A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol

ABSTRACT: BACKGROUND: Knee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) in improving pain and psychological impairments particularly in other chronic pain conditions. Though typically provided separately, there are resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognizant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The aim of this randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA. METHODS: This will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited. Participants will be randomised into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Primary outcomes will be pain measured by a Visual Analogue Scale (VAS) and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. The study will be conducted at two sites, Melbourne and Brisbane, Australia to facilitate generalizabilty of the results and to ensure timely recruitment. CONCLUSION: The findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA. The trial design will conform to CONSORT requirements for non-pharmacological treatment. Trial Registration: Australian New Zealand Clinical Trials Registry reference number: ACTRN12610000533099.     

Trunk lean gait modification and knee joint load in people with medial knee osteoarthritis: The effect of varying trunk lean angles

Objective

To evaluate whether increased lateral trunk lean toward the symptomatic lower extremity during gait in people with medial knee osteoarthritis (OA) immediately alters symptoms or medial knee load, as measured by the external knee adduction moment (KAM).

Methods

Participants with medial knee OA (n = 22) underwent 3‐dimensional gait analysis to measure KAM peaks (early and late stance) and KAM impulse. Following the analysis of natural gait, participants were trained to lean their trunk toward the symptomatic leg during ipsilateral stance over 3 randomly ordered conditions (6°, 9°, and 12° lean). A projection screen displayed real‐time trunk angles and target levels. Pain/discomfort in the knees, the hip, and the back were measured across conditions. Load‐modifying effects of increasing lean magnitudes were investigated using linear mixed models. Mediating effects of peak lean timing and participant characteristics (pain and malalignment) were evaluated.

Results

Increased trunk lean reduced all KAM measures (P < 0.001), with larger lean angles achieving greater reductions. Efficacy of load reduction improved with later peak lean timing for all measures of the KAM. Participant characteristics did not mediate the effect of trunk lean on the KAM, and symptoms did not change across conditions (P > 0.05).

Conclusion

Increased trunk lean reduced medial knee load in a dose‐response manner. Slightly later achievement of peak trunk lean improved the load‐modifying effect of this gait strategy. No immediate symptomatic changes were identified. Future research should determine if long‐term implementation of this gait strategy is feasible and whether it can modify disease symptoms and OA progression.     

Successful partnerships are the key to improving Aboriginal health

Partnership is a process that must be recognised as a fundamental part of any strategy for improving health outcomes for Aboriginal people. Addressing the inequities in health outcomes between Aboriginal people and other Australians will require a sustained, coordinated and well-informed approach that works to a set of goals and targets developed with input from the Aboriginal community. Partnerships provide the most effective mechanism for obtaining this essential input from Aboriginal communities and their representative organisations, enabling Aboriginal people to have an influence at all stages of the health-care process. Within the health sector, effective partnerships harness the efforts of governments and the expertise of Aboriginal Community Controlled Health Services, which offer the most effective means of delivering comprehensive primary health care to Aboriginal people.     

Multiple point-of-testing nutrition counseling sessions reduce risk factors for chronic disease among older adults

The objectives of this study were to explore the relationships of baseline dietary intakes and frequency of attendance at point-of-testing nutrition counseling sessions to selected risk factors for chronic diseases during a 3-year intervention. This study was part of a large multidisciplinary, community-based health outreach project conducted in a rural community of northern Louisiana. Screenings, point-of-testing counseling, weekly group exercise sessions, and group nutrition education sessions were provided over a period of 3 years. Outcome variables assessed at 6-month intervals over 3 years were body mass index (BMI), systolic and diastolic blood pressure, fasting blood glucose, and total and LDL cholesterol and dietary intake. Repeated measure analysis of variance was used to investigate the impact of the frequency of counseling sessions on outcome variables. Paired t-tests were used to identify points at which significant changes occurred. A total of 159 subjects ages 65 years and older participated in this study. The majority of the participants were female (62%) and White (82%). Attending the point of testing counseling for more than two sessions was important for a significant improvement in BMI (p ≤ 0.001), LDL cholesterol (p ≤ 0.03), blood glucose (p ≤ 0.03), and diastolic blood pressure (p ≤ 0.045). Participants who attended at least three sessions had significant reductions in risk factors for obesity and related chronic diseases, underscoring the importance of follow-up sessions after health screening.     

