Good Life with Osteoarthritis in Denmark (GLA: D™): Evidence-Based Education and Supervised Neuromuscular Exercise Delivered by Certified Physiotherapists Nationwide

2020 Training Manual Adapted infor use Canada LifeosteoArthritis with Good inDenmark

and Australiaand

GLA:D® INTERNATIONALLY

Danish Founders Ewa M Roos Søren Thorgaard Skou

Canadian Collaborators Project Leads: Aileen Davis Rhona McGlasson Project Coordinator: Mariel Ang Data Manager: Rose Wong

Australian Team Project Lead: Professor Kay Crossley Project Coordinators: Dr Christian Barton Dr Joanne Kemp Project Managers: Matt Francis Karen Dundules Mailing Address: Latrobe Sport and Exercise Medicine Research Centre Level 5, Health Sciences 3 La Trobe University Plenty Rd, Bundoora, VIC 3086 Email contact: [email protected]

GLA:D™ Australia is supported by the Latrobe Sport and Exercise Medicine Research Centre. TABLE OF CONTENTS

1 Overview

2 Procedures

3 Education Resources

4 Exercise Resources

5 References

6 Participant Information and Consent Form

7 Withdrawal of Consent

8 Participant Log Form (example)

9 Physical Outcome Measures

10 Physiotherapist Permission Form 1 OVERVIEW

BACKGROUND AND OBJECTIVES FOR GLA:D™ AUSTRALIA One in 11 in Australia has osteoarthritis (OA), meaning it affects more than 2.2 million Australians. OA can be caused and/or influenced by modifiable factors such as previous joint damage, being overweight, heavy work, weak muscles and irreversible factors such as age, sex and heredity. Typically, the disease develops slowly over many years and affects articular structures like the joint capsule, menisci and ligaments. The final stage of OA is consistent with articular cartilage loss and changes in the underlying bone, for example bone marrow lesions. The knee and hip joints are most often affected and represent the largest clinical population and cost.

Clinical guidelines for the treatment of knee and hip OA recommend patient education, exercise and weight loss (if needed) as first line treatment. However, clinical practice in Australia does not often follow these recommendations of in patients with OA of the knees or hips before referral to an orthopedic surgeon. Good Life with OA in Denmark (GLA:D®) represents a nationwide evidence-based initiative that follows the current recommendations for the treatment of knee and hip OA. GLA:D® includes patient education and a neuromuscular exercise program conducted twice a week for six weeks. The associated GLA:D® registry allows monitoring of participants with OA of the knee and hip from symptom onset, through treatment effects and follow-up. The GLA:D® program is currently being implemented in Australia.

THE GLA:D™ AUSTRALIA PROGRAM

People with knee or hip OA are offered treatment by a certified GLA:D™ Australia physiotherapist (with or without referral from another health professional) (see figure 1). Following registration by their physiotherapists, knee and hip OA participants enter characteristics and various outcomes including pain, function and quality of life are entered in the GLA:D™ Australia database prior to the start of the GLA:D™ Australia program, and at 3 and 12 months after the participant starts the program. GLA:D™ Australia includes two patient education sessions conducted by the physiotherapist. A third education session, conducted by a previous GLA:D™ Australia participant is also encouraged but optional depending on timing and feasibility. The GLA:D® patient education is adapted to the Australian context, having initially been developed from the Danish GLA:D® and GLA:D™ Canada programs. It contains information about OA and its treatment options. Patient education should occur within the first few GLA:D™ Australia sessions, although it does not have to occur prior to the start of the exercise program. The exercise program includes 6 weeks (twice a week) of supervised neuromuscular exercise (NEMEX) for approximately 60 minutes in a small group or individually. Supervised exercise is often more effective, and the group format is highly recommended. USE AND RELEVANCE Following the goals and objectives of GLA:D® implementation in Denmark, GLA:D™ Australia will highlight the importance of early intervention for people with mild, moderate and severe symptoms of hip and/or knee OA. It has the potential to improve the quality of life of this extensive group of patients, and may delay or prevent the need for surgery for hip or knee OA. At the same time, the program will allow the health care sector to identify patients from their baseline symptoms and target the treatment to the individual. This can ultimately obtain comprehensive insight into the costs of OA in Australia. Since the first GLA:D® course for physiotherapists in Denmark and the initiation of the GLA:D® registry in January 2013, more than 400 GLA:D® units have provided GLA:D® treatment to more than 28,000 patients.

DISSEMINATION

The results of the GLA:D™ Australia initiative will be disseminated to relevant health professionals and other stakeholders at meetings, courses and seminars. In addition, the results of the project will be presented in an annual report that will be published on the GLA:D™ Australia website. 2 PROCEDURES

2.1 SELECTION AND ELIGIBILITY

Indications for participation in GLA:D™ Australia Hip or knee joint problems that resulted in visiting a health care provider.

Exclusion criteria • Other reasons for the problems (for example tumor, inflammatory joint disease, sequela after hip fracture; soft tissue or connective tissue problems) • Other symptoms that are more pronounced than the osteoarthritis problems (for example chronic generalized pain or fibromyalgia) • Unable to understand and communicate in English

2.2 INTERVENTION

General Information Minimal intervention (education and neuromuscular exercise) as outlined in the flowchart will always be included in the treatment of patients. Participants are encouraged to start the exercise in supervised groups. Local variations with additional elements (including dietician, occupational therapist etc) can occur.

Participants in GLA:D™ Australia are asked to consent to include their data in the GLA:D™ Australia database under ethics approval. This does not affect the general patient record. Treatments such as orthotics, pain treatment etc, which are not included in GLA:D™ Australia may be prescribed by a doctor or physiotherapist but are beyond the objectives of the GLA:D™ Australia program. However, such additional treatments do not prohibit participation and registration in GLA:D™ Australia.

The physiotherapist is committed to supporting the collection of GLA:D™ Australia data by facilitating participants to record their data in the GLA:D™ Australia database.

Trauma or other acute events that occur during the GLA:D™ Australia program and require other treatment should be referred to a physician or physiotherapist, and reported to GLA:D™ Australia.

Assessment The physiotherapist will conduct the assessment as appropriate for an individual presenting with hip or knee pain. If the person is eligible for participation in GLA:D™ Australia, they will explain the program including potential risks and benefits, and the requirement for data collection. This information will be given in order for the patient to make an informed decision about participating in the program and their consent to provide data.

The assessment will also include setting goals with the patient that relate to their needs and expectations of their physiotherapy intervention, including GLA:D®. Standard assessment and screening with Physiotherapist

Physiotherapist conducts physical outcome measures and provides results to participant

Physiotherapist registers eligible participants online

Participants complete baseline questionnaire online via electronic link sent by email

Participant Education

First session (60mins) Second session (60mins) Third session (optional) What is osteoarthritis (OA) Exercise OA communicator Risk Factors Activities in daily living and former program Symptoms Coping participant living Introduction to treatment Self-help tools with OA

Six weeks of two x 60 min neuromuscular exercise (NEMEX)sessions Can be group, 1:1 or home based (group preferred) Minimal Intervention

Follow-up 3 month Physical 3 months post baseline Outcome Participants complete questionnaire online via link sent by email Measures 12 months post baseline Online questionnaire completion via electronic link sent by email

Consent When a patient decides to participate in the GLA:D™ Australia program, information about the program and what is involved will be provided in the Participant Information and Consent Form. This is embedded in the email invitation and the questionnaire sent once they are registered.

Registration Registration is done online at: www.gladaustralia.com.au/registry

The registration will trigger an email to the patient with an electronic link for the patient to use to complete the consent form and the first pre-GLA:D™ Australia questionnaire. This step can also be completed at the clinic site if computing resources allow. The patient must be able to sit undisturbed and complete the questionnaire without advice / instructions on how to answer the baseline questionnaire.

If participants do not have computer/internet access at home and the clinic cannot provide them with the computing resources to register and complete the necessary questionnaires, paper copies of the questionnaires are available. These should be mailed or emailed to GLA:D™ Australia.

Physical Tests During the first visit, the physiotherapist will complete two physical tests (“40m fast paced walk test” and “30 second chair stand test”). Results from the two physical tests will be provided to the participant for them to submit results to the database.

Participant education Participant education includes two mandatory and one optional (although preferred) session. The patient education materials can be found online in the GLA:D™ Australia dropbox. Clinics are responsible for providing these materials to their participants. The third session of the patient education includes a peer who has undergone the GLA:D™ Australia program and can share their experience of living with OA and participating in GLA:D™ Australia. This is only viable once the GLA:D™ Australia program has been delivered several times in a local area.

Exercise Participants are encouraged to complete the neuromuscular exercise program in a supervised group. Participation in all or most of the 12 exercise classes during the six weeks is most effective. Exercise classes will be around 60 minutes in duration. Participants who need to miss one or two exercise classes may attend exercise sessions beyond the six weeks, but all 12 exercise classes will ideally be completed within no more than eight weeks.

The exercise program is tailored to the individual in relation to their level of function and goals. All participants can participate in the exercises, and even active participants will be challenged in regard to quality and control of movement in the exercises.

The participant can do some of the exercises at home, providing the physiotherapist believes they can be done with proper positioning and control. This will only be done when the participant is familiar with the program and if full participation in the supervised sessions is not possible.

After the course, the participant will be encouraged to continue the exercises and follow the principles of the GLA:D™ Australia course at home, including engaging in other appropriate physical activities. Clinics are responsible for providing a copy of the neuromuscular exercise program for completion at home.

The exercises during GLA:D™ Australia will be supplemented by the general recommendations of the Australian Physical Activity and Sedentary Behaviour Guidelines https://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth- strateg-phys-act-guidelines.

3 months post baseline follow-up Participants will have a review appointment with the physiotherapist 3 months following registration for GLA:D™ Australia. The purpose of this appointment is to: • Complete follow-up testing and provide results to participant • Review goals set at assessment • Plan next steps • Remind participant to complete 3-month and 12-month follow-up questionnaires via links emailed to them

All participants will complete the 3 months post baseline follow-up. If there is a delay starting the exercise program, the follow-up will still be done at the 3-month time-point. If a participant has ceased attending exercise classes, they will still complete the 3-month follow-up; if they don’t attend a review appointment they will still complete the online questionnaires. Note that the physical testing and participant questionnaires should not be done at the end of an exercise class because fatigue will affect the results.

12 months post baseline follow-up 12-month follow-up takes place 12 months after the participant’s registration in GLA:D™ Australia. An email is automatically sent to the participant with the link for them to complete the questionnaire. No physical tests are completed at this time.

2.3 DATA COLLECTION

All GLA:D™ Australia registration will take place electronically, although paper submission forms are made available for participants who are unable to use email.

