BACKGROUND:Guidelines recommend a corticosteroid injection or exercise therapy for shoulder pain in primary care, but long-term comparative studies are lacking. OBJECTIVE:To examine the effectiveness of a corticosteroid injection versus physiotherapist-led exercise therapy over 12 months in patients with shoulder pain presenting in primary care. DESIGN:A pragmatic randomized controlled trial. METHODS:Patients with a new episode of shoulder pain were included and randomly allocated to a corticosteroid injection or 12 sessions of physiotherapist-led exercise therapy. Questionnaires were administered at baseline, 6 weeks, 3, 6, 9 and 12 months. The primary outcome was pain and function measured with the Shoulder Pain and Disability Index (SPADI) over 12 months. RESULTS:99 patients were included in the injection group and 101 in the exercise therapy group. Side effects were reported in 25 % of the exercise therapy group and 7 % of the injection group. At 12 months follow-up, the exercise therapy group showed a statistically significantly greater improvement of SPADI-score (mean difference = 8·5, 95 % CI = 1·2 to 15·8) compared to the injection group. This was also seen at 6 months (mean difference = 9·6, 95 % CI = 2·3 to 16·9) and 9 months (mean difference = 7·9, 95 % CI = 0·4 to 15·4). The injection group showed a statistically significantly greater improvement of SPADI-score at 6 weeks (mean difference = -7·7, 95 % CI = -14·9 to -0·6). CONCLUSION:There is an indication that treatment with exercise therapy gives statistically significant better SPADI-scores over 12 months follow-up. However, wide confidence intervals indicate uncertainty in the effect estimates. REGISTRATION:The Netherlands Trial Registry (NL-OMON52854).

Objectives Weight loss through combined lifestyle interventions (CLIs) can slow down knee osteoarthritis (OA) progression. However, gender-related factors may influence both the implementation of and participation in CLIs. Therefore, the aims were to identify gender-related facilitators and barriers to CLI implementation among healthcare professionals (HCPs) and uptake and adherence among individuals with early-stage knee OA and overweight or obesity.Design Semi-structured interviews were conducted in this qualitative study. Thematic analysis, combining inductive and deductive approaches, was performed according to the Consolidated Framework for Implementation Research (CFIR) domains.Setting HCPs and individuals with knee OA and overweight or obesity were interviewed in Dutch between December 2023 and May 2024.Participants 16 HCPs who referred or delivered a CLI and 23 individuals with knee OA and overweight or obesity who participated in a CLI were purposively recruited. 16 participants identified themselves as women and 7 as men; no other gender identities were reported.Results HCPs experienced resistance to CLIs of both men and women. Additionally, HCPs perceived that women were more open and available to participate in CLIs, tended to prioritise others over themselves and often lacked familial support compared with men. Women valued trust, preferred female HCPs and struggled with self-prioritisation. Men were motivated by female HCPs and participants due to their empathy and interaction. Across men and women, barriers included conflicting HCP advice, work stress, caregiving tasks and lack of discipline, while social environment support was a key facilitator.Conclusions Addressing gender-related facilitators and barriers in the design and implementation of the CLI may improve long-term engagement and efficacy in individuals with knee OA and overweight or obesity.Trial registration number Overview of Medical Research in the Netherlands (OMON), managed by the CCMO: NL75367.078.20

