EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis

Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: an observational study

OBJECTIVE

To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels.

METHODS

For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models.

RESULTS

Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use.

CONCLUSION

After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities.

A survey of footwear advice, beliefs and wear habits in people with knee osteoarthritis

Background

Expert opinion recommends cushioned and supportive footwear for people with knee osteoarthritis (OA). However, little is known about the footwear advice people receive from healthcare professionals, or the beliefs and footwear habits of people with knee OA. This study aimed to determine i) what types of shoes people are advised to wear for their knee OA and by whom; ii) establish which types of shoes people with knee OA believe are best for managing their knee OA symptoms and (iii) which shoes they wear most often.

Methods

204 people with symptomatic knee OA completed an online survey. The survey comprised 14 questions asking what footwear advice people had received for their knee OA and who they received it from, individual beliefs about optimal footwear styles for their knee OA symptoms and the types of footwear usually worn.

Results

Only one third (n = 69, 34%) of participants reported receiving footwear advice for their knee OA, and this was most frequently received from a podiatrist (n = 47, 68%). The most common advice was to wear sturdy/supportive shoes (n = 96, 47%) or shoes with arch supports (n = 84, 41%). These were also amongst the shoe styles that participants believed were best for their knee OA (n = 157 (77%) and n = 138 (68%) respectively). The type of shoes most frequently worn were athletic (n = 131, 64%) and sturdy/supportive shoes (n = 116, 57%).

Conclusions

Most people with knee OA who completed our survey had not received advice about footwear for their knee OA symptoms. Our participants typically believed that sturdy/supportive shoes were best for their knee OA and this shoe style was most frequently worn, which is reflective of expert opinion. Future research is needed to confirm whether sturdy/supportive shoes are indeed optimal for managing symptoms of knee OA.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-014-0043-8) contains supplementary material, which is available to authorized users.

Effects of contralateral versus ipsilateral cane use on gait in people with knee osteoarthritis

OBJECTIVE

To compare the immediate effects of contralateral versus ipsilateral cane use on spatiotemporal gait parameters and peak vertical ground force in overweight or obese adults with symptomatic knee osteoarthritis (OA).

DESIGN

Prospective observational study.

SETTING

An academic tertiary Veterans Affairs Healthcare Center.

PARTICIPANTS

Thirty-eight overweight or obese subjects with symptomatic knee OA who had not used a cane for the past 30 days.

METHODS

Spatiotemporal gait data were obtained with an optical motion capture system while subjects walked without a cane, with a cane contralateral to the more painful lower limb, or with a cane ipsilateral to the more painful lower limb at self-selected speeds. An in-shoe dynamic pressure distribution system was used to measure the vertical ground reaction force.

MAIN OUTCOME MEASUREMENTS

Spatiotemporal measures of gait and peak vertical ground reaction force on both lower limbs were recorded for each walking condition: no cane, contralateral cane, and ipsilateral cane.

RESULTS

Walking with a cane either contralateral or ipsilateral to the more symptomatic limb led to significant reductions in gait velocity (14%-16%), cadence (12%-14%), and peak vertical ground reaction force (normalized for body weight; 11%-12%) on the more painful lower limb compared with walking unaided (P < .05). There were no significant differences in the peak vertical ground reaction force on either lower limbs when comparing walking with a cane contralateral to the more painful limb or walking with a cane ipsilateral to the more painful limb. Subjects also experienced a significant decrease in gait velocity with contralateral or ipsilateral cane use compared with walking without a cane; the lower walking speed was due to a decrease in cadence.

CONCLUSIONS

These results support the prescription of a single-point cane to offload a lower limb with painful knee OA by holding the cane either ipsilateral or contralateral to the more painful lower limb.

Comparison of the clinical effectiveness of thermal cure and rehabilitation in knee osteoarthritis. A randomized therapeutic trial

OBJECTIVE

To compare the benefits of a thermal cure and non-thermal rehabilitation in treatment of knee osteoarthritis (KOA).

METHODS

Randomized therapeutic trial including patients with knee osteoarthritis (American College of Rheumatology criteria). Patients were randomly divided into two groups. Spa treatment consisted of underwater shower, massage-jet showers, hydromassage, pool rehabilitation and peloid therapy. Non-thermal rehabilitation consisted of analgesic physiotherapy, muscle strengthening and group physical rehabilitation. A blinded evaluation was carried out at day 21 and 12months following treatment. It was based on the visual analogic scale of pain (VAS), which represented the primary endpoint.

RESULTS

Two hundred and forty patients were included (February-June 2005). The spa treatment and non-thermal rehabilitation groups included 119 and 121 patients respectively. Two hundred and thirty-three patients completed their treatments. Significant improvement of the visual analogic scale of pain was noted in the thermal cure group (61.6±15 at day 0 versus 46.5±22.4 at 12months, P<0.001), but not in the non-thermal group (64.1±15 at day 0 versus 62±29 at 12months, P=0.68). At day 21, comparison of the two groups revealed no significant difference on the VAS (P=0.08). However, at 12months, the thermal cure group was significantly more improved (P=0.000).

CONCLUSION

In our study, crenobalneotherapy had resulted, at 12months, in more pronounced long-term improvement of the painful symptoms of KOA than had non-thermal rehabilitation.

