Osteoarthritis

Exercise for osteoarthritis of the knee

BACKGROUND

Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non-pharmacological interventions recommended by international guidelines.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.

SEARCH METHODS

Five electronic databases were searched, up until May 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land-based therapeutic exercise (as opposed to exercise conducted in the water) with a non-exercise group or a non-treatment control group.

DATA COLLECTION AND ANALYSIS

Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).

MAIN RESULTS

In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self-reported.High-quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) -0.49, 95% confidence interval (CI) -0.39 to -0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100-point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate-quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD -0.52, 95% CI -0.39 to -0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100-point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High-quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100-point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).High-quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.In addition, 12 included studies provided two to six-month post-treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD -0.24, 95% CI -0.35 to -0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100-point scale, and of physical function (SMD -0.15 95% CI -0.26 to -0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100-point scale.Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class-based exercise programmes or home-based programmes; however between-study heterogeneity was marked within the individually provided treatment delivery subgroup.

AUTHORS' CONCLUSIONS

High-quality evidence indicates that land-based therapeutic exercise provides short-term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate-quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non-steroidal anti-inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.

Burden of disability due to musculoskeletal (MSK) disorders

This chapter summarises the global and regional prevalence, disability (Years Lived with Disability (YLDs)) and overall burden (Disability Adjusted Life Years (DALYs)) and costs for the common musculoskeletal disorders including low back and neck pain, hip and knee osteoarthritis, rheumatoid arthritis, gout, and a remaining combined group of other MSK conditions. The contribution of the role of pain in disability burden is introduced. Trends over time and predictions of increasing MSK disability with demographic changes are addressed and the particular challenges facing the developing world are highlighted.

Transient anabolic effects accompany epidermal growth factor receptor signal activation in articular cartilage in vivo

Introduction

Signals from the epidermal growth factor receptor (EGFR) have typically been considered to provide catabolic activities in articular cartilage, and accordingly have been suggested to have a causal role in osteoarthritis progression. The aim of this study was to determine in vivo roles for endogenous EGFR signal activation in articular cartilage.

Methods

Transgenic mice with conditional, limb-targeted deletion of the endogenous intracellular EGFR inhibitor Mig-6 were generated using CreLoxP (Mig-6-flox; Prx1Cre) recombination. Histology, histochemical staining and immunohistochemistry were used to confirm activation of EGFR signaling in the articular cartilage and joints, and to analyze phenotypic consequences of Mig-6 loss on articular cartilage morphology, proliferation, expression of progenitor cell markers, presence of chondrocyte hypertrophy and degradation of articular cartilage matrix.

Results

The articular cartilage of Mig-6-conditional knockout (Mig-6-cko) mice was dramatically and significantly thicker than normal articular cartilage at 6 and 12 weeks of age. Mig-6-cko articular cartilage contained a population of chondrocytes in which EGFR signaling was activated, and which were three to four times more proliferative than normal Mig-6-flox articular chondrocytes. These cells expressed high levels of the master chondrogenic regulatory factor Sox9, as well as high levels of putative progenitor cell markers including superficial zone protein (SZP), growth and differentiation factor-5 (GDF-5) and Notch1. Expression levels were also high for activated β-catenin and the transforming growth factor beta (TGF-β) mediators phospho-Smad2/3 (pSmad2/3). Anabolic effects of EGFR activation in articular cartilage were followed by catabolic events, including matrix degradation, as determined by accumulation of aggrecan cleavage fragments, and onset of hypertrophy as determined by type × collagen expression. By 16 weeks of age, the articular cartilage of Mig-6-cko knees was no longer thickened and was degenerating.

Conclusions

These results demonstrate unexpected anabolic effects of EGFR signal activation in articular cartilage, and suggest the hypothesis that these effects may promote the expansion and/or activity of an endogenous EGFR-responsive cell population within the articular cartilage.

Self-reported musculoskeletal pain predicts long-term increase in general health care use: a population-based cohort study with 20-year follow-up

AIMS

Musculoskeletal pain and disability is a modern epidemic and a major reason for seeking health care. The aim of this study is to determine absolute and relative rates of care seeking over 20 years for adults reporting musculoskeletal complaints.

METHODS

Interview data on musculoskeletal pain reported during the past two weeks from the Danish National Cohort Study were merged with data from the Danish National Health Insurance Registry and the National Patient Registry containing information on consultations in the Danish primary and secondary care sector. Absolute and relative rates for all seeking of care with general practitioners, physiotherapists, chiropractors, outpatient hospital contacts and hospital admissions are reported for persons reporting no musculoskeletal pain and for persons reporting pain in the neck, shoulder, wrist/hands, mid back, low back, hips, knees and ankles/feet.

