BackgroundThe COVID-19 pandemic has impacted the psychological health and health service utilisation of older adults with multimorbidity, who are particularly vulnerable.AimTo describe changes in loneliness, mental health problems, and attendance to scheduled medical care before and after the onset of the COVID-19 pandemic.Design and settingTelephone survey on a pre-existing cohort of older adults with multimorbidity in primary care.MethodMental health and health service utilisation outcomes were compared with the outcomes before the onset of the COVID-19 outbreak in Hong Kong using paired t-tests, Wilcoxon’s signed-rank test, and McNemar’s test. Loneliness was measured by the De Jong Gierveld Loneliness Scale. The secondary outcomes (anxiety, depression, and insomnia) were measured by the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder tool, and the Insomnia Severity Index. Appointments attendance data were extracted from a computerised medical record system. Sociodemographic factors associated with outcome changes were examined by linear regression and generalised estimating equations.ResultsData were collected from 583 older (≥60 years) adults. There were significant increases in loneliness, anxiety, and insomnia, after the onset of the COVID-19 outbreak. Missed medical appointments over a 3-month period increased from 16.5% 1 year ago to 22.0% after the onset of the outbreak. In adjusted analysis, being female, living alone, and having >4 chronic conditions were independently associated with increased loneliness. Females were more likely to have increased anxiety and insomnia.ConclusionPsychosocial health of older patients with multimorbidity markedly deteriorated and missed medical appointments substantially increased after the COVID-19 outbreak.

PURPOSE To test the efficacy of intra-articular hypertonic dextrose prolotherapy (DPT) vs normal saline (NS) injection for knee osteoarthritis (KOA). METHODS A single-center, parallel-group, blinded, randomized controlled trial was conducted at a university primary care clinic in Hong Kong. Patients with KOA (n = 76) were randomly allocated (1:1) to DPT or NS groups for injections at weeks 0, 4, 8, and 16. The primary outcome was the Western Ontario McMaster University Osteoarthritis Index (WOMAC; 0-100 points) pain score. The secondary outcomes were the WOMAC composite, function and stiffness scores; objectively assessed physical function test results; visual analogue scale (VAS) for knee pain; and EuroQol-5D score. All outcomes were evaluated at baseline and at 16, 26, and 52 weeks using linear mixed model. RESULTS Randomization produced similar groups. The WOMAC pain score at 52 weeks showed a difference-indifference estimate of-10.34 (95% CI,-19.20 to-1.49, P = 0.022) points. A similar favorable effect was shown on the differencein-difference estimate on WOMAC function score of-9.55 (95% CI,-17.72 to-1.39, P = 0.022), WOMAC composite score of-9.65 (95% CI,-17.77 to-1.53, P = 0.020), VAS pain intensity score of-10.98 (95% CI,-21.36 to-0.61, P = 0.038), and EuroQol-5D VAS score of 8.64 (95% CI, 1.36 to 5.92, P = 0.020). No adverse events were reported. CONCLUSION Intra-articular dextrose prolotherapy injections reduced pain, improved function and quality of life in patients with KOA compared with blinded saline injections. The procedure is straightforward and safe; the adherence and satisfaction were high.

PurposeThis is an ongoing prospective cohort aiming to examine the biopsychosocial health profiles and predictors of health outcomes of older patients with multimorbidity in primary care in Hong Kong.ParticipantsFrom April 2016 to October 2017, 1077 patients aged 60+ years with at least two chronic diseases were recruited in four public primary care clinics in the New Territories East Region of Hong Kong.Findings to dateAfter weighting, the patients had 4.1 (1.8) chronic conditions and 2.5 (1.9) medications on average; 37% forgot taking medication sometimes; 71% rated their health as fair or poor; 17% were frail; 73% reported one (21%) or two or more (52%) body pain areas; 62% were overweight/obese; 23% reported chewing difficulty, 18% reported incontinence; 36% had current stage 1/2 hypertension; 38% had handgrip strength below the cut-off; 10% screened positive in sarcopenia; 17% had mild or severer cognitive impairment; 17% had mild to severe depression; 16% had mild to severe anxiety; 50% had subthreshold to severe insomnia; 28% indicated being lonely; 12% needed help in at least one out of the five daily functions and the EuroQoL-5-Dimensions-5-Level index score was 0.81 (0.20) and its Visual Analogue Scale (VAS) score was 67.6 (14.6). In the past 12 months, 17% were hospitalised, 92% attended general outpatient clinics, 70% attended specialist outpatient clinics and 10% used elderly daycare centre services, the median out-of-pocket health cost was HK$1000 (US$150). Female and male patients showed significant differences in many biopsychosocial health aspects.Future plansWith assessments and clinical data, the cohort can be used for understanding longitudinal trajectories of biopsychosocial health profiles of Chinese older patients with multimorbidity in primary care. We are also initially planning cohort studies on factors associated with various health outcomes, as well as quality of life and healthcare use.Cohort registration numberChiCTR-OIC-16008477

PURPOSE We performed a phase 2 randomized clinical trial to evaluate the preliminary effectiveness of a clinic-based patellar mobilization therapy (PMT) in patients with knee osteoarthritis. METHODS We recruited 208 patients with knee osteoarthritis at primary care clinics in Hong Kong. Patients were randomly assigned (1:1) to the intervention group or the control group. The intervention group received 3 PMT treatment sessions from primary care physicians at 2-month intervals, with concomitant prescription of a home-based vastus medialis oblique muscle exercise. The control group received PMT after the study period. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Secondary outcomes included the WOMAC composite, function, and stiffness scores; the visual analog scale score for pain; objective physical function tests (30-s chair stand, 40-m walk test, timed up and go test, and EuroQol-5D). All outcomes were evaluated at baseline and at 24 weeks through intention-to-treat analysis. RESULTS We observed no baseline between-group differences. The WOMAC pain score showed greater improvement in the intervention group than in the control group at 24 weeks (between-group difference-15.6, 95% CI,-20.5 to-10.7, P <.001). All secondary outcomes also demonstrated significant betweengroup differences. CONCLUSIONS Patellar mobilization therapy has the potential to reduce pain and improve function and quality of life for patients with knee osteoarthritis. Future clinical trials with comparison to other active comparator controls will help determine the overall efficacy and facilitate the deployment of PMT in realworld practice.