Student nurses' reasons behind the decision to receive or decline influenza vaccine: A cross-sectional survey

This cross-sectional questionnaire survey examined influenza vaccination among 430 student nurses. Only 12.2% (95% CI 9.1-15.3%) of student nurses received the seasonal vaccine regularly with 27.6% (95% CI 23.3-31.8%) ever having received seasonal or pandemic H1N1 vaccine. Intention to be vaccinated was associated with having previously been vaccinated (p<0.001) but not whether the vaccine was perceived as beneficial (p=0.36). Previous influenza illness was associated with having the influenza vaccine (p<0.001). The most frequently reported reason for receiving the seasonal influenza vaccine was being deemed at risk (42.4%) and for H1N1 vaccine was because it was offered for free (32.6%). For both vaccines the most reported reason for not being vaccinated was a perception of it not being needed. Student nurses form a substantial and influential part of the future healthcare workforce but to translate the widely held acceptance that influenza vaccine is beneficial into actual uptake, a more targeted and persuasive message is needed.     

Pyrethroid and organophosphate pesticide-associated toxicity in two coastal watersheds (California, USA)

Portions of the Santa Maria River and Oso Flaco Creek watersheds in central California, USA, are listed as impaired under section 303(d) of the Clean Water Act and require development of total maximum daily load (TMDL) allocations. These listings are for general pesticide contamination, but are largely based on historic monitoring of sediment and fish tissue samples that showed contamination by organochlorine pesticides. Recent studies have shown that toxicity in these watersheds is caused by organophosphate pesticides (water and sediment) and pyrethroid pesticides (sediment). The present study was designed to provide information on the temporal and spatial variability of toxicity associated with these pesticides to better inform the TMDL process. Ten stations were sampled in four study areas, one with urban influences, and the remaining in agriculture production areas. Water toxicity was assessed with the water flea Ceriodaphnia dubia, and sediment toxicity was assessed with the amphipod Hyalella azteca. Stations in the lower Santa Maria River had the highest incidence of toxicity, followed by stations influenced by urban inputs. Toxicity identification evaluations and chemical analysis demonstrated that the majority of the observed water toxicity was attributed to organophosphate pesticides, particularly chlorpyrifos, and that sediment toxicity was caused by mixtures of pyrethroid pesticides. The results demonstrate that both agriculture and urban land uses are contributing toxic concentrations of these pesticides to adjacent watersheds, and regional water quality regulators are now using this information to develop management objectives.     

Respiratory and nonrespiratory effects of doxapram in congenital central hypoventilation syndrome.

Doxapram is a respiratory stimulating drug that affects both peripheral chemoreceptors and medullary respiratory and nonrespiratory neurons. We administered doxapram 60 2 infants with congenital central hypoventilation syndrome. In 6 separate trials at a dose range of 0.32 to 2.0 mg per kg of body weight per min, quiet-sleep tidal volume increased from 4.9 +/- 1.0 to 8.5 +/- 0.9 ml per kg of body weight, minute ventilation increased from 140 +/- 38 to 286 +/- 31 ml per kg of body weight per min, and alveolar PCO2 decreased from 60 +/- 5 to 32 +/- 2 mm Hg. In all instances, the maximal quiet-sleep ventilatory response was achieved within 10 min. The ventilatory response to steady-state CO2 breathing was not improved with doxapram. A continuous infusion of doxapram for 5.2 days in one infant successfully maintained normal quiet-sleep ventilation. In both infants, multiple nonrespiratory effects of doxapram occurred; enteral administration was associated only with generalized neuromuscular stimulation, but the 5-day intravenous infusion was also associated with acute hepatotoxicity and a perforated duodenal ulcer. The medullary respiratory neurons in central hypoventilation syndrome may be incapable of responding to doxapram, and the ventilatory responses observed may be due entirely to stimulation of peripheral chemoreceptors. Although quiet-sleep ventilation can be successfully maintained with intravenous and enteral administration of doxapram, and tachyphylaxis has not been observed, we have been unable to avoid at least the neuromuscular manifestations of nonrespiratory medullary stimulation.