A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain--protocol

BACKGROUND

Chronic musculoskeletal pain is highly prevalent, affecting around one in five people across Europe. Osteoarthritis, low back pain, neck pain and other musculoskeletal disorders are leading causes of disability worldwide and the most common source of chronic pain. Exercise and/or physical activity interventions have the potential to address not only the pain and disability associated with chronic pain but also the increased risk of morbidity and mortality seen in this population. Although exercise and/or physical activity is widely recommended, there is currently a paucity of research that offers an evidence base upon which the development or optimisation of interventions can be based. This systematic review will investigate the components of interventions associated with changes in physical activity levels in adults with chronic musculoskeletal pain.

METHODS/DESIGN

This systematic review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidance. Randomised and quasi-randomised controlled trials of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: CENTRAL in the Cochrane Library, the Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two review authors will independently screen articles retrieved from the search for eligibility, extract relevant data on methodological issues and code interventions according to the behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques. As complex healthcare interventions can be modified by a wide variety of factors, data will be summarised statistically when the data are available, are sufficiently similar and are of sufficient quality. A narrative synthesis will be completed if there is insufficient data to permit a formal meta-analysis.

DISCUSSION

This review will be of value to clinicians working in chronic pain services and to researchers involved in designing and evaluating interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO reference: CRD42014010640.

Exercise therapy in hip osteoarthritis--a randomized controlled trial

BACKGROUND

Roughly one in ten persons in the industrialized world suffers from hip osteoarthritis, a disease for which there is no cure. The goal of conservative therapy is to relieve symptoms, preferably with methods that let patients assume responsibility for their own treatment, e.g., physical training.

METHOD

In a randomized controlled trial, we studied the effectiveness of twelve weeks of exercise therapy in patients with hip osteoarthritis (THüKo), compared to no treatment (control group) and placebo ultrasound treatment of the hip (placebo ultrasound group). The primary endpoint was a comparison of the pain scores of the intervention versus control groups on the generic SF-36 health questionnaire. Secondary endpoints included comparisons across all three study groups of scores on the 7 other scales of the SF-36 and on the pain, physical function, and stiffness scales of the osteoarthritis-specific WOMAC Index. The statistical analysis was performed with ANCOVA, with baseline values as a covariate. Between-group effects were subsequently tested pairwise (two-tailed t-tests, alpha = 0.05).

RESULTS

As for the primary endpoint, pain reduction was significantly greater in the intervention than in the control group (mean difference 5.7 points, 95% confidence interval [CI] 0.4-11.1 points, p = 0.034). The comparisons across all three study groups (i.e., secondary endpoints, with 71 subjects in the intervention group, 68 in the control group, and 70 in the placebo group) revealed no significant between-group effects with respect to the SF-36. On the WOMAC Index, however, statistically significant differences were found for pain reduction between the intervention and control group (mean difference 7.4 points, 95% CI 3.0-11.8, p = 0.001) and between the intervention and placebo group (mean difference 5.1 points, 95% CI 0.7-9.4, p = 0.024). Comparable mean differences were also found for functional improvement.

CONCLUSION

Twelve weeks of exercise therapy in hip osteoarthritis patients of normal vitality reduced pain and improved physical function. No significant improvement was found in these patients' general health-related quality of life.

Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, and this widespread use is complicated by safety issues.

METHOD

A Literature review was conducted.

RESULTS

NSAIDs are a leading cause of drug-related morbidity, especially in the elderly and patients with comorbidities. Most adverse effects are related to generalized inhibition of the major targets of NSAIDs: cyclooxygenases I and II. These enzymes are not only involved in pain and inflammation pathogenesis but are also required in the gastrointestinal (GI) tract for mucosal protection and gut motility, and in the kidneys for functional integrity. Thus, the mechanisms of NSAID toxicity are well understood, but the consequences are largely uncontrolled in clinical practice. GI ulcers, including bleeding ulcers, may occur in several percent of all chronic unprotected, high-dose NSAID users. Renal side effects may precipitate renal failure, resulting in acute dialysis and chronic retention. This includes sodium retention, resulting in arterial hypertension, heart failure, and atherosclerotic events. Cardiovascular risk may be tripled by chronic high-dose NSAID use in long-term clinical trials though "real-life studies" indicate lower risk ratios. Off-target side effects include allergic reactions, drug-induced liver injury, and central nervous system effects.

CONCLUSIONS

Management of pain and inflammation must consider those risks and find alternative drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity. Alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies, need to be further utilized. The appalling equation "less pain-more deaths/morbidity" ultimately necessitates treatment optimization in the individual patient.

Osteoarthritis research priorities: a report from a EULAR ad hoc expert committee

Osteoarthritis (OA) currently affects over 40 million Europeans, with its associated personal suffering and significant economic burden for health systems set to dramatically escalate in a rapidly ageing Europe. Given the very limited effective therapeutic options for OA, the European League Against Rheumatism (EULAR) created an ad hoc committee of OA researchers, clinicians and patients to consider a research agenda focussed on the areas of epidemiology, pathogenesis, imaging and biomarkers, and therapies. The committee deliberated and listed research needs in these areas and also established some cross-area priority themes: predictors of OA progression, especially where this might enable stratified interventions; understanding mechanisms of OA pain; improved understanding of tissue communication in a process where multiple tissue pathologies are common; developing concepts of, and consequently interventions for, early OA where both pain and structural processes may be more effectively targeted than in typical clinical presentations; and the need for new treatment strategies, with examples discussed on pathology-targeted therapies and optimal combinations of therapies. This research agenda should provide useful guidance for all researchers in this field and hopefully lead to improved OA care.

