Oral or transdermal opioids for osteoarthritis of the knee or hip

Therapeutic potential of SOX family transcription factors in osteoarthritis

BACKGROUND

As the worldwide population ages, osteoarthritis has significantly increased. This musculoskeletal condition has become a pressing global health issue and thus, prevention and treatment of osteoarthritis have become the primary focus of domestic and international research. Scholarly investigations of the molecular mechanisms that are related to the occurrence and development of osteoarthritis have shed light on the pathological causes of this condition to a certain extent, providing a foundation for its prevention and treatment. However, further research is necessary to fully understand the critical role of the transcription factor SOX9 in chondrocyte differentiation and the development of osteoarthritis. As a result, there has been widespread interest in SOX transcription factors. While SOX9 has been utilized as a biomarker to indicate the occurrence and prognosis of osteoarthritis, investigations into other members of the SOX family and the development of targeted treatments around SOX9 are still required.

PURPOSE

This article considers the impact of the SOX protein on the development and inhibition of osteoarthritis and highlights the need for therapeutic approaches targeting SOX9, as supported by existing research.

RESULTS

SOX9 can contribute to the process of osteoarthritis through acetylation and ubiquitination modifications. The regulation of the WNT signalling pathway, Nrf2/ARE signalling pathway, NF-κB signalling pathway and SOX9 is implicated in the emergence of osteoarthritis. Non-coding RNA may play a role in the onset and progression of osteoarthritis by modulating various SOX family members, including SOX2, SOX4, SOX5, SOX6, SOX8, SOX9 and SOX11.

CONCLUSION

SOX9 has the capability of mitigating the onset and progression of osteoarthritis through means such as medication therapy, stem cell therapy, recombinant adeno-associated virus (rAAV) vector therapy, physical therapy and other approaches.

[Conservative treatment of patellofemoral cartilage lesions and patellofemoral osteoarthritis]

BACKGROUND

The causes of patellofemoral cartilage lesions or joint degeneration are multifactorial. Small, traumatic cartilage lesions can be treated without relevant cartilage regenerative therapies. Surgical treatment is recommended for larger lesions (> 1 cm2).

CONSERVATIVE THERAPY

Conservative therapy is the mainstay of treatment for incipient or advanced patellofemoral osteoarthritis. Consequently, a thorough examination is essential to identify the underlying factors and to establish precise and efficient treatment planning. An individualized, stage-appropriate, and multimodal treatment strategy, supported by comprehensive patient education, is critical for therapeutic success. In the presence of functional or muscular imbalances, physiotherapy and exercise therapy, potentially supplemented by EMG biofeedback training, play a central role. When combined with weight reduction, patellar taping, cryotherapy, or extracorporeal shock wave therapy, these measures form the foundation of any conservative therapeutic approach. In the acute phase, nonsteroidal anti-inflammatory drugs or opioids may be employed for pain relief. If non-injection-based interventions remain ineffective, an injection therapy option may be considered.

Preoperative chronic opiate use associated with a worse joint-specific function and quality of life before and after total hip and knee arthroplasty

Aims

The aim of this study was to assess whether chronic pre-arthroplasty use of strong opiates impacted the pre- and postoperative joint-specific function, quality of life (QoL), pain scores, and satisfaction in those undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods

This prospective study assessed 1,487 patients (THA n = 729; TKA n = 758). Preoperative opiate use of more than a month was used to define the opioid group. Patient demographics, comorbidities, Oxford Hip Score (OHS), Oxford Knee Score (OKS), and EuroQol five-dimension questionnaire (EQ-5D) scores were collected preoperatively and at six months postoperatively. Patient satisfaction with their joint was assessed at six months.

Results

The opioid groups consisted of 95 patients in both the THA (13.0%) and TKA (12.5%) cohorts. Pre- and postoperative OHS, OKS, and EQ-5D were clinically (greater than the minimal clinically important difference) and statistically (p < 0.001) significantly worse for the opioid groups undergoing THA and TKA. The opioid group was independently associated with a significantly worse improvement in OHS (-3.0, 95% CI -4.8 to -1.2; p = 0.001) and EQ-5D (-0.089, 95% CI -0.132 to -0.041; p < 0.001) for those undergoing THA, but no significant (OKS, p = 0.650 and EQ-5D, p = 0.485) association was demonstrated in the TKA cohort. There was no difference in satisfaction with their arthroplasty between opioid and opiate-naive groups undergoing THA (p = 0.133) or TKA (p = 0.797).

