condition resulting inpain, functional disability and reduced quality of life. In the early stages ofthe disease, a combination of non-pharmacological and pharmacological treatmentis recommended. There is evidence from several trials that exercise therapy iseffective. In addition, single trials suggest that patient education in the form of a hip school is a promising intervention and that manual therapy is superiorto exercise.METHODS/DESIGN: This is a randomized clinical trial. Patients with clinical andradiological hip osteoarthritis, 40-80 years of age, and without indication forhip surgery were randomized into 3 groups. The active intervention groups A and

Breceived six weeks of hip school, taught by a physiotherapist, for a total of 5sessions. In addition, group B received manual therapy consisting of jointmanipulation and soft-tissue therapy twice a week for six weeks. Group C receiveda self-care information leaflet containing advice on "live as usual" andstretching exercises from the hip school. The primary time point for assessingrelative effectiveness is at the end of the six weeks intervention period withfollow-ups after three and 12 months.Primary outcome measure is pain measured on an eleven-point numeric rating scale. Secondary outcome measures are the hipdysfunction and osteoarthritis outcome score, patient's global perceived effect,

patient specific functional scale, general quality of life and hip range ofmotion.DISCUSSION: To our knowledge this is the first randomized clinical trialcomparing a patient education program with or without the addition of manualtherapy to a minimal intervention for patients with hip osteoarthritis.TRIAL REGISTRATION: ClinicalTrials NCT01039337.




30. BMC Musculoskelet Disord. 2011 Jun 2;12:123. doi: 10.1186/1471-2474-12-123.

Systematic review and meta-analysis comparing land and aquatic exercise forpeople with hip or knee arthritis on function, mobility and other healthoutcomes.

Batterham SI, Heywood S, Keating JL.

Department of Physiotherapy, Monash University Peninsula Campus, McMahons Rd,Frankston, Australia.

BACKGROUND: Aquatic and land based exercise are frequently prescribed to maintainfunction for people with arthritis. The relative efficacy of these rehabilitationstrategies for this population has not been established.This review investigated the effects of aquatic compared to land based exercise on function, mobility orparticipants' perception of programs for people with arthritis.METHODS: Medline, CINAHL, AMED and the Cochrane Central Register of ControlledClinical Trials were searched up to July 2010. Ten randomised, controlledclinical trials that compared land to aquatic exercise for adults with arthritis

were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers.Standardised mean differences between groups for key outcomes were calculated.Meta-analyses were performed for function, mobility and indices that pooledhealth outcomes across multiple domains.RESULTS: No differences in outcomes were observed for the two rehabilitationstrategies in meta-analysis. There was considerable variability between trials inkey program characteristics including prescribed exercises and design quality.Components of exercise programs were poorly reported by the majority of trials.No research was found that examined participant preferences for aquatic compared

to land based exercise, identifying this as an area for further research.CONCLUSION: Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, orfind land based exercise difficult, aquatic programs provide an enablingalternative strategy.


31. BMC Musculoskelet Disord. 2011 Aug 2;12:177. doi: 10.1186/1471-2474-12-177.

Activity pacing for osteoarthritis symptom management: study design andmethodology of a randomized trial testing a tailored clinical approach usingaccelerometers for veterans and non-veterans.

Murphy SL, Lyden AK, Clary M, Geisser ME, Yung RL, Clauw DJ, Williams DA.

Department of Physical Medicine and Rehabilitation, University of Michigan, AnnArbor, MI, USA. [email protected]



BACKGROUND: Osteoarthritis (OA) is a prevalent chronic disease and a leadingcause of disability in adults. For people with knee and hip OA, symptoms (e.g.,pain and fatigue) can interfere with mobility and physical activity. Whereassymptom management is a cornerstone of treatment for knee and hip OA, limitedevidence exists for behavioral interventions delivered by rehabilitationprofessionals within the context of clinical care that address how symptomsaffect participation in daily activities. Activity pacing, a strategy in whichpeople learn to preplan rest breaks to avoid symptom exacerbations, has beeneffective as part of multi-component interventions, but hasn't been tested as astand-alone intervention in OA or as a tailored treatment using accelerometers.In a pilot study, we found that participants who underwent a tailored activitypacing intervention had reduced fatigue interference with daily activities. Weare now conducting a full-scale trial.METHODS/DESIGN: This paper provides a description of our methods and rationalefor a trial that evaluates a tailored activity pacing intervention led byoccupational therapists for adults with knee and hip OA. The intervention uses a wrist accelerometer worn during the baseline home monitoring period to gleanrecent symptom and physical activity patterns and to tailor activity pacinginstruction based on how symptoms relate to physical activity. At 10 weeks and 6 months post baseline, we will examine the effectiveness of a tailored activitypacing intervention on fatigue, pain, and physical function compared to generalactivity pacing and usual care groups. We will also evaluate the effect of

tailored activity pacing on physical activity (PA).DISCUSSION: Managing OA symptoms during daily life activity performance can bechallenging to people with knee and hip OA, yet few clinical interventionsaddress this issue. The activity pacing intervention tested in this trial isdesigned to help people modulate their activity levels and reduce symptom flares caused by too much or too little activity. As a result of this trial, we will be able to determine if activity pacing is more effective than usual care, and amongthe intervention groups, if an individually tailored approach improves fatigueand pain more than a general activity pacing approach.TRIAL REGISTRATION: ClinicalTrials.gov: NCT01192516.


32. BMC Musculoskelet Disord. 2010 Oct 14;11:238. doi: 10.1186/1471-2474-11-238.

Efficacy of a multimodal physiotherapy treatment program for hip osteoarthritis: a randomised placebo-controlled trial protocol.

Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Metcalf B, McManus F, WrigleyTV, Forbes A, Harris A, Buchbinder R.

Centre for Health, Exercise & Sports Medicine, School of Health Sciences,University of Melbourne, Melbourne, VIC, Australia. [email protected]

BACKGROUND: Hip osteoarthritis (OA) is a common condition leading to pain,disability and reduced quality of life. There is currently limited evidence tosupport the use of conservative, non-pharmacological treatments for hip OA.Exercise and manual therapy have both shown promise and are typically usedtogether by physiotherapists to manage painful hip OA. The aim of this randomised



controlled trial is to compare the efficacy of a physiotherapy treatment program with placebo treatment in reducing pain and improving physical function.METHODS: The trial will be conducted at the University of Melbourne Centre forHealth, Exercise and Sports Medicine. 128 participants with hip pain greater orequal to 40/100 on visual analogue scale (VAS) and evidence of OA on x-ray willbe recruited. Treatment will be provided by eight community physiotherapists inthe Melbourne metropolitan region. The active physiotherapy treatment willcomprise a semi-structured program of manual therapy and exercise plus education and advice. The placebo treatment will consist of sham ultrasound and theapplication of non-therapeutic gel. The participants and the study assessor will be blinded to the treatment allocation. Primary outcomes will be pain measured byVAS and physical function recorded on the Western Ontario and McMasterUniversities Osteoarthritis Index (WOMAC) immediately after the 12 weekintervention. Participants will also be followed up at 36 weeks post baseline.CONCLUSIONS: The trial design has important strengths of reproducibility andreflecting contemporary physiotherapy practice. The findings from this randomisedtrial will provide evidence for the efficacy of a physiotherapy program forpainful hip OA.



Whole body vibration compared to conventional physiotherapy in patients withgonarthrosis: a protocol for a randomized, controlled study.

Stein G, Knoell P, Faymonville C, Kaulhausen T, Siewe J, Otto C, Eysel P,Zarghooni K.

Department of Orthopaedic and Trauma Surgery, University of Cologne, Kerpener

Strasse 62, 50924 Cologne, Germany. [email protected]: Osteoarthritis (OA) is the most common degenerative arthropathy.Load-bearing joints such as knee and hip are more often affected than spine orhands. The prevalence of gonarthrosis is generally higher than that ofcoxarthrosis.Because no cure for OA exists, the main emphasis of therapy isanalgesic treatment through either mobility or medication. Non-pharmacologictreatment is the first step, followed by the addition of analgesic medication,and ultimately by surgery.The goal of non-pharmacologic and non-invasive therapy is to improve neuromuscular function, which in turn both prevents formation ofand delays progression of OA. A modification of conventional physiotherapy, whole

body vibration has been successfully employed for several years. Since itsintroduction, this therapy is in wide use at our facility not only forgonarthrosis, but also coxarthrosis and other diseases leading to muscularimbalance.METHODS/DESIGN: This study is a randomized, therapy-controlled trial in a primarycare setting at a university hospital. Patients presenting to our outpatientclinic with initial symptoms of gonarthrosis will be assessed against inclusionand exclusion criteria. After patient consent, 6 weeks of treatment will ensue.During the six weeks of treatment, patients will receive one of two treatments,



conventional physiotherapy or whole-body-vibration exercises of one hour threetimes a week. Follow-up examinations will be performed immediately aftertreatment and after another 6 and 20 weeks, for a total study duration of 6months. 20 patients will be included in each therapy group.Outcome measurementswill include objective analysis of motion and ambulation as well as examinations of balance and isokinetic force. The Western Ontario and McMaster UniversitiesArthritis Index and SF-12 scores, the patients' overall status, and clinicalexaminations of the affected joint will be carried out.DISCUSSION: As new physiotherapy techniques develop for the treatment of OA, itis important to investigate the effectiveness of competing strategies. With this study, not only patient-based scores, but also objective assessments will be usedto quantify patient-derived benefits of therapy.TRIAL REGISTRATION: Deutsches Register Klinischer Studien (DRKS)DRKS00000415Clinicaltrials.gov NCT01037972EudraCT 2009-017617-29.



