optimizing care for patients with oa 111 joost dekker phd department of rehabilitation medicine...

Optimizing care for patients with OA

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Joost Dekker PhDDepartment 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

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Level of care

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

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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

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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

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Criteria for the appropriateness of TKA

10Escobar et al, 2003

Evaluation of the appropriateness of TKA

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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

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Contents

• Current level of care

• Organizing care

• Developing and improving interventions

• Adherence to exercise and physical activity

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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

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Stepped care

• BART Strategy - Beating osteoARThritis– Less intensive interventions are tried first– More intensive interventions reserved for those insufficiently

helped by the initial intervention

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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

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Developing and improving interventions

• Exercise therapy

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Exercise therapy in knee OA

• Exercise is dominant intervention– Pain relieve– Improved performance of activities

• Exercise recommended in all major guidelines

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Exercise therapy in OA

• Effect size small to moderate– How to improve ?

• Therapy targeting risk factor for functional decline– Comorbidity

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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

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Exercise adapted to comorbidity

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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 <by my previous therapist>, … 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

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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

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100 3 15 60

Chan

ge in

phy

sical

func

tion

(WO

MAC

)

Adherence

Non-adherence

Months

Adherence and outcome

Improvement

Pisters et al, 2010

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Patients’ barriers

Holden et al, 2012

Dekker, 2012

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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

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