Conclusion

Preoperative opiate use was associated with clinically significantly worse pre- and postoperative joint-specific function and QoL. Those undergoing THA had a clinically worse improvement in their joint-specific function, but this was not observed in those undergoing TKA. However, patients were equally satisfied with outcomes.

Opioid Use Prior to Adult Spine Deformity Correction Surgery is Associated With Worse Pre- and Postoperative Back Pain and Prolonged Opioid Demands

Study DesignProspective multicenter database post-hoc analysis.ObjectivesOpioids are frequently prescribed for painful spinal conditions to provide pain relief and to allow for functional improvement, both before and after spine surgery. Amidst a current opioid epidemic, it is important for providers to understand the impact of opioid use and its relationship with patient-reported outcomes. The purpose of this study was to evaluate pre-/postoperative opioid consumption surrounding ASD and assess patient-reported pain outcomes in older patients undergoing surgery for spinal deformity.MethodsPatients ≥60 years of age from 12 international centers undergoing spinal fusion of at least 5 levels and a minimum 2-year follow-up were included. Patient-reported outcome scores were collected using the Numeric Rating Scale for back and leg pain (NRS-B; NRS-L) at baseline and at 2 years following surgery. Opioid use, defined based on a specific question on case report forms and question 11 from the SRS-22r questionnaire, was assessed at baseline and at 2-year follow-up.ResultOf the 219 patients who met inclusion criteria, 179 (81.7%) had 2-year data on opioid use. The percentages of patients reporting opioid use at baseline (n = 75, 34.2%) and 2 years after surgery (n = 55, 30.7%) were similar (P = .23). However, at last follow-up 39% of baseline opioid users (Opi) were no longer taking opioids, while 14% of initial non-users (No-Opi) reported opioid use. Regional pre- and postoperative opioid use was 5.8% and 7.7% in the Asian population, 58.3% and 53.1% in the European, and 50.5% and 40.2% in North American patients, respectively. Baseline opioid users reported more preoperative back pain than the No-Opi group (7.0 vs 5.7, P = .001), while NRS-Leg pain scores were comparable (4.8 vs 4, P = .159). Similarly, at last follow-up, patients in the Opi group had greater NRS-B scores than Non-Opi patients (3.2 vs 2.3, P = .012), but no differences in NRS-Leg pain scores (2.2 vs 2.4, P = .632) were observed.ConclusionsIn this study, almost one-third of surgical ASD patients were consuming opioids both pre- and postoperatively world-wide. There were marked international variations, with patients from Asia having a much lower usage rate, suggesting a cultural influence. Despite both opioid users and nonusers benefitting from surgery, preoperative opioid use was strongly associated with significantly more back pain at baseline that persisted at 2-year follow up, as well as persistent postoperative opioid needs.

Treatment Utilisation and Satisfaction With Management in Individuals With Osteoarthritis and Metabolic Multimorbidity: A Cross-Sectional Multi-Country Study

PURPOSE

To compare treatment utilisation for osteoarthritis (OA) and satisfaction with OA management between individuals with and without comorbid metabolic conditions (e.g., diabetes, obesity, dyslipidaemia, hypertension).

METHODS

Secondary analysis of a cross-sectional international survey study (Italy, Russia, Sweden) on people ≥ 40 years old with knee/hip OA. Metabolic comorbidity was self-reported. We used direct standardisation with prevalence ratios and mixed-effect models to estimate the associations between comorbidity with treatment utilisation and satisfaction (score 0-100).

RESULTS

We analysed 401 individuals (48% Sweden, 28% Italy, 24% Russia; 53% with ≥ 1 metabolic condition). Those with and without comorbid metabolic conditions showed similar prevalence for first-line interventions (exercise, education, and weight management). Metabolically unhealthy individuals showed higher use of opioids (prevalence ratio [95% CI] 1.9 [1.3-2.4]), antidepressants (1.8 [1.1-2.5]), corticosteroid injections (1.4 [1.0-1.8]), and homoeopathic products (2.1 [1.2-3.0]). Satisfaction with care (adjusted difference: -3.9 [95% CI: -8.5 to 2.4]) and information received about treatments (-4.0 [-9.7 to 1.7]) were similar.