RESULTS

Regardless of site, persons experiencing a musculoskeletal complaint had a statistically increased risk of consulting a general practitioner when compared with persons reporting no musculoskeletal complaint. For physiotherapists and chiropractors, only persons complaining of neck pain and back pain had an increased risk of seeking care. Regardless of pain site, except for shoulder pain, persons reporting musculoskeletal pain had a statistically significant increased risk of outpatient hospital consultations and hospital admissions. Few differences were found between pain sites in relation to any of the outcomes.

CONCLUSIONS

Self-report of musculoskeletal pain reported within the past two weeks predicts a statistically significant long-term increase in general use of health care services in both the primary and the secondary health care sector.

Selecting those to refer for joint replacement: who will likely benefit and who will not?

Osteoarthritis (OA) is one of the 10 most disabling diseases in developed countries and worldwide estimates are that 10% of men and 18% of women aged over 60 years have symptomatic OA, including moderate and severe forms. Total joint replacement (TJR) is considered the most effective treatment for end-stage OA in those who have exhausted available conservative interventions. The demand for TJR is continually rising due to the ageing population; in the United States, more than 1 million TJRs were performed in 2010 and the number of procedures is projected to exceed 4 million in the US by 2030. It has been estimated that of all hip and knee replacements performed, approximately one quarter of the patients may be considered inappropriate candidates. Predicting who will benefit from TJR and who will not would seem critical in terms of containing the current and projected expenditure as well as improving satisfaction in TJR recipients. Few formal predictive tools are available to aid referring clinicians to determine those likely to be good or poor responders to surgery and current available tools tend to focus on disease severity alone with little consideration of risk factors that may predict a poor outcome or impede an effective response to surgery. This review examines the tools available to assist with assessing appropriateness for TJR; investigates the modifiable risk factors associated with poor outcome; and identifies areas for future research in selecting those appropriate for joint replacement.

The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study

OBJECTIVE

To estimate the global burden of hip and knee osteoarthritis (OA) as part of the Global Burden of Disease 2010 study and to explore how the burden of hip and knee OA compares with other conditions.

METHODS

Systematic reviews were conducted to source age-specific and sex-specific epidemiological data for hip and knee OA prevalence, incidence and mortality risk. The prevalence and incidence of symptomatic, radiographic and self-reported hip or knee OA were included. Three levels of severity were defined to derive disability weights (DWs) and severity distribution (proportion with mild, moderate and severe OA). The prevalence by country and region was multiplied by the severity distribution and the appropriate disability weight to calculate years of life lived with disability (YLDs). As there are no deaths directly attributed to OA, YLDs equate disability-adjusted life years (DALYs).

RESULTS

Globally, of the 291 conditions, hip and knee OA was ranked as the 11th highest contributor to global disability and 38th highest in DALYs. The global age-standardised prevalence of knee OA was 3.8% (95% uncertainty interval (UI) 3.6% to 4.1%) and hip OA was 0.85% (95% UI 0.74% to 1.02%), with no discernible change from 1990 to 2010. Prevalence was higher in females than males. YLDs for hip and knee OA increased from 10.5 million in 1990 (0.42% of total DALYs) to 17.1 million in 2010 (0.69% of total DALYs).

CONCLUSIONS

Hip and knee OA is one of the leading causes of global disability. Methodological issues within this study make it highly likely that the real burden of OA has been underestimated. With the aging and increasing obesity of the world's population, health professions need to prepare for a large increase in the demand for health services to treat hip and knee OA.

The global burden of musculoskeletal conditions for 2010: an overview of methods

The objective of this paper is to provide an overview of methods used for estimating the burden from musculoskeletal (MSK) conditions in the Global Burden of Diseases 2010 study. It should be read in conjunction with the disease-specific MSK papers published in Annals of Rheumatic Diseases. Burden estimates (disability-adjusted life years (DALYs)) were made for five specific MSK conditions: hip and/or knee osteoarthritis (OA), low back pain (LBP), rheumatoid arthritis (RA), gout and neck pain, and an 'other MSK conditions' category. For each condition, the main disabling sequelae were identified and disability weights (DW) were derived based on short lay descriptions. Mortality (years of life lost (YLLs)) was estimated for RA and the rest category of 'other MSK', which includes a wide range of conditions such as systemic lupus erythematosus, other autoimmune diseases and osteomyelitis. A series of systematic reviews were conducted to determine the prevalence, incidence, remission, duration and mortality risk of each condition. A Bayesian meta-regression method was used to pool available data and to predict prevalence values for regions with no or scarce data. The DWs were applied to prevalence values for 1990, 2005 and 2010 to derive years lived with disability. These were added to YLLs to quantify overall burden (DALYs) for each condition. To estimate the burden of MSK disease arising from risk factors, population attributable fractions were determined for bone mineral density as a risk factor for fractures, the occupational risk of LBP and elevated body mass index as a risk factor for LBP and OA. Burden of Disease studies provide pivotal guidance for governments when determining health priority areas and allocating resources. Rigorous methods were used to derive the increasing global burden of MSK conditions.