A multicentre, pragmatic, parallel group, randomised controlled trial to compare the clinical and cost-effectiveness of three physiotherapy-led exercise interventions for knee osteoarthritis in older adults: the BEEP trial protocol (ISRCTN: 93634563)

BACKGROUND

Exercise is consistently recommended for older adults with knee pain related to osteoarthritis. However, the effects from exercise are typically small and short-term, likely linked to insufficient individualisation of the exercise programme and limited attention to supporting exercise adherence over time. The BEEP randomised trial aims to improve patients' short and long-term outcomes from exercise. It will test the overall effectiveness and cost-effectiveness of two physiotherapy-led exercise interventions (Individually Tailored Exercise and Targeted Exercise Adherence) to improve the individual tailoring of, and adherence to exercise, compared with usual physiotherapy care.

METHODS/DESIGN

Based on the learning from a pilot study (ISRCTN 23294263), the BEEP trial is a multi-centre, pragmatic, parallel group, individually randomised controlled trial, with embedded longitudinal qualitative interviews. 500 adults in primary care, aged 45 years and over with knee pain will be randomised to 1 of 3 treatment groups delivered by fully trained physiotherapists in up to 6 NHS services. These are: Usual Physiotherapy Care (control group consisting of up to 4 treatment sessions of advice and exercise), Individually Tailored Exercise (an individualised, supervised and progressed lower-limb exercise programme) or Targeted Exercise Adherence (supporting patients to adhere to exercise and to engage in general physical activity over the longer-term). The primary outcomes are pain and function as measured by the Western Ontario and McMaster Osteoarthritis index. A comprehensive range of secondary outcomes are also included. Outcomes are measured at 3, 6 (primary outcome time-point), 9, 18 and 36 months. Data on adverse events will also be collected. Semi-structured, qualitative interviews with a subsample of 30 participants (10 from each treatment group) will be undertaken at two time-points (end of treatment and 12 to 18 months later) and analysed thematically.

DISCUSSION

This trial will contribute to the evidence base for management of older adults with knee pain attributable to osteoarthritis in primary care. The findings will have important implications for healthcare commissioners, general practitioners and physiotherapy service providers and it will inform future education of healthcare practitioners. It may also serve to delay or prevent some individuals from becoming surgical candidates.

TRIAL REGISTRATION ISRCTN

ISRCTN93634563.

Exercise in osteoarthritis: moving from prescription to adherence

Exercise is recommended for the management of osteoarthritis (OA) in all clinical guidelines irrespective of disease severity, pain levels, and functional status. For knee OA, evidence supports the benefits of various types of exercise for improving pain and function in the short term. However, there is much less research investigating the effects of exercise in patients with OA at other joints such as the hip and hand. It is important to note that while the magnitude of exercise benefits may be considered small to moderate, these effects are comparable to reported estimates for simple analgesics and oral nonsteroidal anti-inflammatory drugs for OA pain but exercise has much fewer side effects. Exercise prescription should be individualized based on assessment findings and be patient centered involving shared decision making between the patient and clinician. Given that patient adherence to exercise declines over time, appropriate attention should be pain as reduced adherence attenuates the benefits of exercise. Given this, barriers and facilitators to exercise should be identified and strategies to maximize long-term adherence to exercise implemented.

Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons - a scoping review

Obesity is widely acknowledged as a risk factor for both the incidence and progression of osteoarthritis, and has a negative influence on outcomes. Loss of at least 10% of body weight, coupled with exercise, is recognized as a cornerstone in the management of obese patients with osteoarthritis, and can lead to significant improvement in symptoms, pain relief, physical function and health-related quality of life. However, questions still remain surrounding optimal management. Given the significant health, social and economic burden of osteoarthritis, especially in obese patients, it is imperative to advance our knowledge of osteoarthritis and obesity, and apply this to improving care and outcomes. This paper overviews what is already known about osteoarthritis and obesity, discusses current key challenges and ongoing hypotheses arising from research in these areas, and finally, postulates what the future may hold in terms of new horizons for obese patients with osteoarthritis.

Association of knee confidence with pain, knee instability, muscle strength, and dynamic varus-valgus joint motion in knee osteoarthritis

OBJECTIVE

To investigate associations between self-reported knee confidence and pain, self-reported knee instability, muscle strength, and dynamic varus-valgus joint motion during walking.

METHODS

We performed a cross-sectional analysis of baseline data from 100 participants with symptomatic and radiographic medial tibiofemoral compartment osteoarthritis (OA) and varus malalignment recruited for a randomized controlled trial. The extent of knee confidence, assessed using a 5-point Likert scale item from the Knee Injury and Osteoarthritis Outcome Score, was set as the dependent variable in univariable and multivariable ordinal regression, with pain during walking, self-reported knee instability, quadriceps strength, and dynamic varus-valgus joint motion during walking as independent variables.

RESULTS

One percent of the participants were not troubled with lack of knee confidence, 17% were mildly troubled, 50% were moderately troubled, 26% were severely troubled, and 6% were extremely troubled. Significant associations were found between worse knee confidence and higher pain intensity, worse self-reported knee instability, lower quadriceps strength, and greater dynamic varus-valgus joint motion. The multivariable model consisting of the same variables significantly accounted for 24% of the variance in knee confidence (P < 0.001).

CONCLUSION

Worse knee confidence is associated with higher pain, worse self-reported knee instability, lower quadriceps muscle strength, and greater dynamic varus-valgus joint motion during walking. Since previous research has shown that worse knee confidence is predictive of functional decline in knee OA, addressing lack of knee confidence by treating these modifiable impairments could represent a new therapeutic target.

What are the factors that influence physical activity participation in adults with knee and hip osteoarthritis? A systematic review of physical activity correlates

Objective:

To determine the factors associated with physical activity participation in adults with hip or knee osteoarthritis.