CONCLUSIONS

While first-line OA interventions were similarly used, those with metabolic conditions relied more on second-line and non-recommended treatments, showing comparable satisfaction. More effort is needed to increase the adoption of lifestyle-focused treatments in OA and to minimise the use of less recommended options among individuals with metabolic comorbidities.

Recent advances in the management of knee osteoarthritis: a narrative review

Knee osteoarthritis (OA) is a common condition that causes pain and reduces the quality of life for many people. It also leads to high health and financial costs. Managing knee OA pain requires using different methods together for the best results. This review overviews current therapeutic options for knee OA pain, focusing on their efficacy, safety, and potential roles in clinical practice. Topical treatments, such as NSAIDs and capsaicin, offer significant pain relief with minimal systemic side effects and are suitable for initial therapy, together with nonpharmacologic interventions like exercise and, when relevant, weight loss. Oral analgesics, including acetaminophen and opioids, have limited efficacy and serious side effects, making them appropriate only for short-term or rescue therapy. Intra-articular injections, such as corticosteroids, hyaluronic acid, and platelet rich plasma, demonstrate varying levels of efficacy and safety. Nutritional supplements, including curcumin, Boswellia serrata, and glucosaminechondroitin combinations, offer modest benefits and are best used as adjuncts to standart treatment. Nonpharmacological treatments, such as transcutaneous electrical nerve stimulation (TENS), acupuncture, and local heat therapy, provide variable pain relief and should be customized based on individual patient responses. Targeted biologic agents, such as antibodies to TNF-α, IL-1, and NGF, hold promise for more precise pain relief; however, further research is required to establish their routine use. Treating knee OA pain should be personalized, combining several methods. Research must continue to improve treatments and make them safer.

Patterns of pain medication usage and self-reported pain in older Irish adults with osteoarthritis: A latent class analysis of data from the Irish Longitudinal Study on Ageing

BACKGROUND

This study aimed to identify and describe links between pain medication use and self-reported pain among people aged ≥ 50 years with osteoarthritis (OA) in an Irish population, and to examine the relationships between pain, medication usage and socioeconomic and clinical characteristics.

METHODS

Secondary data analysis of wave 1 cross-sectional data from The Irish Longitudinal Study on Ageing (TILDA) was undertaken of 1042 people with self-reported doctor-diagnosed OA. We examined use of medications typically included in OA clinical guidelines, including non-opioid analgesics (e.g. paracetamol), topical and oral non-steroidal anti-inflammatory drugs (NSAIDs), opioids and nutraceuticals. Latent Class Analysis (LCA) was used to identify underlying clinical subgroups based on medication usage patterns, and self-reported pain severity. Multinomial logistic regression was used to explore sociodemographic and clinical characteristic links to latent class membership.

RESULTS

A total of 358 (34.4%) of the 1042 people in this analysis were taking pain medications including oral NSAIDs (17.5%), analgesics (11.4%) and opioids (8.7%). Nutraceutical (glucosamine/chondroitin) use was reported by 8.6% and topical NSAID use reported by 1.4%. Three latent classes were identified: (1) Low medication use/no pain (n = 382, 37%), (2) low medication use/moderate pain (n = 523, 50%) and (3) moderate medication use/high pain (n = 137, 13%). Poorer self-rated health and greater sleep disturbance were associated with classes 2 and 3; depressive symptoms and female gender were associated with class 2, and retirement associated with class 3.

CONCLUSIONS

Whilst pain medication use varied with pain severity, different medication types reported broadly aligned with OA guidelines. The two subgroups exhibiting higher pain levels demonstrated poorer self-rated health and greater sleep disturbance.

Targeting the TRPV1 pain pathway in osteoarthritis of the knee

INTRODUCTION

The growing prevalence and lack of effective pain therapies for knee osteoarthritis (KOA) results in a substantial unmet need for novel analgesic therapies. The transient receptor potential vanilloid 1 (TRPV1) receptor is expressed in subsets of nociceptive sensory neurons and has major roles in pain transmission and regulation. In the structures of the knee joint, nociceptors are present in abundance.

AREAS COVERED

TRPV1-expressing nociceptors in the knee represent a rational target to modulate activity at the origin of the pain pathway in KOA and may avoid systemic side effects seen with currently available analgesics. TRPV1 antagonists can induce analgesia, but hyperthermia and thermal hypesthesia side effects have limited their utility. Clinical development of TRPV1 agonists for pain management has progressed further than that of TRPV1 antagonists. Capsaicin and resiniferatoxin have provided proof-of-concept for the modulation of TRPV1 activity in KOA.