Feasibility of neuromuscular training in patients with severe hip or knee OA: theindividualized goal-based NEMEX-TJR training program.

Ageberg E, Link A, Roos EM.

Department of Orthopedics, Clinical Sciences Lund, Lund University, [email protected]

BACKGROUND: Although improvements are achieved by general exercise, training toimprove sensorimotor control may be needed for people with osteoarthritis (OA).The aim was to apply the principles of neuromuscular training, which have beensuccessfully used in younger and middle-aged patients with knee injuries, to

older patients with severe hip or knee OA. We hypothesized that the trainingprogram was feasible, determined as: 1) at most acceptable self-reported painfollowing training; 2) decreased or unchanged pain during the training period; 3)few joint specific adverse events related to training, and 4) achievedprogression of training level during the training period.METHODS: Seventy-six patients, between 60 and 77 years, with severe hip (n = 38, 55% women) or knee OA (n = 38, 61% women) underwent an individualized, goal-basedneuromuscular training program (NEMEX-TJR) in groups for a median of 11 weeks(quartiles 7 to 15) prior to total joint replacement (TJR). Pain wasself-reported immediately after each training session on a 0 to 10 cm, no pain t

opain as bad as it could be, scale, where 0-2 indicates safe, > 2 to 5 acceptable and > 5 high risk pain. Joint specific adverse events were: not attending orceasing training because of increased pain/problems in the index joint related totraining, and self-reported pain > 5 after training. The level of difficulty oftraining was registered.RESULTS: Patients with severe OA of the hip or knee reported safe pain (median 2



cm) after training. Self-reported pain was lower at training sessions 10 and 20(p = 0.04) and unchanged at training sessions 5 and 15 (p = 0.170, p = 0.161)compared with training session 1. There were no joint specific adverse events in terms of not attending or ceasing training. Few patients (n = 17, 22%) reportedadverse events in terms of self-reported pain > 5 after one or more trainingsessions. Progression of training level was achieved over time (p < 0.001).CONCLUSIONS: The NEMEX-TJR training program is feasible in patients with severehip or knee OA, in terms of safe self-reported pain following training, decreasedor unchanged pain during the training period, few joint specific adverse events, and achieved progression of training level during the training period.


35. BMC Musculoskelet Disord. 2009 Jan 19;10:9. doi: 10.1186/1471-2474-10-9.

Exercise and manual physiotherapy arthritis research trial (EMPART): amulticentre randomised controlled trial.

French HP, Cusack T, Brennan A, White B, Gilsenan C, Fitzpatrick M, O'Connell P,

Kane D, Fitzgerald O, McCarthy GM.

School of Physiotherapy, Royal College of Surgeons in Ireland, 123 St Stephen'sGreen, Dublin 2, Ireland. [email protected]

BACKGROUND: Osteoarthritis (OA) of the hip is a major cause of functionaldisability and reduced quality of life. Management options aim to reduce pain andimprove or maintain physical functioning. Current evidence indicates thattherapeutic exercise has a beneficial but short-term effect on pain anddisability, with poor long-term benefit. The optimal content, duration and typeof exercise are yet to be ascertained. There has been little scientific

investigation into the effectiveness of manual therapy in hip OA. Only onerandomized controlled trial (RCT) found greater improvements in patient-perceivedimprovement and physical function with manual therapy, compared to exercisetherapy.METHODS AND DESIGN: An assessor-blind multicentre RCT will be undertaken tocompare the effect of a combination of manual therapy and exercise therapy,exercise therapy only, and a waiting-list control on physical function in hip OA.One hundred and fifty people with a diagnosis of hip OA will be recruited andrandomly allocated to one of 3 groups: exercise therapy, exercise therapy withmanual therapy and a waiting-list control. Subjects in the intervention groupswill attend physiotherapy for 6-8 sessions over 8 weeks. Those in the control

group will remain on the waiting list until after this time and will then bere-randomised to one of the two intervention groups. Outcome measures willinclude physical function (WOMAC), pain severity (numerical rating scale),patient perceived change (7-point Likert scale), quality of life (SF-36), mood(hospital anxiety and depression scale), patient satisfaction, physical activity (IPAQ) and physical measures of range of motion, 50-foot walk and repeated sit-tostand tests.DISCUSSION: This RCT will compare the effectiveness of the addition of manual



therapy to exercise therapy to exercise therapy only and a waiting-list controlin hip OA. A high quality methodology will be used in keeping with CONSORTguidelines. The results will contribute to the evidence base regarding theclinical efficacy for physiotherapy interventions in hip OA.


36. BMC Musculoskelet Disord. 2009 Feb 23;10:24. doi: 10.1186/1471-2474-10-24.

The effects of exercise and weight loss in overweight patients with hiposteoarthritis: design of a prospective cohort study.

Paans N, van den Akker-Scheek I, van der Meer K, Bulstra SK, Stevens M.

Department of Orthopaedic Surgery, University Medical Center Groningen,Groningen, The Netherlands. [email protected].

BACKGROUND: Hip osteoarthritis (OA) is recognised as a substantial source ofdisability, with pain and loss of function as principal symptoms. An agingsociety and a growing number of overweight people, which is considered a riskfactor for OA, contribute to the growing number of cases of hip OA. In knee OApatients, exercise as a single treatment is proven to be very effective towards

counteracting pain and physical functionality, but the combination of weight lossand exercise is demonstrated to be even more effective. Exercise as a treatmentfor hip OA patients is also effective, however evidence is lacking for thecombination of weight loss and exercise. Consequently, the aim of this study isto get a first impression of the potential effectiveness of exercise and weightloss in overweight patients suffering from hip OA.METHODS/DESIGN: This is a prospective cohort study. Patients aged 25 or older,overweight (BMI > 25) or obese (BMI > 30), with clinical and radiographicevidence of OA of the hip and able to attend exercise sessions will be included. The intervention is an 8-month exercise and weight-loss lifestyle program. Maingoal is to increase aerobic capacity, lose weight and stimulate a low-calorie an

dactive lifestyle. Primary outcome is self-reported physical functioning.Secondary outcomes include pain, stiffness, health-related quality of life andhabitual activity level. Weight loss in kilograms and percentage of fat-free masswill also be measured.DISCUSSION: The results of this study will give a first impression of potentialeffectiveness of exercise and weight loss as a combination program for patientswith OA of the hip. Once this program is proven to be effective it may lead topostponing the moment of total hip replacement.TRIAL REGISTRATION NUMBER: NTR1053.

PMCID: PMC2649885



Effectiveness of physiotherapy exercise following hip arthroplasty forosteoarthritis: a systematic review of clinical trials.

Minns Lowe CJ, Barker KL, Dewey ME, Sackley CM.



Department of Primary Care Clinical Sciences, University of Birmingham,Edgbaston, Birmingham, UK. [email protected]

BACKGROUND: Physiotherapy has long been a routine component of patientrehabilitation following hip joint replacement. The purpose of this systematicreview was to evaluate the effectiveness of physiotherapy exercise afterdischarge from hospital on function, walking, range of motion, quality of lifeand muscle strength, for osteoarthritic patients following elective primary totalhip arthroplasty.METHODS: Design: Systematic review, using the Cochrane Collaboration Handbook forSystematic Reviews of Interventions and the Quorom Statement. Database searches: AMED, CINAHL, EMBASE, KingsFund, MEDLINE, Cochrane library (Cochrane reviews,Cochrane Central Register of Controlled Trials, DARE), PEDro, The Department ofHealth National Research Register. Handsearches: Physiotherapy, Physical Therapy,Journal of Bone and Joint Surgery (Britain) Conference Proceedings. No languagerestrictions were applied. Selection: Trials comparing physiotherapy exerciseversus usual/standard care, or comparing two types of relevant exercisephysiotherapy, following discharge from hospital after elective primary total hipreplacement for osteoarthritis were reviewed. Outcomes: Functional activities of

daily living, walking, quality of life, muscle strength and range of hip jointmotion. Trial quality was extensively evaluated. Narrative synthesis plusmeta-analytic summaries were performed to summarise the data.RESULTS: 8 trials were identified. Trial quality was mixed. Generally poor trial quality, quantity and diversity prevented explanatory meta-analyses. The results were synthesised and meta-analytic summaries were used where possible to provide a formal summary of results. Results indicate that physiotherapy exercise afterdischarge following total hip replacement has the potential to benefit patients.CONCLUSION: Insufficient evidence exists to establish the effectiveness of

physiotherapy exercise following primary hip replacement for osteoarthritis.Further well designed trials are required to determine the value of postdischarge exercise following this increasingly common surgical procedure.



A comparison of Kneipp hydrotherapy with conventional physiotherapy in thetreatment of osteoarthritis of the hip or knee: protocol of a prospectiverandomised controlled clinical trial.

Schencking M, Otto A, Deutsch T, Sandholzer H.