ABSTRACT Introduction Osteoarthritis (OA) is a chronic joint disease, often leading to pain, joint stiffness and impaired function. The first metatarsophalangeal (MTP-1) joint is the most frequently affected joint in foot OA. Footwear interventions might have potential to reduce pain for people with MTP-1 joint OA. The aim of this study is to determine the effectiveness and cost-effectiveness of orthopaedic modifications to off-the-shelf footwear in addition to usual care, compared to usual care alone, for people with MTP-1 joint OA. Methods and analyses We perform a pragmatic, non-blinded, two-armed, parallel-group, randomised controlled trial (RCT). A total of 136 people with MTP-1 joint OA and presence of foot pain are recruited. Participants are randomised to orthopaedic modifications to off-the-shelf footwear in addition to usual care or to usual care alone. The footwear modifications comprise a combination of sole-stiffening, rocker sole adjustments and custom-made insoles. During a 12-month follow-up period, participants receive monthly questionnaires. Primary outcomes include walking pain at 6-month follow-up and quality-adjusted life years and societal costs at 12-month follow-up. Secondary outcomes include walking pain at 12-month follow-up and foot health, physical activity level, patient acceptability and self-reported recovery at 6- and 12-month follow-up. Intention-to-treat and per-protocol analyses will be performed using (generalised) linear mixed models. Ethics and dissemination The study is approved by the local Medical Ethics Committee of the Erasmus MC University Medical Center Rotterdam, The Netherlands (MEC-2024-0615). Prior to study participation, participants provide informed consent. Results will be disseminated amongst researchers through peer-reviewed scientific articles and presentations at conferences; and amongst people with MTP-1 joint OA and healthcare professionals through layman articles in newsletters, on websites and on social media. Discussion This is the first RCT to investigate the effectiveness and cost-effectiveness of orthopaedic modifications to off-the-shelf footwear in addition to usual care, compared to usual care alone for people with MTP-1 joint OA. Study findings will support healthcare professionals in making substantiated decisions in the treatment of people with MTP-1 joint OA. Trial registration number Overview of Medical Research in the Netherlands (OMON): NL87646.078.24

Objective This study aimed to identify barriers and facilitators affecting implementation of perioperative music interventions in general practice.Design A qualitative implementation study using semistructured interviews. The updated Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. The domains used were: innovation, outer setting, inner setting and individuals. Primary outcomes were barriers and facilitators for the implementation of perioperative music interventions in general practice.Setting General practices in the Netherlands.Participants Dutch general practitioners.Results 15 participants were included, among which 11 general practice owners, one salaried general practitioner, two locum general practitioners and one general practitioner in training. In total, 19 key barriers and 34 key facilitators were identified. For the innovation domain, a lack of research conducted in primary care and low awareness of the intervention were considered barriers whereas user-friendliness and low costs were seen as facilitators. For the outer setting domain, no barriers were identified and possibilities for external financing, inclusion in clinical guidelines and patient and media pressure were considered facilitators. For the inner setting, the lack of readily accessible information aimed at primary care was seen as a barrier, whereas a shared belief in minimising perioperative pain and anxiety was seen as a facilitator. For the individuals domain, a pre-existing heavy workload and understaffing were seen as barriers, whereas the autonomous role of general practitioners was seen as a facilitator.Conclusions Several key barriers and facilitators for implementation of perioperative music interventions in general practice were identified. A lack of research performed in the setting of primary care of the efficacy of the music intervention and low awareness among general practitioners were examples of barriers. Notable facilitators were user-friendliness, low-costs and the autonomous position of the general practitioner. Implementation of music intervention by general practitioners seems feasible, yet there is still room for more research to be performed in the specific context of primary care.

Background Hand osteoarthritis (OA) is the second most prevalent form of OA, often associated with pain, reduced function, and diminished quality of life. Despite its prevalence, patients frequently report unmet needs in primary care, where the condition is typically managed.AimTo explore patient perspectives on the management of hand OA in primary care, and identify key barriers and facilitators to care.Design and Setting A qualitative study based on semi-structured interviews with hand OA patients in the Netherlands.Method Semi-structured interviews were conducted with 16 patients using a framework-based interview guide. Patients were recruited through purposive sampling. Thematic analysis identified key themes. Respondent validation was performed via a follow-up questionnaire completed by 51 patients.ResultsSeven barriers and three facilitators were found. The quality of guidance provided by the GP, the availability of information and explanation about hand OA, and the perceived effectiveness of treatment were described as barriers when insufficient and facilitators when adequate. Other barriers included a demotivating attitude toward hand OA, poor collaboration between healthcare providers, perceived limited treatment options, and patient reluctance to pursue certain treatments.ConclusionHand OA patients face several barriers in primary care, many related to GP communication, support, and coordination. Patients desire an engaged GP who offers practical tools and guidance for managing their condition in daily life. To support GPs in this role, improved training, clearer clinical guidelines, and accessible patient education resources are needed. These measures can enable proactive, patient-centred care and improve outcomes for people with hand OA.