EXPERT OPINION

Intra-articular administration of TRPV1 agonists enables direct delivery to target nerve terminals in the knee, offering a potentially transformative approach for the management of pain associated with KOA. Here, we explore the advances in understanding innervation of the knee joint in KOA, the role of TRPV1-expressing neurons and progress in developing TRPV1 modulators for KOA.

Effect of 4 weeks vs 8 weeks of acupuncture for knee osteoarthritis in China: protocol for a randomised controlled trial

INTRODUCTION

Knee osteoarthritis represents the prevalent and incapacitating disease. Acupuncture, a widely used clinical treatment for knee osteoarthritis, has been shown to ameliorate pain and enhance joint function in affected individuals. However, there is a lack of evidence comparing different courses of acupuncture for knee osteoarthritis. In this trial, we will assess the effect of 4 weeks vs 8 weeks of acupuncture in patients with knee osteoarthritis.

METHODS AND ANALYSIS

The protocol is a pragmatic, parallel, two-arm randomised controlled trial, with the data analyst and assessor being blinded. 148 eligible patients with knee osteoarthritis will be randomly allocated in a 1:1 ratio to receive 4-week or 8-week acupuncture. Electroacupuncture will be administered three times per week for 4 or 8 weeks, respectively. Patients with knee osteoarthritis in both groups will be followed up to 26 weeks. The primary outcome is the response rate at week 26, and secondary outcomes include knee joint pain, knee joint function, knee joint stiffness, quality of life, patient global assessment, the Osteoarthritis Research Society International response rate and rescue medicine. A cost-effectiveness analysis will be carried out over 26 weeks.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Ethical Committee of Beijing University of Chinese Medicine (2023BZYL0506). The study findings will be disseminated through presentation in a medical journal. Additionally, we plan to present them at selected conferences and scientific meetings.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR2300073383; https://www.chictr.org.cn/showproj.html?proj=199310).

Non-operative Treatment Options for Osteoarthritis in the Hip

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study

BACKGROUND

COVID-19 has had a detrimental impact on access to hip and knee arthroplasty surgery. We set out to examine whether this had a subsequent impact on preoperative opioid prescribing rates for those awaiting surgery.

METHODS

Data regarding patient demographics and opioid utilisation were collected from the electronic health records of included patients at a large university teaching hospital. Patients on the outpatient waiting list for primary hip and knee arthroplasty as of September 2020 (COVID-19 group) were compared with historical controls (Controls) who had previously undergone surgery. A sample size calculation indicated 452 patients were required to detect a 15% difference in opioid prescription rates between groups.

RESULTS

A total of 548 patients (58.2% female) were included, 260 in the COVID-19 group and 288 in the Controls. Baseline demographics were similar between the groups. For those with data available, the proportion of patients on any opioid at follow-up in the COVID-19 group was significantly higher: 55.0% (143/260) compared with 41.2% (112/272) in the Controls (p=0.002). This remained significant when adjusted for confounding (age, gender, Scottish Index of Multiple Deprivation, procedure and wait time). The proportion of patients on a strong opioid was similar (4.2% (11/260) vs 4.8% (13/272)) for COVID-19 and Controls, respectively. The median waiting time from referral to follow-up was significantly longer in the COVID-19 group compared with the Controls (455 days vs 365 days; p<0.0001).

CONCLUSION

The work provides evidence of potential for an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services. Viable alternatives to opioid analgesia for those with end-stage arthritis should be explored, and prolonged waiting times for surgery ought to be avoided in the recovery from COVID-19 to prevent more widespread opioid use.

High-dose opioids for chronic non-cancer pain: an overview of Cochrane Reviews

BACKGROUND

This overview was originally published in 2017, and is being updated in 2022.  Chronic pain is typically described as pain on most days for at least three months. Chronic non-cancer pain (CNCP) is any chronic pain that is not due to a malignancy. Chronic non-cancer pain in adults is a common and complex clinical issue, for which opioids are prescribed by some physicians for pain management. There are concerns that the use of high doses of opioids for CNCP lacks evidence of effectiveness, and may increase the risk of adverse events.

OBJECTIVES

To describe the evidence from Cochrane Reviews and overviews regarding the efficacy and safety of high-dose opioids (defined as 200 mg morphine equivalent or more per day) for CNCP.