Kneipp Clinic (Sebastianeum & Kneippianum) Bad WÃ¶rishofen, Bad WÃ¶rishofen,Germany. [email protected]

BACKGROUND: The increasing age of the population, especially in the westernworld, means that the prevalence of osteoarthritis is also increasing, withcorresponding socioeconomic consequences. Although there is no curativeintervention at present, in accordance with US and European guidelines,



pharmacotherapeutic and non-pharmacological approaches aim at pain control andthe reduction of functional restriction.It has been established that hydrotherapyfor osteoarthritis of the hip or knee joint using serial cold and warm waterstimulation not only improves the range of movement but also reduces painsignificantly and increases quality of life over a period of up to three months. Weight reduction is important for patients with osteoarthritis of the hip orknee. In addition, conventional physiotherapy and exercise therapy have both beenshown, at a high level of evidence, to be cost-effective and to have long-termbenefits for pain relief, movement in the affected joint, and patient quality of life.METHODS/DESIGN: The study design consists of a prospective randomised controlled three-armed clinical trial, which will be carried out at a specialist clinic for integrative medicine, to investigate the clinical effects of hydrotherapy onosteoarthritis of the knee or hip joint, in comparison with conventionalphysiotherapy.One hundred and eighty patients diagnosed with osteoarthritis ofhip or knee will be randomly assigned to one of three intervention groups:hydrotherapy, physiotherapy, and both physiotherapy and hydrotherapy of theaffected joint. In the first group, patients will receive Kneipp hydrotherapy

daily, with water applied in the form of alternate cold and warm thigh affusions (alternating cold and warm water stimulation is particularly relevant to the kneeand hip regions).Patients in the second group will receive physiotherapy of thehip or knee joint three times a week. Patients in the physiotherapy-hydrotherapy combination group will receive both joint-specific physiotherapy three times aweek and alternate cold and warm thigh affusions every day. Follow-up assessmentswill be on three levels: clinical assessment by the investigator; subjectivepatient assessment consisting of a patient diary, and questionnaires on admission

and at the end of the treatment phase; and a final telephone assessment by theexternal evaluation centre. Assessments will be made at baseline, after two weeksof inpatient treatment, and finally after a further ten weeks of follow-up. Theprimary outcome measure will be pain intensity of the affected joint in thecourse of inpatient treatment, judged by the patient and the investigator.Secondary outcomes include health-related quality of life and joint-specific painand mobility in the course of the study. Statistical analysis of the results willbe on an intention-to-treat basis.CONCLUSION: This study methodology has been conceived according to the standards

of the CONSORT recommendations. The results will contribute to establishinghydrotherapy as a non-invasive, non-interventional, reasonably priced,therapeutic option with few side effects, in the concomitant treatment ofosteoarthritis of the hip or knee.TRIAL REGISTRATION: Trial registration number: NCT 00950326.




39. BMJ. 1995 Sep 30;311(7009):853-7.

Management of hip osteoarthritis.

Dieppe P.

Department of Medicine, Bristol Royal Infirmary.


40. Br J Gen Pract. 2011 Aug;61(589):e452-8. doi: 10.3399/bjgp11X588411.

Activity Increase Despite Arthritis (AÃDA): phase II randomised controlled trialof an active management booklet for hip and knee osteoarthritis in primary care.

Williams NH, Amoakwa E, Belcher J, Edwards RT, Hassani H, Hendry M, Burton K,Lewis R, Hood K, Jones J, Bennett P, Linck P, Neal RD, Wilkinson C.

Department of Primary Care and Public Health, School of Medicine, CardiffUniversity, Cardiff, UK.

BACKGROUND: The Hip & Knee Book: Helping you cope with osteoarthritis was

developed to change disadvantageous beliefs and encourage physical activity inpeople with hip or knee osteoarthritis.AIM: To assess the feasibility of conducting a definitive randomised controlledtrial (RCT) of this evidence-based booklet in people with hip or kneeosteoarthritis.DESIGN: Phase II feasibility randomised controlled trial (RCT).METHOD: Computerised searches of patients' record databases identified peoplewith osteoarthritis of the hip or knee, who were invited to participate in theRCT comparing the new booklet with a control booklet. Outcomes were measured atbaseline, 1 month, and 3 months, and included: beliefs about hip and knee pain,exercise, and fear avoidance; level of physical activity; and health service use.RESULTS: The trial methods were feasible in terms of recruitment, randomisation,

and follow-up, but most participants recruited had longstanding establishedsymptoms. After one and 3 months, there was a small relative improvement inillness, exercise, and fear-avoidance beliefs and physical activity level in The Hip & Knee Book group (n = 59) compared with the control group (n = 60), whichprovides some proof of principle for using these outcomes in future trials.CONCLUSION: This feasibility study provided proof of principle for testing TheHip & Knee Book in a larger definitive RCT.


41. Br J Gen Pract. 2010 Feb;60(571):64-82. doi: 10.3399/bjgp10X483166.

The Hip and Knee Book: developing an active management booklet for hip and kneeosteoarthritis.

Williams NH, Amoakwa E, Burton K, Hendry M, Lewis R, Jones J, Bennett P, Neal RD,Andrew G, Wilkinson C.



Department of Primary Care and Public Health, Cardiff University, School ofMedicine, North West Wales Clinical School, Wrexham. [email protected]

Comment inBr J Gen Pract. 2010 Feb;60(571):79-80.

BACKGROUND: The pain and disability of hip and knee osteoarthritis can beimproved by exercise, but the best method of encouraging this is not known.AIM: To develop an evidence-based booklet for patients with hip or kneeosteoarthritis, offering information and advice on maintaining activity.DESIGN OF STUDY: Systematic review of reviews and guidelines, then focus groups.SETTING: Four general practices in North East Wales.METHOD: Evidence-based messages were developed from a systematic review,synthesised into patient-centred messages, and then incorporated into anarrative. A draft booklet was examined by three focus groups to improve thephrasing of its messages and discuss its usefulness. The final draft was examinedin a fourth focus group.RESULTS: Six evidence-based guidelines and 54 systematic reviews were identified.The focus groups found the draft booklet to be informative and easy to read. Theyreported a lack of clarity about the cause of osteoarthritis and were surprisedthat the pain could improve. The value of exercise and weight loss beliefs was

accepted and reinforced, but there was a perceived contradiction about heavyphysical work being causative, while moderate exercise was beneficial. There was a fear of dependency on analgesia and misinterpretation of the message onhyaluranon injections. The information on joint replacement empowered patients todiscuss referral with their GP. The text was revised to accommodate these issues.CONCLUSION: The booklet was readable, credible, and useful to end-users. Arandomised controlled trial is planned, to test whether the booklet influencesbeliefs about osteoarthritis and exercise.

PMCID: PMC2814291


42. Clin Interv Aging. 2011;6:201-6. doi: 10.2147/CIA.S23130. Epub 2011 Jul 25.

Comparison of two treatments for coxarthrosis: local hyperthermia versus radioelectric asymmetrical brain stimulation.

Castagna A, Rinaldi S, Fontani V, Mannu P, Margotti ML.

Rinaldi Fontani Institute, Department of Neuro Psycho Physio Pathology, Florence,Italy.

BACKGROUND: It is well known that psychological components are very important in the aging process and may also manifest in psychogenic movement disorders, suchas coxarthrosis. This study analyzed the medical records of two similar groups ofpatients with coxarthrosis (n = 15 in each) who were treated in two differentclinics for rehabilitation therapy.METHODS: Patients in Group A were treated with a course of traditionalphysiotherapy, including sessions of local hyperthermia. Group B patients were



treated with only a course of radioelectric asymmetrical brain stimulation (REAC)to improve their motor behavior.RESULTS: Group A showed a significant decrease in symptoms of pain and stiffness,and an insignificant improvement in range of motion and muscle bulk. A singlepatient in this group developed worsened symptoms, and pain did not resolvecompletely in any patient. The patients in Group B had significantly decreasedlevels of pain and stiffness, and a significant improvement in range of motionand muscle bulk. No patients worsened in Group B, and the pain resolvedcompletely in one patient.CONCLUSION: Both treatments were shown to be tolerable and safe. Patients whounderwent REAC treatment appeared to have slightly better outcomes, with anappreciable improvement in both their physical and mental states. These aspectsare particularly important in the elderly, in whom functional limitation is oftenassociated with or exacerbated by a psychogenic component.


43. Clin Rheumatol. 2010 Jul;29(7):739-47. doi: 10.1007/s10067-010-1392-8. Epub2010

Feb 23.Osteoarthritis of the hip or knee: which coexisting disorders are disabling?

Reeuwijk KG, de Rooij M, van Dijk GM, Veenhof C, Steultjens MP, Dekker J.