OBJECTIVES:The objective of the study is to compare care pathways of patients with musculoskeletal (MSK) complaints-from first presentation in primary care to referral and follow-up in rheumatology-across 5 European healthcare systems, and to explore how healthcare system characteristics influence these pathways. METHODS:Routinely collected healthcare data from 5 European countries (UK, Sweden, the Netherlands, Spain, and Hungary) were analysed. Primary care data included > 4 million adults with at least 1 MSK encounter, and secondary rheumatology data included > 600,000 patients. Primary care consultation rates, referral rates to specialist care, and rheumatology follow-up duration were compared across countries. Healthcare characteristics were extracted from the literature. RESULTS:The distribution of MSK complaints in primary care was similar across countries, with 25% to 30% of residents visiting their general practitioner annually for an MSK complaint (UK data not available). In contrast, referral of such patients with MSK complaints to rheumatology varied considerably (5%-38%). Among those referred, 46% to 70% were discharged within 3 months, whereas only 13% to 43% remained in long-term rheumatology care. We observed that countries with a high proportion of sustained long-term rheumatology care (UK and Sweden) had lower referral rates, fewer rheumatologists per capita, and employed a selective triaging system, whereas countries where referrals more frequently resulted in short-term rheumatology care (the Netherlands, Spain, and Hungary) had higher referral rates and employed nonselective triaging. CONCLUSIONS:Substantial cross-country variation exists in the management of MSK complaints. Although primary care MSK presentations are similar, referral rates and the patient-mix reaching rheumatology differ widely between countries-an important consideration for developing cross-national clinical guidelines and diagnostic tools.

OBJECTIVES:Lifestyle changes-such as adopting healthy nutrition and increasing physical activity-are essential for alleviating symptoms in patients with knee osteoarthritis (OA) and overweight, with weight loss being a key outcome of these changes. Since 2019, healthcare professionals (HCPs) in the Netherlands have been able to refer these patients to a reimbursed combined lifestyle intervention (CLI). This study aims to identify determinants affecting CLI implementation for individuals with knee OA and overweight from both patient and HCP perspectives. DESIGN:Semistructured interviews were conducted in a qualitative study with 23 individuals with knee OA and overweight and 16 HCPs (general practitioners (GPs) and lifestyle coaches). Interviews were transcribed verbatim and coded independently by two researchers using the updated Consolidated Framework for Implementation Research (CFIR). SETTING:Primary care, including GPs and lifestyle coaches from the Greater Rotterdam region in the Netherlands. PARTICIPANTS:23 individuals with knee OA and overweight and 16 HCPs (GPs and lifestyle coaches). RESULTS:Determinants were explored within four CFIR domains: innovation, outer setting, inner setting and individuals. Key facilitators included recognition of the programme's potential, strong social support and positive participant-coach relationships. Major barriers involved the absence of an exercise component, financial constraints limiting its inclusion, scepticism among GPs about care quality, limited expertise of lifestyle coaches addressing OA-specific needs and difficulties adapting the programme to participants' diverse knowledge levels and health literacy. CONCLUSIONS:To improve the implementation of the CLI for patients with knee OA, it is essential to incorporate a tailored exercise component, strengthen lifestyle coaches' expertise, address financial barriers and build trust among GPs through education and clear communication of programme outcomes. Tailoring the CLI to better meet participant needs is crucial to ensure its long-term effectiveness and sustainability as a treatment for individuals with knee OA and overweight. TRIAL REGISTERATION NUMBER:Netherlands Trial Registry (NL9355).

OBJECTIVE:Only few studies have investigated quantitative magnetic resonance imaging (MRI) T2 mapping of knee cartilage in population-based cohorts. Our objective was to evaluate the association between T2 relaxation times of different cartilage segments and the presence of knee MRI-based osteoarthritis (OA) and patient characteristics in a large population-based cohort. DESIGN:In this cross-sectional study, we included 673 females (mean age: 59.8 years; standard deviation: 3.7) scanned with 1.5T-MRI from a sub-cohort of the Rotterdam Study. T2 relaxation times were calculated in six femoral and tibial cartilage regions of interest. Associations between T2 relaxation times, MRI Osteoarthritis Knee Score (MOAKS)-based tibiofemoral OA, and Knee injury and Osteoarthritis Outcome Score (KOOS)-based symptom status were evaluated using multivariate fixed effects regression analyses. RESULTS:A total of 1332 knees were included, of which 237 (17.7%) had MRI-based OA. Patients with OA had higher T2 relaxation times across all cartilage segments, and T2 values positively correlated with BMI (r = 0.17-0.46), the strongest correlations being in the lateral compartment. Weak associations were found between T2 relaxation times and age. After adjustments, T2 values in the lateral weight-bearing femur (OR: 0.67; 95%CI: 0.56-0.79), lateral tibia (OR: 1.11; 95%CI: 1.00-1.24), lateral posterior femur (OR: 1.48; 95%CI: 1.28-1.72), and medial posterior femur (OR: 1.14; 95%CI: 1.01-1.30), were associated with the presence of OA. T2 relaxation times were not associated with the KOOS-based symptom status. CONCLUSION:In this population-based cohort, T2 values were associated with BMI. Additionally, T2 values in the lateral cartilage subregions were associated with MRI-based OA.