METHODS

We identified Cochrane Reviews and overviews by searching the Cochrane Database of Systematic Reviews in The Cochrane Library. The date of the last search was 21 July 2022. Two overview authors independently assessed the search results. We planned to analyse data on any opioid agent used at a high dose for two weeks or more for the treatment of CNCP in adults.

MAIN RESULTS

We did not identify any reviews or overviews that met the inclusion criteria. The excluded reviews largely reflected low doses or titrated doses, where all doses were analysed as a single group; we were unable to extract any data for high-dose use only.

AUTHORS' CONCLUSIONS

There is a critical lack of high-quality evidence, in the form of Cochrane Reviews, about how well high-dose opioids work for the management of CNCP in adults, and regarding the presence and severity of adverse events.  No evidence-based argument can be made on the use of high-dose opioids, i.e. 200 mg morphine equivalent or more daily, in clinical practice. Considering that high-dose opioids have been, and are still being used in clinical practice to treat CNCP, knowing about the efficacy and safety of these higher doses is imperative.

Discharge to inpatient rehabilitation following arthroplasty is a strong predictor of persistent opioid use 90 days after surgery: a prospective, observational study

BACKGROUND

Total knee and hip arthroplasty are considered a clinically and cost-effective intervention, however, persistent pain post-surgery can occur, and some continue to take opioid medications long-term. One factor which has infrequently been included in prediction modelling is rehabilitation pathway, in particular, one which includes inpatient rehabilitation. As discharge to inpatient rehabilitation post-arthroplasty is common practice, we aimed to identify whether rehabilitation pathway (discharge to in-patient rehabilitation or not) predicts continued use of opioids at 3 months (90 days) post- total knee arthroplasty (TKA) and total hip arthroplasty (THA) whilst controlling for other covariates.

METHODS

The study was nested within a prospective observational study capturing pre-operative, acute care and longer-term data from 1900 osteoarthritis (OA) patients who underwent primary TKA or THA. The larger study involved a part-random, part-convenience sample of 19 high-volume hospitals across Australia. Records with complete pre-and post-operative analgesic (35 days and 90 days) use were identified [1771 records (93% of sample)] and included in logistic regression analyses.

RESULTS

Three hundred and thirteen people (17.8%) reported ongoing opioid use at 90 days post-operatively. In the adjusted model, admission to inpatient rehabilitation after surgery was identified as an independent and significant predictor of opioid use at 90-days. Inpatient rehabilitation was associated with almost twice the odds of persistent opioid use at 90-days compared to discharge directly home (OR = 1.9 (1.4, 2.5), p < .001).

CONCLUSION

The inpatient rehabilitation pathway is a strong predictor of longer-term opioid use (90 days) post-arthroplasty, accounting for many known and possible confounders of use including sex, age, insurance status, major complications, smoking status and baseline body pain levels.

TRIAL REGISTRATION

The study was nested within a prospective cohort observational study capturing pre-operative, acute-care and longer-term data from patients undergoing primary TKA or THA for osteoarthritis (ClinicalTrials.gov NCT01899443).

Quality Improvement of a Hip Injection Service

Background Osteoarthritis is a substantive burden on the population and National Health Service (NHS) in the United Kingdom. A recent systematic review suggests that intra-articular steroid injections are an efficacious conservative treatment modality. The NHS Constitution states that "patients should wait no longer than 18 weeks from GP referral to treatment." An NHS hospital trust failed to meet this standard in a quarter of patients waiting for an intra-articular steroid injection of the hip. Strategies were considered to improve the time from referral to treatment (RTT). The aim of this quality improvement project was to improve the efficiency and capacity of the injection list. Materials and methods Patients who underwent an injection on a list between January and April 2019 were identified. Data were retrospectively collected and included the sites of injection and waiting times. Proformas for documentation and discharge summaries were introduced. Time taken for each appointment pre- and post-intervention were compared with the aim to increase the number of patients per list. Results Thirty-six (26%) of 138 patients experienced delays beyond 18 weeks from RTT. The mean (standard deviation [SD]) number of weeks waiting for an injection from the time of referral was 14 (6). The mean (SD) time for each appointment was 12 minutes 36 seconds (7 minutes 36 seconds) pre-intervention and 8 minutes 36 seconds (3 minutes 12 seconds) post-intervention. Discussion and conclusion Our standardized proformas led to an improvement in efficiency by reducing the time taken for documentation and capacity by subsequently increasing the number of patients per list.