Summary of items to collect Baseline: Baseline questions Physical tests 3-month: 3-month questions Physical tests 12-month: 12-month questions First visit and assessment Physical tests • Complete and record results for the two physical tests. The tests are to be performed during the first visit assessment with the physiotherapist and before commencing the exercise component of the program. o See OARSI guidelines for a description of the “40m Fast Paced Walk Test” and the “30 sec Chair Stand Test” • Provide results to the participant so that they can enter their results into the GLA:D™ Australia database. • Enter participant details into online registry. This will initiate the questionnaires. Care needs to be taken at registration to ensure the email address of the participant is correct so all questionnaires can be completed. • All participants need to be encouraged to provide their data to the database for monitoring outcomes. However, a small number of participants will decline to provide data. These participants should still be entered on the database. They will then be given opportunity to decline consent to data collection.

Participant questionnaires • Participants should complete the baseline questionnaires before coming to the first exercise class. • The participants will require their physical test results when completing these questionnaires. An e-mail is automatically sent to the participant with the link for them to complete the questionnaire. This procedure is used to standardise the collection of data as much as possible. If necessary, the participant can contact the data manager who is familiar with all the questionnaires if any questions are unclear. The participant must independently answer the questions with minimal assistance. • Participants who have no email account should be provided with a paper copy of the questionnaire and the Participant Informed Consent Form by their physiotherapist. They should return the completed questionnaire to their physiotherapist who will arrange for it to be sent to GLA:D™ Australia by mail or email.

3 months post-baseline follow-up Physical tests • Complete and record results for the two physical tests. The tests are to be performed at the 3 months post baseline follow-up. o See OARSI guidelines for a description of the “40m Fast Paced Walk Test” and the “30 sec Chair Stand Test” • Provide results to the participant so that they can enter them in their questionnaire. • Remind the participant that they will receive an e-mail with a link to the participant questionnaires after 12 months.

Participant questionnaire • The questionnaire is completed at 3 months post baseline follow-up (i.e. once the participant finishes the program). An e-mail is automatically sent to the participant with the link for them to complete the questionnaire. • Participants who have no email account should be provided with a paper copy of the questionnaire by their physiotherapist. They should return the completed questionnaire to their physiotherapist who will arrange for it to be sent to GLA:D™ Australia by mail or email • Participants who decline to attend their 3-month follow-up will still be surveyed and their responses collected.

12 months post baseline follow-up The questionnaire is completed 12 months post baseline up. An e-mail is automatically sent to the participant with the link for them to complete the questionnaire.

Participants who have no email account will be provided with a paper copy of the questionnaire by their physiotherapist. They will return the completed questionnaire to their physiotherapist who will arrange for it to be sent to GLA:D™ Australia by mail or email.

2.4 VARIATIONS AND EXCEPTIONS

Participant does not want to provide data to the GLA:D™ Australia database • Participants who express that they do not want to provide data upon initial program registration should still be entered into the registry. They will be allocated an ID number and will receive an initial questionnaire. At the beginning of this questionnaire they will be given the option to decline consent. • Participants who have no email account and do not wish to provide their data to the program should still be entered into the database. They will not be required to complete the questionnaires.

Participant decides to stop the GLA:D™ Australia program • Data will be collected from all eligible participants unless the participant withdraws consent.

Participant has stopped for reasons other than surgery in the joint being treated by the program • The participant should, wherever possible and with consent, still complete the 3 months post baseline questionnaire.

Participant has undergone surgery in the joint being treated by the program and does not attend the 3 months post baseline follow up (ie The participant stops the program throughout the exercise component of the program) • The participant should, wherever possible and with consent, still complete the 3 months post baseline questionnaire. • The participant will indicate on their questionnaire that they underwent surgery.

Participant has undergone surgery in the joint being treated by the program and attends 3 months post baseline follow up • The participant should, wherever possible and with consent, still complete the 3 months post baseline questionnaire. • Complete the physical tests and enter into database. • The participant will indicate on their questionnaire that they underwent surgery. Participant undergoes surgery in the joint being treated by the program between 3 and 12 months post baseline • The participant should, wherever possible and with consent, still complete the 12 months post baseline questionnaire. • The participant will indicate on their questionnaire that they underwent surgery.

If the participant withdraws consent for providing data to the program, the "Withdrawal of Consent" form must be emailed or posted into the GLA:D™ Australia office at Latrobe University.

2.5 FREQUENTLY ASKED QUESTIONS Participants will be completing questionnaires independently online. Here are some answers to frequently asked questions.

Most affected joint For the purpose of this research, the most affected joint is selected on the first questionnaire and is referenced as such throughout the program.

How often do you have pain in your hip / knee? Pain at night also counts. If the participant, for example experiences pain every night, check the "every day" box.

Pain Scale It is a Nominal Rating Scale and Visual Analog Scale where 0 represents no pain and 100 represents the worst pain imaginable. It is up to the participant to select their level of pain intensity.

Do you have so much trouble and pain from your hip / knee that you want to have surgery? The participant needs to understand that their doctor or a surgeon will not get their answers. The answer does not affect whether the surgery will occur or not. The participant answers only based on if he or she would choose to have surgery at this time.

HOOS/KOOS-12 – Questions about activity If the participant avoids the activity altogether because of their hip or knee pain, they should select ‘Extreme’.

Completed treatment The participant will check the boxes of which parts of GLA:D™ Australia they attended. It is recommended that you remind the participant how many education and exercise classes they attended.

If the participant has had surgery in the knee or hip since the last visit All types of joint-related surgeries should be noted, but not surgery of the muscles. Participants will select from a drop-down list.

Questions or Concerns? Please send through any questions or concerns to: [email protected] 3 EDUCATION RESOURCES: Participant Education Presentations Patient Education Session 1

It is important to acknowledge the founders of this great initiative from Denmark and the GLA:D Canada team for helping establish GLA:D in Australia.

GLA:D, run as a not-for-profit initiative, is now an international community and receives support from all around the world, with all countries helping each other.

La Trobe University’ Sport and Exercise Medicine Research Centre and associated staff, along with many hard-working lecturers and tutors from around Australia continue to support the quality and development of GLA:D in Australia.

Designed for people with knee and/or hip OA • 2 education sessions (90 min) • Individual assessment (sit to stand, 40m walk test), online questionnaires • 12 supervised neuromuscular exercise sessions over approximately 6 weeks • Retest of sit to stand and 40m walk, online questionnaires at 3 months • Online questionnaires emailed at 12 months

It is really important you complete the questionnaires to the program can continue to be improved, and to help improving funding from government and private health to improve osteoarthritis care in Australia. Education is a vital part of the GLA:D program. Understanding osteoarthritis, including your potential treatment options and their likelihood of helping you, is the first step to you improving how you manage you hip or knee pain.

• Most common life style disease in people over 65 years of age (more common than high BP and diabetes) • It is one of the most common reasons people in Australia see their GP • Persistent hip and knee pain, which is often an early sign of osteoarthritis is very common, even in younger people

• Lifelong joint disease, can start without any obvious reason • Cartilage on ends of the bones changes structure and can thin over time • Joint capsule, ligaments, muscles and underlying bone also affected • Leading cause of physical inactivity in people over 65 years of age • Osteoarthritis is often described as a “wear and tear disease”. This description should be avoided since it leads many people to think that they cannot and should not be physically active. This is wrong, cartilage needs moderate load through physical activity to regenerate itself. • The focus on the structure of the cartilage is also often unhelpful since the causes of pain and disability associated with osteoarthritis is quite complex, as we will discuss next. • In fact, routine scans such as X-rays and MRIs are no longer recommended for people with osteoarthritis. • It is important to spend time understanding the multiple factors specific to each person which might influence their pain and disability

Factors that contribute to pain and disability in people with osteoarthritis are complex. Although structural changes may play a role, there are many other factors, some less obvious, which contribute to each persons experience with osteoarthritis. The following can make your pain and symptoms worse: - Being overweight - Muscle weakness - Doing too much - Fatigue and being inactive - Poor sleep - Stress, depression, and feeling isolated - Fear of damage and lack of joint confidence - Other negative beliefs and mood Many of these factors can be changed with appropriate guidance and support

• Age - OA becomes more frequent with increasing age (because it is an irreversible disease) - OA is irreversible but the symptoms can be reduced and even disappear - Pain is more dependent on muscle strength than on x ray changes • Sex - OA is more common in women - Women=often OA of hands & knee - Men= hip OA more common - During middle age more men than women have knee OA (may be related to more men having injured their joints during sports and work early on in life) • Heredity - If one or both parents have osteoarthritis, the risk of their child having OA as an adult is increased - We can to some extent modify this genetic risk by adopting a healthy lifestyle

2 ways to diagnose OA: • X ray will show: reduced joint space, osteophytes, cyst formations, increased density of the bone beneath the cartilage • Based on symptoms, existing risk factors and findings from a clinical examination • Common to experience symptoms for 10-15 years before OA shows up on an x-ray • The link between x ray changes and symptoms is generally poor • It is always the patients symptoms and not the x ray changes that guide the choice of treatment

Scans may be important in the case of a traumatic injury, or if something other than osteoarthritis is thought to potentially be the cause of your pain and symptoms. In almost all cases, the diagnoses of osteoarthritis can be made based on pain and symptoms you report, a clinical examination, and potential risk factors specific to you. X-Rays are still needed to help make a final decision of whether to undergo joint replacement, since those with only small to moderate structural changes are less likely to respond to surgery.

• Joint Anatomy - Ends of bone covered by cartilage - Surrounded by articular capsule, produces synovial fluid which lubricates and nourishes the cartilage - Ligaments and muscles help stabilize the joint • Cartilage has no blood supply; needs nourishment from synovial fluid - Through dynamic load: cycles of loading and unloading the joint - Cartilage is like a sponge. Pressure pushes fluid out, but when pressure is released cartilage sucks fluid back in - Regular exercise ensures cartilage remains efficient at drawing fluid back in

• Provide basic anatomy of the knee joint • Use knee model if available

• Provide basic anatomy of the hip joint • It has no menisci, which makes it different from the knee joint • Use hip model if available

• Structural changes in your joint may be due to: - Cartilage being exposed to too much load all at once (an acute injury) - Too much load over a long time (overuse injury) - Too little load – your tissues need a stimulus to regenerate and remain strong - Can happen with a normal load if the cartilage is diseased to start with. Remember, your hip or knee pain can be made worse by many factors that you may not immediately think about (poor sleep, diet, stress, your beliefs, etc.)

• OA usually starts in one joint. Symptoms develop slowly and may stop completely • Experiences will vary from person to person • Stiffness especially in the morning or after sitting down for a period of time, usually short lived (less than 30 minutes) • In the beginning, pain occurs only during weight bearing • Later, the pain may also occur at rest and at night • Inflammation=Swelling, red, hot (steroid injection may help but is short lived (1-4 weeks) • Pain associated with OA is not from the articular cartilage, it comes from bone, ligaments, joint capsule, where tendon joins the bone, muscles • Symptoms can be random and vary (often no link of intense symptoms to activities)

Osteoarthritis can create challenges to completing many activities. What of these activities do you have trouble with? Are there other activities not listed that you find challenging due to you osteoarthritis? You can work with your physiotherapists to develop realistic goals to improve your ability to do the things you want to do. GLA:D may help achieve many of these goals, but there may be other exercises or treatments which can be added to help you get there.

