Optimizing care for patients with OA 111 Joost Dekker PhD Department of Rehabilitation Medicine & Department of Psychiatry VU University Medical Center, Amsterdam, Netherlands

Contents Current level of care Organizing care Developing and improving interventions Adherence to exercise and physical activity 2

Level of care Lack of care –Patients with OA do not seek care –Patients with OA are discouraged to seek care 3

Level of care Lack of care –Patients with OA do not seek care –Patients with OA are discouraged to seek care Exercise therapy and physical activity –Lack of trust among GP, PT’s and patients 5

8 Patients’ barriers Holden et al, 2012 Dekker, 2012

Level of care Lack of care –Patients with OA do not seek care –Patients with OA are discouraged to seek care Exercise therapy and physical activity –Lack of trust among GP, PT’s and patients Appropriateness of care –Total knee arthroplasty 9

Criteria for the appropriateness of TKA 10 Escobar et al, 2003

Evaluation of the appropriateness of TKA 11 Riddle et al, 2014

Level of care Lack of care –Patients with OA do not seek care –Patients with OA are discouraged to seek care Exercise therapy and physical activity –Lack of trust among GP, PT’s and patients Appropriateness of care –Total knee arthroplasty 12

Contents Current level of care Organizing care Developing and improving interventions Adherence to exercise and physical activity 13

Organizing care Range of professionals and interventions –GP, orthopedic surgeon, rheumatologist, physiotherapist, dietician, multidisciplinary rehabilitation –Pharmacological interventions –Surgical interventions –Exercise, physical activity –Education, life style advise –Intra-articular injections –Diet 14

Stepped care BART Strategy - Beating osteoARThritis –Less intensive interventions are tried first –More intensive interventions reserved for those insufficiently helped by the initial intervention 15

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17 Results No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). Conclusion The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.

Contents Current level of care Organizing care Developing and improving interventions Adherence to exercise and physical activity 18

Developing and improving interventions Exercise therapy 19

Exercise therapy in knee OA Exercise is dominant intervention –Pain relieve –Improved performance of activities Exercise recommended in all major guidelines 20

Exercise therapy in OA Effect size small to moderate –How to improve ? Therapy targeting risk factor for functional decline –Comorbidity 21

22 OA does not come alone Comorbidity –High rate: 68 – 85% Wide range of comorbid diseases –Cardiac diseases, hypertension –Type 2 diabetes, obesity, –Chronic obstructive pulmonary diseases (COPD) –OA of the foot and hand –Chronic pain, low back pain –Depression –Visual or hearing impairments –Chronic cystitis –Stroke –Bowel disorders

Comorbidity and exercise Reduced intensity of exercise –Physical therapists –Patients Exercise therapy unlikely to be effective Need to adapt exercise to comorbidity 23

24 Exercise adapted to comorbidity

25 Exercise adapted to comorbidity ’I felt more confident in performing exercises and was less afraid to get hypoglycaemia during or after the training, because the therapist had more knowledge about my diseases and training possibilities. When I was treated, … I was afraid … of becoming hypoglycaemic. Therefore I wasn’t really motivated to do my exercises’’. More evidence needed de Rooij et al, 2014

Contents Current level of care Organizing care Developing and improving interventions –Focus of KNEEMO Adherence to exercise and physical activity 26

27 Adherence and outcome in OA Adherence to home exercises –3 months: 58 % –15 months: 44 % –60 months: 30 % Adherence associated with better outcome –Pain, physical function Pisters et al, 2010

28 Months Adherence and outcome Improvement Pisters et al, 2010

29 Patients’ barriers Holden et al, 2012 Dekker, 2012

30 Improving adherence Use professional body of knowledge Behavioral approaches Delivery of exercise Tailoring of exercise to phenotypes and comorbidity Web-based interventions, mobile phones Jordan et al, 2010

Summary Current level of care –Not adequate Organizing care Developing and improving interventions –Focus of KNEEMO Adherence to exercise and physical activity Other options to improve care for patients with OA 31