Faculty of Earth and Life Science, VU University, Amsterdam, The [email protected]

Exercise therapy is generally recommended in osteoarthritis (OA) of the hip orknee. However, coexisting disorders may bring additional impairments, which maynecessitate adaptations to exercise for OA of the hip or knee. For the purpose of

developing an adapted protocol for exercise therapy in OA patients withcoexisting disorders, information is needed on which specific coexistingdisorders in OA are associated with activity limitations and pain. To describethe relationship between specific coexisting disorders, activity limitations, andpain in patients with OA of the hip or knee, a cross-sectional cohort study among288 older adults (50-85 years of age) with OA of hip or knee was conducted.Subjects were recruited from three rehabilitation centers and two hospitals.Demographic data, clinical data, information about coexisting disorders (i.e.,comorbidity and other disorders), activity limitations (WOMAC: physicalfunctioning domain), and pain (visual analogue scale (VAS)) were collected byquestionnaire. Statistical analysis included descriptive statistics and

multivariate regression analysis. Coexisting disorders associated with activitylimitations were chronic back pain or hernia, arthritis of the hand or feet, and other chronic rheumatic diseases (all musculoskeletal disorders); diabetes andchronic cystitis (non-musculoskeletal disorders); hearing impairments in aface-to-face conversation, vision impairments in long distances, and dizziness incombination with falling (all sensory impairments); and overweight and obesity.Coexistent disorders associated with pain were arthritis of the hand or feet,other chronic rheumatic diseases (musculoskeletal disorders), and diabetes



(non-musculoskeletal disorder). Specific disorders coexisting next to OA andassociated with additional activity limitations and pain were identified. Thesecoexisting disorders need to be addressed in exercise therapy and rehabilitation for patients with OA of the hip or knee.


44. Dan Med J. 2012 Dec;59(12):A4554.

Group education and exercise is feasible in knee and hip osteoarthritis.

Skou ST, Odgaard A, Rasmussen JO, Roos EM.

OrtopÃ¦dkirurgisk Forskningsenhed, Aalborg Hospital, Aarhus University Hospital,Research and Innovation Center, SÃ¸ndre Skovvej 15, Aalborg 9000, [email protected]

INTRODUCTION: Clinical practice does not reflect current clinical guidelinesrecommending an early multimodal non-surgical treatment for knee and hiposteoarthritis (OA). The purpose of this study was to examine the feasibility of

such an initiative (Good Life with osteoArthritis in Denmark (GLA:D) in personswith mild to moderate knee and/or hip OA-related pain.MATERIAL AND METHODS: This was a pilot study with a 36-patient cohort andthree-month follow-up. The treatment consisted of two 1.5-hour sessions ofpatient education and six weeks of individualized supervised neuromuscularexercise according to the previously published NEuroMuscular Exercise programme. The primary outcome was pain on a visual analogue scale (0-100). Secondaryoutcomes were Euro-Quality-of-Life - 5 Dimensional form (EQ-5D), ArthritisSelf-Efficacy Scale (ASES), 30-second chair stand test, timed 20-meter walk andbody mass index. Furthermore, compliance was registered.RESULTS: Thirty-four (94%) participants completed the follow-up. There weresignificant improvements (p < 0.05) in the primary outcome pain (-16 mm), in tim

ein the 20-meter walk test (-0.7 s), in EQ-5D (0.053), in ASES (7.3) and in thenumber of complete chair stands (1.4). Compliance was high in relation to bothpatient education and exercise.CONCLUSION: The pilot study demonstrated that the intervention is feasible andthat it is possible to implement GLA:D in clinical care. Introducing GLA:Dnationwide could improve the adherence to clinical guidelines and the quality of the treatment of knee and hip OA.


45. Eur J Phys Rehabil Med. 2010 Sep;46(3):337-45. Epub 2010 May 6.

Quality indicators indicate good adherence to the clinical practice guideline on "Osteoarthritis of the hip and knee" and few prognostic factors influence outcomeindicators: a prospective cohort study.

Jansen MJ, Hendriks EJ, Oostendorp RA, Dekker J, De Bie RA.



Department of Epidemiology, Maastricht University, Maastricht, The Netherlands.

BACKGROUND: Evaluation with quality indicators of adherence to the clinicalpractice guideline on "Osteoarthritis of the hip and knee" and of treatmentoutcomes.AIM: Furthermore to determine prognostic factors for outcome indicators.DESIGN: Prospective cohort study.POPULATION: Twenty-seven well informed physical therapists recorded patient andtreatment characteristics of 103 community-dwelling patients referred by ageneral practitioner diagnosed with osteoarthritis of hip or knee.METHODS: With selected process and outcome indicators adherences to the guidelineand treatment outcomes were assessed. Prognostic factors were calculated forAlgofunctional Index (AI) and Visual Analogue Scale (VAS) for pain (decreases of â¤25% indicating "poor outcome"), number of sessions (>12) and duration oftreatment (>6 weeks), using multivariate logistic regression models.RESULTS: Process indicators showed that information & advice was given to 95% of the patients and functions and activities were exercised in 97% respectively 87%.Aftercare was arranged for 46% of the patients, that was clearly lower than thebenchmark of 90%. Outcome indicators VAS-pain and AI decreased by 45% and 36%,respectively. The combination ">12 months" duration of complaints and age â¥65"

was associated with a "poor outcome" on AI (OR 2.53; 95% CI 1.01-6.38).Co-morbidity (OR 2.8; 95% CI 1.17-6.88), and "VAS-pain at baseline â¥51 mm" (OR3.1; 95% CI 1.34-7.23) were associated with a higher number of treatmentsessions. CONCLUSION AND CLINICAL REHABILITATION IMPACT: and Quality indicatorsshowed that a group of well-informed physical therapists could to a large extent adhere to key recommendations of the guideline and that clinically relevantimprovements were obtained in terms of pain and physical functioning. Prognostic factors for poorer outcome on outcome indicators were comorbidity, a higher pain score at baseline and the combination ">12 months' duration of complaints and age

â¥65".PMID: 20926999 [PubMed - indexed for MEDLINE]

46. Eur J Phys Rehabil Med. 2009 Sep;45(3):303-17. Epub 2009 Feb 23.

Rehabilitation after total hip arthroplasty: a systematic review of controlledtrials on physical exercise programs.

Di Monaco M, Vallero F, Tappero R, Cavanna A.

Osteoporosis Research Center, San Camillo Hospital, Turin, Italy.

[email protected]

Total hip arthroplasty (THA) has revolutionized the care of patients withend-stage joint disease, leading to pain relief, functional recovery, andsubstantial improvement in quality of life. However, long-term studies indicatepersistence of impairment and functional limitation after THA, and the optimalrehabilitation protocols are largely unknown. The aim of this paper was tosystematically review the controlled trials published on the effectiveness ofphysical exercise programs after THA. Nine studies were retrieved from MEDLINEand reviewed. Results show that the physical exercise protocols most frequently



used after THA in the early postoperative phase are neither supported nor denied by clinical controlled trials. Convincing evidence for the effectiveness ofsingle interventions in addition to usual exercise programs exists for each ofthe three following options: treadmill training with partial body-weight support,unilateral resistance training of the quadriceps muscle (operated side), andarm-interval exercises with an arm ergometer. In the late postoperative phase(operation interval > 8 weeks) exercise programs consistently improve bothimpairment and ability to function. Weight-bearing exercises with hip-abductoreccentric strengthening may be the crucial component of the late-phase protocols.Substantial limitations were found in the nine studies, including small samplesize, patient selection, heterogeneity of outcome assessments, and potentialsources of variability not investigated. Despite limitations, we conclude thatthree main suggestions emerge from controlled trials on physical exercise afterTHA: early postoperative protocols should include additive interventions whoseeffectiveness has been shown. Late postoperative programs are useful and shouldcomprise weight-bearing exercises with hip-abductor eccentric strengthening.


47. Eura Medicophys. 2005 Jun;41(2):155-61.

Physical therapy and rehabilitation programs in the management of hiposteoarthritis.

Arokoski JP.

Department of Physical and Rehabilitation Medicine Kuopio University Hospital,Finland. [email protected]

Nonpharmacological treatment programmes are as important as drug treatment in hiposteoarthritis (OA). Drugs (analgesic and nonsteroidal anti-inflammatory drugs)should not be used as sole treatments in hip OA. Patient education and weight

reduction are the primary therapeutic approaches. Different types of exercisesare beneficial for patients with hip OA. Occupational therapy plays a centralrole in the management of hip OA patients with functional limitations. More andbetter-designed trials are needed to evaluate the efficacy of nonpharmacological treatment programmes used in hip OA.


48. Health Technol Assess. 2005 Aug;9(31):iii-iv, ix-xi, 1-114.

Randomised controlled trial of the cost-effectiveness of water-based therapy for

lower limb osteoarthritis.

Cochrane T, Davey RC, Matthes Edwards SM.

Faculty of Health and Sciences, Staffordshire University, Stoke-on-Trent, UK.