OBJECTIVES:Within the first phase of developing classification criteria for Early-stage Symptomatic Knee Osteoarthritis, among individuals with knee osteoarthritis (OA) we explored: 1) symptoms within the first year of noticing their knee(s); 2) features that indicated OA was the cause; and 3) timing and reasons that initially prompted seeking healthcare. DESIGN:We conducted a cross-sectional online survey of individuals with knee OA recruited from Australia, Canada, the Netherlands, and the USA. Only individuals who indicated they recalled their first symptoms were eligible. Using free-text, participants described changes in how their knee looked, felt, moved, their overall state within the first year of noticing their knee(s), features perceived to indicate knee OA was the cause, and reasons for initially seeking healthcare. We assessed the timing of seeking care by an ordinal scale. Data were analyzed using descriptive statistics and summative content analysis. RESULTS:We included 92 participants (median age 67 years [interquartile range (IQR) 59,75], 69% women, median body mass index (BMI) 26 kg/m2 [IQR 24,30]). Within the first year from onset, frequently reported symptoms were knee pain (70%), swelling (58%), crepitus (42%), stiffness (29%), and instability (24%). While few could provide specific clinical features, approximately half (53%) perceived medical imaging as important to indicate OA. Only 35% sought healthcare within the first year of experiencing symptoms. CONCLUSIONS:Individuals with knee OA recalled varied knee symptoms within the first year and few sought healthcare. We were unable to ascertain, from the perspective of patients, specific clinical features that indicated they had OA and not another condition.

BACKGROUND:The effectiveness of footwear modifications for the first metatarsophalangeal (MTP) joint osteoarthritis (OA) compared to usual general practitioner (GP) care has never been studied. Understanding patients' perspectives is essential for assessing the feasibility of a randomized controlled trial (RCT) on this topic. Our objective is to explore experiences, expectations, beliefs, and opinions of patients with the first MTP joint OA regarding symptoms and limitations, healthcare management, footwear intervention, and research participation for designing a successful future effectiveness trial. METHOD:A qualitative research design was embedded within a feasibility pilot study for the recruitment of participants diagnosed with the first MTP joint OA. Qualitative data from semistructured interviews were categorized analyzed. RESULTS:All participants (n = 10) experienced limitations on the activity and participation level due to pain symptoms in the first MTP joint. Patients experienced varying approaches and treatment outcomes in primary and secondary healthcare, leading to both positive and negative perspectives. Most participants highlighted the importance of the cosmetic appearance of modified footwear, indicating that this is crucial for compliance with the intervention. Participants showed willingness to participate in an RCT, with strong preference for randomization into an intervention group with a modified footwear alongside usual GP care rather than GP care alone. CONCLUSION:Our study identified key considerations for designing a successful future trial, including recruiting incident cases, offering the deferred footwear intervention to the control group, providing clear information during recruitment and randomization phase, and the significance of the cosmetic appearance of modified footwear for patients with the first MTP joint OA.

