Effect of Lifestyle Modification on Patients with Knee Osteoarthritis Attending NRC Rheumatology Clinic

I) Pre-intervention was done by:

1. Sociodemographic questionnaire: to gather information regarding participants age, gender, marital status, occupation, level of education, smoking habits, duration of the disease, medical history and medications taken.
2. Osteoarthritis Knee and Hip Quality of Life (OAKHQOL) questionnaire: The OAKHQOL is a specific tool to measure QOL in knee and hip OA as it takes into account specific themes that are exclusive to the QOL of patients with knee and hip OA (social support, sleep, side effects of drugs, plans for the future, embarrassment to be seen by people, use of public transport, difficulty in moving after staying in the same position, and sexuality). The concept of this questionnaire was based on the World Health Organization definition of QOL. It is a self-administered questionnaire the original questionnaire was developed in French and later in English, while in the current study, it was translated by the researcher into the Arabic language. It has 43 items which fall into five domains: physical activity (16 items), mental health (13 items), pain (4 items), social support (4 items), social functioning (3 items), and three items are independent. Response to all items is by a Numerical Rating Scale (NRS) (0-10). A total score for each subscale is calculated by averaging the values for items of the same dimension and is normalized to a score from 0 (worst HRQOL) to 100 (best HRQOL). Evaluation of the OAKHQOL has shown the reliability of the five domains to be satisfactory (interclass correlation coefficients: 0.70-0.85), the construct validity to be adequate (Spearman correlation coefficients: 0.43-0.75), and the discrimination to be satisfactory (Rat et al, 2006).
3. Western Ontario and McMaster Universities Arthritis Index (WOMAC): WOMAC is a disease-specific, self-administered health status measure that is widely used to assess the symptoms and physical disability for people with knee and/or hip OA. WOMAC has been translated into more than 65 different languages worldwide, in the current study it was translated by the researcher into the Arabic language, it has been validated for usage via telephone interviews, multimedia with audio-visual presentations, verbally spoken computer programs, and mobile phone applications. It is widely used in OA research especially to monitor the course of the disease or to determine the effectiveness of a variety of interventions (pharmacologic, surgical, physiotherapy etc.). It provides an excellent look at a patient's functional capacity and complements the more objective data provided by magnetic resonance imaging, arthroscopy, cartilage biopsy, and radiographs. It consists of 24 items divided into three subscales:

• Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing upright
• Stiffness (2 items): after first waking and later in the day
• Physical Function (17 items): using stairs, rising from sitting, standing, bending, walking, getting in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy domestic duties, light domestic duties.

The Index is available in 5-point Likert (LK), 100mm visual analog (VA), and 11-point numerical rating (NR) scaling formats. On the Likert scale, each question had five alternatives where 0=no constraints or difficulties, 1 = slight, 2=moderate, 3=severe, 4= extreme. The highest score for each subscale on WOMAC on the Likert scale was 20 for pain, 8 for stiffness and 68 for physical function. The highest total score (96) denotes worse or more symptoms and the strongest physical constraints. 4. Knowledge, Attitude and Practice (KAP) questionnaire: to identify participants' knowledge about OA (what is KOA, symptoms, possible risk factors, complications, how to delay progression, management choices, and side effects), attitude towards non-surgical interventions and practices (nutritional habits, physical activity, treatment, and positions that worsen the condition or protect the knees). 5. Clinical assessment: the studied participants were subjected to clinical examination and anthropometric measurements (body mass index, waist and hip circumference). 6. Preintervention assessment of concentration of serum biomarker (IL-6) : A blood sample of 3cm was collected from all the participants after 12- hours fasting (to avoid the inflammatory effect of food) to measure inflammatory biomarkers (IL-6). This assessment was done on a sub sample of participants according to certain circumstances (as not receiving anti-inflammatory drugs in in the past 3 months and those who were adherent to the program of health education).

II) Health Education program Implementation: Nine educational sessions were held. In each session, 10-15 participants attended with total number of 109 participants. The session took 120 minutes.