Burden of reduced work productivity among people with chronic knee pain: a systematic review

OBJECTIVE

The aims of this systematic review were to determine the prevalence of reduced work productivity among people with chronic knee pain as well as specifically categorise determinants of work productivity losses into individual, disease and work-related factors, conduct an evaluation of study methodological quality and present a best-evidence synthesis.

METHODS

We searched the literature using combinations of key words such as knee pain, knee osteoarthritis, absenteeism (days taken off work) and presenteeism (reduced productivity while at work) for observational studies published in English. Methodological quality appraisal and a best-evidence synthesis were used to pool the study findings.

RESULTS

The studies were conducted exclusively in high income countries of North America, Western Europe and Hong Kong. 17 studies were included in the review, 10 measuring absenteeism and six measuring presenteeism. Of the 10 studies reporting absenteeism, seven found a 12-month absenteeism prevalence ranging from 5% to 22%. Only two studies evaluated presenteeism prevalence and reported a range from 66% to 71%. Using best-evidence synthesis: three high quality cohort studies and three cross-sectional studies provided strong evidence that knee pain or knee osteoarthritis was associated with absenteeism; two high quality cross-sectional studies and one cohort study provided limited evidence for an association with presenteeism; one cross-sectional study provided limited evidence for an association among age, high job demands and low coworker support and absenteeism among nurses with knee pain. No studies examined individual or work-related factors associated with presenteeism.

CONCLUSIONS

A number of high quality studies consistently demonstrated that chronic knee pain or knee osteoarthritis is associated with absenteeism. However, data are lacking regarding presenteeism and individual or work-related risk factors for reduced work productivity among older workers with chronic knee pain.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO registry number: CRD42013004137.

Protective effect of resveratrol against IL-1β-induced inflammatory response on human osteoarthritic chondrocytes partly via the TLR4/MyD88/NF-κB signaling pathway: an "in vitro study"

Resveratrol is a natural polyphenolic compound that prevents inflammation in chondrocytes and animal models of osteoarthritis (OA) via yet to be defined mechanisms. The purpose of this study was to determine whether the protective effect of resveratrol on IL-1β-induced human articular chondrocytes was associated with the TLR4/MyD88/NF-κB signaling pathway by incubating human articular chondrocytes (harvested from osteoarthritis patients) with IL-1β before treatment with resveratrol. Cell viability was evaluated using the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assay and TNFα levels in culture supernatants were measured by ELISA(Enzymelinked immunosorbent assay). The levels of TLR4 and its downstream signaling targets (MyD88 and TRAF6) and IL-1β were assessed by measuring the levels of mRNA and protein expression by real-time RT-PCR and western blot analysis, respectively, in addition to assessing NF-κB activation. In addition, TLR4 siRNA was used to block TLR4 expression in chondrocytes further demonstrating that resveratrol prevented IL-1β-mediated inflammation by TLR4 inhibition. We found that resveratrol prevented IL-1β-induced reduction in cell viability. Stimulation of chondrocytes with IL-1β caused a significant up-regulation of TLR4 and its downstream targets MyD88 and TRAF6 resulting in NF-κB activation associated with the synthesis of IL-1β and TNFα. These IL-1β-induced inflammatory responses were all effectively reversed by resveratrol. Furthermore, activation of NF-κB in chondrocytes treated with TLR4 siRNA was significantly attenuated, but not abolished, and exposure to resveratrol further reduced NF-κB translocation. These data suggested that resveratrol prevented IL-1β-induced inflammation in human articular chondrocytes at least in part by inhibiting the TLR4/MyD88/NF-κB signaling pathway suggesting that resveratrol has the potential to be used as a nutritional supplement to counteract OA symptoms.

Exercise for osteoarthritis of the hip

BACKGROUND

Current international treatment guidelines recommending therapeutic exercise for people with symptomatic hip osteoarthritis (OA) report are based on limited evidence.

OBJECTIVES

To determine whether land-based therapeutic exercise is beneficial for people with hip OA in terms of reduced joint pain and improved physical function and quality of life.

SEARCH METHODS

We searched five databases from inception up to February 2013.

SELECTION CRITERIA

All randomised controlled trials (RCTs) recruiting people with hip OA and comparing some form of land-based therapeutic exercise (as opposed to exercises conducted in water) with a non-exercise group.

DATA COLLECTION AND ANALYSIS

Four review authors independently selected studies for inclusion. We resolved disagreements through consensus. Two review authors independently extracted data, assessed risk of bias and the quality of the body of evidence for each outcome using the GRADE approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) and dichotomous outcomes (proportion of study withdrawals).