Methods:

A systematic review was conducted including searches of AMED, PsycINFO, CINAHL, MEDLINE, EMBASE, PubMed and the Cochrane Library from inception until October 2013. Studies presenting quantitative correlates of physical activity in adults with hip and/or knee osteoarthritis were included. Two independent authors conducted the searches, extracted data and completed methodological quality assessment. Correlates were analysed using the summary code approach within the socio-ecological model.

Results:

A total of 170 correlates were identified from 29 publications analysing 8076 individual people with hip or knee osteoarthritis. Methodological quality was generally good. For knee osteoarthritis, factors consistently negatively associated with physical activity (reported more than four studies) were increasing age (number of participants in studies supporting association = 4558), non-white ethnicity ( n = 3232), increased osteoarthritis symptoms ( n = 2374) and female gender ( n = 4816). Greater lower limb function ( n = 1671) and faster gait speed were ( n = 4098) positively associated with physical activity. Social (e.g. support from spouse ( n = 141)) and environment (outdoor temperature ( n = 38)) factors were identified as possible factors that influence physical activity. For hip osteoarthritis, higher body mass index ( n = 99), increased comorbidities ( n = 1021), lower mental health ( n = 189) and unemployment ( n = 65) were negatively associated with physical activity; while better social functioning ( n = 1055) and health-related quality of life were positively associated with physical activity ( n = 34).

Conclusion:

Demographic, physical, social, psychological and environmental factors are all important correlates for physical activity for people with knee or hip osteoarthritis. Clinicians should consider these in clinical practice.

Effect of rocker-soled shoes on parameters of knee joint load in knee osteoarthritis

PURPOSE

This study evaluated the immediate effects of rocker-soled shoes on parameters of the knee adduction moment (KAM) and pain in individuals with knee osteoarthritis (OA).

METHODS

Three-dimensional gait analysis was performed on 30 individuals (mean (SD): age, 61 (7) yr; 15 (50%) male) with radiographic and symptomatic knee OA under three walking conditions in a randomized order: i) wearing rocker-soled shoes (Skechers Shape-ups), ii) wearing non-rocker-soled shoes (ASICS walking shoes), and iii) barefoot. Peak KAM and KAM angular impulse were measured as primary indicators of knee load distribution. Secondary measures included the knee flexion moment (KFM) and knee pain during walking.

RESULTS

Peak KAM was significantly lower when wearing the rocker-soled shoes compared with that when wearing the non-rocker-soled shoes (mean difference (95% confidence interval), -0.27 (-0.42 to -0.12) N·m/BW × Ht%; P < 0.001). Post hoc tests revealed no significant difference in KAM impulse between rocker-soled and non-rocker-soled shoe conditions (P = 0.13). Both peak KAM and KAM impulse were significantly higher during both shoe conditions compared with those during the barefoot condition (P < 0.001). There were no significant differences in KFM (P = 0.36) or knee pain (P = 0.89) between conditions.

CONCLUSIONS

Rocker-soled shoes significantly reduced peak KAM when compared with non-rocker-soled shoes, without a concomitant change in KFM, and thus may potentially reduce medial knee joint loading. However, KAM parameters in the rocker-soled shoes remained significantly higher than those during barefoot walking. Wearing rocker-soled shoes did not have a significant immediate effect on walking pain. Further research is required to evaluate whether rocker-soled shoes can influence symptoms and progression of knee OA with prolonged wear.

Post-operative rehabilitation and nutrition in osteoarthritis

Osteoarthritis (OA) is a degenerative process involving the progressive loss of articular cartilage, synovial inflammation and structural changes in subchondral bone that lead to loss of synovial joint structural features and functionality of articular cartilage. OA represents one of the most common causes of physical disability in the world. Different OA treatments are usually considered in relation to the stage of the disease. In the early stages, it is possible to recommend physical activity programs that can maintain joint health and keep the patient mobile, as recommended by OA Research Society International (OARSI) and European League Against Rheumatism (EULAR). In the most severe and advanced cases of OA, surgical intervention is necessary. After, in early postoperative stages, it is essential to include a rehabilitation exercise program in order to restore the full function of the involved joint. Physical therapy is crucial for the success of any surgical procedure and can promote recovery of muscle strength, range of motion, coordinated walking, proprioception and mitigate joint pain. Furthermore, after discharge from the hospital, patients should continue the rehabilitation exercise program at home associated to an appropriate diet. In this review, we analyze manuscripts from the most recent literature and provide a balanced and comprehensive overview of the latest developments on the effect of physical exercise on postoperative rehabilitation in OA. The literature search was conducted using PubMed, Scopus, Web of Science and Google Scholar, using the keywords 'osteoarthritis', 'rehabilitation', 'exercise' and 'nutrition'. The available data suggest that physical exercise is an effective, economical and accessible to everyone practice, and it is one of the most important components of postoperative rehabilitation for OA.

Web-based therapeutic exercise resource center as a treatment for knee osteoarthritis: a prospective cohort pilot study

BACKGROUND

Although beneficial effects of exercise in the management of knee osteoarthritis (OA) have been established, only 14 -18% of patients with knee OA receive an exercise from their primary care provider. Patients with knee OA cite lack of physician exercise advice as a major reason why they do not exercise to improve their condition. The purpose of this pilot study was to investigate use of a web-based Therapeutic Exercise Resource Center (TERC) as a tool to prescribe strength, flexibility and aerobic exercise as part of knee OA treatment. It was hypothesized that significant change in clinical outcome scores would result from patients' use of the TERC.

