Purpose: Exercise therapy and patient education is recommended as first line treatment for patients with knee and hip osteoarthritis (OA). Good Life with osteoArthritis from Denmark (GLA:D®) is an 8-week structured patient education and exercise program targeting patients with knee and hip OA. The program is implemented in clinical practice in different countries and reporting outcomes across countries may show what to expect when implementing such a program. The aim of the study was to report and compare outcomes and predictors across three countries for patients with symptomatic knee and hip OA attending the evidence-based education and exercise therapy program GLA:D®.
Methods: GLA:D® is a structured treatment program for knee and hip OA including 2-3 patient education sessions and 12 supervised exercise sessions delivered by certified health care practitioners. The program was introduced in Denmark in 2013, in Canada 2015 and in Australia 2016 and data were retrieved from the national electronic GLA:D® databases on August 1, 2019 (Denmark and Canada) and on July 1, 2019 (Australia). Patients with complete baseline measurements no later than the end of February 2019 were included in the study. Baseline characteristics were reported. Mean change in pain intensity (NRS 0-10, best to worst), number of stands in the 30 seconds chair stand test (more is better), time to complete the 40 meter walk test (shorter time is better) and KOOS/HOOS QOL subscale score (0-100, worst to best) from baseline to immediately after treatment were reported as means and 95 % CIs for each country. The analyses were conducted as complete case analyses supplemented by a sensitivity analysis using multiple imputation where follow-up values were missing. The association of age, gender, BMI, hip/knee joint as primary complaint, symptom duration and prior surgery with change in each outcome was evaluated using multiple linear regression with stepwise selection for each country.
Results: Across countries mean ages were 64-65 years, three quarters were women, three quarters had the knee joint as primary complain and one of three in Denmark and four of ten in Canada and Australia were obese (BMI ≥ 30 kg/m2). There were no clinically meaningful differences in baseline status between those with complete or those without follow-up data. Change in outcome measurements are shown in table 1. Patients from the three countries improved 26-33% in mean pain intensity, 7-13% in walking speed, 18-30% in chair stand ability and 12-26% in joint related quality of life from baseline to immediately after treatment. Patients from Canada and Australia seem to have slightly larger improvement in pain intensity and chair stand test than patients from Denmark. Patients in Australia have the largest improvement in KOOS/HOOS QOL followed by patients from Canada and with patients from Denmark having the lowest mean improvement. The sensitivity analysis imputing the missing values at follow up support the complete cases analyses. There was no consistency in factors associated with outcomes across the three countries, and factors associated with the outcome explained only up to 5% of the variance in the different change scores (R2 0.0036 to 0.0528).
Conclusions: Patients with symptomatic knee and hip OA attending a structured supervised patient education and exercise program across three countries on three continents improve overall in pain intensity, functional performance and joint-related quality of life. The results show minor differences in improvement patterns among the three countries studied, although these differences are not likely clinically meaningful. Among a range of baseline characteristics there was no consistency in factors associated with outcome change across countries and the included factors had low explanatory value. Similar results across different countries indicate successful implementation of the GLA:D®-program in the three countries and shows that positive results can be obtained when health care practitioners nationwide take a standardized approach to implementing clinical guidelines for knee and hip OA into practice.
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