MAIN RESULTS

We considered that seven of the 10 included RCTs had a low risk of bias. However, the results may be vulnerable to performance and detection bias as none of the RCTs were able to blind participants to treatment allocation and, while most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self reported. One of the 10 RCTs was only reported as a conference abstract and did not provide sufficient data for the evaluation of bias risk.High-quality evidence from nine trials (549 participants) indicated that exercise reduced pain (standardised mean difference (SMD) -0.38, 95% confidence interval (CI) -0.55 to -0.20) and improved physical function (SMD -0.38, 95% CI -0.54 to -0.05) immediately after treatment. Pain and physical function were estimated to be 29 points on a 0- to 100-point scale (0 was no pain or loss of physical function) in the control group; exercise reduced pain by an equivalent of 8 points (95% CI 4 to 11 points; number needed to treat for an additional beneficial outcome (NNTB) 6) and improved physical function by an equivalent of 7 points (95% CI 1 to 12 points; NNTB 6). Only three small studies (183 participants) evaluated quality of life, with overall low quality evidence, with no benefit of exercise demonstrated (SMD -0.07, 95% CI -0.23 to 0.36). Quality of life was estimated to be 50 points on a norm-based mean (standard deviation (SD)) score of 50 (10) in the general population in the control group; exercise improved quality of life by 0 points. Moderate-quality evidence from seven trials (715 participants) indicated an increased likelihood of withdrawal from the exercise allocation (event rate 6%) compared with the control group (event rate 3%), but this difference was not significant (risk difference 1%; 95% CI -1% to 4%). Of the five studies reporting adverse events, each study reported only one or two events and all were related to increased pain attributed to the exercise programme.The reduction in pain was sustained at least three to six months after ceasing monitored treatment (five RCTs, 391 participants): pain (SMD -0.38, 95% CI -0.58 to -0.18). Pain was estimated to be 29 points on a 0- to 100-point scale (0 was no pain) in the control group, the improvement in pain translated to a sustained reduction in pain intensity of 8 points (95% CI 4 to 12 points) compared with the control group (0 to 100 scale). The improvement in physical function was also sustained (five RCTs, 367 participants): physical function (SMD -0.37, 95% CI -0.57 to -0.16). Physical function was estimated to be 24 points on a 0- to 100-point scale (0 was no loss of physical function) in the control group, the improvement translated to a mean of 7 points (95% CI 4 to 13) compared with the control group.Only five of the 10 RCTs exclusively recruited people with symptomatic hip OA (419 participants). There was no significant difference in pain or physical function outcomes compared with five studies recruiting participants with hip or knee OA (130 participants).

AUTHORS' CONCLUSIONS

Pooling the results of these 10 RCTs demonstrated that land-based therapeutic exercise programmes can reduce pain and improve physical function among people with symptomatic hip OA.

Osteoarthritis incidence and trends in administrative health records from British Columbia, Canada

OBJECTIVE

To calculate the incidence rates of osteoarthritis (OA) and to describe the changes in incidence using 18 years of administrative health records.

METHODS

We analyzed visits to health professionals and hospital admission records in a random sample (n = 640,000) from British Columbia, Canada, from 1991/1992 through 2008/2009. OA was defined in 2 ways: (1) at least 1 physician diagnosis or 1 hospital admission; and (2) at least 2 physician diagnoses in 2 years or 1 hospital admission. Crude and age-standardized rates were calculated, and the annual relative changes were estimated from the Poisson regression models.

RESULTS

In 2008/2009, the overall crude incidence rate (95% CI) of OA using definition 1 was 14.6 (14.0-14.8); [12.5 (12.0-13.0) among men and 16.3 (15.8-16.8) among women] per 1000 person-years. The rates were lower by about 44% under definition 2. For the period 2000/2001-2008/2009, crude incidence rates based on definition 1 varied from 11.8 to 14.2 per 1000 person-years for men, and from 15.7 to 18.5 for women. Annually, on average, crude rates rose by about 2.5-3.3% for both men and women. The age-adjusted rates increased by 0.6-0.8% among men and showed no trend among women.

CONCLUSION

Our study generated updated incidence rates of administrative OA for the Province of British Columbia. Physician-diagnosed overall incidence rates of OA varied with the case definitions used; however, trends were similar in both case definitions. Age-adjusted rates among men increased slightly during the period 2000/2001-2008/2009. These findings have implications for projecting future prevalence and costs of OA.

Genetic, clinical and radiographic signs in knee osteoarthritis susceptibility

INTRODUCTION

Osteoarthritis (OA) is considered to be a multifactorial and polygenic disease and diagnosis is mainly clinical and radiological. Correlation between radiographic data and clinical status has been reported. However, very few studies, especially in Caucasian people, describe the association between the Kellgren and Lawrence OA grading scale (KL) and genetic alterations to better understand OA etiopathogenesis and susceptibility. In order to update the knee OA grading, in this study we assessed the associations between KL grade, clinical features such as American Knee Society Score (AKSS), age, and polymorphisms in the principal osteoarthritis susceptibility (OS) genes in Sicilian individuals.