METHODS

Sixty five individuals diagnosed with mild/moderate knee OA based on symptoms and radiographs were enrolled through outpatient physician clinics. Using exercise animations to facilitate proper technique, the TERC assigned and progressed patients through multiple levels of exercise intensity based on exercise history, co-morbidities and a validated measure of pain and function. Subjects completed a modified short form WOMAC (mSF-WOMAC), World Health Organization Quality of Life (WHO-QOL) and Knee Self-Efficacy Scale (K-SES) at baseline and completion of the 8 week program, and a user satisfaction survey. Outcomes were compared over time using paired t-tests and effect sizes calculated using partial point biserial (pr).

RESULTS

Fifty two participants completed the 8 week program with average duration of knee pain 8.0 ± 11.0 yrs (25 females; 61.0 ± 9.4 yrs; body mass index, 28.8 ± 6.3 kg/m2). During the study period, all outcome measures improved: mSF-WOMAC scores decreased (better pain and function) (p<.001; large effect, pr=0.70); WHO-QOL physical scores increased (p=.015; medium effect, pr=0.33); and K-SES scores increased (p<.001; large effect, pr=0.54). No significant differences were found in study outcomes as a function of gender, age, BMI or symptom duration. Patients reported very positive evaluation of the TERC (94% indicated the website was easy to use; 90% specified the exercise animations were especially helpful).

CONCLUSION

This pilot study demonstrated the web-based TERC to be feasible and efficacious in improving clinical outcomes for patients with mild/moderate knee OA and supports future studies to compare TERC to current standard of care, such as educational brochures.

Development of comorbidity-adapted exercise protocols for patients with knee osteoarthritis

Background

Exercise therapy is generally recommended for patients with osteoarthritis (OA) of the knee. Comorbidity, which is highly prevalent in OA, may interfere with exercise therapy. To date, there is no evidence-based protocol for the treatment of patients with knee OA and comorbidity. Special protocols adapted to the comorbidity may facilitate the application of exercise therapy in patients with knee OA and one or more comorbidities.

Purpose

The purpose of this study was to develop comorbidity-adapted exercise protocols for patients with knee OA and comorbidity.

Method

Several steps were undertaken to develop comorbidity-adapted protocols: selection of highly prevalent comorbidities in OA, a literature search to identify restrictions and contraindications for exercise therapy for the various comorbid diseases, consultation of experts on each comorbid disease, and field testing of the protocol in eleven patients with knee OA and comorbidity.

Results

Based on literature and expert opinion, comorbidity-adapted protocols were developed for highly prevalent comorbidities in OA. Field testing showed that the protocols provided guidance in clinical decision making in both the diagnostic and the treatment phase. Because of overlap, the number of exercise protocols could be reduced to three: one for physiological adaptations (coronary disease, heart failure, hypertension, diabetes type 2, chronic obstructive pulmonary diseases, obesity), one for behavioral adaptations (chronic a-specific pain, nonspecific low back pain, depression), and one for environmental adaptations (visual or hearing impairments). Evaluation of patient outcome after treatment showed significant (P<0.05) and clinically relevant improvements in activity limitations and pain.

Conclusion

Comorbidity-adapted exercise protocols for patients with knee OA were developed, providing guidance in clinical reasoning with regard to diagnostics and treatment. To evaluate the effectiveness of treatment in line with our protocols, a randomized clinical trial should be performed.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

OBJECTIVES

Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint.

METHODS

ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus.

RESULTS

Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated.

CONCLUSIONS

The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

Hip abductor function in individuals with medial knee osteoarthritis: Implications for medial compartment loading during gait

BACKGROUND

Hip abductor muscles generate moments of force that control lower extremity frontal plane motion. Strengthening these muscles has been a recent trend in therapeutic intervention studies for knee osteoarthritis. The current study investigated the relationship between hip abductor muscle function (strength and activation) and the net external knee adduction moment during gait in those with medial compartment knee osteoarthritis.

METHODS

54 individuals with moderate knee osteoarthritis walked at their self-selected velocity while gluteus medius electromyograms, segment motions and ground reaction forces were recorded. Net external knee adduction moment (KAM) and linear enveloped electromyographic profiles were calculated. Peak KAM was determined and then principal component analyses (PCA) were applied to KAM and electromyographic profiles. Isometric hip abductor strength, anthropometrics and gait velocity were measured. Multiple regression models evaluated the relationship between walking velocity, hip abductor strength, electromyographic variables recorded during gait and KAM waveform characteristics.

FINDINGS

Minimal peak KAM variance was explained by abductor strength (R(2)=9%, P=0.027). PCA-based KAM waveform characteristics were not explained by abductor strength. Overall gluteus medius amplitude (PP1-scores) was related to a reduction in the bi-modal KAM (PP3-scores) pattern (R(2)=16%, P=0.003).

INTERPRETATION

There was no clear relationship between hip abductor muscle strength and specific amplitude and temporal KAM characteristics. Higher overall gluteus medius activation amplitude was related to a sustained KAM during mid-stance. 84 to 90% of the variance in KAM waveform characteristics was not explained by hip abductor muscle function showing hip abductor muscle function has minimal association to KAM characteristics.

Effect of eccentric isokinetic strengthening in the rehabilitation of patients with knee osteoarthritis: Isogo, a randomized trial

Background

Femorotibial knee osteoarthritis is associated with muscle weakness in the lower limbs, particularly in the quadriceps, which results in disease progression. The interest of having muscular strengthening as part of the therapeutic arsenal for the medical treatment of knee osteoarthritis is now well established.

