Objective. To evaluate the nature, risks, and benefits of osteoarthritis (OA) management by primary care physicians and rheumatologists.
Methods. Subjects were 419 patients followed for symptoms of ...knee OA by either a specialist in family medicine (FM) or general internal medicine (GIM) or by a rheumatologist (RH). Management practices were characterized by in‐home documentation by a visiting nurse of drugs taken to relieve OA pain or to prevent gastrointestinal side effects of nonsteroidal anti‐inflammatory drugs (NSAIDs) and by patient report (self‐administered survey) of nonpharmacologic treatments. Changes in outcomes (knee pain and physical function) over 6 months were measured with the Western Ontario and McMaster Universities Osteoarthritis Index.
Results. Patients of RHs were 2‐3 years older (P = 0.035) and tended to exhibit greater radiographic severity of OA (P = 0.064) and poorer physical function (P = 0.076) at baseline than the other 2 groups. In all 3 groups, knee pain and physical function improved slightly over 6 months; however, between‐group differences were not significant. Compared to drug management of knee pain by FMs or RHs, that by the GIMs was distinguished by greater utilization of acetaminophen and nonacetylated salicylates (P = 0.008), lower prescribed doses of NSAIDs (P = 0.007), and, therefore, lower risk of iatrogenic gastroenteropathy (P < 0.001). In contrast, patients of RHs were more likely than those of FMs and GIMs to report that they had been instructed in use of isometric quadriceps and range‐of‐motion exercises (P ≦ 0.001), application of heat (P = 0.051) and cold (P < 0.001) packs, and in the principles of joint protection (P = 0.016). Neither physician specialty nor specific management practices accounted for variations in patient outcomes.
Conclusion. This observational study identified specialty‐related variability in key aspects of the management of knee OA in the community (i.e., frequency and dosing of NSAIDs, use of nonpharmacologic modalities) that bear strong implications for long‐term safety and cost. However, changes in knee pain and function over 6 months were unrelated to variations in management practices.
A randomized, controlled study entitled, the Diabetes Education Study (DIABEDS), assessed the effects of patient and physician education. A sample of 532 diabetic patients, predominantly elderly, ...black women with Type II diabetes was randomly assigned into two groups, and offered up to seven modules of patient education. Patients in the experimental group experienced significantly greater reductions in fasting blood glucose levels, glycosylated hemoglobin, weight, blood pressure, and serum creatinine than the control group.(lsp)
Objective
To identify changes in joint pain, stiffness, and functional ability in patients with knee osteoarthritis (OA) after use of a knee sleeve that prevents loss of body heat by the joint.
...Methods
Subjects with symptomatic knee OA (n = 52) were randomized to 2 treatment groups: verum sleeve (specially fabricated to retain body heat) or placebo sleeve (standard cotton/elastane sleeve). Subjects wore the sleeve over the more painful OA knee for at least 12 hours daily for 4 weeks. Pain, stiffness, and functional impairment (Western Ontario and McMaster Universities Osteoarthritis Index WOMAC) in the index knee were measured at baseline and after 4 weeks of wear, after which sleeve use was discontinued. Telephone followup interviews were conducted 2 and 4 weeks later.
Results
After 4 weeks of sleeve wear, subjects in the active treatment group reported a 16% decrease in mean WOMAC pain score relative to baseline (P = 0.001). Those who wore the placebo sleeve reported a 9.7% decrease from baseline (P = 0.002). The difference between treatment groups was not statistically significant (P = 0.12). However, it was found that the 12 subjects who believed correctly that they had received the verum sleeve reported a highly significant decrease in WOMAC pain score (−27.5% relative to baseline, P = 0.0001). In comparison, subjects who received the verum sleeve but believed they had received the placebo sleeve exhibited only a marginally significant improvement in pain (−13.0% relative to baseline, P = 0.07). In the placebo group, the modest improvement in pain scores appeared unrelated to the subject's impression of the type of sleeve worn.
Conclusion
This pilot study was insufficiently powered to be a definitive trial of the heat‐retaining sleeve. Given the magnitude of changes in knee pain in the active treatment group, heat retention merits further scientific investigation as a treatment modality for patients with knee OA.
OBJECTIVE:The objective of this study was to evaluate a nurse-directed self-management intervention for managed care patients with knee osteoarthritis (OA), emphasizing nonpharmacologic (NonPharm) ...management of pain and functional impairments and minimization of exposure to the risks and costs of nonsteroidal antiinflammatory drugs (NSAIDs).