BackgroundKnee Osteoarthritis (KOA) is a very common condition with prevalence rising with age. It is a major contributor to global disability and has a large socioeconomic burden worldwide. Conservative therapies have marginal effectiveness, and surgery is reserved for severe symptomatic KOA. Dextrose Prolotherapy (DPT) is an evidence-based injection-based therapy for chronic musculoskeletal conditions including KOA. The standard “whole joint” injection method includes intra-articular injection and multiple extra-articular injections at soft tissue bony attachments. The procedure is painful and requires intensive procedural training often unavailable in conventional medical education, which potentially limits access. Intra-articular injection offers the possibility of a less painful, more accessible treatment. The aim of this project is to assess the clinical efficacy of intra-articular injection of DPT versus normal saline (NS) for KOA.MethodSeventy-six participants with KOA will be recruited from the community. We will conduct a single center, parallel group, superiority randomized controlled trial comparing DPT and NS injections, with blinding of physician, participants, outcome assessors and statisticians. Each group will receive injections at week 0, 4, 8 and 16. The primary outcome will be the Western Ontario McMaster University Osteoarthritis Index pain scale (WOMAC), and secondary outcomes include WOMAC composite score, the WOMAC function and stiffness subscale, the Visual Analogue Score of pain, objective physical function tests (the 30 s chair stand, 40- m fast paced walk test, the Timed up and go test) and the EuroQol-5D (EQ-5D). All outcomes will be evaluated at baseline, and 16, 26 and 52 weeks. All analyses will be conducted on an intention-to-treat basis using linear mixed regression models.DiscussionThis paper presents the rationale, design, method and operational aspects of the trial. The findings will determine whether IA DPT, an inexpensive and simple injection, is a safe and effective non-surgical option for KOA. The results can be translated directly to clinical practice, with potentially substantial impact to patient care.Trial registrationThe trial (ChiCTR-IPC-15006617) is registered under Chinese Clinical Trials Registry on 17th June 2015.

Aim: Platelet Rich Plasma (PRP) is an emerging therapy for knee osteoarthritis (KOA). Studies have evaluated the effectiveness of intra-articular PRP, which ignores extra-articular tissue dysfunction and may provide incomplete treatment of KOA. The study aimed to pilot test a leukocyte-rich (mononuclear cells) PRP injection protocol for primary KOA, which consisted of single intra-articular injection and extra-articular injections on the medial coronary and medial collateral ligaments.Methods: A prospective 26-week single-arm uncontrolled feasibility pilot study. Patients (N = 12) with primary KOA as defined by the American Rheumatology Association, with moderate to severe medial knee pain which failed conservative management, were recruited in a university primary care clinic and received a single session of PRP injection in week 1. The primary outcome was the feasibility of the protocol at 26 weeks as defined by rates of recruitment, compliance, retention, dropout, side effects or adverse events; and treatment satisfaction. Secondary outcomes included the Western Ontario McMaster University Osteoarthritis Index, the Intermittent and Constant Osteoarthritis Pain total and subscales, objective physical function tests and EuroQol-5D.Results: Twelve of 40 potential patients were recruited in 3 months period (recruitment rate 30%, x2 = 3.33, P = 0.068). All participants adhered to the protocol and completed the follow up assessment with no dropouts (dropout rate 0%, X2= 2.67, P = 0.103). Satisfaction was high; no related adverse events were reported. Most secondary outcomes showed statistically significant improvement. Conclusions:Concomitant intra-articular and extra-articular PRP injections were feasible and produced preliminary favourable outcomes.

No abstract

Background: Exercise therapy is commonly prescribed by primary care physicians (PCPs) in the management of chronic musculoskeletal (MSK) pain. Aims: We evaluated the clinical effectiveness of a supervised neuromuscular (NM) exercise program in older people with chronic MSK pain. Design: A 12-week, two-arm randomized controlled trial comparing 6 weeks supervised NM exercise versus waiting list control. Setting: We enrolled 72 participants with chronic MSK pain in a primary care clinic. Methods: Participants were randomly allocated (block size of 12) in 1:1 ratio to the NM (N=36) and control group (N=36). Data were collected at baseline, 6 and 12 weeks. The primary outcome was the Brief Pain Inventory (BPI) score at 6 weeks (post-intervention). Secondary outcomes included the Pain Self-Efficacy Questionnaire (PSEQ), Short form of Health Survey (SF-12), General Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9) scores, and functional measurement using the Timed-Up-and-Go test and handgrip strength. Results: Compared with the control group at 6 weeks, the NM group demonstrated a significantly greater improvement in the BPI-severity pain (between-group difference -1.27, 95% CI = -2.08 to -0.45, P = 0.002) and PSEQ (between-group difference 6.50, 95% CI = 2.022 to 10.77, P = 0.003). Participants who complied to the protocol also demonstrated statistical significant improvement in the SF-12-physical score and PHQ-9 score. Conclusion and implications: NM exercise has the potential of reducing pain, improving self-efficacy, physical function and mood in older people with chronic MSK pain. It can be an option to PCPs in exercise prescriptions.