Fluctuation of visual analog scale pain scores and opioid consumption before and after total hip arthroplasty

BACKGROUND

Patients who undergo orthopedic procedures are often given excess opioid medication. Understanding the relationship between pain and opioid consumption following total hip arthroplasty (THA) is key to creating safe and effective opioid prescribing guidelines.

AIM

To evaluate the association between the quantity of opioid consumption in relation to pain scores both pre-and postoperatively in patients undergoing primary THA.

METHODS

We retrospectively reviewed patients who underwent primary THA from November 2018-May 2019 and answered both the visual analog scale (VAS) pain and opioid medication questionnaires pre-and postoperatively. Both surveys were delivered daily for 7-days before surgery through the first 30 postoperative days. Survey results were divided into preoperative, postoperative days 1-7, postoperative days 8-14, and postoperative days 15-30 for analysis. Mean opioid pill consumption and VAS pain scores in each time period were determined and compared to patients' preoperative status using hierarchical Poisson and linear regressions, respectively.

RESULTS

There were 105 patients included. Mean VAS pain scores were the highest preoperatively 7.41 ± 1.72. However, VAS pain scores significantly declined in each successive postoperative category compared to preoperative scores: postoperative day 1-7 (5.07 ± 1.79; P < 0.001), postoperative day 8-14 (3.60 ± 1.64; P < 0.001), and postoperative day 15-30 (3.15 ± 1.63; P < 0.001). Mean opioid pill consumption preoperatively was 0.68 ± 1.29 pills. Compared to preoperative opioid consumption, opioid use was significantly greater between postoperative days 1-7 (1.51 ± 1.58; P = 0.001) and postoperative days 8-14 (1.00 ± 1.27; P = 0.043). Opioid consumption declined below preoperative levels between postoperative days 15-30 (0.35 ± 0.72; P = 0.160) which correlates with a VAS pain score of 3.15.

CONCLUSION

All patients experienced significant benefit and pain relief from having undergone THA. Average postoperative opioid consumption decreased below preoperative consumption between postoperative days 15-30, which was associated with a VAS pain score of 3.15. These results can be used to appropriately guide opioid prescribing practices and set patient expectations regarding pain management following THA.

Opioid use among Danish patients with severe knee osteoarthritis: a drug utilization study

PURPOSE

Knee osteoarthritis (OA) is one of the most common musculoskeletal diseases. Opioids have been increasingly used in the treatment of severe knee OA-related pain, particularly in the USA. Less is known about the patterns of use of opioids among Danish patients with severe knee OA. We investigated opioid use among Danish patients with severe knee OA in the 5 years preceding knee replacement surgery (KR).

METHODS

We identified adults who had undergone KR from January 1st, 2005, to December 31st, 2018, using the Danish National Patient Register. These patients were considered to have severe knee OA in the 5-year period leading up to KR. Individual-level data on prescribed opioids were retrieved from the Danish National Prescription Registry.

RESULTS

We identified 77,168 severe knee OA patients (mean age 66 years). The prevalence of opioid users increased from 21% 5 years before KR to 40% 1 year before. Total use of opioids increased each year and doubled from 3254 mg oral morphine equivalents (OMEQ)/1000 individuals/day 5 years before to 6396 mg OMEQ/1000 individuals/day the year before KR corresponding to an increase of 3141 mg OMEQ (95% confidence interval 3010 to 3273). Tramadol was the most frequently used opioid. About 10% of the population accounted for 90% of the total opioid use.

CONCLUSION

Among patients with severe knee OA, the prevalence and total use of opioids doubled during the 5 years before KR. In addition, 10% of the study population was responsible for 90% of the opioids used.

Treatment Options for Patellofemoral Arthritis

PURPOSE OF REVIEW

To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis RECENT FINDINGS: Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.

