What instructions should be provided as part of an activity pacing programme for people with osteoarthritis?
How should activity pacing education be delivered for people with osteoarthritis?
What is the efficacy and/or effectiveness of activity pacing for people with osteoarthritis?
A search of published and unpublished literature databases will be conducted. All databases will be searched from their inception to the search date.
Databases searched will include: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, current issue), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE), Allied and Complementary Medicine (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Biomed Central.
Unpublished literature and on-going clinical trials databases will be assessed using the databases: the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the United States National Institute of Health Trials Registry, Open Grey (System for Information on Grey Literature in Europe).
The reference lists of all potentially eligible papers will be reviewed. All corresponding authors from all eligible papers will be contacted to identify any papers omitted from the initial search results.
No restrictions will be placed on the search strategy in respect to age of publication, source of evidence, or language of final full-text paper.
Types of study to be included
No restrictions will be enforced on the type of study designs eligible for inclusion.
Condition or domain being studied
The condition under investigation is osteoarthritis. This is a common musculoskeletal condition, particularly affecting the hips and knees. In North America alone, the overall prevalence of adults affected by OA in any joint in 2005 was estimated to be 27 million. With an aging population, and an increasing incidence of obesity, this figure is expected to significantly increase during the next two decades. The major consequences of osteoarthritis include joint pain and stiffness, which lead to immobility, reduced functional capability and loss of independence.
The participants under investigation include those with osteoarthritis affecting any joint. It is expected that this will be principally assessed in those with hip and knee osteoarthritis, although this will not be limited specifically.
The study eligibility criteria are:
Inclusion criteria: Studies where the principle aim was to assess the efficacy or effectiveness of a pacing or activity modification/change programmes for those with osteoarthritis. All study designs will be included. No studies will be excluded based on methodological quality. No constraints will be placed on the eligibility of papers based on their language or date of publication.
Exclusion criteria: Those studies assessing combined self-management programmes consisting of pacing and behaviour modification with education, exercises and other interventions. This is justified since the objective of this review is to identified the efficacy or effectiveness of pacing activities/modification alone. Studies assessing cognitive behavioural therapy for exercise and increasing activity purposes will be excluded since this is distinct from pacing and changing lifestyle which is the aim of this study.
Activity pacing is the intervention under investigation. This is defined as the education provided to an individual to encourage the use of rest periods within activities, to adapt tasks into smaller stages. Activity pacing is proposed to address inefficient activity patterns, such as periods of over-activity, which lead to prolong periods of inactivity, leading to impaired physical capacity and increased disability. This educational intervention is therefore targeted to encourage people not to exacerbate their symptoms, through better planning of daily activity and rest breaks, and dividing tasks into multiple short time blocks.
Activity pacing is often provided by occupational therapist and physiotherapists, and has been widely used in other populations such as those with chronic pain and chronic fatigue syndrome.
The comparator group will be those who do not receive activity pacing education.
Secondary comparator groups may include the assessment of clinical outcomes from different methods of delivering activity pacing interventions.
This intervention may be delivered in a one-on-one setting in a clinical environment, or as a group, classroom, intervention.
Perceived pain scores.
Pain will be assessed within 12 months of commencing the intervention.
(1) participant functional outcomes as measured through questionnaire-based assessments such as the WOMAC or Oxford Hip and Knee Scores.
(2) objective functional assessments such as timed 6 meter walk test, timed-get-up-and-go test.
(3) analgesic requirement.
(4) general health perception and quality of life scores such as the Short-Form 12 or 36, or the EQ-5D measurement.
(5) Participant fatigue levels.
These will be assessed (preferably) at a 12 month follow-up.
Data extraction, (selection and coding)
All titles and abstracts from the search strategy will be independently reviewed by two reviewers. These will be assessed against the pre-defined eligibility criteria. Full-text papers of all potentially eligible papers will be obtained, and further re-evaluated against the eligibility criteria. Following this, all eligibility papers will be examined, and data will be collected from these.
Data extraction will be performed by one reviewer, and the results verified independently by a second reviewer. All data will be extracted onto a pre-defined data extraction table. Any disagreements in paper eligibility or data extraction findings will be resolved through discussion.
Risk of bias (quality) assessment
The methodological assessment of each included paper will be assessed using the PEDro critical appraisal tool. This will be performed by one reviewer, and independently verified by a second reviewer. Any disagreement in critical appraisal score will be resolved through discussion.
Strategy for data synthesis
The findings of the data extraction table will be reviewed. If appropriate, based on study homogeneity and results provided, a meta-analysis will be conducted. Continuous data outcomes will be assessed using mean difference or standardised mean difference. Categorical data will be assessed using relative risk. All results will be provided, complimented with 95% confidence intervals. A fixed-effects model will be adopted when I-squared statistical test result is less than 20% and Chi-squared is less than p=0.10. When I-squared greater than 20% and Chi-squared greater than p=0.10, a random effects model will be adopted.
If statistical meta-analysis is not indicated, the results will be narratively reviewed for each outcome measurement.
Analysis of subgroups or subsets
A subgroup analysis will be conducted to assess the method of delivering activity pacing educational intervention. This may include an assessment of one-on-one versus group education or general activity pacing interventions versus tailored, person-specific activity pacing interventions.
Dependent on the available literature, a sensitivity analysis of randomised control trial results versus non-randomised controlled trial results will be made.
We plan to report the findings of this study in an international peer-review orthopaedic, rheumatology or allied health professional academic journal.
Contact details for further information
Faculty of Medicine and Health Sciences
University of East Anglia
Norwich, NR4 7TJ
Organisational affiliation of the review
University of East Anglia
Dr Toby Smith,
Ms Leigh Davies, Norfolk and Norwich University Hospital, Norwich Dr Sherif Hosny, St George's Hospital, London Miss Caroline Hing, St George's Hospital, London
Details of any existing review of the same topic by the same authors
No other reviews are known on this topic to the authors.
Anticipated or actual start date
04 June 2012
Anticipated completion date
03 September 2012
No funding associated with this study.
Conflicts of interest
Other registration details
This study has not been registered elsewhere.
Subject index terms status
Subject indexing assigned by CRD
Subject index terms
Activities of Daily Living; Exercise Tolerance; Humans; Osteoarthritis; Patient Education as Topic; Rest
Any other information
No other information is currently available
Reference and/or URL for protocol
No published protocol is currently available.
Date of registration in PROSPERO
29 June 2012
Date of publication of this revision
14 December 2012
Details of final report/publication(s)
This paper has been submitted for peer-review in an international rheumatology journal.
Stage of review at time of this submission
Piloting of the study selection process
Formal screening of search results against eligibility criteria
Risk of bias (quality) assessment
PROSPERO This information has been provided by the named contact for this review. CRD has accepted this information in good faith and registered the review in PROSPERO. CRD bears no responsibility or liability for the content of this registration record, any associated files or external websites.