OBJECTIVES: To determine the efficacy of community water-based therapy for themanagement of lower limb osteoarthritis (OA) in older patients.DESIGN: A pre-experimental matched-control study was used to estimate efficacy o



fwater-based exercise treatment, to check design assumptions and deliveryprocesses. The main study was a randomised controlled trial of the effectiveness of water-based exercise (treatment) compared with usual care (control) in olderpatients with hip and/or knee OA. The latter was accompanied by an economicevaluation comparing societal costs and consequences of the two treatments.SETTING: Water exercise was delivered in public swimming pools in the UK.Physical function assessments were carried out in established laboratorysettings.PARTICIPANTS: 106 patients (93 women, 13 men) over the age of 60 years withconfirmed hip and/or knee OA took part in the preliminary study. A similar, butlarger, group of 312 patients (196 women, 116 men) took part in the main study,randomised into control (159) and water exercise (153) groups.INTERVENTIONS: Control group patients received usual care with quarterlysemi-structured telephone interview follow-up only. The intervention in the main study lasted for 1 year, with a further follow-up period of 6 months.MAIN OUTCOME MEASURES: Pain score on the Western Ontario and McMasterUniversities OA index (WOMAC). Additional outcome measures were included toevaluate effects on quality of life, cost-effectiveness and physical functionmeasurements.RESULTS: Short-term efficacy of water exercise in the management of lower limb OA

was confirmed, with effect sizes ranging from 0.44 [95% confidence interval (CI) 0.03 to 0.85] on WOMAC pain to 0.76 (95% CI 0.33 to 1.17) on WOMAC physicalfunction. Of 153 patients randomised to treatment, 82 (53.5%) were estimated tohave complied satisfactorily with their treatment at the 1-year point. This haddeclined to 28 (18%) by the end of the 6-month follow-up period, during whichsupport for the intervention had been removed and those wishing to continueexercise had to pay their own costs for maintaining their exercise treatment.High levels of co-morbidity were recorded in both groups. Nearly two thirds ofall patients had a significant other illness in addition to their OA. Fifty-four control and 53 exercise patients had hospital inpatient episodes during the study

period. Water exercise remained effective in the main study but overall effectsize was small, on WOMAC pain at 1 year, a reduction of about 10% in group meanpain score. This had declined, and was non-significant, at 18 months. Mean costdifference estimates showed a saving in the water exercise group of pound123--175per patient per annum and incremental cost-effectiveness ratios ranged frompound3838 to pound5951 per quality-adjusted life-year (QALY). Net reduction inpain was achieved at a net saving of pound135--175 per patient per annum and the ceiling valuation of pound580--740 per unit of WOMAC pain reduction wasfavourably low.CONCLUSIONS: Group-based exercise in water over 1 year can produce significantreduction in pain and improvement in physical function in older adults with lowe

rlimb OA, and may be a useful adjunct in the management of hip and/or knee OA. Thewater-exercise programme produced a favourable cost--benefit outcome, usingreduction in WOMAC pain as the measure of benefit. Further research is suggested into other similar public health interventions. Investigation is also needed intohow general practice can best be supported to facilitate access to participantsfor research trials in healthcare, as well as an examination of the



infrastructure and workforce capacities for physical activity delivery and thepotential extent to which healthcare may be supported in this way. More detailed research is required to develop a better understanding of the types of exercisethat will work for the different biomechanical subtypes of knee and hip OA andinvestigation is needed on access and environmental issues for physical activity programmes for older people, from both a provider and a participant perspective, the societal costs of the different approaches to the management of OA and longerterm trends in outcome measures (costs and effects).


49. Int Orthop. 2012 Mar;36(3):491-8. doi: 10.1007/s00264-011-1280-0. Epub 2011May25.

Reduced postoperative pain in total hip arthroplasty after minimal-invasiveanterior approach.

Goebel S, Steinert AF, Schillinger J, Eulert J, Broscheit J, Rudert M, NÃ¶th U.

Department of Orthopaedic Surgery, KÃ¶nig-Ludwig-Haus, Julius-MaximiliansUniversity, Brettreichstr. 11, 97074, WÃ¼rzburg, [email protected]

PURPOSE: The development of minimal-incision techniques for total hip replacementwith preservation of soft tissue is generally associated with fasterrehabilitation, reduction of postoperative pain and increased patient comfort.The aim of this study was to compare a minimal-incision anterior approach with a transgluteal lateral technique for hip replacement surgery with respect topostoperative pain, consumption of rescue medication, length of hospital stay an

dtime to reach a defined range of motion.METHODS: In this retrospective cohort study we investigated 100 patients with aminimal-incision anterior approach (group I) and 100 patients with a transgluteallateral approach (group II) retrospectively undergoing unilateral hipreplacement. The study variables were pain at rest and during physiotherapy,amount of rescue medication, the time to reach a defined flexion and time inhospital.RESULTS: The patients of group I consumed less rescue medication (19.6âÂ±â6.9 mgvs. 23.6âÂ±â11.3 mg; âp =â0.005) and experienced less pain on the day of surger(1.3âÂ±â1 vs. 2.3âÂ±â1.3, pâ=â0.0001) and the first postoperative day (0.41vs. 0.66âÂ±â1.1, pâ=â0.036). The time to reach the defined range of motion

(6.4âÂ±â2 days vs. 7.4âÂ±â2.1 days; pâ=â0.001) and the length of hospital sshorter (10.2âÂ±â1.9 days vs. 13.4âÂ±â1.6 days; pâ=â0.0001) for group I. Hopain during physiotherapy was higher on the third and sixth through ninth daysafter surgery in comparison to group II (pâ=â0.001-0.013).CONCLUSION: The implantation of a hip prosthesis through a minimal-incisionanterior approach is successful in reducing postoperative pain and consumption ofpain medication. Time to recovery and length of hospital stay are also influencedpositively. Pain increases during physiotherapy, and may be mitigated by adoptin



glimited weight bearing during the early postoperative period.


50. Int Orthop. 2006 Oct;30(5):395-8. Epub 2006 Mar 28.

Reducing incision length or intensifying rehabilitation: what makes thedifference to length of stay in total hip replacement in a UK setting?

Peck CN, Foster A, McLauchlan GJ.

Department of Orthopaedic Surgery, Chorley & South Ribble District GeneralHospital, Lancashire Teaching Hospitals, NHS Trust, Preston Road, Chorley,Lancashire, PR7 1PP, UK. [email protected]

Minimal-incision surgery for hip arthroplasty and intensive post-op physiotherapyhave both been shown to allow early mobilisation and to reduce hospital stay.Forty-five patients undergoing primary total hip arthroplasty using a standardposterior approach were compared with 51 patients using a minimal incision. Inboth groups, physiotherapy involved either a routine or intensive regime.

Patients were matched in age, sex and body mass index. There was no significantdifference in blood loss, post-operative stay and change in Oxford hip scores at one year between the mini- and standard-incision groups. There was a significant difference (P=0.003) in length of stay between routine- andintensive-physiotherapy groups (11.4 vs. 7.9 days). The dislocation rate washigher in the mini-incision group. This study suggests that in a standard UKsetting, intensive physiotherapy can significantly decrease in-patient stay, but reducing the incision length does not.

PMCID: PMC3172761


51. J Am Osteopath Assoc. 2004 May;104(5):193-202.

A randomized controlled trial of osteopathic manipulative treatment followingknee or hip arthroplasty.

Licciardone JC, Stoll ST, Cardarelli KM, Gamber RG, Swift JN Jr, Winn WB.

University of North Texas Health Science Center at Fort Worth-Texas College ofOsteopathic Medicine, 3500 Camp Bowie Blvd, Fort Worth, TX 76107, [email protected]

Comment inJ Am Osteopath Assoc. 2004 Oct;104(10):405-6; author reply 406.

CONTEXT: Preliminary study results suggest that osteopathic manipulativetreatment (OMT) may reduce pain, improve ambulation, and increase rehabilitation efficiency in patients undergoing knee or hip arthroplasty.OBJECTIVE: To determine the efficacy of OMT in patients who recently underwentsurgery for knee or hip osteoarthritis or for a hip fracture.



DESIGN: Randomized controlled trial involving hospital and postdischarge phases.SETTING: Hospital-based acute rehabilitation unit.PATIENTS: A total of 42 women and 18 men who were hospitalized between October1998 and August 1999.INTERVENTION: Patients were randomly assigned to groups that received either OMT or sham treatment in addition to standard care. Manipulation was individualizedand performed according to study guidelines regarding frequency, duration, andtechnique.MAIN OUTCOME MEASURES: Changes in Functional Independence Measure (FIM) scoresand in daily analgesic use during the rehabilitation unit stay; length of stay;rehabilitation efficiency--defined as the FIM total score change perrehabilitation unit day; and changes in Medical Outcomes Study Short Form-36scores from rehabilitation unit admission to 4 weeks after discharge.RESULTS: Of 19 primary outcome measures, the only significant difference between groups was decreased rehabilitation efficiency with OMT (2.0 vs 2.6 FIM totalscore points per day; P = .01). Stratified analyses demonstrated that poorer OMT outcomes were confined to patients with osteoarthritis who underwent total kneearthroplasty (length of stay, 15.0 vs 8.3 days; P = .004; rehabilitationefficiency, 2.1 vs 3.4 FIM total score points per day; P < .001).CONCLUSION: The OMT protocol used does not appear to be efficacious in thishospital rehabilitation population.


52. J Appl Physiol. 2004 Nov;97(5):1954-61. Epub 2004 Jul 9.

Training-induced changes in muscle CSA, muscle strength, EMG, and rate of forcedevelopment in elderly subjects after long-term unilateral disuse.

Suetta C, Aagaard P, Rosted A, Jakobsen AK, Duus B, Kjaer M, Magnusson SP.

