6 of 12 Top Hip Papers of 2023 | GLA:D program outcomes for hip and knee OA
It's Day 6 of my series of miniblogs featuring 12 top hip papers from 2024. Half way already!! Hope you've enjoyed the first 5. If you missed Day 5, you'll find a link at the bottom of this page to take you back.
For day 6 we'll be taking a look at a study that reported on the association between GLA:D program outcomes and hip and knee replacement.
6 of 12 Top Hip Papers of 2024: Association between GLA:D program outcomes and hip and knee replacement1
Background:
The GLA:D program involves group education and exercise for patients with hip and knee osteoarthritis. Originally developed in Denmark, it is now available in a number of countries around the world. If you are running, or considering running, the GLA:D program in your clinic, the results of this study may be of particular interest to you.
Study Aim:
To evaluate whether short-term outcomes from exercise therapy and patient education for osteoarthritis are associated with hip or knee replacement within two years.
What was done:
An individual patient data study, reporting on outcomes of patients clinically diagnosed with hip osteoarthritis (OA) (n=2,304) and knee OA (n=7,035), from the Good Life with osteoArthritis in Denmark (GLA:D) registry.
Patients undertaking the GLA:D program for hip and knee OA are diagnosed clinically by a health professional, with no imaging required. They then complete 2-3 group education sessions and 12 group exercise sessions over an 8-week period. Participants warm up for 10 minutes on an exercise bike before performing exercises in each of 4 stations.
They then warm down with 10 minutes of walking forwards and backwards, and standing on one leg and rotating the pelvis on the femur - this weightbearing rotation is only performed by the hip OA patients as it is considered too provocative for knee OA patients.
Key Findings:
- 30% of patients with hip osteoarthritis undertaking the GLA:D program progress to total hip replacement with 2 years (at 11 months on average).
- In comparison only 10% of knee OA patients in the program progressed to joint replacement within the same time frame.
- Mean group improvements in pain rated on a 100 point scale, and the Hip disability and osteoarthritis outcome score (HOOS) were quite small at the completion of the 3 month program.
- However, those with hip OA who experienced at least a 10-point improvement in the HOOS, had a 26% lower likelihood of hip replacement within 2 years.
Clinical Implications:
- It’s unclear why almost 1/3 of hip OA patients required total hip arthroplasty within 2 years of the GLA:D program. Severity of hip OA? Imaging was not available, but only 2% were waitlisted for joint replacement, as per the knee OA group.
- Improvements for Hip OA patients were small - lower than expected for a clinically meaningful improvement.
- The GLA:D program may not be as beneficial for hip OA patients as knee OA patients. Does the program need some revision?
This paper reported that 30% of Hip Osteoarthritis (OA) patients completing the GLA:D program progressed to joint replacement at an average of 11 months post-program, compared with 10% of Knee OA patients.
Could this indicate that those in the hip OA group enter the program in a more advanced state of joint deterioration? This is unknown as imaging is not collected or required for entry into the program. However, only 2% of each group (hip OA and knee OA) were on a surgical waiting list on entry to the program.
Patients who progressed to joint replacement had worse symptoms before the program, and they experienced smaller improvements in pain intensity and joint-related quality of life after the program, and deterioration in arthritis self-efficacy.Those who achieved at least a 10-point improvement in the HOOS had a 26% lower likelihood of hip replacement in the following 2 years.
Overall GLA:D program outcomes achieved for hip OA patients appear quite small at a group level, unlikely to represent clinically meaningful improvements. It is surprising then, that there was only discussion of possible Patient Factors to explain the relatively high level of progression to hip replacement from the hip OA group. Program Factors were not mentioned.
Looking closely at the program, could we optimise some of the exercises? For example, open-chain banded hip abduction may be less than ideal in optimising muscle balance within the hip abductor synergy, and open-chain extension can be provocative for some with anterior hip pain and may not represent an ideal exercise for gluteus maximus loading. Walking backwards and rotating on a single leg can also be quite provocative for some people with hip OA.
The GLA:D initiative has certainly been an incredible body of work and the encouragement of an education and exercise approach for OA, in an affordable group environment, is highly commendable and a big step forward. However, does the program need review for those with hip OA, or should those who achieve less than a 10point HOOS improvement progress to a more individualised program?
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I hope you enjoyed the infographics and key learnings from Day 6 of my 12 Top Hip Papers of 2024. There are still 6 more papers to come, so keep an eye out, to see what other top papers and infographics I have prepared for you!
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