• People may stop doing physical activities that they like due to feeling tired and lacking energy. Once they have done all the things they “must” do, they are exhausted. • Fatigue cannot be slept away. Fatigue is different than ordinary tiredness. • Ordinary tiredness=tiredness you feel when you have not gotten enough sleep at night. This goes away if you get a good night’s sleep • Fatigue is common in inflammatory joint diseases and other lifelong illnesses • The cause of fatigue might be a combination of an ongoing disease process and longstanding pain and stiffness. • We know that poor physical and psychological status increases fatigue. • What can you do to decrease fatigue? Being physically active and being in better physical shape helps reduce fatigue • Start slowly and gradually build your activity levels

• Treatment aims at reducing symptoms and improving joint function • Every person seeking care for joint pain should be offered education, exercise and weight reduction (if needed) – this recommendation is supported by Australia’s national guidelines for osteoarthritis care. • If the first line of treatment doesn’t lead to a satisfactory outcome, it can be complimented with pain medications, TENS, manual therapy, braces, shoe insoles, other aids, and in some instances injections. However, these strategies cannot address the range of factors contributing to pain and disability. For example, the only way to improve your strength is to complete an exercise program. • For those with very severe symptoms (10-15%), surgery may be considered. - Joint replacement (joint surfaces replaced with metal or plastic) - Osteotomy - Arthroscopic knee surgery has no better effect than a sham or placebo

The Australian clinical practice guidelines which are published by the Royal Australian College of General Practitioners recommend that all Australian’s seeking care for osteoarthritis should be offered exercise. GLA:D provides a great option to provide this

It is essential to understand the possible causes of OA, what can be done, the importance of self-management since it is a lifelong disease • Exercise is effective for pain relief - Different types of exercise like walking and strength training are effective in relieving pain - Neuromuscular exercise is just as effective for pain relief and in addition targets the OA joint and improves stability and trust in the affected joint - Dose of exercise matters. More is better. - During neuromuscular exercise you will practice doing things you do everyday like getting down on the floor and up again, rising from a chair, walking etc. with good movement quality and loading the joint the best possible way. This is what makes the program unique; the activities are applicable to your everyday life.

• Weight reduction - Normal walking= knee joint is loaded with at least 2-3x your body weight with each step - Being overweight increases the risk of the cartilage and joint becoming overloaded - A relatively small reduction in weight has a big effect on joint load - For every kilo you lose, the load is reduced by at least 2-3x - Improved diet and exercise used to reduced weight is also likely to be beneficial to your pain due to improve general health

Second line treatments have varying levels of evidence to support their use. Often they are associated with benefit in reducing pain in the short term. Second line treatments should not replace first line treatments.

• Shoe inserts,/orthotics, taping and braces may help reduce pain and improve your confidence. However, alone, they are rarely a long term solution • Dry needling/acupuncture and manual therapy can help reduce pain in the short term, but long term these treatments are unlikely to help • Using a cane or walking stick in the opposite hand when walking reduces the load on the aching joint, which may help prevent limping • Walking poles do not provide the same support as a cane but they provide a bigger support surface, resulting in better balance. • Hot and cold pack, and electrical stimulators can also help reduce pain, and are easy to use independently These treatments should never be used in place of first line treatments such as education, exercise and weight management where indicated. Think of them as complimentary

Paracetamol has few side effects, and can help pain in the short term. There are no long term benefits to regular use in comparison to a placebo. Non-steroidal anti-inflammatories are estimated to 3 x more effective for pain relief compared to paracetamol. However, they are associated with greater risk including stomach ulcers, and not recommended in people with other chronic diseases like heart disease

Always consult your doctor about what pain medications might be appropriate for you We recommend that these treatments not to be used in place of first line treatments such as education, exercise and weight management where indicated. Think of them as complimentary.

There is no evidence opioids like oxycontin, endone etc. will help. In fact, they may make pain worse in the long term Some research indicates 1 in 550 who regularly take opioids will die of an overdose Guidelines around the world recommend against taking opioids. If you are taking opioids, you may wish to speak to your doctor about strategies to reduce your dependency.

Can be helpful for short term pain relief, but no benefit in the long term compared to a placebo (salt water) injection Occasional adverse events such as joint infections can occur Repeated injections (x8) of cortisone over 2 years leads to more rapid cartilage loss

Hylauronic Acid (Synvisc) is and artificial fluid proposed to replace joint fluid. There is limited evidence of short term benefit, and risks include joint infection and worsening of you condition Platelet Rich Plasma, or PRP is proposed to increase the concentration of growth factors in your joint. It uses your own blood, which is processed, and then reinjected into your joint. There is limited evidence that it helps pain for up to 12 months, but this is not conclusive. We recommend that these treatments not to be used in place of first line treatments such as education, exercise and weight management where indicated. Think of them as complimentary.

Surgery should be reserved only for people not responding to first and second line treatments.

Very common procedure, and is associated with a reduction in pain – usually about 30%. However, arthroscopy is no more effective than a placebo (fake surgery) in multiple studies of people with knee pain. Fake surgery is also associated with around a 30% pain reduction, meaning benefits are likely due to factors not related to the procedure. This could be post surgical rehabilitation, better management of loads, reduced fear of exercise, or any number of other factors. The age of patients in these studies is 35 years and older, so not just older people. Any surgical procedure has risks which must be considered. In the knee, guidelines all around the world recommend that arthroscopy should not be performed for people with knee osteoarthritis. In the hip, there is much less guidance at this point in time.

Joint replacement is a good operation for the right person. Should not be provided to people who have not adequately trialled first line treatments including education, exercise and weight management where indicated. Most people with knee osteoarthritis will delay surgery following the completion of a program like GLA:D. 2/3 will delay for at least 2 years Although most people benefit from this big procedure, not all do. As with all surgeries, there are risks and potential complications. Completing an exercise program first means you are better prepared for the surgery. If you have osteoarthritis in only one part of the knee, the surgeon may suggest osteotomy. This procedure takes a wedge-shaped part of the bone of the lower leg and places it in the knee to help redistribute the load. Another common surgical procedure is a partial knee replacement which typically involves replacing just the surfaces on the inside of the joint.

There are many benefits associated with completing GLA:D Continue to talk to your physiotherapist about your progress, and set goals. There are a range of other treatment options available, so if you are not reaching all of your goals, there may be other treatments or exercise approaches you could add or try.

Discuss additional resources: • GLA:D Australia Website • RACGP Guidelines • TREK NEMEX Website • MSK Australia

Next session we will go into detail about exercise as treatment for osteoarthritis, and how to cope better with everyday life.

Patient Education Session 2

Let’s review the treatment pyramid Treatment guidelines from around the world are based on recent research, and emphasise the the importance of early treatment- education, exercise and weight management (if necessary) Other treatments may help but they should compliment, not replace first line care

• Physical activity is good for every one, and staying active is an important part of managing osteoarthritis. Physical activity can occur during leisure activities (walking, sport) or occupation activities (e.g. your job). You may not always have control of the load your body undergoes at work, or during leisure activities. - For example, carrying a box heavier than what your fitness level can handle may lead to pain - Another example might be trying keep up with friends in a walking group, who walk faster than what you are capable of - Exercising to get stronger and improve your fitness level can help you deal better with what you need to, or want to do • Therapeutic exercise is carried out with a specific purpose, can be guided by a health professional, and can improve you ability to be physically active in work and leisure time.

Therapeutic exercise can be designed to work on many things to help people with osteoarthritis. • Neuromuscular exercise, which is a big focus in GLA:D, can improve the way you move and give you more confidence to do other exercise • In GLA:D, exercises are also completed to improve muscle endurance and strength, along with your ability to perform common functions well, like standing up from sitting and walking on stairs • Exercises can also be given to improve muscle power, where your muscles generate force quickly. This may help improve your balance, and ability to do activities requiring more muscle power (e.g. walking quickly, running) • Exercises to improve flexibility like stretching may help you joint range of movement • Aerobic exercises (e.g. walking program, exercise bike) may help improve you physical fitness, which is can assist you to get back to many recreational physical activity. (Continued in Education Presentation)

Exercise and Physical Activity is Medicine. Being inactive increases our risk of at least 35 chronic disease Exercising and being active can help has prevent and treat many other chronic diseases, not just osteoarthritis. This includes cardiovascular and heart disease, diabetes, dementia, and certain cancers There are many positive effects from being physically active • Lowers blood pressure • Improves the way your body handles blood lipids/cholesterol and blood sugar levels • Better physical fitness will reduce how tired you feel after exercise. Your body will use less energy to do the same amount of work • Your body will improve connection and control to your muscles; they will become better nourished and stronger • Bone density will increase • As explained in the previous session, cartilage requires dynamic load to regenerate • Your appetite and body energy metabolism is affected with exercise; exercising might increase your muscle mass (since your muscles are growing). Since muscle weighs more than fat, you might actually see an increase in weight. However, having more muscle is better than fat and is linked to other positive health effects. • Exercise increases the endorphins released by the body, which results in less pain and better mood STRETCH BREAK

Guidelines in Australia recommend at least 150 minutes of moderate (feels slightly difficult), or 75 minutes of vigorous physical activity per week. You will receive further benefits by completing twice this amount. A simple aim is to complete 30 minutes per day. Importantly exercise should be completed in bouts (or blocks) or at least 10 minutes.

Exercise should be completed at an intensity where you start sweating and become slightly short of breath. This means endorphins (a natural high) will be released and you will start the adaptation process to get stronger and fitter.

To improve your physical fitness, exercise at 60% of your max heart rate. An easy way to calculate what your max heart rate is is to subtract your age from 220.

For some people, 30 minutes a day seems a long way off. It may be helpful to set a smaller initial goal. For example, most people with severe knee osteoarthritis can complete 10 minutes of moderate intensity walking per day, without increasing their pain. Doing something is always better than doing nothing.

