Structured versus Usual Practice in Educating Patients with Knee OA (The ARTIST Study)

One of the recommendations in the local clinical practice guidelines for knee OA is that there is insufficient evidence to recommend structured arthritis self-management programs over the usual clinical practice (consisting of physician advise and reading materials). This is contrary to what the American College of Rheumatology (ACR) suggests in its 2000 Guidelines for Knee OA where the Arthritis Foundation Self-Management Program was specifically identified. The local guidelines were first presented in the February 2009 Philippine Rheumatology Association Annual Meeting in Davao City.

Now, I’m adding to the muddle by discussing the ARTIST study published in the British Medical Journal in 2009. Not that I’m contradicting the local guidelines but maybe there is a role for some structure in the way we do things.

PATIENTS – Out-patients aged 45-75 years who were consulting a rheumatologist who were (1) diagnosed with OA based ACR Clinical and Radiographic Definition, (2) experiencing knee pain rated 30-70 mm on a numerical scale, (3) necessitating treatment with NSAIDs, (4) had a BMI >25 and <35 and (5) able to understand and speak French (the study was done in France). 154 allocated to experimental/ standardized consultation vs 182 to control/ usual care.

INTERVENTION – Goal-oriented visits as follows:

Visit 1 (Day 0) – Education and advise related to OA and its treatment
Visit 2 (Day 15) – Discussion on joint protection and the need for exercise. Doctors proposed an exercise regimen consisting of three 30-minute sessions a week progressed to three 60-minute sessions a week of either rapid walking or cycling depending on patient preference.
Visit 3 (Day 30) – Discussion on body weight and its influence on knee OA. Doctors would propose a strategy for losing or maintaining weight. The doctors should also implement the US NIH evidence based guidelines for the management of obesity.

OUTCOME – Evaluations at Baseline, Days 15, 30, 120 (Short Term) and 12 months (Long Term) – weight, time spent on physical exercises, pain, physical function subscale of WOMAC, global disease activity and SF-12 score.

METHODOLOGY – Open cluster randomized controlled trial

APPRAISAL

  1. Were all groups similar at baseline – NO. Patients in the experimental group were heavier and had a longer delay from symptom onset to consultation.
  2. Were the patients blinded – NO
  3. Were the physicians blinded – NO
  4. Were outcome assessors blinded – NO
  5. Were groups treated similarly (aside from intervention) – NO. More patients in the usual care group were advised to go on a diet, consulted a dietitian, underwent exercise at home, physiotherapy, and using knee orthoses and insoles. All these would have tilted outcomes in favor of the usual care group. Also, more patients in the control group were using analgesics.

  6. Was there allocation concealment – YES
  7. Was there intention to treat analysis – YES

THE RESULTS
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At 4 months, patients in the standardized consultation group had greater weight loss and spent more time adhering to physical exercises. There was a difference also in the patients’ level of pain and global assessment of disease activity. The changes in secondary endpoints were sustained at 12 months.

CONCLUSION – A structured consultation program for patients with knee OA resulted in short term improvements in weight loss and time spent on physical activity at four months and sustained improvement in pain and global assessment of disease activity at four and twelve months.

REFERENCE:

Ravaud P, Flipo RM, Boutron I, et al. ARTIST (Osteoarthritis Intervention Standardized) study of standardized consultation versus  usual care for patients with OA of the knee in primary care in France. BMJ 2009; 338: b421.

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