The functional disability induced by knee osteoarthritis manifests itself principally when walking, notably downhill, during which the muscles are called upon to contract eccentrically.

We can therefore think that eccentric muscular strengthening could bring a functional benefit that is superior to concentric muscular strengthening.

Methods/Design

This is a prospective, randomized, bicenter, parallel-group, international study. Eighty patients aged from 40 to 75 years old, suffering from medical-stage knee osteoarthritis, will undertake 6 weeks of isokinetic muscular strengthening. Randomization determines the mode of muscular strengthening: either exclusively eccentric or exclusively concentric.

The principal objective is to demonstrate the superiority of the improvement in the quadriceps isokinetic torque after isokinetic muscular strengthening by the eccentric mode compared to the concentric mode.

The following parameters are also evaluated: the variations in the level of pain, the parameters of walking (maximum speed over 10 and 200 meters, analysis on a computerized Gaitrite™ treadmill), static equilibrium (on a FUSYO™ force platform), and the functional status of the patient using the Western Ontario and MacMaster Universities osteoarthritis index (WOMAC) questionnaire after the strengthening period and at 6 months.

Discussion

A better knowledge of the most effective mode of muscular strengthening is needed to optimize the functional benefits to the patients. In case of superiority in terms of efficacy of the eccentric mode, the latter could be given priority in the rehabilitation treatment of knee osteoarthritis patients.

Trial registration

Clinical trials.gov number: NCT01586130.

Future directions for the management of pain in osteoarthritis

Osteoarthritis (OA) is the predominant form of arthritis worldwide, resulting in a high degree of functional impairment and reduced quality of life owing to chronic pain. To date, there are no treatments that are known to modify disease progression of OA in the long term. Current treatments are largely based on the modulation of pain, including NSAIDs, opiates and, more recently, centrally acting pharmacotherapies to avert pain. This review will focus on the rationale for new avenues in pain modulation, including inhibition with anti-NGF antibodies and centrally acting analgesics. The authors also consider the potential for structure modification in cartilage/bone using growth factors and stem cell therapies. The possible mismatch between structural change and pain perception will also be discussed, introducing recent techniques that may assist in improved patient phenotyping of pain subsets in OA. Such developments could help further stratify subgroups and treatments for people with OA in future.

[Physiotherapy from the view of health insurance financing]

Physiotherapy lacks studies performed with the use of the modern research methodology and, therefore, its use based on empirical considerations. International practice guidelines do not recommend unequivocally the use of all kinds of physiotherapy with the exception of exercise therapy, but Hungarian guidelines support its use in the treatment of several different conditions. National health insurance in Hungary provides financial support for the use of physiotherapy in the fields of home care, out- and inpatient care and spa treatment. In 2011 national health insurance in Hungary supported spa treatments with 4 billion HUF, and the most frequently used treatment was thermal bath in about 2 million occasions. National health insurance in Hungary spent about 1 billion HUF for physiotherapy used in outpatient care; both ultrasound and interference treatments were financed in 2 million occasions in 2011.

Immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis: a randomised controlled trial

OBJECTIVE

To compare the immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis.

METHODS

Sixty patients with knee osteoarthritis, with a pain intensity of ≥2 on the pain Numerical Rating Scale, were included. The patients were randomised into two groups: manual acupuncture and electroacupuncture. Pain intensity, degree of dysfunction (Timed Up and Go (TUG) test), maximal voluntary isometric contraction and pressure pain threshold were assessed before and after a single session of manual acupuncture or electroacupuncture treatments.

RESULTS

Both groups showed a significant reduction in pain intensity (p<0.001) and time to run the TUG test after the acupuncture treatment (p=0.005 for the manual acupuncture group and p=0.002 for the electroacupuncture group). There were no differences between the groups regarding pain intensity (p=0.25), TUG test (p=0.70), maximum voluntary isometric contraction (p=0.43) or pressure pain threshold (p=0.27).

CONCLUSIONS

This study found no difference between the immediate effects of a single session of manual acupuncture and electroacupuncture on pain, muscle strength and mobility in patients with knee osteoarthritis.

TRIAL REGISTRATION NUMBER

RBR-9TCN2X.

Unloading shoes for osteoarthritis of the knee: protocol for the SHARK randomised controlled trial

Background

Knee osteoarthritis (OA) is a common and disabling condition. Abnormalities in knee loading play an important role in disease pathogenesis, yet there are few non-surgical treatments for knee OA capable of reducing knee load. This two-arm randomised controlled trial is investigating the efficacy of specially-designed unloading shoes for the treatment of symptoms in people with knee OA.

Methods/Design

164 people with symptomatic medial tibiofemoral joint OA will be recruited from the community and randomly allocated to receive either unloading shoes or control shoes. Unloading shoes have a specially-designed triple-density midsole where the medial side is softer than normal and the lateral side harder as well as a lateral wedge between the sole and sock-liner. Control shoes are standard athletic shoes and do not contain these features. Participants will be blinded to shoe allocation and will be instructed to wear the shoes as much as possible every day for 6 months, for a minimum of 4 hours per day. The primary outcomes are knee pain (numerical rating scale) and self-reported physical function (Western Ontario and McMaster Universities Osteoarthritis Index) measured at baseline and 6 months. Secondary outcomes include additional measures of knee pain, knee stiffness, participant global ratings of change in symptoms, quality-of-life and physical activity.

Conclusions

The findings from this study will help determine whether specially-designed unloading shoes are efficacious in the management of knee OA.

Trial registration

Australian New Zealand Clinical Trials Registry reference: ACTRN12613000851763.