Meta-analysis of clinical trials focusing on hypertonic dextrose prolotherapy (HDP) for knee osteoarthritis

Hypertonic dextrose prolotherapy (HDP) is an injection of a concentrated dextrose solution for the purpose of local treatment of musculoskeletal pain and possible enhancement of repair mechanisms. This systematic review and meta-analysis examines the clinical utility of HDP injection for treatment of knee osteoarthritis (OA). Randomized controlled trials (RCTs) utilizing HDP to treat knee OA were retrieved from MEDLINE, EMBASE, and Cochrane Library (CENTRAL). Identification and inclusion of RCTs utilizing intra-articular and extra-articular administration of HDP vs administration of other injectate or physical therapy as control for knee OA were included. Primary clinical outcomes were changes in knee WOMAC, pain and function score. Secondary outcomes were adverse events related to HDP. For continuous outcomes with same or different measurements, we calculated, respectively the weighted mean difference (WMD) or the standardized mean difference (SMD), respectively. Results were pooled using DerSimonian and Laird random effect models across the included studies and heterogeneity between studies was estimated using the I² index. Five studies comprising a total of 319 treated patients met inclusion criteria and were included in the final analysis. At a mean of 22.8 weeks follow-up, HDP treatment significantly improved total WOMAC score (WMD = 13.77, 95% CI: 6.75-20.78; p < 0.001; I² = 90%), pain (SMD = 1.33, 95% CI: 0.49-2.17; p < 0.001; I² = 91%) and knee function (SMD = 1.30, 95% CI: 0.45-2.14; p < 0.001; I² = 91%) compared with control group. There were no severe adverse events related to dextrose injection reported in all the included studies. HDP is a promising treatment for knee OA with a reasonable safety profile. Further research in mechanism of HDP activity and long-term follow-up study will be needed for exploring this novel therapy modality.

Systemic therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer

BACKGROUND

Adjuvant aromatase inhibitors (AI) improve survival compared to tamoxifen in postmenopausal women with hormone receptor-positive stage I to III breast cancer. In approximately half of these women, AI are associated with aromatase inhibitor-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS may have significant and prolonged impact on women's quality of life. AIMSS reduces adherence to AI therapy in up to a half of women, potentially compromising breast cancer outcomes. Differing systemic therapies have been investigated for the prevention and treatment of AIMSS, but the effectiveness of these therapies remains unclear.

OBJECTIVES

To assess the effects of systemic therapies on the prevention or management of AIMSS in women with stage I to III hormone receptor-positive breast cancer.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, WHO International Clinical Trials Registry Platform (ICTRP) and Clinicaltrials.gov registries to September 2020 and the Cochrane Breast Cancer Group (CBCG) Specialised Register to March 2021.  SELECTION CRITERIA: We included all randomised controlled trials that compared systemic therapies to a comparator arm. Systemic therapy interventions included all pharmacological therapies, dietary supplements, and complementary and alternative medicines (CAM). All comparator arms were allowed including placebo or standard of care (or both) with analgesia alone. Published and non-peer-reviewed studies were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies, extracted data, and assessed risk of bias and certainty of the evidence using the GRADE approach. Outcomes assessed were pain, stiffness, grip strength, safety data, discontinuation of AI, health-related quality of life (HRQoL), breast cancer-specific quality of life (BCS-QoL), incidence of AIMSS, breast cancer-specific survival (BCSS) and overall survival (OS). For continuous outcomes, we used vote-counting by reporting how many studies reported a clinically significant benefit within the confidence intervals (CI) of the mean difference (MD) between treatment arms, as determined by the minimal clinically importance difference (MCID) for that outcome scale. For dichotomous outcomes, we reported outcomes as a risk ratio (RR) with 95% CI.

