The Better Management of Patients with Osteoarthritis Program: Outcomes after evidence-based education and exercise delivered nationwide in Sweden

Autoři: Thérése Jönsson aff001;  Frida Eek aff002;  Andrea Dell’Isola aff001;  Leif E. Dahlberg aff001;  Eva Ekvall Hansson aff002
Působiště autorů: Department of Clinical Sciences Lund, Ortopedics, Lund University, Lund, Sweden aff001;  Department of Health Sciences, Division of Physiotherapy, Lund University, Lund, Sweden aff002
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0222657


We evaluated a structured education- and exercise-based self-management program for patients with knee or hip osteoarthritis (OA), using a registry-based study of data from 44,634 patients taken from the Swedish “Better Management of Patients with Osteoarthritis” registry. Outcome measures included a numeric rating scale (NRS), EuroQol five dimension scale (EQ-5D), Arthritis self-efficacy scale (ASES-pain and ASES-other symptoms), pain frequency, any use of OA medication, desire for surgery, fear–avoidance behavior, physical activity, and sick leave were reported at baseline, 3 and 12 month. Changes in scale variables were analyzed using general linear models for repeated measures and changes in binary variables by McNamara’s test. All analyses were stratified by joint. At the 3-month follow-up, patients with knee (n = 30686) and hip (n = 13948) OA reported significant improvements in the NRS-pain, the EQ-5D index, the ASES-other symptoms, and ASES-pain scores with standardized effect size (ES) ranges for patients with knee OA of 0.25–0.57 and hip OA of 0.15–0.39. Significantly fewer patients reported pain more than once weekly, took OA medication, desired surgery, showed fear–avoidance behavior, and were physically inactive. At the 12-month follow-up, patients with knee (n = 21647) and hip (n = 8898) OA reported significant improvements in NRS-pain, EQ-5D index, and a decrease in ASES-other symptoms and ASES-pain scores with an ES for patients with knee OA of –0.04 to 0.43 and hip OA of –0.18 to 0.22. Significantly fewer patients reported daily pain, desired surgery (for hip OA), reported fear–avoidance behavior, and reported sick leave. Following these interventions, patients with knee and hip OA experienced significant reductions in symptoms and decreased willingness to undergo surgery, while using less OA medication and taking less sick leave. The results indicate that offering this program as the first-line treatment for OA patients may reduce the burden of this disease.

Klíčová slova:

Medicine and health sciences – Rheumatology – Arthritis – Osteoarthritis – Pelvis – Hip – Health care – Patients – Surgical and invasive medical procedures – Public and occupational health – Physical activity – Biology and life sciences – Anatomy – Musculoskeletal system – Body limbs – Legs – Knees – Skeletal joints – Knee joints – People and places – Geographical locations – Europe – European Union – Sweden


1. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England). 2017;390(10100):1211–59.

2. Kingsbury SR, Gross HJ, Isherwood G, Conaghan PG. Osteoarthritis in Europe: impact on health status, work productivity and use of pharmacotherapies in five European countries. Rheumatology (Oxford, England). 2014;53(5):937–47.

3. Turkiewicz A, Petersson IF, Bjork J, Hawker G, Dahlberg LE, Lohmander LS, et al. Current and future impact of osteoarthritis on health care: a population-based study with projections to year 2032. Osteoarthritis Cartilage. 2014;22(11):1826–32. doi: 10.1016/j.joca.2014.07.015 25084132

4. Misso ML, Pitt VJ, Jones KM, Barnes HN, Piterman L, Green SE. Quality and consistency of clinical practice guidelines for diagnosis and management of osteoarthritis of the hip and knee: a descriptive overview of published guidelines. The Medical journal of Australia. 2008;189(7):394–9. 18837684

5. Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 2010;18(4):476–99. doi: 10.1016/j.joca.2010.01.013 20170770

6. Larmer PJ, Reay ND, Aubert ER, Kersten P. Systematic review of guidelines for the physical management of osteoarthritis. Archives of physical medicine and rehabilitation. 2014;95(2):375–89. doi: 10.1016/j.apmr.2013.10.011 24184307

7. Basedow M, Esterman A. Assessing appropriateness of osteoarthritis care using quality indicators: a systematic review. J Eval Clin Pract. 2015;21(5):782–9. doi: 10.1111/jep.12402 26083547

8. Hagen KB, Smedslund G, Osteras N, Jamtvedt G. Quality of Community-Based Osteoarthritis Care: A Systematic Review and Meta-Analysis. Arthritis care & research. 2016;68(10):1443–52.

