Diversity Within Movement-Based Mind-Body Interventions For Lower Extremity Osteoarthritis: A Systematic Review Of United States Randomized Clinical Trials

Abstract

Purpose: Older adults, females, and racial and ethnic minority individuals bear a disproportionate burden of osteoarthritis (OA) pain, disability, and activity limitations in the United States (U.S.). The American College of Rheumatology and the Arthritis Foundation strongly recommend tai chi and conditionally recommend yoga for managing knee and hip OA. The 2018 Physical Activity Guidelines Advisory Committee, however, found insufficient evidence to determine whether the effect of movement-based mind-body exercise (MBMBE) on lower extremity OA pain and physical function varies by age, sex, race/ethnicity, and socioeconomic status. Similarly, it is unknown whether treatment effects might differ by sociodemographic and other characteristics such as employment/retirement status, preferred language, occupation, rural/urban residence, LGBTQ status, gender identity, physical disability, or intellectual/cognitive disability. Ensuring inclusion of diverse individuals in clinical trials is essential for informing evidence-based OA treatment guidelines, informing individually-tailored exercise prescriptions, and elimination of health disparities in OA outcomes through public health policy and practice. Therefore, the aims of this systematic review are to: (a) examine the frequency of reporting of demographic, medical, and socio-economic characteristics of enrolled participants, (b) compare representation of diverse groups in randomized controlled trials with U.S. census population estimates and/or estimates of arthritis prevalence across diverse groups, and (c) assess changes in reporting and/or representation of diverse groups over time. Methods: This systematic review was registered in PROSPERO (2021 CRD42021271932) and followed PRISMA guidelines. For inclusion, studies had to meet the following criteria: (a) present original data in a peer-reviewed journal, (b) be a randomized clinical trial, (c) include a MBMBE intervention, (d) include a non-MBMBE control group, (e) include participants with a self-reported clinical diagnosis or be clinically and/or radiographically diagnosed with lower extremity OA. Studies had to be conducted in the U.S. to enable comparisons of the representativeness of study participants with 2019 U.S. Census population estimates and/or estimates of U.S. OA prevalence across diverse groups. Multiple databases were searched using variations of the key terms yoga, tai chi, mind-body, and osteoarthritis. Keywords or limits were set for randomized controlled trials, clinical trials, and English language. The initial search was conducted from inception to August 12, 2021, and then updated through August 27, 2022. Two authors independently reviewed articles for inclusion/exclusion criteria. Disagreements were resolved through discussion and tracked to calculate a kappa statistic for inter-rater agreement. Data were extracted from included studies using a standardized extraction form. Results: A total of 774 studies were identified, and 73 full study reports were assessed for inclusion. Ten studies were included in the review. Kappa statistics indicated substantial agreement (>.70). Results demonstrate a general lack of reporting of important participant characteristics. The most commonly reported socio-demographic characteristics were self-reported sex (10/10; 100%), age (10/10; 100%), race (7/10; 70%), and the intervention language (5/10; 50%). Education (4/10; 40%), ethnicity (1/10; 10%), and physical/mental disability status (1/10; 10%) were insufficiently reported. No studies reported income, employment status, rural/urban residential classification, gender identity, or sexual orientation. Compared to U.S. census data, men, racial/ethnic minority groups, individuals 45-64, individuals with physical/cognitive disabilities, and those with high school education or less were under-represented in clinical trials. Due to the small number of studies and low reporting of sociodemographic variables, a statistical test for change in reporting over time could not be conducted. Conclusions: Inadequate recruitment, collection, and reporting of diverse participant characteristics in MBMBE interventions for lower extremity OA limits our understanding of the generalizability of MBMBE efficacy to diverse groups. In turn, healthcare providers and allied health professionals may be hindered from prescribing MBMBE. Additionally, individuals from underrepresented and marginalized groups with OA may be unintentionally deterred from participating in MBMBE due to lack of representation. We recommend that principal investigators, journal editors, and funding agencies adopt policies and practices designed to increase recruitment of diverse individuals into MBMBE clinical trials and increase reporting of participant characteristics. The methods presented can be applied internationally and to other OA treatments to ensure equitable representation across diverse population sub-groups.