Programs like GLA:D can help you build your capacity to be active, and achieve physical activity goals It is important to find activities that you like, they should fit into your daily life so you can prioritise regular physical activity. Here are examples of a wide variety of activities to consider: • Walking is a simple activity. Start with small distances and gradually increase. Later you may like to also try to increase speed. • Running is something people often avoid with osteoarthritis. However, there is no evidence to suggest small amounts of running is harmful. Ensure you work to build you capacity to run through targeted therapeutic exercise, and gradually introduce it. Some people who have not run for many years get back to running after GLA:D, but it can take many months. Other people completing GLA:D already run regularly. Osteoarthritis does not necessarily mean you need to stop. • Cycling is very effective in improving physical fitness, less joint load than walking. Requires a knee bend of 110. Adjust saddle height so knee is kept at 10 bend when most extended • Swimming and other water exercise like running in water or water aerobics can be a great form of physical activity. It places less load on hips, knees and feet. • Dancing is a great form of physical activity and enjoyed by many people. Like all exercise, you should start slowly, especially if you have not done it for a while. Don’t mix with alcohol. Importantly, some forms of dancing can be quite challenging for people with osteoarthritis. Talk to your physiotherapist about exercise strategies to build you capacity to dance. • Aerobics- Improves strength, stamina and coordination. Wear proper shoes. Be cautious of jumps and sudden changes in direction. Like all things, start slowly. • Strength Training has many benefits. In fact guidelines recommend 2 sessions of strength training per week, due to benefits for things like bone density, balance and cardiovascular health. (Continued in Education Presentation)

Cartilage needs to be appropriately loaded to regenerate itself - When loaded and unloaded, synovial fluid is pumped in and out of the cartilage - This stimulates new development of cartilage which improves its shock absorbing capacity Inactivity, excessive load from hard manual labor for many years, and some elite sports can cause an imbalance between the development and degradation of cartilage Starting to exercise early will have a greater effect on the development of cartilage compared to if you start when you already have severe stages of OA The things you practice doing are the things you get good at- by increasing range of motion in the joint and strength of surrounding muscles, it will become easier to perform everyday activities

• Having strong muscles helps stabilize the joints and improve your confidence to complete acivities you need to, or want to, complete • Using the right muscles at the right time with appropriate force, makes it easier to control your movements, and complete functional tasks • It is important to give your body time to recover and rebuild itself between exercise sessions. - This is why our exercise classes are spread out over the week, happening twice a week.

• Hip, knee, foot should be well aligned when you exercise • Control, quality and concentration are required for neuromuscular exercise to load the joint more evenly • Ideally, the knee should not fall inward or outward when you sit down or stand up or complete other activities. However, this can depend on each person’s structure and function. • A neuromuscular approach to exercise is effective at reducing pain and improving confidence in most people with osteoarthritis, even in people who are about to have a joint replacement.

• Like any treatment, exercise needs to be adequately dosed. • Completing exercise less than 2 x per week is unlikely to be effective. 3 to four times per week is likely to be more effective than 2 x per week • 6 weeks should be the minimum period an exercise program is completed for to give it a chance to work. Research shows that shorter programs will not help, and do not allow long enough to improve strength. • 12 weeks will be more effective • The best exercise is the exercise that gets done • 10 min of walking a day = 70 min a week = more than 60 hours a year! At slow speed, this would be well over 200km in a year

It is important when starting a new exercise, or exercise program, not to do too much too soon. This is important in programs like GLA:D, and also other exercise you may choose to do. You need to learn the correct amount of load and it is very individual. The right amount of load will help you get stronger, and improve the health of your cartilage. Each person needs to learn their correct amount of loading. This load can also be trained up as you do more exercise. After a break from exercise (e.g. having the flu), someone's load would have to be adjusted again.

• It is vital to understand that pain does not equal damage. • Pain is a companion to OA and it often hurts when you start exercising. It is OK if it hurts when you exercise to a certain limit • Humans are hardwired to treat pain as a warning signal. However with OA, this can prevent people from exercising Firstly, pain during exercise must be perceived as acceptable Secondly, any increase in pain during and/or after exercising should subside within 24 hours • This same guidance has been used successfully by thousands of people with OA to help take control of pain when exercising • It has been shown repeatedly that the more exercise you do, the less pain you will have • Exercise is dose-dependent, and in this case, more is better! • Pain does not originate in the knee…pain is created in our brains based on different factors like thoughts, feelings, experiences and beliefs.

Ask participants for some barriers they experience with exercise. Collectively try to come up with solutions. • Finding/making the time in your everyday life, without interfering with your everyday plans • Seeing the purpose and knowing the importance of exercise and/or weightloss can be motivating. Write down your goals • In GLA:D, we measure how long it takes you to walk 40m and how many times you can stand from sitting in 30 sec. Find other ways to check your improvement - Ex. Time it takes to walk around the house, or up the stairs - Be prepared for times where you see minimal or no improvement. This happens to everyone (even high level atheltes), it’s good to plan a strategy on how to handle it if it happens • It’s important to have support and access to someone who can help make adjustments to your exercise program, or someone to answer your OA questions • It’s important to have knowledge on how to start exercise and deal with OA • How you want to structure physical activity and exercise is completely individual. • Remember, the best exercise is the exercise that gets done!

Always remember, it takes a lot to damage your joints and muscle Being active doesn’t just help osteoarthritis. It helps prevent more than 35 other chronic diseases, including depressions, cardiovascular and heart disease, diabetes and falling. Getting more active will help. What will are your long terms plans to become more active, or stay active? Do something you like can be a strategy to divert your attention from the pain - Can you remember a time when you forgot about the pain because you were preoccupied with an activity? - Using activities in this way can be a good strategy to cope with pain. Try having a healthy relationship with your pain Create a plan of how you will stay active

3 different coping strategies. Have you used any of these strategies? Is there something you have stopped doing due to OA? Is it a good strategy to stop an activity becasue you are in pain or feel stiff? - You need to think very carefully before you give up an activity, especially if it helps you keep up your physical fitness or feels meaningful to you, or provides social stimulation and a sense of belonging - Research shows that those who stop doing activities have an increased risk of getting sad and depressed

Highlight these points and discuss with participants what strategies they use/have found useful

1. Stay active (aim for daily exercise) – find things you enjoy 2. Don’t sit for too long (< 20 minutes) 3. Reward yourself when you achieve goals 4. Take charge of your own disease 5. Listen to your body 6. Use relaxation techniques 7. Monitor you range of movement 8. Get strong, stay strong (especially your thigh, hip and trunk muscles) 9. Strive for optimal body weight 10. Avoid limping, aim for good joint control with exercise

4a EXERCISE RESOURCES: NeuroMuscular Exercise Program (NeMEx) Exercise program ® GLA:D KNEE/HIP NAME

This exercise diary may be printed or copied exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians. Other use requires written permission from SDU. Pain registration EXERCISE DIARY

REGISTRATION OF PAIN DURING EXERCISE

Exercise-induced pain is common. Please register the pain intensity you feel in the table below. Use the pain scale of 0-10 to assess your pain during and after each training session. Zero indicates the absence of pain, while 10 represents the most intense pain possible.

A pain intensity score above 5 will often call for an adjustment of the exercises in consultation with your physiotherapist. Intensified pain lasting longer than 24 hours after a training session also indicates that your program needs to be adjusted. Your physiotherapist may help you.

0 2 5 10

Safe Acceptable Avoid

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Pain Pain Pain Pain Pain Pain Pain Pain

Date Date Date Date Date Date Date Date

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Pain Pain Pain Pain Pain Pain Pain Pain

Date Date Date Date Date Date WEEK 7 & 8 EXTENDED PROGRAM - OPTIONAL, Date Date

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 2 The exercise program CONTENTS

THE EXERCISE PROGRAM CONSISTS OF THE FOLLOWING ELEMENTS:

• Warm up

• Core stability Exercises that focus on core/spine stability as this affects a person’s ability to stabilize and control his or her hip and knee joints.

• Alignment of joints Exercises that focus on an appropriate position of the joints in relation to each other, i.e. that the hip, knee and ankle joints are properly aligned (see picture).

• Leg strength Exercises that focus on strengthening the hip and knee muscles

• Functional exercises Exercises that prepare the body for daily activities

• Walking exercise/Cool down/Stretching

EXERCISE PRINCIPLES Each exercise consists of 2-3 sets of 10-15 repetitions and rest corresponding to one set between each set and exercise. Each exercise can be progressed through four different levels. The exercises are performed with both the affected and the unaffected leg. Some of the exercises should be performed in front of a mirror to get a visual feedback of the performance. It is important that the hip, knee and ankle joints are properly aligned (see picture). A GLA:D® program lasts for at least 6 weeks (12 training sessions) and is supervised by a physiotherapist. The exercise diary allows you to register up to 8 weeks.

The exercise program has been designed on the basis of Ageberg et al. Feasibility of neuromuscular training in patients with severe hip or knee OA: The individualized goal-based NEMEX-TJR training program. BMC Musculoskeletal Disorders, 2010. Photographer: Jørn Ungstrup

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 3 The program WARM UP

THE WARM UP CONSISTS OF 10 MINUTES OF STATIONARY CYCLING

Warm-up consists of ergometer cycling for 10 minutes. The work load is set individually and can be increased during the 10 minutes, aiming at reaching a perceived exertion of “somewhat hard”. The height of the saddle must be adjusted so that the knee cannot be fully extended.

Warm-up is important as the discomfort associated with OA tends to subside with movement. Also, a good warm up will get your muscles ready for action and lubricate your joints. Exerci- sing will be easier when you are warmed up.

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 4 Exercise 1A Pelvic lift

Level 1 Level 2 Level 3 Level 4 Lie on your back with your legs resting on Same as level 1, but with a longer lever arm so Single leg pelvic lift. Be careful not to over- Pelvic lift with your arms across your chest. top of the gym ball. Short lever arm. Spread that only your heels are resting on top of the extend your knee and control your pelvic tilt. The exercise can be done with one or both your arms out to your sides. Lift your hips ball. Be careful not to overextend your knees Perform the exercise for both legs. legs on the gym ball. Be careful not to over- off the floor and push your hips toward the when you lift your hips off the floor. extend your knees and control your pelvic ceiling, then go back to the starting position. tilt. Avoid exaggerated lumbar curve.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 5 Exercise 1B Sit-ups

Level 1 Level 2 Level 3 Level 4 Lie on your back, calves on top of the gym Lie on your back, calves on top of the gym ball Lie on your back, calves on top of the gym ball Lie on your back, calves on top of the gym ball and arms straight forward. Roll your and arms across your chest. Roll your shoul- and hands behind your neck. Roll your shoul- ball. Roll your shoulder blades up and lower shoulder blades up and lower yourself back der blades up and lower yourself back down der blades up and lower yourself back down yourself back down after a short pause while down after a short pause. after a short pause. after a short pause. Place your hands by your holding hand weights. ears to avoid straining your neck.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 6 Exercise 2A Backward sliding lunges

Level 1 Level 2 Level 3 Level 4 Standing position, weight-bearing on one Same as level 1, but standing on uneven surfa- Standing position, take a large step forward, Same as level 3, but holding hand weights. leg, other leg on sliding surface. Slide ce with weight-bearing leg (e.g. foam pillow or bend the knee of the step-out leg while en- backwards while bending the knee of the thick mattress). Use hand support for balance suring proper alignment of hip, knee and ankle weight-bearing leg, then slowly return to the if needed. joints, then push yourself back to the starting starting position. Ensure proper alignment of position. hip, knee and ankle joints. Use hand support for balance if needed. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 7 Exercise 2B Sideways sliding lunges