OBJECTIVES:To investigate the relationship between offset analgesia magnitude and the responsiveness to conditioned pain modulation (CPM), temporal summation of (second) pain (TSP), and clinical pain severity in people with knee osteoarthritis (KOA). METHODS:Electrical stimuli were applied to 88 participants with KOA to measure offset analgesia at the volar forearm of the dominant hand, and CPM and TSP at the most symptomatic knee and ipsilateral volar wrist. Clinical pain severity was assessed using the pain subscale of the Knee injury and Osteoarthritis Outcome Score (KOOS PAIN ). Linear mixed-effects models evaluated pain modulatory effects across all tests, and Spearman partial correlations assessed associations between offset analgesia, CPM, TSP, and KOOS PAIN while accounting for covariates of interest. Participants unable to validly finish all psychophysical tests were excluded from effect and correlation analyses but were evaluated for predictors of nonvalid completion using bivariate Stochastic Search Variable Selection. RESULTS:Significant pain modulation was observed across all psychophysical tests ( P <0.05), and no meaningful predictors of nonvalid test completion were found. Offset analgesia magnitude did not significantly correlate with CPM, TSP, or KOOS PAIN ( P ≥0.05), with a maximum partial correlation coefficient of ρ =0.21. DISCUSSION:Offset analgesia was not associated with CPM, TSP, or KOOS PAIN in people with KOA. Despite the lack of case-control studies comparing offset analgesia between people with KOA and healthy controls, these findings suggest that offset analgesia may provide information about endogenous pain modulation beyond CPM and TSP, though its clinical translation remains uncertain.

Objective Aerobic exercise is recommended for the management of knee osteoarthritis (OA), but knee pain is often a barrier for participation. Some types of aerobic exercise may be less painful to undertake than others, though little is known about which are the most “knee friendly,” that is, unlikely to exacerbate knee pain to an unacceptable level. This study aimed to identify aerobic exercise activities that (1) are knee friendly and (2) meet requirements for targeting cardiovascular health. Methods We conducted a three‐phase international survey. In phase 1, persons living with knee OA provided descriptions of knee friendly exercise types, defined as activities that would cause shortness of breath and difficulty talking without worsening symptoms to an unacceptable level (cause severe symptoms and/or lasting more than 24 hours). In phase 2, exercise physiologists identified exercise activities meeting requirements for increasing aerobic fitness, which were grouped into broader aerobic exercise activities. In phase 3, participants nominated each aerobic exercise activity for “knee friendliness.” Results In phase 1, 487 respondents (Denmark: 259; the Netherlands: 144; Australia: 57; and North America: 15) provided a total of 1,590 exercise descriptions. In phase 2, 154 exercise activities were identified and grouped into a list of 30 broader aerobic exercise activities. In phase 3, 349 participants (Denmark: 195; the Netherlands: 114; Australia: 32; and North America: 8) nominated indoor biking and water exercise as most knee friendly (82% and 70%, respectively). Participants were predominantly women (60.7%), the mean ± SD age was 68.4 ± 8.81 years, the mean ± SD body mass index was 27.5 ± 5.8, the mean ± SD self‐efficacy score was 7.3 ± 3.0 (0–10 scale), the mean ± SD symptom duration was 11.7 ± 9.05 years, and the mean ± SD current knee pain was 4.5 ± 2.2 (0–10 scale). Conclusion A catalog of 30 knee friendly aerobic exercise activities was generated for individuals living with knee OA. The catalog aims to empower individuals living with knee OA, offering suitable aerobic exercise options without exacerbating knee pain.

PURPOSE:The aim of this study was to examine the relationship between testosterone levels (total and free) and the prevalence, incidence and progression of radiographic osteoarthritis (OA) and chronic pain outcomes in the knee and hand joints. METHODS:This study is embedded in the Rotterdam Study cohort, a population-based prospective study with participants aged 45 and older. The association between testosterone levels and OA was tested in more than 8600 individuals, using generalized linear models and generalized estimating equations models, adjusting for age, body mass index (BMI), lifestyle factors and co-morbidities. RESULTS:Higher total testosterone (Relative Risk [RR] 0.84, 95% Confidence Interval [CI] 0.69-1.00) and higher free testosterone (RR 0.85, 95% CI 0.70-1.00) were significantly associated with a lower prevalence of radiographic knee OA in females, but not significant in males. Higher free testosterone was significantly associated with lower incidence of chronic knee pain (CKP) in females (RR 0.85, 95% CI 0.71-0.98), but not in males. In contrast, higher free testosterone (RR 1.07, 95% CI 1.02-1.11) and total testosterone (RR 1.08, 95% CI 1.03-1.13) were significantly associated with higher severity of hand OA in males, but not in females. These associations were independent of BMI, other lifestyle factors, co-morbidities and years since menopause. CONCLUSIONS:Our findings suggest a protective effect of free testosterone for CKP only in females. Future replication of our findings is needed in prospective cohort studies.