9. Egerton T, Diamond LE, Buchbinder R, Bennell KL, Slade SC. A systematic review and evidence synthesis of qualitative studies to identify primary care clinicians' barriers and enablers to the management of osteoarthritis. Osteoarthritis Cartilage. 2017;25(5):625–38. doi: 10.1016/j.joca.2016.12.002 27939622

10. Ghomrawi HM, Schackman BR, Mushlin AI. Appropriateness criteria and elective procedures—total joint arthroplasty. N Engl J Med. 2012;367(26):2467–9. doi: 10.1056/NEJMp1209998 23268663

11. Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis & rheumatology (Hoboken, NJ). 2014;66(8):2134–43.

12. Johan Kärrholm MM, Daniel Odin, Johanna Vinblad, Cecilia Rogmark, Ola Rolfson. Annual repport 2017, Swedish Hip Arthroplasty Register. 2018.

13. Thorstensson CA, Garellick G, Rystedt H, Dahlberg LE. Better Management of Patients with Osteoarthritis: Development and Nationwide Implementation of an Evidence-Based Supported Osteoarthritis Self-Management Programme. Musculoskeletal care. 2014.

14. BOA-Better management of patients with osteoarthritis [Available from:

15. Skou ST, Roos EM. Good Life with osteoArthritis in Denmark (GLA:D): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord. 2017;18(1):72. doi: 10.1186/s12891-017-1439-y 28173795

16. Risberg M, Tryggestad C, Nordsletten L, Engebretsen L, Holm I. Active living with osteoarthritis implementation of evidence-based guidelines as first-line treatment for patients with knee and hip osteoarthritis. Osteoarthritis and Cartilage. 2018;26:S34.

17. Dahlberg LE, Grahn D, Dahlberg JE, Thorstensson CA. A Web-Based Platform for Patients With Osteoarthritis of the Hip and Knee: A Pilot Study. JMIR research protocols. 2016;5(2):e115. doi: 10.2196/resprot.5665 27261271

18. Jonsson T, Ekvall Hansson E, Thorstensson CA, Eek F, Bergman P, Dahlberg LE. The effect of education and supervised exercise on physical activity, pain, quality of life and self-efficacy—an intervention study with a reference group. BMC Musculoskelet Disord. 2018;19(1):198. doi: 10.1186/s12891-018-2098-3 30037339

19. Hansson EE, Jonsson-Lundgren M, Ronnheden AM, Sorensson E, Bjarnung A, Dahlberg LE. Effect of an education programme for patients with osteoarthritis in primary care—a randomized controlled trial. BMC Musculoskelet Disord. 2010;11:244. doi: 10.1186/1471-2474-11-244 20969809

20. Coleman S, Briffa NK, Carroll G, Inderjeeth C, Cook N, McQuade J. A randomised controlled trial of a self-management education program for osteoarthritis of the knee delivered by health care professionals. Arthritis research & therapy. 2012;14(1):R21.

21. Cronstrom A, Nero H, Dahlberg LE. Factors associated with patients' willingness to consider joint surgery after completion of a digital osteoarthritis treatment program: A prospective cohort study. Arthritis care & research. 2018.

22. Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Rasmussen S, et al. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthritis Cartilage. 2018;26(9):1170–80. doi: 10.1016/j.joca.2018.04.014 29723634

23. Svege I, Nordsletten L, Fernandes L, Risberg MA. Exercise therapy may postpone total hip replacement surgery in patients with hip osteoarthritis: a long-term follow-up of a randomised trial. Ann Rheum Dis. 2015;74(1):164–9. doi: 10.1136/annrheumdis-2013-203628 24255546

24. Fernandes L, Hagen KB, Bijlsma JW, Andreassen O, Christensen P, Conaghan PG, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125–35. doi: 10.1136/annrheumdis-2012-202745 23595142

25. Charnley J. The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. The Journal of bone and joint surgery British volume. 1972;54(1):61–76. 5011747

26. Thong ISK, Jensen MP, Miro J, Tan G. The validity of pain intensity measures: what do the NRS, VAS, VRS, and FPS-R measure? Scandinavian journal of pain. 2018;18(1):99–107. doi: 10.1515/sjpain-2018-0012 29794282

27. Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain measurement: a ratio measure? Pain practice: the official journal of World Institute of Pain. 2003;3(4):310–6.