Institute of Sports Medicine, Bispebjerg Hospital, University of Copenhagen, 2400

NV Copenhagen, Denmark. [email protected] ability to develop muscle force rapidly may be a very important factor toprevent a fall and to perform other tasks of daily life. However, information is still lacking on the range of training-induced neuromuscular adaptations inelderly humans recovering from a period of disuse. Therefore, the present studyexamined the effect of three types of training regimes after unilateral prolongeddisuse and subsequent hip-replacement surgery on maximal muscle strength, rapidmuscle force [rate of force development (RFD)], muscle activation, and musclesize. Thirty-six subjects (60-86 yr) were randomized to a 12-wk rehabilitationprogram consisting of either 1) strength training (3 times/wk for 12 wk), 2)

electrical muscle stimulation (1 h/day for 12 wk), or 3) standard rehabilitation (1 h/day for 12 wk). The nonoperated side did not receive any intervention andthereby served as a within-subject control. Thirty subjects completed the trial. In the strength-training group, significant increases were observed in maximalisometric muscle strength (24%, P < 0.01), contractile RFD (26-45%, P < 0.05),and contractile impulse (27-32%, P < 0.05). No significant changes were seen inthe two other training groups or in the nontrained legs of all three groups. Mean



electromyogram signal amplitude of vastus lateralis was larger in thestrength-training than in the standard-rehabilitation group at 5 and 12 wk (P <0.05). In contrast to traditional physiotherapy and electrical stimulation,strength training increased muscle mass, maximal isometric strength, RFD, andmuscle activation in elderly men and women recovering from long-term muscledisuse and subsequent hip surgery. The improvement in both muscle mass and neuralfunction is likely to have important functional implications for elderlyindividuals.


53. J Bone Joint Surg Br. 2004 Jul;86(5):639-42.

Mechanical prophylaxis of deep-vein thrombosis after total hip replacement arandomised clinical trial.

Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J.

Department of Orthopaedic Surgery, Middlemorc Hospital, South Auckland ClinicalSchool, University of Auckland, Auckland, New Zealand.

Routine prophylaxis for venous thromboembolic disease after total hip replacemen

t(THR) is recommended. Pneumatic compression with foot pumps seems to provide analternative to chemical agents. However, the overall number of patientsinvestigated in randomised clinical trials has been too small to drawevidence-based conclusions. This randomised clinical trial was carried out tocompare the effectiveness and safety of mechanical versus chemical prophylaxis ofDVT in patients after THR. Inclusion criteria were osteoarthritis of the hip and age less than 80 years. Exclusion criteria included a history of thromboembolicdisease, heart disease, and bleeding diatheses. There were 216 consecutivepatients considered for inclusion in the trial who were randomised either formanagement with the A-V Impulse System foot pump. We excluded 16 patients who di

dnot tolerate continuous use of the foot pump or with low-molecular-weight heparin(LMWH). Patients were monitored for DVT using serial duplex sonography at 3, 10and 45 days after surgery. DVT was detected in three of 100 patients in thefoot-pump group and with six of 100 patients in the LMWH group (p < 0.05). Themean post-operative drainage was 259 ml in the foot-pump group and 328 ml in the LMWH group (p < 0.05). Patients in the foot-pump group had less swelling of thethigh (10 mm compared with 15 mm; p < 0.05). One patient developedheparin-induced thrombocytopenia. This study confirms the effectiveness andsafety of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the

foot pump.


54. J Orthop Sports Phys Ther. 2009 Dec;39(12):858-66. doi: 10.2519/jospt.2009.3207.

Conservative management of a young adult with hip arthrosis.



Cook KM, Heiderscheit B.

Physical Therapy Orthopaedic Specialists, Inc, Plymouth, MN, [email protected]

STUDY DESIGN: Case report.BACKGROUND: Clinical practice guidelines regarding the conservative management ofdegenerative hip conditions in older adults routinely incorporate therapeuticexercise and manual therapy. However, the application of these recommendations toyoung, active adults is less clear. The purpose of this case report is todescribe the management of a young adult with advanced hip arthrosis using amultifaceted rehabilitation program.CASE DESCRIPTION: A 28-year-old female with severe left hip degeneration, asidentified with diagnostic imaging, was referred to physical therapy. Reduced hiprange of motion and strength, sacroiliac joint asymmetries, and a modified HarrisHip Score of 76 were observed. She was seen for 12 visits over a 3-month periodand treated with an individualized program including manual therapy, therapeutic exercise, and neuromuscular re-education.OUTCOME: Substantial improvements were noted in pain, hip range of motion, and

strength and function (modified Harris Hip Score of 97). In addition, shediscontinued the use of anti-inflammatory medications and returned to her priorlevel of activity. Improvements were maintained at a 3-month follow-up, withsymptom recurrence managed using a self-mobilization technique to the left hipand massage to the left iliopsoas.DISCUSSION: Degenerative hip conditions are common among older adults but arerelatively rare in the younger population. Although it is likely that thispatient will experience a return of her symptoms and functional limitations asher hip disease progresses, the immediate improvements may delay the need foreventual surgical management. These outcomes suggest that physical therapymanagement should be considered in those with an early onset of degenerative hip disease and are consistent with results previously reported in the older

population.LEVEL OF EVIDENCE: Therapy, level 4.


55. J Physiother. 2010;56(1):41-7.

Behavioural graded activity results in better exercise adherence and morephysical activity than usual care in people with osteoarthritis: acluster-randomised trial.

Pisters MF, Veenhof C, de Bakker DH, Schellevis FG, Dekker J.

Netherlands Institute for Health Services Research (NIVEL), Utrecht, TheNetherlands. [email protected]

QUESTION: Does behavioural graded activity result in better exercise adherenceand more physical activity than usual care in people with osteoarthritis of thehip or knee?DESIGN: Analysis of secondary outcomes of a cluster-randomised trial withconcealed allocation, assessor blinding, and intention-to-treat analysis.



PARTICIPANTS: Two hundred patients with hip and/or knee osteoarthritis.INTERVENTION: Experimental group received 18 sessions of behavioural gradedactivity over 12 weeks and up to 7 booster sessions over the next year. Thecontrol group received 18 sessions of usual care over 12 weeks according to theDutch physiotherapy guideline.OUTCOME MEASURES: Exercise adherence was measured using a questionnaire andphysical activity was measured using the SQUASH questionnaire at baseline, 13,and 65 weeks.RESULTS: Adherence to recommended exercises was significantly higher in theexperimental group than in the control group at 13 weeks (OR 4.3, 95% CI 2.1 to9.0) and at 65 weeks (OR 3.0, 95% CI 1.5 to 6.0). Significantly more of theexperimental than the control group met the recommendations for physical activityat 13 weeks (OR 5.3, 95% CI 1.9 to 14.8) and at 65 weeks (OR 2.9, 95% CI 1.2 to6.7).CONCLUSION: Behavioural graded activity results in better exercise adherence and more physical activity than usual care in people with osteoarthritis of the hipor knee, both in the short- and long-term.TRIAL REGISTRATION: NCT00522106.


56. J Rehabil Res Dev. 2004 Jul;41(4):611-20.Perceived exertion and rehabilitation with arm crank in elderly patients aftertotal hip arthroplasty: a preliminary study.

Grange CC, Maire J, Groslambert A, Tordi N, Dugue B, Pernin JN, Rouillon JD.

Laboratory of Sport Sciences (Unite de formation en sciences et techniques desactivites physiques et sportives[UFRSTAPS]) of BesanÃ§on, BesanÃ§on, [email protected]

This preliminary study examined, in a restricted randomized trial, the effects of

a 6-week arm-crank rehabilitation training program in elderly osteoarthrosispatients after total hip arthroplasty, first on physiological and perceptualresponses and second on physical function. Two groups of patients were studied:atraining group (N = 7, mean age = 74.9 yr, standard deviation [SD] = 5.0 yr) who followed a training program in addition to traditional rehabilitation, and acontrol group who followed traditional rehabilitation only (N = 7 mean age = 75.4yr, SD = 5.1 yr). At the beginning of the training program, the heart rate andthe perceived exertion were not significantly correlated during the exercisesession. However, at the end of the training program, five patients had asignificant heart rate/perceived exertion relationship (p < 0.05). Furthermore,

positive effects of the arm-crank rehabilitation training program were observedon cardioventilatory and functional responses in the training group compared withthe control group. These results suggest that after an habituation period, mostof our elderly osteoarthrosis patients experienced physical sensations that were connected to physiological responses. Therefore, perceived exertion could beuseful in these patients to regulate exercise intensity, especially at the end ofand after the rehabilitation period.




57. N Engl J Med. 2008 Jan 31;358(5):534; author reply 534-5. doi:10.1056/NEJMc073030.

Osteoarthritis of the hip.

Hando BR, Gill NW 3rd.

Comment onN Engl J Med. 2007 Oct 4;357(14):1413-21.


58. Phys Ther. 2011 Oct;91(10):1525-41. doi: 10.2522/ptj.20100430. Epub 2011 Aug4.

Building the rationale and structure for a complex physical therapy intervention within the context of a clinical trial: a multimodal individualized treatment for

patients with hip osteoarthritis.Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Buchbinder R.