Level 1 Level 2 Level 3 Level 4 Standing position, weight-bearing on one Same as level 1, but standing on uneven surfa- Standing position, take a large step to the side, Same as level 3, but with resistance band leg, other leg on sliding surface. Slide ce with weight-bearing leg (e.g. foam pillow or bend the knee of the step-out leg while en- around your ankles. Sideways while bending the knee of the thick mattress). Use hand support for balance suring proper alignment of hip, knee and ankle weight-bearing leg, then slowly return to the if needed. joints, then push yourself back to the starting starting position. Ensure proper alignment of position. hip, knee and ankle joints. Use hand support for balance if needed.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 8 Exercise 3A Hip abductors

Level 1 Level 2 Level 3 Level 4 Standing with light resistance band in tensi- Same as level 1, but with medium or heavy Same as level 1-2, but standing on uneven Standing with a resistance band tied to- on, lift your outer leg up and straight out to resistance band. surface (e.g. foam pillow or thick mattress). gether in a circle around your ankles and the side as far as possible and stretch the weight-bearing on one leg. Lift your other band. Keep stance leg and torso stable, do leg up and straight out to the side as far as not lean forward or to the side and do not possible while keeping stance leg and torso twist your body. Be careful not to overextend stable. To progress the exercise, try standing the weight-bearing knee. on a foam pillow.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 9 Exercise 3B Hip adductors

Level 1 Level 2 Level 3 Level 4 Standing on one leg with light resistance band Same as level 1, but with medium or heavy Same as level 1-2, but standing on uneven Lie down on one side, resting on your elbow around the other leg. Pull your leg in towards resistance band. surface (e.g. foam pillow or thick mattress). and forearm. Place your upper leg on the the weight-bearing leg against the resistance chair while resting your lower leg on the of the band. Keep stance leg and torso stable, floor. Raise the lower leg towards the bottom do not lean forward or to the side and do not of the chair against gravity. Hold for a few twist your body. Be careful not to overextend seconds and return your leg to the floor. To the weight-bearing knee. progress the exercise, try moving further away from the chair so that only your foot is placed on the chair. WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 10 Exercise 4A Knee flexors

LIGHT MEDIUM HEAVY EXTRA HEAVY RESISTANCE RESISTANCE RESISTANCE RESISTANCE BAND BAND BAND BAND

Level 1 Level 2 Level 3 Level 4 Sitting position. Light resistance band Use medium resistance band. Use heavy resistance band. Use extra heavy resistance band. around one foot. Sit at the front of the chair to allow full range of movement when bending and straightening your knee. Pull the leg backwards against the resistance of the band and bend your knee.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 11 Exercise 4B Knee extensors

Level 1 Level 2 Level 3 Level 4 Place the center of a resistance band under Sitting position with light resistance band Use medium resistance band. Use heavy resistance band. one foot and hold an end in each hand. around one foot (see picture). Push resistance Bend and straighten your knee against the band forward by extending your knee. resistance of the band while keeping your hands still.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 12 Exercise 5A Chair stands

Level 1 Level 2 Level 3 Level 4 Start in a seated position, feet parallel and Same as level 1, but without hand support. Perform the exercise with one foot in front of Perform the exercise while holding hand shoulder-width apart, putting load on both the other. This exercise is a single leg standup weights. Keep your elbows at a 90 degree legs. Slight hand support for balance. Stand exercise with weight-bearing and focus on angle. up while ensuring proper alignment of hip, your back leg. Perform the exercise for both knee and ankle joints. Do not let yourself legs. collapse back down into the chair. Rather, control your lowering as much as possible.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 13 Exercise 5B Step ups

LOW STEP BOARD MEDIUM STEP BOARD HIGH STEP BOARD

Level 1 Level 2 Level 3 Level 4 Step up onto a low step board or stair with Same as level 1, but using a medium step Same as level 2, but using a high step board. Step up onto the step board with one leg and or without slight hand support for balance. board. step across and back again with your other Then step backward to the starting position. leg. Ensure proper alignment of hip, knee and ankle joints.

WEEK 1 WEEK 2 WEEK 3 WEEK 4 WEEK 5 WEEK 6 WEEK 7 WEEK 8 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION 1ST SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps

2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION 2ND SESSION Level Level Level Level Level Level Level Level

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Reps Reps Reps Reps Reps Reps Reps Reps WEEK 7 & 8 EXTENDED PROGRAM OPTIONAL,

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 14 Walking exercise/Stretches

WALKING EXERCISE STRETCHES Walk forwards and backwards Stretching of the major muscle groups of the lower extremities will increase flexibility. in front of a mirror with focus on Hold the stretch for at least 20 seconds. For added support, stand by a wall or something proper alignment of the hip, knee to support yourself while doing the stretches. Focus on appropriate alignment of the hip, and ankle joints. knee and ankle joints.

Exclusively for use in connection with GLA:D® knee/hip programs supervised by certified clinicians Page 15 4b EXERCISE RESOURCES: Tips for Teaching NeMEx 4b EXERCISE RESOURCES: Tips for Teaching NeMEx

Exercise circle 1: Core stability/postural function (Pelvic lift/sit-ups)

Pelvic lift

What is important? That the abdominal muscles, the buttocks and the inner thigh muscles are activated, in this order, to perform the movement with quality and control. What is less important? How high you lift. Examples of cues to improve movement quality: • ”Tighten your abs to pull up your behind a little. Tighten your buttocks as well to pull up and lift your behind somewhat further from the floor. Now your behind is in the air and your legs are balancing on the ball. Finally, squeeze your knees together to activate your inner thigh muscles.” • Place your hand, or the patient’s hand, on the muscles to be activated. Feel the muscles tighten and become harder. • Place a soft ball or a folded towel between the patient’s knees and ask him/her to squeeze the ball/towel. Ways to progress: • Decrease the support surface: During pelvic lifts, lift one leg at the time and bear weight on one leg only instead of on both legs. Alternate the weight-bearing leg (left, right). When alternating legs, start with both arms on the ground, and progress from there via support from the upper arms only until you no longer need support from the arms. This requires good muscle activation and body balance. • Increase the lever arm: ball further away during pelvic-lift.

Sit-ups

What is important? That the abdominal muscles are activated. What is less important? How high you lift. Examples of cues to improve movement quality: • “Tighten your abdominal muscles and press your lower back down towards the floor. Lift your head first, then your shoulders from the floor. You should pull your chin in and look at your stomach.” • Place your hand, or the patient’s hand, on the muscles to be activated. Feel the muscles tighten and become harder. • Place your hand, or the patient’s hand, in the lower back and feel the lower back being pressed against the hand. Ways to progress: • Decrease the support surface: First lift the lower arms, then the upper and lower arms from the ground during sit-ups. • Increase the lever arm: Arms over head during sit-ups.

Exercise circle 2: Dynamic alignment (Slide exercise – forward/backward and sideways)

What is important? Movement quality. That the hip, knee and foot are well aligned in relation to each other. What is less important? How far you slide. Examples of cues: • Focus on the standing weight-bearing leg. This is the leg that is being exercised the most. • Look at your knee of the standing weight-bearing leg. The kneecap should be over the foot. If kneecap is inside (medially) of the foot, it helps to tighten (contract) your outer hip muscles to rotate your knee outwards. • Place your hand, or the patient’s hand, on the hip rotators and feel that the muscles become tighter and harder. Ways to progress: • Decrease the surface: Standing on a piece of foam makes the surface unsteady OR avoid use of balance support. • Increase the lever arm: Take a longer step forward or sideways. • Increase the speed: Try to mimic the speed you would like to keep when walking up or down a stair. • Increase the number of repetitions: From 2x10 via 3x10 to 3x15

Exercise circle 3: Lower extremity muscle strength (hip and knee muscles)

New Alternative! Seated closed kinetic chain knee extension exercise: Sitting in chair with maximally flexed hip and knee, and elastic band under foot. The other foot is in normal position on the floor. Hold the elastic band with your hands; make sure it is tight. During this exercise you provide the resistance with your own hands. Extend the hip and knee in one movement to straighten the leg against the resistance from the elastic band.

This alternative closed-kinetic-chain knee extension exercise may work particularly well for patients experiencing anterior knee pain when doing the standard exercise.

What is important? • Movement quality. That the hip, knee and foot are well aligned in relation to each other. • Focus on improving muscle strength, make sure there is tension in the elastic band throughout the movement. Examples of cues • For the standing exercise, focus on the weight-bearing leg. This is the leg that is being exercised the most. • Look at your knee of the standing weight-bearing leg. The kneecap should be over the foot. If kneecap is inside (medially) of the foot, it helps to tighten (contract) your outer hip muscles to rotate your knee outwards.

• Place your hand, or the patient’s hand, on the hip rotators (in between the side of the hip and the buttocks) and hip abductors (on the side of the hip), alternate between the two positions, and feel that the muscles become tighter and harder on the weight- bearing leg. For the hip adductors it is the inner thigh muscles that are working, these are more difficult to feel. • Place the patient’s hand on the knee extensors and ask them to feel how the muscles tighten and become harder when they extend their knee in sitting. Ways to progress: • Increase the load: Change to a more difficult colour of the elastic band while doing the same number of repetitions or increase the number of repetitions from 2x10 via 3x10 to 3x15. • Decrease the support surface: Sitting without back support, i.e. on a stool instead of in a chair.

Exercise circle 4: Functional exercises (Chair stands and stair climbing)

What is important? • Movement quality. • That the hip, knee and foot are well aligned in relation to each other. • Check that your body weight is equally distributed between your right and left legs. • Check that your body weight is equally distributed over your foot soles, both the outer and inner side of the foot should be in equal contact with the ground.

What is less important? • Speed. Take the time you need to keep the desired movement quality. Examples of cues: • Look at your toes. They should be pointing forward. If not, correct. • Look at your knee of the standing weight-bearing leg. The kneecap should be over the foot. If kneecap is inside (medially) of the foot, it helps to tighten (contract) your outer hip muscles to rotate your knee outwards. • Make sure you weight-bear equally on right and left leg. • Make sure your body weight is equally distributed over the inner and outer sides of the foot. • Look in the mirror and make sure your body is straight and not leaning to the right or left. Ways to progress: • Decrease the support surface: Decrease or remove hand/balance support. Increase weight bearing on the leg being exercised by placing the other foot 1) in front or 2) behind the leg being exercised when doing chair stands. • Increase the load: Increase the height of the step board or add hand-held weights. Increase the speed while movement quality is maintained.