METHODS:Subjects were 186 patients from a large health maintenance organization (HMO) who satisfied American College of Rheumatology clinical criteria for knee OA. Two of 4 HMO sites (and their patient cohorts) were randomly assigned to the education group; the other 2 served as a delayed-intervention control group. At each location of care for the education group, an arthritis nurse educator, in consultation with the patientʼs primary care physician (PCP), followed a detailed algorithm for implementing and monitoring the response to NonPharm treatment modalities (eg, quadriceps strengthening exercises, counseling in principles of joint protection, use of thermal modalities). The nurses apprised the PCP of the patientʼs progress and made algorithm-based recommendations, as appropriate, for reduction of dose, and eventual discontinuation, of NSAIDs in favor of acetaminophen. Outcomes (measured at baseline, 3, 6, and 12 months) included pain and function scales from the Western Ontario and McMaster Universities (WOMAC) OA Index.
RESULTS:The treatment groups were similar at baseline with respect to sociodemographic and clinical characteristics. Medical record audits revealed that NonPharm treatments (most often exercise) were implemented by 75% of patients in the education group but by only 18% of patients receiving routine care (P < 0.00001). Over the subsequent 12 months, 20 patients (26%) in the education group, but only 3 (5%) in the control group (P = 0.002), underwent changes in drug treatment of OA pain consistent with the NSAID-sparing goals of the intervention, ie, acetaminophen as initial drug of choice; reduction in dose, or discontinuation, of NSAID; switch from an NSAID to an analgesic. Only one patient in the education group required reinstitution of NSAIDs because of an increase in knee pain. Mean WOMAC scores indicated no deterioration of pain control or function over 12 months in the group treated according to the algorithm.
CONCLUSION:Incorporation into the primary care setting of self-care education for patients with knee OA, with collaboration between a proactive arthritis nurse and the patientʼs PCP, can reduce reliance on NSAIDs without a resultant increase in OA pain and disability.
Objective
To determine whether baseline lower extremity muscle weakness is a risk factor for incident radiographic osteoarthritis (OA) of the knee.
Methods
This prospective study involved 342 elderly ...community‐dwelling subjects (178 women, 164 men) from central Indiana, for whom baseline and followup (mean interval 31.3 months) knee radiographs were available. Lower extremity muscle strength was measured by isokinetic dynamometry and lean tissue (i.e., muscle) mass in the lower extremities by dual x‐ray absorptiometry.
Results
Knee OA was associated with an increase in body weight in women (P = 0.0014), but not in men. In both sexes, lower extremity muscle mass exhibited a strong positive correlation with body weight. In women, after adjustment for body weight, knee extensor strength was 18% lower at baseline among subjects who developed incident knee OA than among the controls (P = 0.053), whereas after adjustment for lower extremity muscle mass, knee extensor strength was 15% lower than in the controls (P not significant). In men, in contrast, adjusted knee extensor strength at baseline was comparable to that in the controls. Among the 13 women who developed incident OA, there was a strong, highly significant negative correlation between body weight and extensor strength (r = ‐0.740, P = 0.003), that is, the more obese the subject, the greater the reduction of quadriceps strength. In contrast, among the 14 men who developed incident OA, a modest positive correlation existed between weight and quadriceps strength (r = 0.455, P = 0.058). No correlation between knee flexor (hamstring) strength and knee OA was seen in either sex.
Conclusion
Reduced quadriceps strength relative to body weight may be a risk factor for knee OA in women.
Objective
To describe the methods by which remarkable levels of subject retention and adherence were achieved in a 30‐month multicenter randomized placebo‐controlled trial (RCT) of a ...disease‐modifying osteoarthritis drug (DMOAD).
Methods
Subjects were obese 45–64‐year‐old women with unilateral knee osteoarthritis. Before randomization, each volunteer completed a 4‐week “faintness‐of‐heart” (FOH) test, during which she was required to demonstrate reliable appointment keeping and ≥80% adherence to the dosing regimen. Subjects who passed the FOH test were randomized to treatment with doxycycline or placebo for 30 months. The double‐blind phase entailed 15 bimonthly followup visits; intervisit adherence data were downloaded from the dosing monitor and used to estimate therapeutic coverage and to identify correctable patterns of nonadherence. Subjects received token incentives and a small cash payment at each followup visit. Measures to prevent or treat side effects of doxycycline were dispensed free of charge. Study coordinators monitored safety and reinforced participation through between‐visit telephone calls.