METHODS

In 66 Sicilian individuals affected by primary knee OA, the clinical and radiographic evaluation was performed using 2 sub-scores of AKSS (knee score (KS) and function score (FS)) and KL. The patients were also classified according to age. Online Mendelian Inheritance in Man (OMIM) and Database of Single Nucleotide Polymorphisms (dbSNP) Short Genetic Variations databases were used to select gene regions containing the following polymorphisms to analyze: FRZB rs288326 and rs7775, MATN3 rs77245812, ASPN D14 repeats, PTHR2 rs76758470, GDF5 rs143383 and DVWA rs11718863. Patient genotypes were obtained using Sanger DNA sequencing analysis.

RESULTS

In our cohort of patients a statistical association between the variables analyzed was reported in all associations tested (KL versus KS, FS and age). We observed that a mild to severe OA radiographic grade is related to severe clinical conditions and loss of articular function and that the severity of symptoms increases with age. Concerning the genotyping analysis, our results revealed a significant statistical association between KL grading and GDF5 rs143383 and DVWA rs11718863 genetic alterations. The latter was also associated with a more severe radiographic grade, displaying its predictive role as OA marker progression. Statistically significant association between clinical, radiographic and genetic signs observed, suggests extending the actual grading of knee OA based mainly on X-ray features.

CONCLUSIONS

This work represents a multidisciplinary and translational medicine approach to study OA where clinical, radiological, and OS5 and OS6 SNPs evaluation could contribute to better define grading and progression of OA and to the development of new therapies.

Pelvis: normal variants and benign findings in FDG-PET/CT imaging

With the widespread use of whole-body fluorodeoxyglucose (FDG)-PET/computed tomography as a diagnostic tool in patients with cancer, incidental findings are of increasing importance. This is particularly true within the pelvis, where several benign findings might present with increased FDG uptake. In addition, physiologic excretion of radiotracer by way of the urinary tract can complicate image analysis. This article reviews potential incidental benign findings in the pelvis that one should be aware of when interpreting FDG-PET/computed tomography scans.

Illness experiences in middle-aged adults with early-stage knee osteoarthritis: findings from a qualitative study

AIM

To understand the illness experiences of middle-aged adults with early knee osteoarthritis.

BACKGROUND

Knee osteoarthritis is one of the most common causes of lower limb disability in middle-aged adults and older people. Nurses lack understanding of the illness experiences of middle-aged patients who were confirmed to have early knee osteoarthritis and of how they manage the disease in Taiwan.

DESIGN

A qualitative descriptive design was applied.

METHODS

Participants with knee osteoarthritis, aged 40-55 years, were recruited by purposive sampling (n = 17). The data were collected through semi-structured interviews from July-December 2010. All interview transcripts were analysed using qualitative inductive content analysis to identify key themes.

FINDINGS

Illness experiences of the seventeen participants were classified into three major themes: (i) unfamiliarity with osteoarthritis; (ii) effects on daily life; and (iii) protection and alleviation. The three main themes occurred repeatedly and affected the life experiences of the patients.

CONCLUSIONS

This study indicates that patients with osteoarthritis have insufficient knowledge related to disease process and they do not know how to cope effectively. They need healthcare providers to supply them with adequate osteoarthritis disease information. Nurses should also develop interventions in their practices and guide patients to use suitable techniques to improve the functional status of their knee joint(s).

Risk factors associated with reduced work productivity among people with chronic knee pain

OBJECTIVE

To determine the burden and risk factors associated with reduced work productivity among people with chronic knee pain.

METHOD

A longitudinal study, nested within a randomised controlled trial (RCT) evaluating the long-term effects of dietary supplements, was conducted among people with chronic knee pain in paid employment (n = 360). Participants recorded days off work (absenteeism) and reduced productivity while at work (presenteeism) for seven days every two months over a 12-month period in a study specific diary. Examined risk factors included knee pain severity, occupational group, radiographic disease severity, physical activity, body mass index (BMI), health-related quality of life (SF-12) and co-morbidity.

RESULTS

Over the 12-month follow up period, 50 (14%) participants reported one or more days off work due to knee problems, while 283 (79%) reported reduced productivity while at work (presenteeism <100%). In multivariate analysis, the only significant risk factor for absenteeism was having an SF-12 Mental Component Summary (MCS) score <40 (OR: 2.49 [95% CI: 1.03-5.98]). Significant risk factors for presenteeism included; reporting an; SF-12 Physical Component Summary (PCS) score <50 (OR: 1.99 [95% CI: 1.05-3.76]), semi-manual labour (OR: 2.23 [1.09-4.59]) or manual labour (OR: 6.40 [1.44-28.35]) or a high maximum knee pain (4-6 out of 10) (OR: 2.29 [1.17-4.46]).