GLA:D™ Australia Training Course – Recommended Readings:

Ageberg E, Link A, Roos EM: Feasibility of neuromuscular training in patients with severe hip or knee OA: the individualized goal-based NEMEX-TJR training program. BMC Musculoskelet Disord 2010, 11:126.

Bennell KL, Hall M, Hinman RS: Osteoarthritis year in review 2015: rehalbilitation and outcomes. Osteoarthritis Cartilage. 2016, 24:58-70.

Bijlsma JW, Berenbaum F, Lafeber FP. Osteoarthritis: an update with relevance for clinical practice. Lancet. 2011 Jun 18;377(9783):2115-26.

Carr AJ, Robertsson O, Graves S, Price AJ, Arden NK, Judge A, et al. Knee replacement. Lancet. 2012 Apr 7;379(9823):1331-40.

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 Jul;72(7):1125-35.

Juhl C, Christensen R, Roos EM, Zhang W, Lund H. Impact of exercise type and dose on pain and disability in knee osteoarthritis: A systematic review and meta- regression analysis of randomized controlled trials. Arthritis Rheumatol. 2014 Mar;66(3):622-36. doi: 10.1002/art.38290.

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 Mar;22(3):363-88.

Skou, S. T., & Roos, E. M. (2017). Good Life with osteoArthritis in Denmark (GLA: D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC musculoskeletal disorders, 18(1), 72. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-017- 1439-y

Skou ST, Odgaard A, Rasmussen JO, Roos EM. Group education and exercise is feasible in knee and hip osteoarthritis Dan Med J. 2012 Dec; 59(12): A4554. Available at: http://www.danmedj.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname =9436984.PDF

Skou ST, Simonsen ME, Odgaard A, Roos EM. Predictors of long-term effect from education and exercise in patients with knee and hip pain. Danish Medical Journal 2014; 61(7): A4867. Available at: http://www.danmedj.dk/portal/pls/portal/!PORTAL.wwpob_page.show?_docname =10577185.PDF

Skou ST, Roos EM. GLA:D Annual report 2015. Good Life with Arthritis in Denmark, 2015. Available at: https://www.glaid.dk/pdf/English%20Summary%20annual%20report%202014%2 0GLAD.pdf

Skou ST, Roos EM, Laursen MB, Rathleff MS, Arendt-Nielsen L, Simonsen O, Rasmussen S.A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med. 2015 Oct 22;373(17):1597-606. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1505467

Participant Information Sheet/Consent Form

Good Living with osteoarthritis from Denmark Title (GLA:D) Australia Short Title GLA:D Australia La Trobe Sports and Exercise Medicine Project Sponsor Research Centre

Coordinating Principal Investigator/ Professor Kay Crossley Principal Investigator Dr Christian Barton Associate Investigator(s) Dr Joanne Kemp Location La Trobe University, Bundoora, VIC

Part 1 What does my participation involve?

1 Introduction You are invited to take part in this research project. The research project is collecting information about an evidenced based treatment program for hip/knee osteoarthritis. The treatment program is called GLA:D Australia (Good Living with osteoArthritis from Denmark).

The GLA:D Australia Program is a 6-week program, consisting of 12 x 60minute exercise sessions and 2 x 60-90minute education sessions delivered by a GLA:D trained physiotherapist.

This Participant Information Sheet tells you about the research project. It explains what is involved. Knowing what is involved will help you decide if you want to allow us to collect information about your participation in the GLA:D Australia program. Please read this information carefully. Ask questions about anything that you don’t understand or want to know more about. Before deciding whether or not to take part, you might want to talk about it with a relative, friend, your physiotherapist or your local doctor.

Participation in this research is voluntary. If you don’t wish to take part, you don’t have to. You will receive the best possible care whether or not you take part.

If you decide you DO NOT want to take part in the research project, you will be asked to tick a box below indicating this. If you do not tick the box, it is implied that you consent to taking part, and that you: • Understand what you have read • Consent to take part in the research project • Consent to the use of your personal and health information as described • Consent to the use of data collected during this research project in future research projects that are related to the current project topic. You also understand that you may or may not be informed of the use of data in future research projects

2 What is the purpose of this research? The aim of this study is to collect information about the GLA:D Australia Program for improving osteoarthritis related hip/knee pain and/or disability. This is needed as current treatment approaches, including arthroscopic surgery, braces, medication, injections, etc. are costly, can have dangerous side effects and may not be the best first option for treating osteoarthritis related hip/knee pain and/or disability. The information we collect about the GLA:D Australia program will allow us to continue to refine and improve the program for Australians with osteoarthritis.

La Trobe University Human Research Ethics Committee (HREC) number S17-193)

The results of this study will strengthen the body of evidence supporting the GLA:D Program for osteoarthritis related hip/knee pain and/or disability documented overseas. GLA:D is effective at reducing symptoms, improving function, decreasing use of painkillers and reducing sick leave in Denmark. Findings of this study may also assist with future application for funding/subsidies from state and federal governments or reimbursements from private health insurers to make the treatment more accessible and affordable.

3 What does participation in this research involve? Participation in the research involves answering some questions about yourself and your hip or knee problem online, when you start the GLA:D Australia program. You will be sent an email to answer the same questions 3 months and 12 months after starting the GLA:D Australia program. Participation in the GLA:D Australia program is separate to the research, and you can still do the program even if you choose not to participate in the research by providing your information.

The information we will ask you will include your age, your address, your email address, how much pain you have, whether you have had surgery, whether you have any other health conditions and how much your arthritis affects your lifestyle. It will take you 5-10 minutes to complete the online questions at each time point (baseline, 3 months, 12 months). Your physiotherapist will ask you to stand up and sit down as many times as possible in 30 seconds, and will time how quickly you can walk 40 metres (at the start of the program and 3 months after starting the program). This information will also be recorded and entered online.

The information will be collected online, and will be stored online in a secure database onsite at Latrobe University, using secure password-protected methods. You can choose to withdraw your information. You can also choose to be sent information about your individual results, as well as the overall results of the research, by contacting the investigators at La Trobe University. The information collected in the project will enable us to continue to improve the GLA:D Australia program.

4 What do I have to do? You have already chosen to participate in the 6-week GLA:D Australia Program, which includes attending an initial assessment before you commence the program, 12 x 60minute supervised exercise sessions, 2 x 60-90minute education session and a follow-up assessment at 3 months. If you also choose to take part in the research, you will be required to answer some questions online at the start of the program, and 3-months and 12-months after starting the program. Participating in the GLA:D Australia research project will not affect your routine care in anyway.

5 Other relevant information about the research project This is a nation-wide project aimed at assisting some of the 2.1 million Australians suffering from osteoarthritis by participating in the GLA:D Australia Program offered at all of the GLA:D accredited private practices, community healthcare centres and hospitals. La Trobe University are collaborating with researchers from Denmark and Canada to continue to improve and refine the GLA:D program.

6 Do I have to take part in this research project? Participation in any research project is voluntary. If you do not wish to take part, you do not have to. If you decide to take part and later change your mind, you are free to withdraw from the project at any stage. Your decision whether to take part or not to take part, or to take part and then withdraw, will not affect your routine treatment, your relationship with those treating you or your relationship with La Trobe University.

7 What are the alternatives to participation? You do not have to take part in this research project to do the GLA:D Australia program. You can still complete the GLA:D Australia program, even if you do not take part. Your physiotherapist can discuss this option with you before you decide whether or not to take part in this research project. You can also discuss the options with your local doctor.

La Trobe University Human Research Ethics Committee (HREC) number S17-193)

8 What are the possible benefits of taking part? There will be no clear benefit to you from your participation in this research, however providing us with the information about your condition online will enable us to continue to refine and improve the GLA:D Australia program.

9 What are the possible risks and disadvantages of taking part? You have already chosen to take part in the GLA:D Australia program. The research project only involves the collection of your information online, and will not affect your participation in the GLA:D Australia education and exercise program in anyway. The risks and side effects of taking part in this research are very small, but should be acknowledged. Given the online nature of the data collection, there is a very small risk that your personal (name, address, email address, date of birth) and health-related (medical history, impact of arthritis on your lifestyle) information could become public. The researchers have employed all security measures to minimise the likelihood of this occurring, and only they will have access to the data collected.

10 Can I have other treatments during this research project? There are no limitations to the health-related treatment or care you receive while taking part in this research project. As part of the online questions you will be asked about past and current treatment you are receiving for your arthritis.

11 What if I withdraw from this research project? If you decide to withdraw from the project, please notify a member of the research team. If you do withdraw your consent during the research project, the physiotherapist and relevant study staff will not collect additional personal information from you, although personal information already collected will be retained to ensure that the results of the research project can be measured properly and to comply with law. You should be aware that data collected up to the time you withdraw will form part of the research project results.

14 What happens when the research project ends? When the research project ends, your information will be stored indefinitely in a secure online repository at Latrobe University. You are able to obtain a copy of your individual results and the overall study results (online annual report) by contacting the research team.

Part 2 How is the research project being conducted?

15 What will happen to information about me? By signing the consent form, you consent to the relevant research staff collecting and using personal information about you for the research project. Any information obtained in connection with this research project that can identify you will remain confidential. All information is stored in a secure online facility indefinitely and is only accessible to the members of the research team. Your information will only be used for the purpose of this research project and it will only be disclosed with your permission, except as required by law.

It is anticipated that the results of this research project will be published and/or presented in a variety of forums. In any publication and/or presentation, information will be provided in such a way that you cannot be identified.

Any data you provide will be dealt with on a strictly confidential basis. In accordance with relevant Australian privacy and other relevant laws, you have the right to request access to your information collected and stored by the research team. Please contact the study team member named at the end of this document if you would like to access your information.

17 Who is organising and funding the research? This research project is being conducted by Professor Kay Crossley, Dr Christian Barton and Dr Joanne Kemp of Latrobe Sport and Exercise Medicine Research Centre, La Trobe University.

18 Who has reviewed the research project?

La Trobe University Human Research Ethics Committee (HREC) number S17-193)

All research in Australia involving humans is reviewed by an independent group of people called a Human Research Ethics Committee (HREC). The ethical aspects of this research project have been approved by the HREC of La Trobe University. This project will be carried out according to the National Statement on Ethical Conduct in Human Research (2007). This statement has been developed to protect the interests of people who agree to participate in human research studies.

19 Further information and who to contact If you want any further information concerning this project, you can contact Dr Christian Barton or Dr Joanne Kemp on 03 94791428 or [email protected] or [email protected]

For matters relating to the GLA:D Australia program, but not the research, you should speak to your treating physiotherapist.