28. Hurley MV, Walsh NE, Mitchell HL, Pimm TJ, Patel A, Williamson E, et al. Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: a cluster randomized trial. Arthritis Rheum. 2007;57(7):1211–9. doi: 10.1002/art.22995 17907147

29. Dolan P. Modeling valuations for EuroQol health states. Medical care. 1997;35(11):1095–108. doi: 10.1097/00005650-199711000-00002 9366889

30. Lorig K, Chastain RL, Ung E, Shoor S, Holman HR. Development and evaluation of a scale to measure perceived self-efficacy in people with arthritis. Arthritis Rheum. 1989;32(1):37–44. doi: 10.1002/anr.1780320107 2912463

31. Brand E, Nyland J, Henzman C, McGinnis M. Arthritis self-efficacy scale scores in knee osteoarthritis: a systematic review and meta-analysis comparing arthritis self-management education with or without exercise. J Orthop Sports Phys Ther. 2013;43(12):895–910. doi: 10.2519/jospt.2013.4471 24175602

32. Lomi C, Nordholm LA. Validation of a Swedish version of the Arthritis Self-efficacy Scale. Scandinavian journal of rheumatology. 1992;21(5):231–7. doi: 10.3109/03009749209099230 1439631

33. Olsson SJ, Ekblom O, Andersson E, Borjesson M, Kallings LV. Categorical answer modes provide superior validity to open answers when asking for level of physical activity: A cross-sectional study. Scandinavian journal of public health. 2016;44(1):70–6. doi: 10.1177/1403494815602830 26392418

34. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423–34. doi: 10.1249/mss.0b013e3180616b27 17762377

35. Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale: L. Erlbaum Associates; 1988.

36. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. The Cochrane database of systematic reviews. 2015;1:CD004376. doi: 10.1002/14651858.CD004376.pub3 25569281

37. Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. The Cochrane database of systematic reviews. 2014(4):Cd007912. doi: 10.1002/14651858.CD007912.pub2 24756895

38. Goh SL, Persson MSM, Stocks J, Hou Y, Welton NJ, Lin J, et al. Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis. Sports Med. 2019.

39. Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, et al. AHRQ Comparative Effectiveness Reviews. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018.

40. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363–88. doi: 10.1016/j.joca.2014.01.003 24462672

41. Min J, Osborne V, Kowalski A, Prosperi M. Reported Adverse Events with Painkillers: Data Mining of the US Food and Drug Administration Adverse Events Reporting System. Drug safety. 2018;41(3):313–20. doi: 10.1007/s40264-017-0611-5 29098610

42. Fransen M, McConnell S. Land-based exercise for osteoarthritis of the knee: a metaanalysis of randomized controlled trials. J Rheumatol. 2009;36(6):1109–17. doi: 10.3899/jrheum.090058 19447940

43. Pisters MF, Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG, et al. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Arthritis Rheum. 2007;57(7):1245–53. doi: 10.1002/art.23009 17907210

44. Hubertsson J, Petersson IF, Thorstensson CA, Englund M. Risk of sick leave and disability pension in working-age women and men with knee osteoarthritis. Ann Rheum Dis. 2013;72(3):401–5. doi: 10.1136/annrheumdis-2012-201472 22679305

45. Greene ME, Rolfson O, Gordon M, Garellick G, Nemes S. Standard Comorbidity Measures Do Not Predict Patient-reported Outcomes 1 Year After Total Hip Arthroplasty. Clinical orthopaedics and related research. 2015;473(11):3370–9. doi: 10.1007/s11999-015-4195-z 25700999

46. Cronstrom A, Dahlberg LE, Nero H, Ericson J, Hammarlund CS. 'I would never have done it if it hadn't been digital': a qualitative study on patients' experiences of a digital management programme for hip and knee osteoarthritis in Sweden. BMJ open. 2019;9(5):e028388. doi: 10.1136/bmjopen-2018-028388 31129601

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