CONCLUSIONS

This longitudinal study found that among this cohort of people with chronic knee pain, the burden of reduced work productivity is mainly attributable to presenteeism rather absenteeism. This study demonstrated that effective strategies to increase work productivity should focus on reducing knee pain or physical disability especially among workers in manual or semi-manual labour.

Tramadol/Paracetamol fixed-dose combination for chronic pain management in family practice: a clinical review

The family practitioner plays an important role in the prevention, diagnosis, and early management of chronic pain. He/she is generally the first to be consulted, the one most familiar with the patients and their medical history, and is likely the first to be alerted in case of inadequate pain control or safety and tolerability issues. The family practitioner should therefore be at the center of the multidisciplinary team involved in a patient's pain management. The most frequent indications associated with chronic pain in family practice are of musculoskeletal origin, and the pain is often multimechanistic. Fixed-dose combination analgesics combine compounds with different mechanisms of action; their broader analgesic spectrum and potentially synergistic analgesic efficacy and improved benefit/risk ratio might thus be useful. A pain specialist meeting held in November 2010 agreed that the fixed-dose combination tramadol/paracetamol might be a useful pharmacological option for chronic pain management in family practice. The combination is effective in a variety of pain conditions with generally good tolerability. Particularly in elderly patients, it might be considered as an alternative to conventional analgesics such as NSAIDs, which should be used rarely with caution in this population.

Responsiveness of quantitative cartilage measures over one year in knee osteoarthritis: comparison of radiography and MRI assessments

PURPOSE

To directly compare the responsiveness of quantitative imaging measures of disease progression in knee osteoarthritis (OA). In the medial compartment of the knee comparison was made between: 1) radiographic joint space narrowing (JSN); 2) global quantitative magnetic resonance imaging (qMRI) of cartilage volume; 3) regional qMRI of cartilage thickness; and 4) regional analysis using an ordered value (OV) methodology.

MATERIALS AND METHODS

3T MRI and weight-bearing radiography of the knees were performed at baseline and 1-year timepoints in 23 subjects (mean age 63 years) with symptomatic knee OA. Standardized response means (SRM) were calculated for each measure. Statistical analysis to determine significance of change between timepoints was performed with a two-tailed Student's t-test (JSN, global, regional analysis) and nonparametric Mann-Whitney test (ordered values).

RESULTS

At 1 year, global cartilage volume losses of 2.3% (SRM -0.44) in the medial tibia and 6.9% in the medial femur (SRM -0.74) were recorded. SRM for JSN was -0.46. Regional analysis revealed largest reductions in cartilage thickness in the external (SRM -0.84) weight-bearing subregion of the medial femur and in the posterior subregion of the medial tibia (SRM -0.79). OV analysis in the medial compartment revealed areas of cartilage thinning (four ranked OV) and cartilage thickening (two ranked OV).

CONCLUSION

The MRI OV approach proved to be a superior analysis tool for detecting changes in cartilage morphology over a 1-year period. Radiographically defined JSN was found to be the least responsive measurement method of knee OA disease progression.

A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis

OBJECTIVE

Most of the evidence regarding complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is based on studies of patients with osteoarthritis (OA), with little being known about outcomes in patients with rheumatoid arthritis (RA). The objective of the present study was to review the current evidence regarding rates of THA/TKA complications in RA versus OA.

METHODS

Data sources used were Medline, EMBase, Cinahl, Web of Science, and reference lists of articles. We included reports published between 1990 and 2011 that described studies of primary total joint arthroplasty of the hip or knee and contained information on outcomes in ≥200 RA and OA joints. Outcomes of interest included revision, hip dislocation, infection, 90-day mortality, and venous thromboembolic events. Two reviewers independently assessed each study for quality and extracted data. Where appropriate, meta-analysis was performed; if this was not possible, the level of evidence was assessed qualitatively.

RESULTS

Forty studies were included in this review. The results indicated that patients with RA are at increased risk of dislocation following THA (adjusted odds ratio 2.16 [95% confidence interval 1.52-3.07]). There was fair evidence to support the notion that risk of infection and risk of early revision following TKA are increased in RA versus OA. There was no evidence of any differences in rates of revision at later time points, 90-day mortality, or rates of venous thromboembolic events following THA or TKA in patients with RA versus OA. RA was explicitly defined in only 3 studies (7.5%), and only 11 studies (27.5%) included adjustment for covariates (e.g., age, sex, and comorbidity).

CONCLUSION

The findings of this literature review and meta-analysis indicate that, compared to patients with OA, patients with RA are at higher risk of dislocation following THA and higher risk of infection following TKA.