Results
Of 463 eligible volunteers, 32 (7%) failed the FOH test and were excluded from the double‐blind phase. Among the 431 subjects randomized to treatment groups, 307 (71%) completed the 30‐month RCT and 124 discontinued the study drug prematurely. Nearly half of the dropouts returned for their 16‐ and 30‐month radiographs, resulting in loss to followup of 14.8% of randomized subjects. The 2 treatment groups did not differ significantly with respect to rates of discontinuation or retention. Therapeutic coverage over 30 months was very high in both groups.
Conclusion
The rate of discontinuation in this 30‐month RCT (29%) was lower than that of any DMOAD trial of ≥2 years duration published to date. The proportion of subjects for whom 30‐month radiographs were available (85%) and adherence to the dosing regimen (mean >80%) also were remarkably high.
Using an osteoarthritis (OA) case study, we described the drug therapy that primary care physicians prescribe for uncomplicated OA of the hip, and for OA complicated by a history of gastropathy or ...renal insufficiency. To produce "gold standard" criteria against which to interpret previous results, the same instrument was administered to 126 rheumatologists selected at random from the membership of the American College of Rheumatology. Virtually all rheumatologists prescribed nonsteroidal antiinflammatory drugs (NSAID); 76% specified doses large enough to have significant antiinflammatory effects. In contrast, 65% of the primary care physicians recommended NSAID therapy in a suboptimal antiinflammatory dose (p = 0.055 for the rheumatologist-primary care physician difference). For OA complicated by a history of either gastropathy or renal insufficiency, rheumatologists were more likely than primary care physicians to adopt a therapeutic strategy that did not inhibit prostaglandin synthesis (p < 0.001 for both). Differences also were noted in the ancillary therapies employed by the 2 groups for managing uncomplicated OA. Educational interactions between rheumatologists and primary care physicians could benefit by recognition of the differing perspectives on NSAID dosing, the avoidance of NSAID induced side effects, and ancillary therapies that appear to differentiate subspecialists and generalists.
Objective
To confirm preclinical data suggesting that doxycycline can slow the progression of osteoarthritis (OA). The primary outcome measure was joint space narrowing (JSN) in the medial ...tibiofemoral compartment.
Methods
In this placebo‐controlled trial, obese women (n = 431) ages 45–64 years with unilateral radiographic knee OA were randomly assigned to receive 30 months of treatment with 100 mg doxycycline or placebo twice a day. Tibiofemoral JSN was measured manually in fluoroscopically standardized radiographic examinations performed at baseline, 16 months, and 30 months. Severity of joint pain was recorded at 6‐month intervals.
Results
Seventy‐one percent of all randomized subjects completed the trial. Radiographs were obtained from 85% of all randomized subjects at 30 months. Adherence to the dosing regimen was 91.8% among subjects who completed the study per protocol. After 16 months of treatment, the mean ± SD loss of joint space width in the index knee in the doxycycline group was 40% less than that in the placebo group (0.15 ± 0.42 mm versus 0.24 ± 0.54 mm); after 30 months, it was 33% less (0.30 ± 0.60 mm versus 0.45 ± 0.70 mm). Doxycycline did not reduce the mean severity of joint pain, although pain scores in both treatment groups were low at baseline and remained low throughout the trial, suggesting the presence of a floor effect. However, the frequency of followup visits at which the subject reported a ≥20% increase in pain in the index knee, relative to the previous visit, was reduced among those receiving doxycycline. In contrast, doxycycline did not have an effect on either JSN or pain in the contralateral knee. In both treatment groups, subjects who reported a ≥20% increase in knee pain at the majority of their followup visits had more rapid JSN than those whose pain did not increase.
Conclusion
Doxycycline slowed the rate of JSN in knees with established OA. Its lack of effect on JSN in the contralateral knee suggests that pathogenetic mechanisms in that joint were different from those in the index knee.
In this review, recent research on educational and psychosocial issues in rheumatology are interpreted in light of the prospects for reforms in health care delivery in the United States. Increased ...emphasis on primary care will prompt a reappraisal of the training of medical students and primary care residents in the diagnosis, management, and referral of patients with rheumatologic conditions. Evidence of the economic benefits of arthritis self-care education has begun to appear and, if it continues to accumulate, will help assure the availability of such interventions for arthritis patients. Finally, further understanding of the psychosocial impact of musculoskeletal pain and impairment will better enable us to prevent the disability that is a large and growing drain on the American economy.
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