Centre for Health, Exercise and Sports Medicine, School of Health Sciences,University of Melbourne, 200 Berkeley St, Carlton, Melbourne, Victoria 3010,Australia. [email protected]

Evaluating the efficacy of complex interventions such as multimodal,impairment-based physical therapy treatments in randomized controlled trials isessential to inform practice and compare relative benefits of available treatmentoptions. Studies of physical therapy interventions using highly standardized

intervention protocols, although methodologically rigorous, do not necessarilyreflect "real-world" clinical practice, and in many cases results have beendisappointing. Development of a complex intervention that includes multipletreatment modalities and individualized treatment technique selection requires a systematic approach to designing all aspects of the intervention based on theory,evidence, and practical constraints. This perspective article outlines thedevelopment of the rationale and structure of a multimodal physical therapyprogram for painful hip osteoarthritis to be assessed in a clinical trial. Theresulting intervention protocol comprises a semi-structured program of exercises and manual therapy, advice, physical activity, and optional prescription of a

gait aid that is standardized, yet can be individualized according to physicalassessment and radiographic findings. The program is evidence based and reflects contemporary physical therapist practice, while also being reproducible andreportable. This perspective article aims to encourage physical therapyresearchers involved in evaluation of complex interventions to better documenttheir own intervention development, as well as the outcomes, thus generating abody of knowledge about the development processes and protocols that isgeneralizable to the real-world complexity of providing physical therapy toindividual patients.




59. Phys Ther. 2011 Apr;91(4):510-24. doi: 10.2522/ptj.20100171. Epub 2011 Feb 10.

Predictors of response to physical therapy intervention in patients with primary hip osteoarthritis.

Wright AA, Cook CE, Flynn TW, Baxter GD, Abbott JH.

University of Illinois at Chicago Medical Center, Chicago, IL 60612, [email protected]

BACKGROUND: Few studies have investigated or identified common clinical tests andmeasures as being associated with progression of hip osteoarthritis (OA); fewerstill are longitudinal studies exploring prognostic variables associated withlong-term outcome following physical therapy treatment.OBJECTIVE: The purpose of this study was to determine a set of prognostic factorsthat maximize the accuracy of identifying patients with hip osteoarthritis (OA)

likely to demonstrate a favorable response to physical therapy intervention.DESIGN: This was a prognostic study.METHODS: Ninety-one patients with a clinical diagnosis of hip OA were analyzed todetermine which clinical measures, when clustered together, were most predictive of a favorable response to physical therapy intervention. Responders weredetermined based on OMERACT-OARSI response criteria, which included percent andabsolute changes in pain, function, and global rating of change over 1 year.These data served as the reference standard for determining the predictivevalidity of baseline clinical examination variables. Using multivariateregression analyses and calculations for sensitivity, specificity, and positiveand negative likelihood ratios, a cluster was identified.

RESULTS: Five baseline variables (unilateral hip pain, age of â¤58 years, pain ofâ¥6/10 on a numeric pain rating scale, 40-m self-paced walk test time of â¤25.9seconds, and duration of symptoms of â¤1 year) were retained in the final model.Failure to exhibit a condition of 1 of the 5 predictor variables decreased theposttest probability of responding favorably to physical therapy interventionfrom 32% to <1% (negative likelihood ratio=0.00, 95% confidenceinterval=0.00-0.70). Having at least 2 out of 5 predictor variables at baselineincreased the posttest probability of success with physical therapy intervention from 32% to 65% (positive likelihood ratio=3.99, 95% confidenceinterval=2.66-4.48), and having 3 or more of 5 predictor variables increased the posttest probability of success to 99% or higher. A comparison with a control

group that did not receive physical therapy further substantiated the cluster.LIMITATIONS: The small sample size and the number of variables entered into thelogistic regression model may have resulted in spurious findings. This study mustbe validated in replication studies before it can be considered for use inclinical practice.CONCLUSIONS: This study completed the first step in the development of apreliminary cluster of baseline variables that identify patients with hip OA aspositive responders to physical therapy intervention.




60. Phys Ther. 2010 Apr;90(4):592-601. doi: 10.2522/ptj.20090083. Epub 2010 Feb25.

Development of a therapeutic exercise program for patients with osteoarthritis ofthe hip.

Fernandes L, Storheim K, Nordsletten L, Risberg MA.

Norwegian Research Center for Active Rehabilitation, Orthopedic Centre, OsloUniversity Hospital, Ullevaal and Hjelp24NIMI, Oslo, [email protected]

BACKGROUND AND PURPOSE: No detailed exercise programs specifically for patientswith hip osteoarthritis (OA) have been described in the literature. This lack of data creates a gap between the recommendation that people with OA should exerciseand the type and dose of exercises that they should perform. The purpose of this case report is to describe and demonstrate the use of a therapeutic exercise

program for a patient with hip OA.CASE DESCRIPTION: A 58-year-old woman with hip OA completed a 12-week therapeuticexercise program (TEP) with a 6-month follow-up. The patient reported hip pain,joint stiffness, and limited physical function, and she had decreased hip rangeof motion (ROM) at baseline.OUTCOMES: The patient performed 19 sessions during the TEP, with a mean of 19.5exercises per session. She increased the resistance in 3 of 5 strength(force-generating capacity) training exercises and achieved the highest degree ofdifficulty in all functional exercises. During the TEP and follow-up, the patientreported improvements in pain, joint stiffness, and physical function.

Performance improved on the following physical tests: isokinetic peak torquestrength (60 degrees /s) in hip extension (40%), hip flexion (27%), kneeextension (17%), and knee flexion (42%); hip ROM extension (8 degrees ); and6-minute walk distance (83 m).DISCUSSION: The patient experienced less pain and improved physical function and physical test outcomes after intervention and at the 6-month follow-up. The main challenges when prescribing an exercise program for a patient with hip OA aremonitoring the exercises to provide improvements without provoking persistentpain and motivating the patient to achieve long-term adherence to exercising.Randomized clinical trials are needed to evaluate the efficacy of this TEP inpatients with hip OA.


61. Phys Ther. 2008 Dec;88(12):1591-600. doi: 10.2522/ptj.20080038. Epub 2008 Oct 23.

Use of joint mobilization in a patient with severely restricted hip motionfollowing bilateral hip resurfacing arthroplasty.



Crow JB, Gelfand B, Su EP.

Sports Therapy and Rehabilitation, 160 E 56th St, New York, NY 10022, [email protected]

BACKGROUND AND PURPOSE: Hip resurfacing arthroplasty (HRA) is an alternative for management of end-stage osteoarthritis (OA) in young patients with high activity demands and offers several advantages over total hip arthroplasty. Severelyrestricted hip motion is a rare complication of the surgery. The purpose of this case report is to describe the treatment for a patient who developed severelyrestricted hip motion following bilateral HRA.CASE DESCRIPTION: A 43-year-old, athletic man underwent bilateral HRA anddeveloped severely restricted hip motion. At 3 months postoperatively, thepatient had approximately 90 degrees of hip flexion and 10 degrees of lateralrotation bilaterally. A multimodal treatment approach with an emphasis on jointmobilization was incorporated to improve hip joint mobility by restoringaccessory motion.OUTCOMES: The patient's passive range of motion (PROM) and Harris Hip Score (HHS)at the time of discharge showed clinically significant improvements. Totaldisability, as measured by the HHS, improved by 13 points, and total PROM

increased 82 degrees in the right hip and 101 degrees in the left hip. Thepatient became independent and had full return to all activities and sports.DISCUSSION: The patient showed clinically meaningful improvements in PROMmeasurements and functional activities during a course of care using a multimodaltreatment approach with an emphasis on joint mobilization. This is the first casereport to describe the treatment for a patient who developed severely restricted hip motion following bilateral HRA.


62. Phys Ther. 2007 Jan;87(1):32-43. Epub 2006 Dec 1.

Aquatic physical therapy for hip and knee osteoarthritis: results of asingle-blind randomized controlled trial.

Hinman RS, Heywood SE, Day AR.

Centre for Health Exercise and Sports Medicine, University of Melbourne,Melbourne, Victoria, Australia. [email protected]

BACKGROUND AND PURPOSE: Aquatic physical therapy is frequently used in themanagement of patients with hip and knee osteoarthritis (OA), yet there is littl

eresearch establishing its efficacy for this population. The purpose of this studywas to evaluate the effects of aquatic physical therapy on hip or knee OA.SUBJECTS: A total of 71 volunteers with symptomatic hip OA or knee OAparticipated in this study.METHODS: The study was designed as a randomized controlled trial in whichparticipants randomly received 6 weeks of aquatic physical therapy or no aquatic physical therapy. Outcome measures included pain, physical function, physical



activity levels, quality of life, and muscle strength.RESULTS: The intervention resulted in less pain and joint stiffness and greaterphysical function, quality of life, and hip muscle strength. Totals of 72% and75% of participants reported improvements in pain and function, respectively,compared with only 17% (each) of control participants. Benefits were maintained6weeks after the completion of physical therapy, with 84% of participantscontinuing independently.DISCUSSION AND CONCLUSION: Compared with no intervention, a 6-week program ofaquatic physical therapy resulted in significantly less pain and improvedphysical function, strength, and quality of life. It is unclear whether thebenefits were attributable to intervention effects or a placebo response.


63. Rheumatology (Oxford). 2007 Nov;46(11):1712-7.

Arthritis patients show long-term benefits from 3 weeks intensive exercisetraining directly following hospital discharge.

Bulthuis Y, Drossaers-Bakker KW, Taal E, Rasker J, Oostveen J, van't Pad Bosch P,Oosterveld F, van de Laar M.