Designing a strategy to implement optimal conservative treatments in patients with knee or hip osteoarthritis in orthopedic practice: a study protocol of the BART-OP study

Background

National and international evidence-based guidelines for hip and knee osteoarthritis recommend to start with (a combination of) conservative treatments, followed by surgical intervention if a patient does not respond sufficiently to conservative treatment options. Despite these recommendations, there are strong indications that conservative treatments are not optimally used in orthopedic practice. Our study aims to quantify the use of conservative treatments in Dutch orthopedic practice and to explore the barriers and facilitators for the use of conservative treatments that should be taken into account in a strategy to improve the embedding of conservative treatments in hip and knee osteoarthritis in orthopedic practice.

Methods

This study consists of three phases. First, current use of conservative treatments in patients with hip and knee osteoarthritis will be explored using an internet-based survey among at least 100 patients to identify the underused conservative treatments. Second, barriers and facilitators for the use of conservative treatments in orthopedic practice will be identified using semi-structured interviews among 10 orthopedic surgeons and 5 patients. The interviews will be followed by an internet-based survey among approximately 450 orthopedic surgeons and at least 100 patients in which the identified barriers and facilitators will be ranked by importance. Finally, an implementation strategy will be developed based on the results of the previous phases using intervention mapping.

Discussion

The developed strategy is likely to result in an optimal and standardized use of conservative treatment options in hip and knee osteoarthritis in orthopedic practice, because it is focused on identified barriers and facilitators. In addition, the results of this study can be used as an example for optimizing the use of conservative care in other patient groups. In a subsequent study, the developed implementation strategy will be assessed on its effectiveness, feasibility and costs.

Recommendations for exercise adherence measures in musculoskeletal settings: a systematic review and consensus meeting (protocol)

BACKGROUND

Exercise programmes are frequently advocated for the management of musculoskeletal disorders; however, adherence is an important pre-requisite for their success. The assessment of exercise adherence requires the use of relevant and appropriate measures, but guidance for appropriate assessment does not exist. This research will identify and evaluate the quality and acceptability of all measures used to assess exercise adherence within a musculoskeletal setting, seeking to reach consensus for the most relevant and appropriate measures for application in research and/or clinical practice settings.

METHODS/DESIGN

There are two key stages to the proposed research. First, a systematic review of the quality and acceptability of measures used to assess exercise adherence in musculoskeletal disorders; second, a consensus meeting. The systematic review will be conducted in two phases and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure a robust methodology. Phase one will identify all measures that have been used to assess exercise adherence in a musculoskeletal setting. Phase two will seek to identify published and unpublished evidence of the measurement and practical properties of identified measures. Study quality will be assessed against the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines. A shortlist of best quality measures will be produced for consideration during stage two: a meeting of relevant stakeholders in the United Kingdom during which consensus on the most relevant and appropriate measures of exercise adherence for application in research and/or clinical practice settings will be sought.

DISCUSSION

This study will benefit clinicians who seek to evaluate patients' levels of exercise adherence and those intending to undertake research, service evaluation, or audit relating to exercise adherence in the musculoskeletal field. The findings will impact upon new research studies which aim to understand the factors that predict adherence with exercise and which test different adherence-enhancing interventions. PROSPERO reference: CRD42013006212.

A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument

Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative

PURPOSE

Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers.

METHODS

A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data.

RESULTS

Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin.

CONCLUSIONS

The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs.

Patient reported barriers and facilitators to using a self-management booklet for hip and knee osteoarthritis in primary care: results of a qualitative interview study

BACKGROUND

To enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet "Care for Osteoarthritis" was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient's active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet.

METHODS

Seventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients' view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach.

RESULTS

Three core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient's perceptions about OA and its manageability, and 3) the patient's perceptions about the usefulness of the booklet and patient's information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers' endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients' perceptions about the usefulness of the booklet and patients' information needs were both identified as barriers as well as facilitators for booklet use.

CONCLUSIONS

This study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.

Conflicts of interest in biomedical publications: considerations for authors, peer reviewers, and editors

This article overviews evidence on common instances of conflict of interest (COI) in research publications from general and specialized fields of biomedicine. Financial COIs are viewed as the most powerful source of bias, which may even distort citation outcomes of sponsored publications. The urge to boost journal citation indicators by stakeholders of science communication is viewed as a new secondary interest, which may compromize the interaction between authors, peer reviewers and editors. Comprehensive policies on disclosure of financial and non-financial COIs in scholarly journals are presented as proxies of their indexing in evidence-based databases, and examples of successful medical journals are discussed in detail. Reports on clinical trials, systematic reviews, meta-analyses and clinical practice guidelines may be unduly influenced by author-pharmaceutical industry relations, but these publications do not always contain explicit disclosures to allow the readers to judge the reliability of the published conclusions and practice-changing recommendations. The article emphasizes the importance of adhering to the guidance on COI from learned associations such as the International Committee of Medical Journal Editors (ICMJE). It also considers joint efforts of authors, peer reviewers and editors as a foundation for appropriately defining and disclosing potential COIs.

Systematic review of guidelines for the physical management of osteoarthritis

OBJECTIVE

To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA).

DATA SOURCES

The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000-2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved.

STUDY SELECTION

OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation.

DATA EXTRACTION

The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence.

DATA SYNTHESIS

Seventeen guidelines with recommendations on the physical management of OA met the inclusion criteria and underwent a full critical appraisal. There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from "strongly recommended" to "unsupported." Exercise and education were found to be strongly recommended by most guidelines.

