Effectiveness of Stepped‐Care Intervention in Overweight and Obese Patients With Medial Tibiofemoral Osteoarthritis: A Randomized Controlled Trial

Abstract

Objective To test the effectiveness of a 32‐week, stepped‐care intervention on disease remission rates in overweight and obese patients with medial tibiofemoral osteoarthritis (OA) compared to controls. Methods In this randomized controlled trial, eligible participants were ≥50 years of age with a body mass index of ≥28 kg/m2 and radiographic evidence of medial tibiofemoral OA. Participants were randomized to stepped‐care (n = 87) or control group (n = 84). The stepped‐care group received a 2‐step intervention. The first step consisted of an 18‐week diet and exercise program. The second step consisted of 4 treatment subgroups: 1) diet and exercise maintenance; 2) cognitive–behavioral therapy; 3) unloader knee brace; and 4) muscle strengthening exercises. Allocation into subgroups was based on disease remission state and clinical characteristics. The primary end point was the disease remission rate (yes/no) at 32 weeks, which was reached when participants achieved the Patient Acceptable Symptom State cutoff value for pain and for the patient global assessment of disease activity and/or functional impairment. Results Disease remission at 32 weeks was achieved by 18 of 68 (26%) in the control group and 32 of 82 (39%) in the stepped‐care group (difference 12.6% [95% confidence interval –2.3, 27.4], P = 0.10). The stepped‐care group showed an improvement in pain and function between baseline and 20 weeks. While functional improvement was maintained at 32 weeks, pain levels tended to get worse between weeks 20 and 32. Conclusion The proposed intervention did not promote a significant difference in the rate of disease remission in comparison to the control group for overweight or obese patients with medial tibiofemoral OA.

Exploring Attitudes and Experiences of People With Knee Osteoarthritis Toward a Self-Directed eHealth Intervention to Support Exercise: Qualitative Study

“…These results, in combination with ours, may indicate that people have different preferences for the level of support that should be provided with eHealth self-management programs and highlights that a one-size -fits-all approach to implementation may be inappropriate. As the integration of eHealth interventions into usual care facilitates their successful implementation [ 25 ], one solution may be to integrate the eHealth intervention into a stepped model of OA care [ 44 , 45 ], where it is provided as the first “step” in the care plan. Stepped care is where support or interventions are provided in “steps,” with input escalating based on an individual’s outcomes or preferences for care [ 46 ].…”

Relative Efficacy of Weight Management, Exercise, and Combined Treatment for Muscle Mass and Physical Sarcopenia Indices in Adults with Overweight or Obesity and Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

“…The protocols for diet therapy are summarized in Table 1. Dietary interventions employed intermittent meal replacement (MR) in one RCT [60] and regular MR in 14 RCTs [58][59][60][61][62][63]67,[74][75][76]78,88,89,91]. The MR prescribed was one meal daily (uni-MR) in four RCTs [59,60,62,67] and two or more meals daily (multi-MR) in 12 RCTs [58,60,61,63,67,[74][75][76]78,88,89,91].…”

“…Dietary interventions employed intermittent meal replacement (MR) in one RCT [60] and regular MR in 14 RCTs [58][59][60][61][62][63]67,[74][75][76]78,88,89,91]. The MR prescribed was one meal daily (uni-MR) in four RCTs [59,60,62,67] and two or more meals daily (multi-MR) in 12 RCTs [58,60,61,63,67,[74][75][76]78,88,89,91]. In addition, diet instruction and advisement (DIA), which had been conducted through nutrition classes and cognitive behavior therapy, was employed in five RCTs [68,72,73,82,83] or applied in combination with MR in nine RCTs [58][59][60][61][62][74][75][76]91].…”

“…All the 34 included RCTs employed random allocation, similarity at baseline, between-group comparisons, and point estimates and variability. Moreover, 11 of the 17 (64.7%) high-quality RCTs [59,60,62,64,65,78,[80][81][82][83]90] performed allocation concealment, whereas only 1 medium-quality RCT did [71]. Owing to the intervention nature, it was difficult to blind the participants and therapists in all the included RCTs.…”

Exploring Attitudes and Experiences of People With Knee Osteoarthritis Toward a Self-Directed eHealth Intervention to Support Exercise: Qualitative Study (Preprint)

“…These results, in combination with ours, may indicate that people have different preferences for the level of support that should be provided with eHealth self-management programs and highlights that a one-size -fits-all approach to implementation may be inappropriate. As the integration of eHealth interventions into usual care facilitates their successful implementation [25], one solution may be to integrate the eHealth intervention into a stepped model of OA care [44,45], where it is provided as the first "step" in the care plan. Stepped care is where support or interventions are provided in "steps," with input escalating based on an individual's outcomes or preferences for care [46].…”