Institute for Behavioral Research, University of Twente, Enschede, TheNetherlands.

OBJECTIVE: To examine the efficacy of short-term intensive exercise training(IET) directly following hospital discharge.METHODS: In the Disabled Arthritis Patients Post-hospitalization IntensiveExercise Rehabilitation (DAPPER) study, patients with rheumatoid arthritis orosteoarthritis were eligible when they needed hospitalization for either aflare-up in disease, elective hip or knee arthroplasty. The intervention groupreceived IET for 3 weeks immediately after discharge; the control group wastreated with the usual care (UC). The intensive exercise was provided in aresort. Outcomes were assessed at baseline, after 3, 13, 26 and 52 weeks. Range

of motion was measured using the Escola Paulista de Medicina-Range of Motionscale (EPM-ROM), disability was measured using the HAQ and the McMaster TorontoArthritis Patient Preference Disability Questionnaire (MACTAR), and forhealth-related quality of life (HRQoL), the Research and Development 36-ItemHealth Survey (RAND-36) was used.RESULTS: The IET showed a better and faster improvement than UC on all outcomemeasures except for HRQoL. Up to 52 weeks after baseline, the EPM-ROM and theMACTAR remained favourable in IET compared with UC. At 3 weeks, the MACTARimproved significantly more in the IET compared with the UC: mean difference -5.5(95% CI -8.4 to -2.2). At 26 weeks, the mean difference remained significant(-5.2; 95% CI -10.0 to -0.34). At 52 weeks, the effect was not significant;however, the mean difference in improvement between the groups can be considered

clinically relevant. At 3 weeks, the IET had improved significantly more on theHAQ walking and rising subscales.CONCLUSION: Intensive short-term exercise training of arthritis patients,immediately after hospital discharge results in improved regain of function. The DAPPER programme has a direct effect, which lasts up to 52 weeks.




64. Rheumatology (Oxford). 2005 Jan;44(1):67-73. Epub 2004 Sep 7.

Evidence-based recommendations for the role of exercise in the management ofosteoarthritis of the hip or knee--the MOVE consensus.

Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, Carr A, ChakravartyK, Dickson J, Hay E, Hosie G, Hurley M, Jordan KM, McCarthy C, McMurdo M, MockettS, O'Reilly S, Peat G, Pendleton A, Richards S.

Academic Rheumatology, Clinical Sciences Building, Nottingham City Hospital,Hucknall Road, Nottingham NG5 1PB, UK. [email protected].

Comment inRheumatology (Oxford). 2005 Jan;44(1):5-6.

OBJECTIVES: Exercise is an effective and commonly prescribed intervention forlower limb osteoarthritis (OA). Many unanswered questions remain, however,concerning the practical delivery of exercise therapy. We have producedevidence-based recommendations to guide health-care practitioners.METHODS: A multidisciplinary guideline development group was formed fromrepresentatives of professional bodies to which OA is of relevance and otherinterested parties. Each participant contributed up to 10 propositions describin

gkey clinical points regarding exercise therapy for OA of the hip or knee. Tenfinal recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline,PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted andeffect sizes calculated. The evidence for each recommendation was assessed andexpert consensus highlighted by the allocation of two categories: (1) strength ofevidence and (2) strength of recommendation.RESULTS: The first round of the Delphi process produced 123 propositions. This

was reduced to 10 after four rounds. These related to aerobic and strengtheningexercise, group versus home exercise, adherence, contraindications and predictorsof response. The literature search identified 910 articles; 57 interventiontrials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence tosupport each proposition is presented.CONCLUSION: These are the first recommendations for exercise in hip and knee OAto clearly differentiate research evidence and expert opinion. Gaps in theliterature are identified and issues requiring further study highlighted.


65. Rheumatology (Oxford). 2005 Apr;44(4):461-4. Epub 2005 Feb 3.

Manual therapy in osteoarthritis of the hip: outcome in subgroups of patients.

Hoeksma HL, Dekker J, Ronday HK, Breedveld FC, Van den Ende CH.

Department of PB&R, St Antonius Hospital, Niewegein. [email protected]

OBJECTIVE: To investigate whether manual therapy has particular benefit insubgroups of patients defined on the basis of hip function, range of joint



motion, pain and radiological deterioration.METHODS: The study was performed in the out-patient clinic of physical therapy ofa large hospital. Data on 109 patients with OA of the hip (clinical ACR criteria)participating in a randomized clinical trial on the effects of manual therapywere used. The outcomes for hip function (Harris hip score), range of jointmotion (ROM) and pain (VAS) were compared for specific subgroups. Subgroups were assigned by the median split method. The interaction effect between subgroup and treatment was tested using multiple regression analysis.RESULTS: No differences were observed in the effect of manual therapy in specificsubgroups of patients defined on the basis of baseline levels of hip function,pain and ROM. On the basis of radiological grading of osteoarthritis (OA), wefound that patients with severe radiological grading of OA had significantlyworse outcome on ROM as a result of manual therapy than patients with mild ormoderate radiological grading of OA.CONCLUSION: A significant interaction effect was found for only 1 out of 12hypotheses investigated. Therefore, we conclude that there is no evidence for theparticular benefit of manual therapy in subgroups of patients.


66. Tidsskr Nor Laegeforen. 2010 Nov 4;130(21):2136-40. doi: 10.4045/tidsskr.09.1054.

[Osteoarthritis].

[Article in Norwegian]

Flugsrud GB, Nordsletten L, Reinholt FP, Risberg MA, Rydevik K, Uhlig T.

Ortopedisk avdeling, Oslo universitetssykehus, UllevÃ¥l, 0407 Oslo, Norway.

[email protected]: Osteoarthritis is among the most common causes of functionaldisability and severe pain, and the prevalence of arthritic symptoms among adultsis more than 50%. The article discusses epidemiology, pathology and treatmentoptions.MATERIAL AND METHODS: The review is based on a non-systematic search in PubMedand the authors' experience with treating this patient group.RESULTS: Osteoarthritis is a degenerative disease which leads to loss of jointfunctioning. Symptoms usually present in the hip, hands and knees. Women areaffected more often than men and the prevalence increases with increasing age.Some families have an increased prevalence of osteoarthritis, but the genetic

etiology is not clear. Mechanic conditions such as overweight and heavy physical work explain some of the pathogenesis, but non-mechanical factors are probablyinvolved as well. Loss of weight is likely to have a preventive effect, andsurgical correction of mechanic conditions such as hip dysplasia and varusdeformity can prevent development of osteoarthritis. Treatment of symptomaticosteoarthritis includes educating the patient and continues with stretching,physical exercise, weight reduction, technical aids (supporting braces, walkingsticks) and analgesics. Subsequent options are treatment with paracetamol, NSAIDs



and possibly opiates and finally insertion of an artificial joint. Many patients with disabling osteoarthritis function much better and have markedly less painwith an artificial joint.INTERPRETATION: Current treatment options alleviate but do not cure arthriticsymptoms; preventive actions should be instigated when possible. Treatment ofosteoarthritis involves many medical specialties and treatment modalities.


67. Trials. 2009 Feb 8;10:11. doi: 10.1186/1745-6215-10-11.

Exercise therapy, manual therapy, or both, for osteoarthritis of the hip or knee:a factorial randomised controlled trial protocol.

Abbott JH, Robertson MC, McKenzie JE, Baxter GD, Theis JC, Campbell AJ; MOA Trialteam.

Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. [email protected]

BACKGROUND: Non-pharmacological, non-surgical interventions are recommended asthe first line of treatment for osteoarthritis (OA) of the hip and knee. There isevidence that exercise therapy is effective for reducing pain and improvingfunction in patients with knee OA, some evidence that exercise therapy iseffective for hip OA, and early indications that manual therapy may beefficacious for hip and knee OA. There is little evidence as to which approach ismore effective, if benefits endure, or if providing these therapies iscost-effective for the management of this disorder. The MOA Trial (Management of OsteoArthritis) aims to test the effectiveness of two physiotherapy intervention

sfor improving disability and pain in adults with hip or knee OA in New Zealand.Specifically, our primary objectives are to investigate whether:1. Exercisetherapy versus no exercise therapy improves disability at 12 months;2. Manualphysiotherapy versus no manual therapy improves disability at 12 months;3.Providing physiotherapy programmes in addition to usual care is morecost-effective than usual care alone in the management of osteoarthritis at 24months.METHODS: This is a 2 x 2 factorial randomised controlled trial. We plan torecruit 224 participants with hip or knee OA. Eligible participants will berandomly allocated to receive either: (a) a supervised multi-modal exercisetherapy programme; (b) an individualised manual therapy programme; (c) bothexercise therapy and manual therapy; or, (d) no trial physiotherapy. All

participants will continue to receive usual medical care. The outcome assessors, orthopaedic surgeons, general medical practitioners, and statistician will beblind to group allocation until the statistical analysis is completed. The trial is funded by Health Research Council of New Zealand Project Grants (Projectnumbers 07/199, 07/200).DISCUSSION: The MOA Trial will be the first to investigate the effectiveness and cost-effectiveness of providing physiotherapy programmes of this kind, for the



management of pain and disability in adults with hip or knee OA.TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ref:ACTRN12608000130369.


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