If you have any complaints about any aspect of the project, the way it is being conducted or any questions about being a research participant in general, then you may contact:

[email protected]

La Trobe University Human Research Ethics Committee (HREC) number S17-193)

When a participant wants to stop GLA:D™ Australia

• The purpose of this form is to withdraw consent for data collection. Please complete this form ONLY if the participant no longer wishes to provide their information to GLA:D Australia. • If a participant discontinues the exercise and education component of GLA:D, their information collected via the surveys is still valuable. Please DO NOT complete this form simply because a participant stops attending. • Submit this form by: • email: [email protected] OR • post: Matt Francis, Level 5, HS3, La Trobe University, Bundoora, 3086, VIC

Date of withdrawal of consent:

Name or email address of participant:

Name of physiotherapist:

Name and location of clinic: 8. Program Log EXAMPLE Participant Name UR DOB

Participant Program Log and Physical Test Results

Baseline assessment Date: Physiotherapist: 40m walk seconds Height Weight 30 sec chair stand reps Most problematic joint (please identify ONE): **Participant records these values in survey

Education Sessions Session Date Completed Education Session 1 – What is osteoarthritis? Education Session 2 – Treatment of osteoarthritis Education Session 3 (optional)

Exercise Sessions Pain scores Pain scores Session Date Pre Post 1:1/Group/Home Session Date Pre Post 1:1/Group/Home 1 7 2 8 3 9 4 10 5 11 6 12

3 months post-baseline assessment Date: Physiotherapist: 40m walk seconds Height Weight 30 sec chair stand reps Additional Comments: **Participant records these values in survey

NOTES:

Recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis

Recommended Set

Minimum Core Set

30s Chair Stand Test 40m Fast-paced Walk Test Stair Climb Test

Timed up & Go Test 6 Minute Walk Test

OARSI Funded Initiative Centre for Health Exercise and Sports Medicine Department of Physiotherapy1 University of Melbourne, Australia Contributors and Acknowledgments

Authors: Fiona Dobson1, Kim L. Bennell1 Rana S. Hinman1, J Haxby Abbott2, Ewa M. Roos1,3

Affiliations: 1Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, University of Melbourne, Australia 2Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, New Zealand 3Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark

Corresponding author: Fiona Dobson. 200 Berkeley Street, Victoria, 3010, Australia [email protected]

Acknowledgments: Steering Committee: Kim Bennell, The University of Melbourne, Australia Rana Hinman, The University of Melbourne, Australia J Haxby Abbott, University of Otago, New Zealand Ewa Roos, The University of Southern Denmark, Denmark

Advisory Group: Paul Stratford, McMaster University, Canada Aileen Davis, Toronto Western Research Institute/University of Toronto, Canada Lynn Snyder-Mackler, University of Delaware, USA Rachelle Buchbinder, Monash University, Australia Yves Henrotin, Institute of Pathology Liège, Belgium Julian Thumboo, Singapore General Hospital, Singapore

This project was partly funded by the Osteoarthritis Research Society International (OARSI), NHMRC Program Grant #631717, the Arthritis Australia and States & Territory Affiliates Grant 2012 and University of Otago DSM Dean's Bequest Grant. It forms part of an OARSI initiative to develop a recommended set of physical performance measures for hip and knee osteoarthritis. Kim Bennell is partly funded by an Australian Research Council Future Fellowship. The study sponsor did not play any role in the study design, collection, analysis or interpretation of data; nor in the writing of the manuscript or decision to submit the manuscript for publication.

30-second Chair Stand Test

Abbreviation: 30s-CST

Purpose / Domains A test of sit-to-stand activity. Repeat for 30 seconds Also a test of lower body strength and dynamic balance.

ICF code (1): d410 Changing basic body position.

Description The maximum number of chair stand repetitions possible in a 30 second period (2-4).

Equipment  Timer/stop watch.  Straight back chair with a 44cm (17 inch) seat height, preferably without arms.  Same chair should be used for re-testing within sites.

Preparation Environment  Ensure the chair cannot slide backwards by placing the back of the chair against a wall.

Participant  Comfortable walking footwear (e.g. tennis shoes/cross trainers) should be worn.  The participant sits in the chair in a position that allows them to place their feet flat on the floor, shoulder width apart, with knees flexed slightly more than 90 degrees so that their heels are somewhat closer to the chair than the back of their knees.  The arms are crossed at the wrists and held close to the chest (across chest).

Tester  The tester stands close to the side of the chair for safety and so as they can observe the technique, ensure that the participant comes to a full stand and full sit position during the test.

Practice  A practice trial of one or two slow paced repetitions is recommended before testing to check technique and understanding.

Procedure  From the sitting position, the participant stands up completely up so hips and knees are fully extended, then completely back down, so that the bottom fully touches the seat. This is repeated for 30 seconds.  Same chair should be used for re-testing within site.  If the person cannot stand even once then allow the hands to be placed on their legs or use their regular mobility aid. This is then scored as an adapted test score.

Verbal instructions “For this test, do the best you can by going as fast as you can but don’t push yourself to a point of overexertion or beyond what you think is safe for you. 1. Place your hands on the opposite shoulder so that your arms are crossed at the wrists and held close across your chest. Keep your arms in this position for the test. 2. Keep your feet flat on the floor and at shoulder width apart. 3. On the signal to begin, stand up to a full stand position and then sit back down again so as your bottom fully touches the seat. 4. Keep going for 30 seconds and until I say stop. 5. Get ready and START”.

Scoring  On the signal to begin, start the stop watch. Count the total number of chair stands (up and down equals one stand) completed in 30 seconds. If a full stand has been completed at 30 seconds (i.e. standing fully erect or on the way down to the sitting position), then this final stand is counted in the total.  The participant can stop and rest if they become tired. The time keeps going.  If a person cannot stand even once then the score for the test is zero.  Next, allow the hands to be placed on their legs or use their regular mobility aid. If the person can stand with adaptions, then record the number of stands as an adapted test score (see score sheet). Indicate the adaptations made to the test.

Minimal reporting standards  Chair height.  Adaptations – such as using hands on legs or using a walking aid.

N.B. The individual should use the assistive device (if any) they would normally use to perform the activity at the time of testing, irrespective of how they performed it previously. However, if an assistive device/rail is used, then it should be recorded for that occasion.

REFERENCES 1. World Health Organization. International Classification of Functioning, Disability, and Health: ICF. Geneva, Switzerland 2001. 2. Gill S, McBurney H. Reliability of performance-based measures in people awaiting joint replacement surgery of the hip or knee. Physiother Res Int. 2008;13(3):141-52. 3. Jones CJ, Rikli RE, Beam WC. A 30-s chair-stand test as a measure of lower body strength in community-residing older adults. Res Q Exerc Sport. 1999;70(2):113-9. 4. Kreibich DN, Vaz M, Bourne RB, Rorabeck CH, Kim P, Hardie R, et al. What is the best way of assessing outcome after total knee replacement? Clin Orthop Relat Res. 1996(331):221-5. Epub 1996/10/01.

40m (4x10m) Fast Paced Walk Test Abbreviation: 40m FPWT

Purpose / Domains A test of short distance walking activity. A test of walking speed over short distances and changing direction during walking. ICF codes (1): d410 Changing basic body position, d450 Walking, d455 Moving around. Description A fast-paced walking test that is timed over 4 x 10m (33 ft) for a total 40 m (132 ft) (2).

Guidelines for use  As a direct measure of the ability to walk quickly over short distances, which is an activity that is important but often limited in people with hip and/or knee OA. Equipment  Timer/stop watch.  10 m (33 ft) marked walkway with space to turn safely around at each end.  2 cones place approximately 2 metres beyond each end of the 10m walkway.  Calculator to convert time to speed.

Preparation Environment  Mark out a 10 m (33 ft) walkway with bright coloured tape at each end.  Place a cone approximately 2 metres before the start mark and 2 meters beyond the finish mark of the 10m walkway for turning.  Ensure there is enough space to turn safely around at each end (i.e. 2-3m each end).

Participant  Comfortable walking footwear (e.g. tennis shoes/cross trainers) should be worn.

Tester  If safety is of concern, the tester should follow slightly behind and off to one side to the participant but not as to pace or impede them.  If there is no concern for safety, the tester should follow well to the side so as they can view crossing at the 10m walkway at both ends.

Practice  A practice trial of 1-2 turns is recommended before testing to check understanding.

Procedure  Participants are asked to walk as quickly but as safely as possible, without running, along a 10 m (33 ft) walkway and then turn around a cone, return then repeat again for a total distance of 40 m (132 ft) (3 turns).  Regular walking aid is allowed and recorded.

Verbal instructions “For this test, do the best you can by going as fast as you can, without running, but don’t push yourself to a point of overexertion or beyond what you think is safe for you. 1. Start with both feet on the start line. 2. On start, walk as quickly but as safely as possible, without running. 3. Walk up to the end cone, turn around and walk back to the starting cone behind you, turn again and back to the end cone, then turn once more and return back to the start cone again so that you walk the 10m walkway 4 times in total. 4. Get ready and START”.

Scoring  Timing starts on the signal to start at the start line and terminates once the participant crosses back over the start line after completing the 40 m (4x10 m).  When the participant crosses the 10m mark, timing is paused whilst the participant turns around the cone and then is resumed once they cross the 10m mark again. The same is repeated for the following turns and is stopped once the participant crosses the start line for the final time.  Time of one trial is recorded to the nearest 100th of a second.  Time of one test trial is recorded and expressed as speed m/s by dividing distance (40m) by time (s).  Regular walking aid is allowed and use should be recorded.

Minimal reporting standards  Assistive devices such as usual walking aids - walking stick etc.

REFERENCES 1. World Health Organization. International Classification of Functioning, Disability, and Health: ICF. Geneva, Switzerland 2001. 2. Wright AA, Cook CE, Baxter GD, Dockerty JD, Abbott JH. A Comparison of 3 Methodological Approaches to Defining Major Clinically Important Improvement of 4 Performance Measures in Patients With Hip Osteoarthritis. J Orthop Sports Phys Ther. 2011;41:319-27. Epub 2011/02/22.