The need to address the burden of musculoskeletal conditions

Musculoskeletal conditions are common in men and women of all ages across all socio-demographic strata of society. They are the most common cause of severe long-term pain and physical disability and affect hundreds of millions of people around the world. They impact on all aspects of life through pain and by limiting activities of daily living typically by affecting dexterity and mobility. They affect one in four adults across Europe [1]. Musculoskeletal conditions have an enormous economic impact on society through both direct health expenditure related to treating the sequelae of the conditions and indirectly through loss of productivity. The prevalence of many of these conditions increases markedly with age, and many are affected by lifestyle factors, such as obesity and lack of physical activity. The burden of these conditions is therefore predicted to increase, in particular in developing countries. The impact on individuals and society of the major musculoskeletal conditions is reviewed and effective prevention, treatment and rehabilitation considered. The need to recognise musculoskeletal conditions as a global public health priority is discussed.

Associations between gait and clinical parameters in patients with severe knee osteoarthritis: a multiple correspondence analysis

BACKGROUND

Given the complexity of the gait of patients with knee osteoarthritis, a multiple correspondence analysis may be helpful to optimise the extraction of relevant gait and clinical information. Therefore, the aims of this study are to identify the main associations with clinical and gait biomechanical parameters and to evaluate whether there are more specific knee osteoarthritis groups with different gait profiles.

METHODS

Ninety patients with severe knee osteoarthritis and twenty-six healthy individuals participated in this study. Pain and function were assessed with the WOMAC Index; knee joint deformity was assessed by the hip-knee-ankle angle on full-limb radiography; and full body gait analysis was performed with a motion analysis system and force plates.

FINDINGS

Using multiple correspondence analysis, two categories of gait parameters that best explain the gait variance of patients with knee osteoarthritis were highlighted. The forward displacement category is composed of the parameters speed, stride length, hip flexion and knee flexion. The frontal category is composed of the parameters thorax obliquity and knee adductor moments. Moreover, based on these parameters, four distinct gait profiles were identified: two gait profiles were associated with knee varus deformities, increased thorax obliquity and different forward displacements, while two gait profiles were associated with valgus deformities and different forward displacements.

INTERPRETATION

These gait parameters can be used to simplify the characterisation of the gait of the knee osteoarthritis population. Patients in varus profiles increase thorax obliquity on the stance limb and may reduce forward displacement. Patients in valgus profiles, however, only reduce forward displacement.

Prevalence and status quo of osteoarthritis in Austria. Analysis of epidemiological and social determinants of health in a representative cross-sectional survey

Osteoarthritis has a major impact on mobility and functioning leading to impairment in activities of daily living and quality of life. The aim of our analysis was to reveal the prevalence of self-reported, doctor-diagnosed osteoarthritis with a representative population based survey, including data for 15,474 subjects. Prevalence of osteoarthritis was 11.9 % in men and 18.6 % in women. A total of 73.4 % of men and 74.9 % of women with osteoarthritis reported to have had severe pain in the last 12 months; 60.3 % of male and 67.0 % of female patients reported that the disease was treated within the last 12 months. Age, socio-economic parameters, overweight and obesity, as well as living in a rural area were significant predictors of osteoarthritis. Even if the onset of osteoarthritis may not be averted, public health and prevention programmes may improve quality of life significantly if they are adequately tuned to sex, age and personal capabilities.

The effect of bradykinin B2 receptor polymorphisms on the susceptibility and severity of osteoarthritis in a Chinese cohort

Background. The B2-bradykinin receptor (BDKRB2) has been reported to associate with onset and development of Osteoarthritis (OA); however, the role of BDKRB2 genetic polymorphisms in OA remains unknown. Method. A total of 245 patients with primary knee OA and 264 healthy volunteer were recruited. BDKRB2 gene polymorphisms, −58T/C and +9/−9 bp polymorphisms, were genotyped. Results. The genotype distributions and allele frequencies of +9/−9 bp polymorphisms significantly differed between OA and control subjects. Logistic regression analysis showed carriers with −9/−9 genotype had a significantly increased risk for knee OA compared with the +9/+9 genotype (adjusted OR = 2.356, P < 0.001). The OR for −9 allele carriage was significantly higher than +9 allele carriage (adjusted OR = 1.52, P < 0.001). The +9/−9 bp polymorphisms also determined the OA radiographic severity. The presence of −9 bp was associated with severer OA. The −58T/C polymorphisms did not affect OA risk and severity. Conclusion. The +9/−9 bp polymorphisms of BDKRB2 gene may be used as a genetic marker for the susceptibility and severity of OA.

Disease impact of hand OA compared with hip, knee and generalized disease in specialist rheumatology health care

OBJECTIVE

To describe and compare disease impact in patients with hand OA with those with hip, knee and generalized disease.

METHODS

Patients with OA referred to a specialized rheumatology clinic (408 patients, 86% women) were included in a cross-sectional study. They were examined by a rheumatologist and classified into primary hand, hip, knee and/or generalized (more than two joint localizations) OA. Patient-reported disease impact was collected on numeric rating scales (pain, fatigue), Hopkins Symptom Checklist-25 (emotional distress), Western Ontario and McMaster and Australian/Canadian Hand OA indexes (disease-specific functioning), Short Form 36 (generic health-related quality of life) and a comorbidity checklist.