CONCLUSIONS

Exercise and education were key recommendations supporting the importance of rehabilitation in the physical management of OA. This critical appraisal can assist health care providers who are involved in the management of people with OA.

Efficacy of strength and aerobic exercise on patient-reported outcomes and structural changes in patients with knee osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Despite an extensive literature on treatment interventions for patients with knee osteoarthritis, studies comparing the efficacy of different exercise interventions and living the life as usual on quality of life, cartilage quality and cost-effectiveness are lacking. The aim of the present study is to compare the efficacy of two different exercise programs compared to a control group in individuals with established radiographic and symptomatic knee osteoarthritis on self-reported knee-related quality of life, knee pain, physical function, and cartilage quality.

METHODS/DESIGN

A three-armed randomized controlled trial involving two exercise interventions and a control group of individuals doing as they usually do is described. The patients will have mild to moderate radiographic osteoarthritis according to the Kellgren and Lawrence classification (grade 2-3), and fulfill the American College of Rheumatology clinical criteria, be aged between 45 and 65 years, and have no other serious physical or mental illnesses. The patients will be randomly allocated to a strength exercise group; a cycling group, or a control group. The primary outcome is the Knee injury and Osteoarthritis Outcome Score knee-related quality of life subscale. Secondary outcomes include all five Knee Injury and Osteoarthritis Outcome Score subscales, morphological evaluation of cartilage including focal thickness, subchondral bone marrow edema, proteoglycan content and collagen degradation (measured using magnetic resonance imaging clinical sequences, T2 mapping and T1ρ), specific serum biomarkers, isokinetic muscle strength, maximal oxygen uptake, quality of life (EuroQol 5D), and self-efficacy (Arthritis Self-Efficacy Scale). A sample size calculation on the primary outcome showed that 207 individuals, 69 in each group, is needed to detect a clinically relevant difference of 10 points with 80% power and a significance level of 5%. Assessments will be conducted at baseline, 14 weeks, 1 year and 2 years post-randomization. The interventions will be a 14 weeks exercise program.

DISCUSSION

Although exercise therapy has been found to be effective in knee osteoarthritis, the knowledge of the underlying mechanisms for why exercise works is lacking. This study will contribute with knowledge on the efficacy of strength exercise versus cycling on patient-reported outcomes, cartilage quality and cost-effectiveness.

TRIAL REGISTRATION

Clinicaltrial.gov Identifier: NCT01682980.

Safety and Tolerability of Intra-Articular Hyaluronic Acid Injection (Sinovial®) in Experimental and Clinical Practice

Osteoarthritis (OA) requires long-term treatment, therefore, tolerability is a key factor in treatment choice. Hyaluronic acid (HA), a glycosaminoglycan with viscoelastic properties, a major component of synovial fluid and the extracellular matrix of the joint cartilage, plays key roles in synovial fluid viscosity and maintaining normal cartilage. Viscosupplementation is an intra-articular (IA) injection of exogenous HA in an effort to delay joint mobility loss. Commercially available viscosupplementation includes HA of different average molecular weight (MW), concentration and origins, with varying tolerability. This review describes the tolerability and safety profile of Sinovial® in knee and hip OA. A literature search of PubMed using the search queries [Sinovial® OR hyaluronic acid OR hyaluronan] and [intra-articular OR osteoarthritis] was performed using terms as medical subject headings and free text searches. Studies were selected manually for inclusion in this review. Sinovial® is a low-medium MW HA of non-avian origin, produced by biofermentation to ensure the product is pure and free of allergenic animal proteins. We analyzed data regarding the tolerability of Sinovial® in OA patients. This formulation has a favorable tolerability profile; no systemic reactions have been reported and most adverse events (AEs) are mild, transient and easily managed local injection site reactions. Reactions — pain and burning at the injection site - are typical of IA injections. AEs with Sinovial® used in the hip are similar to knee OA.

Lower body positive pressure: an emerging technology in the battle against knee osteoarthritis?

Background

Knee osteoarthritis (OA) is the most prevalent medical condition in individuals over the age of 65 years, and is a progressive joint degenerative condition with no known cure. Research suggests that there is a strong relationship between knee pain and loss of physical function. The resulting lifestyle modifications negatively impact not only disease onset and progression but also overall health, work productivity, and quality of life of the affected individual.

Purpose

The goal of this investigation was to examine the feasibility of using an emerging technology called lower body positive pressure (LBPP) to simulate weight loss and reduce acute knee pain during treadmill walking exercise in overweight individuals with radiographically confirmed symptomatic knee OA.

Design

Prospective case series.

Methods

Twenty-two overweight individuals with knee OA completed two 20-minute treadmill walking sessions (one full weight bearing and one LBPP supported) at a speed of 3.1 mph, 0% incline. Acute knee pain was assessed using a visual analog scale, and the percentage of LBPP support required to minimize knee pain was evaluated every 5 minutes. Knee Osteoarthritis Outcome Scores were used to quantify knee pain and functional status between walking sessions. The order of testing was randomized, with sessions occurring a minimum of 1 week apart.

Results

A mean LBPP of 12.4% of body weight provided participants with significant pain relief during walking, and prevented exacerbation of acute knee pain over the duration of the 20-minute exercise session. Patients felt safe and confident walking with LBPP support on the treadmill, and demonstrated no change in Knee Osteoarthritis Outcome Scores over the duration of the investigation.

Conclusion

Results suggest that LBPP technology can be used safely and effectively to simulate weight loss and reduce acute knee pain during weight-bearing exercise in an overweight knee OA patient population. These results could have important implications for the development of future treatment strategies used in the management of at-risk patients with progressive knee OA.