Appendix 1: Clinimetrics in OA Summary of clinimetric evidence available up to June 2012 Further information available in: Dobson F, Hinman RS, Hall M, Terwee CB, Roos EM, Bennell KL. Measurement properties of performance- based measures to assess physical function in hip and knee osteoarthritis: a systematic review. Osteoarthritis Cartilage. 2012;20(12):1548-62. Epub 2012/09/05

Abbreviations AUC Area under the curve CI Confidence interval ES Effect size ICC Intraclass correlation coefficient MCII Minimal clinically important improvement

MDC90 Minimal detectable change at 90% confidence OA Osteoarthritis SD Standard deviation SEM standard error of measurement SRM Standard response mean

30-second Chair Stand Test Reliability Intra-tester:

 ICC1,1 0.97-0.98 (95% CI: 0.94, 0.99) (within session) in end-stage hip and knee OA awaiting joint replacement (mean age 70.3years SD 9.8 years) (1) Inter-tester:

 ICC1,1 0.93-0.98 (95% CI: 0.87, 0.99) in end-stage hip and knee OA awaiting joint replacement(mean age 70.3years SD 9.8 years) (1) (2)  ICC2,1 0.81 (95% CI: 0.63, 0.91) hip OA (mean age 66.5 SD 9.4 years) Measurement error: (2)  SEM of 1.3 repetitions and MDC90 of 1.6 repetitions in Hip OA (mean age 66.5 SD 9.4 years)

 SEM of 0.7 repetitions and MDC90 of 1.6 repetitions end-stage hip and knee OA awaiting joint replacement (mean age = 70.3 SD 9.8 years) (1) Responsiveness:  AUC 0.73 (0.55,0.91) in Hip OA (mean age 66.5 SD 9.4 years) after 9 physiotherapy/exercise sessions (2) Interpretability:  MCII: 2 - 3 stands in Hip OA (mean age 66.5 SD 9.4 years)(2)

Stair Climb Test Reliability Intra-tester:

 4-step SCT: ICC2,1 0.94-0.96 (95% CI: 0.75, 0.99) in hip and knee OA (mean age 69.4 years SD 5.9 years) (3) Inter-tester:

 11-step SCT: ICC2,1 0.94 (95%CI: 0.55,0.98) in people following knee joint replacement (mean age 68 years SD 8 years) (4) Test-retest:

 9-step SCT: ICC2,1 0.90 (95% CI: 0.79,0.96) over a long interval (median 178 days) in end-stage hip and knee OA awaiting joint replacement (mean age 63.7 SD 10.7 years) (5) Measurement error:

 9-step SCT: SEM of 2.35s and MDC90 of 5.5s in end-stage hip and knee OA awaiting joint replacement (mean age = 63.7 SD 10.7 years) (5)

 11-step SCT:SEM of 1.14 s and a MDC90 of 2.6 s in people following knee joint replacement (mean age 68.0 years SD 8.0 years) (4)

Responsiveness:  9-step SCT :responsive to detecting initial deterioration ( SRM = -1.74 (95% CI: -2.13, -1.45) then subsequent improvement (SRM = 1.98 (95% CI: 1.68, 2.42) following hip or knee joint replacement (mean age 63.7 SD 10.7 years) (5)  12-step SCT responsive to detecting initial deterioration( ES = -0.71) then subsequent improvement (ES – 0.84) following knee joint replacement (mean age 65.5 SD 9.0 years) (6) Interpretability:  No information found in people with OA

40m (4x10m) Fast Paced Walk Test Reliability Inter-tester: (2)  ICC2,1 0.95 (95% CI: 0.90 0.98) hip OA (mean age 66.5 SD 9.4 years) Measurement error: (2)  SEM of 1.0 m/s and MDC90 of 2.3 m/s in Hip OA (mean age 66.5 SD 9.4 years) Responsiveness:  AUC 0.89 (0.76, 1.00) Hip OA (mean age 66.5 SD 9.4 years) after 9 physiotherapy/exercise sessions (2) Interpretability:  MCII 0.2-0.3 m/sec Hip OA (mean age 66.5 SD 9.4 years)(2)

30-second Chair Stand Test Score Sheet Verbal instruction: “For this test, do the best you can by going as fast as you can but don’t push yourself to a point of overexertion or beyond what you think is safe for you. 1. Place your hands on the opposite shoulder so that your arms are crossed at the wrists and held close across your chest. Keep your arms in this position for the test. 2. Keep your feet flat on the floor and at shoulder width apart. 3. On the signal to begin, stand up to a full stand position and then sit back down again so as your bottom fully touches the seat. 4. Keep going for 30 seconds and until I say stop. 5. Get ready and START”. Complete practice trial (1-2 repetitions to check form and understanding).

Chair seat Score Time point height (Repetitions in Adapted Date (cm) 30 seconds) Adaptations score 1. Uses hands on legs Uses walking aid / / cm Not tested – Unable Not tested - refused 2. Uses hands on legs Uses walking aid / / cm Not tested – Unable Not tested - refused 3. Uses hands on legs Uses walking aid / / cm Not tested – Unable Not tested - refused 4. Uses hands on legs Uses walking aid / / cm Not tested – Unable Not tested - refused 5. Uses hands on legs Uses walking aid / / cm Not tested – Unable Not tested - refused

Normal values Normative scores (i.e. between the 25% and 75% percentiles) for the 30-s CST in community dwelling older people aged 60-94 years (1) Age range Average count for Average count for Men women 60-64 12 to 17 14 to 19 65-69 11 to 16 12 to 18 70-74 10 to 15 12 to 17 75-79 10 to 15 11 to 17 80-84 9 to 14 10 to 15 85-89 8 to 13 8 to 14 90-94 4 to 11 7 to 12 Risk zone for falls: Scores of less than 8 stands for women and men (2). 1. Rikli RE, Jones CJ. Functional fitness normative scores for community-residing older adults, ages 60– 94. J of Aging and Physical Activity. 1999;7:162-81. 2. Jones CJ, Rikli RE. Measuring functional fitness of older adults. The Journal on Active Aging. 2002;March-April:24-30.

40m (4 x 10m) Fast Paced Walk Test Score Sheet Verbal instruction: For this test, do the best you can by going as fast as you can, without running, but don’t push yourself to a point of overexertion or beyond what you think is safe for you. 1. Start with both feet on the start line. 2. On start, walk as quickly but as safely as possible, without running. 3. Walk to the mark 10m away, return to the start line, back again to the 10m mark, then return to the start line again so that you walk the 10m walkway 4 times in total. 4. Get ready and START”.

Complete practice trial of 1-2 turns to check understanding.

Time Speed Assistive (seconds: (40/time in seconds) Date walking aid (list) 00.00) (0.00 m/sec) Adaptations 1. Uses walking aid Not tested – Unable / / Not tested - refused 2. Uses walking aid Not tested – Unable / / Not tested - refused 3. Uses walking aid Not tested – Unable / / Not tested - refused 4. Uses walking aid Not tested – Unable / / Not tested - refused 5. Uses walking aid Not tested – Unable / / Not tested - refused

Normal values Normative fast speed reference values m/s (SD) for healthy adults (1)

Age Maximal speeds (m/s) Converted time Maximal speeds m/s Converted time decade mean (SD) over 40m mean (SD) over 40m women distance (s) men distance (s) women men 40s 2.12 (0.28) 18.87 2.46 (0.36) 16.26 50s 2.01 (0.26) 19.90 2.07 (0.45) 19.32 60s 1.77 (0.25) 22.60 1.93 (0.36) 20.73 70s 1.75 (0.28) 22.86 2.08 (19.6) 19.24 (Note: these values are for gait speed over 1 x 7.62m (25 ft) walk distance only and exclude acceleration and deceleration times. Participants were asked to walk as fast as they could without running)

1. Bohannon RW. Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants. Age Ageing. 1997;26(1):15-9.

10 PHYSIOTHERAPIST PERMISSION FORM

Permission to provide physiotherapy for GLA:D™ Australia program

The GLA:D® Program is an education and 6-week twice a week exercise program for individuals with osteoarthritis (OA) of the knee and/or hip. Training on how to deliver the program is provided by GLA:D™ Australia. The following provides the terms and conditions for individuals who have attended the GLA:D™ Australia training program, to instruct patients entering the GLADTM Australia program.

As a GLA:D trainer, you agree to

• Always deliver the GLA:D Australia program as it is intended, without removing either of the core components of education or exercise (see program outline below). • Not apply for research or implementation funding related to the GLA:D program without consulting with the LTU team.

GLA:D Australia Program Outline

The program will follow the GLA:D™ Australia format including the 2 education sessions and 12 one hour exercise sessions. A third education session using an individual who has participated in the program to answer questions will be made available as soon as these individuals become available.

The exercises will follow the principles of neuromuscular exercise (NEMEX) as presented in the course and described in the material from GLA:D™ Australia.

Database for Quality Monitoring of Outcomes

The patient will be linked to the outcome database on their first assessment visit so that they are offered the ability to provide their outcomes.

Providers of the GLA:D™ Australia program will ensure the necessary ethics and data sharing agreements are in place to provide data from patients attending their location.

GLA:D™ Australia services and support

Through agreeing to provide GLA:D™ Australia, each site will have access to:

• GLA:D™ Australia materials through the website including information on the benefits of the GLA:D program • Electronic information on the performance of the patients within the clinic including their longer term outcomes at one year • Support for the data registration to address any issues • Reports on performance, if desired (fees will be charged to cover costs of report generation)

The following form must be signed by both GLA:D™ Australia and the prospective trainer. A copy of this document will be provided to both parties for their records. A formal certificate of course completion will be sent to the physiotherapist.

Version November 15 2017 The following person has attended the GLA:D™ Australia Physiotherapy course and is permitted to: Use the GLA:D™ Australia Database and GLA:D™ Australia Trainer’s Manual

Personal Information:

First Name Last Name

Email: Telephone Number:

☐Clinic ☐Hospital ☐University

Name of Clinic/Hospital/University:

Address:

City: Postal Code:

Date of GLA:D™ Australia Course: Location:

Level of data access? ☐Clinician ☐Clinic ☐Multiple clinics Describe: ______

I agree to use the GLA:D™ Australia materials as instructed in the course provided listed above. By attending this course and signing this agreement, I understand that I have a duty to provide proper instruction for the program as taught, and use the materials for the purposes of training and instructing the GLA:D™ Australia program at the site listed above only. I understand that I have a responsibility to report outcomes and motivate my participants use the GLA:D™ Australia database.

Trainee Full Name Signature

Date

Instructor Full name Signature

Course Location Date Version November 15 2017 10 PHYSIOTHERAPIST PERMISSION FORM

Permission to provide physiotherapy for GLA:D™ Australia program

As a GLA:D trainer, you agree to

GLA:D Australia Program Outline

The exercises will follow the principles of neuromuscular exercise (NEMEX) as presented in the course and described in the material from GLA:D™ Australia.

Database for Quality Monitoring of Outcomes

The patient will be linked to the outcome database on their first assessment visit so that they are offered the ability to provide their outcomes.

Providers of the GLA:D™ Australia program will ensure the necessary ethics and data sharing agreements are in place to provide data from patients attending their location.

GLA:D™ Australia services and support

Through agreeing to provide GLA:D™ Australia, each site will have access to:

Version November 15 2017

The following person has attended the GLA:D™ Australia Physiotherapy course and is permitted to: Use the GLA:D™ Australia Database and GLA:D™ Australia Trainer’s Manual

Personal Information:

First Name Last Name

Email: Telephone Number:

☐Clinic ☐Hospital ☐University

Name of Clinic/Hospital/University:

Address:

City: Postal Code:

Date of GLA:D™ Australia Course: Location:

Level of data access? ☐Clinician ☐Clinic ☐Multiple clinics Describe: ______

Trainee Full Name Signature

Date

Instructor Full name Signature

Course Location Date Version November 15 2017