RESULTS

Considerable disease impact was detected across all localizations: patients scored >5 on pain (range 0-10), had on average two comorbidities and scored >1.5 on emotional distress (Hopkins Symptom Checklist-25, range 1-4). Patients with hand OA scored poor on disease-specific functioning of the lower extremities, and patients with lower extremity OA also scored poor on disease-specific hand functioning. Patients with hand OA scored better on pain (P = 0.001, one-way analyses of variance) and the Short Form 36 Health Survey physical component (P < 0.001), whereas no major differences were observed for the mental component (P = 0.07).

CONCLUSION

OA patients referred to specialist care reported considerable levels of disease impact across localizations. Regardless of functional impairments related to the primary OA localization, patients generally reported high levels of impaired disease-specific functioning at other sites. In the management of OA clinicians should also consider functioning in joint sites other than the primary OA localization. Trial registration. Current controlled trials, www.controlled-trials.com, ISRCTN25778426.

Dietary polyphenols and mechanisms of osteoarthritis

Osteoarthritis is a condition caused in part by injury, loss of cartilage structure and function, and an imbalance in inflammatory and anti-inflammatory pathways. It primarily affects the articular cartilage and subchondral bone of synovial joints and results in joint failure, leading to pain upon weight bearing including walking and standing. There is no cure for osteoarthritis, as it is very difficult to restore the cartilage once it is destroyed. The goals of treatment are to relieve pain, maintain or improve joint mobility, increase the strength of the joints and minimize the disabling effects of the disease. Recent studies have shown an association between dietary polyphenols and the prevention of osteoarthritis-related musculoskeletal inflammation. This review discusses the effects of commonly consumed polyphenols, including curcumin, epigallocatechin gallate and green tea extract, resveratrol, nobiletin and citrus fruits, pomegranate, as well as genistein and soy protein, on osteoarthritis with an emphasis on molecular antiosteoarthritic mechanisms.

Pooled safety analysis of diclofenac sodium topical solution 1.5% (w/w) in the treatment of osteoarthritis in patients aged 75 years or older

Background

This study aimed to determine the safety of diclofenac sodium topical solution 1.5% (w/w) in 45.5% dimethyl sulfoxide (TDiclo) for the treatment of knee or hand osteoarthritis in persons aged 75 years or older.

Methods

A pooled analysis of safety data from seven multicenter, randomized, blinded, Phase III clinical trials (4–12 weeks’ duration) of TDiclo was conducted. The analysis focused on a subset of patients (n = 280) aged 75 years or older with a primary diagnosis of osteoarthritis of the knee (six trials) or hand (one trial). Patients received one of three topical treatments: TDiclo (n = 138); placebo (2.33% or 4.55% dimethyl sulfoxide, n = 39); or control (45.5% dimethyl sulfoxide, n = 103). Treatment groups were compared using Chi-square analysis, Fisher’s Exact test, or analysis of variance.

Results

The most common adverse events involved the skin or subcutaneous tissue, primarily at the application site. The incidence of dry skin was higher in the TDiclo (36.2%; P < 0.0001) and dimethyl sulfoxide control (18.4%; P = 0.0142) groups than in the placebo group (2.6%); the incidence of other skin or subcutaneous tissue adverse events was similar between the groups. Relatively few patients (<18%) experienced gastrointestinal adverse events, and group differences were not detected. In the TDiclo group, constipation (3.6%), diarrhea (3.6%), and nausea (3.6%) were the most common gastrointestinal adverse events. Cardiovascular and renal/ urinary adverse events were rare, and group differences were not detected. There was one case (0.7%) each of hypertension, spider veins, and vasodilation in the TDiclo group. Changes from baseline to the final visit in blood pressure and hepatic/renal enzyme levels were also similar between the groups.

Conclusion

TDiclo appears to be well tolerated for the treatment of osteoarthritis in persons aged 75 years or older.

Total joint replacement in the past does not relate to a deteriorated functional level and health status in the oldest old

Total hip or knee replacement is effective in improving joint function, quality of life, and pain reduction. The oldest old population with joint replacements (TJR) is underrepresented in current literature. We compared health-related and functional characteristics of oldest olds with and without TJR. Participants (aged 85 years) were divided into a group with and without TJR. Comorbidity, physical and joint functioning, daily living activities, quality of life, and mortality were recorded. Thirty-eight of 599 participants (6.3%) received a TJR in the past. Participants with a TJR had slightly less comorbidities, walked slower (P = 0.006), and complained more about hip-pain (P = 0.007). Mortality of those with a TJR was lower during the first 8-year followup (P = 0.04). All other characteristics were comparable between groups. We conclude that subjects with a TJR performed equally well, besides showing a lower gait speed and a higher frequency of hip-pain. Except for the lower gaitspeed, having a TJR is not associated with poorer health.