MAIN RESULTS

We included 17 studies with 2034 randomised participants. Four studies assessed systemic therapies for the prevention of AIMSS and 13 studies investigated treatment of AIMSS. Due to the variation in systemic therapy studies, including pharmacological, and CAM, or unavailable data, meta-analysis was limited, and only two trials were combined for meta-analysis. The certainty of evidence for all outcomes was either low or very low certainty. Prevention studies The evidence is very uncertain about the effect of systemic therapies on pain (from baseline to the end of the intervention; 2 studies, 183 women). The two studies, investigating vitamin D and omega-3 fatty acids, showed a treatment effect with 95% CIs that did not include an MCID for pain. Systemic therapies may have little to no effect on grip strength (RR 1.08, 95% CI 0.37 to 3.17; 1 study, 137 women) or on women continuing to take their AI (RR 0.16, 95% 0.01 to 2.99; 1 study, 147 women). The evidence suggests little to no effect on HRQoL and BCS-QoL from baseline to the end of intervention (the same single study; 44 women, both quality of life outcomes showed a treatment effect with 95% CIs that did include an MCID). The evidence is very uncertain for outcomes assessing incidence of AIMSS (RR 0.82, 95% CI 0.63 to 1.06; 2 studies, 240 women) and the safety of systemic therapies (4 studies, 344 women; very low-certainty evidence). One study had a US Food and Drug Administration alert issued for the intervention (cyclo-oxygenase-2 inhibitor) during the study, but there were no serious adverse events in this or any study. There were no data on stiffness, BCSS or OS. Treatment studies The evidence is very uncertain about the effect of systemic therapies on pain from baseline to the end of intervention in the treatment of AIMSS (10 studies, 1099 women). Four studies showed an MCID in pain scores which fell within the 95% CI of the measured effect (vitamin D, bionic tiger bone, Yi Shen Jian Gu granules, calcitonin). Six studies showed a treatment effect with 95% CI that did not include an MCID (vitamin D, testosterone, omega-3 fatty acids, duloxetine, emu oil, cat's claw).  The evidence was very uncertain for the outcomes of change in stiffness (4 studies, 295 women), HRQoL (3 studies, 208 women) and BCS-QoL (2 studies, 147 women) from baseline to the end of intervention. The evidence suggests systemic therapies may have little to no effect on grip strength (1 study, 107 women). The evidence is very uncertain about the safety of systemic therapies (10 studies, 1250 women). There were no grade four/five adverse events reported in any of the studies. The study of duloxetine reported more all-grade adverse events in this treatment group than comparator group. There were no data on the incidence of AIMSS, the number of women continuing to take AI, BCCS or OS from the treatment studies.

AUTHORS' CONCLUSIONS

AIMSS are chronic and complex symptoms with a significant impact on women with early breast cancer taking AI. To date, evidence for safe and effective systemic therapies for prevention or treatment of AIMSS has been minimal. Although this review identified 17 studies with 2034 randomised participants, the review was challenging due to the heterogeneous systemic therapy interventions and study methodologies, and the unavailability of certain trial data. Meta-analysis was thus limited and findings of the review were inconclusive. Further research is recommended into systemic therapy for AIMSS, including high-quality adequately powered RCT, comprehensive descriptions of the intervention/placebo, and robust definitions of the condition and the outcomes being studied.

Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty

Background

Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA.

Methods

We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared.

Results

The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05).

Conclusion

Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.

The kappa-opioid receptor agonist, triazole 1.1, reduces oxycodone self-administration and enhances oxycodone-induced thermal antinociception in male rats

RATIONALE

Triazole 1.1 is a novel kappa-opioid receptor (KOR) agonist reported to produce antinociception without KOR-typical adverse effects. When combined with the mu-opioid receptor (MOR) agonist, oxycodone, triazole 1.1 blocks oxycodone-induced pruritis without producing sedation-like effects in nonhuman primates. However, it is unknown if triazole 1.1 can reduce the abuse-related effects or enhance the antinociceptive effects of oxycodone similarly to other KOR agonists.

OBJECTIVES

The aim of the present study was to quantitatively compare the behavioral effects of triazole 1.1 to the KOR agonists, U50,488h and nalfurafine, on oxycodone self-administration and oxycodone-induced thermal antinociception when administered as mixtures with oxycodone.

METHODS

In the self-administration study, male Sprague-Dawley (SD) rats (n = 6) self-administered intravenous (i.v.) oxycodone alone (0.056 mg/kg/inj) or combined with U50,488 h (0.032-0.32 mg/kg/inj), nalfurafine (0.00032-0.0032 mg/kg/inj), or triazole 1.1 (0.32-1.8 mg/kg/inj) under a progressive-ratio schedule of reinforcement. In a hot plate assay, male SD rats (n = 6) received i.v. injections of oxycodone (1.0-5.6 mg/kg), U50,488h (1.0-18.0 mg/kg), nalfurafine (0.01-1.0 mg/kg), or triazole 1.1 (3.2-32.0 mg/kg) alone or in combinations of fixed proportion with oxycodone based on the relative potencies of the single drugs. Each study concluded with administration of the KOR antagonist nor-BNI and some degree of retesting of the previous conditions to verify that the behavioral effects were mediated by KOR activation.

RESULTS

All KOR agonists reduced oxycodone self-administration in a dose-dependent manner. Moreover, all single drugs and drug combinations produced dose-dependent, fully efficacious thermal antinociception. All KOR agonist:oxycodone combinations produced either additive or super-additive thermal antinociception. Finally, each KOR agonist was blocked in effect by nor-BNI in both behavioral measures.

CONCLUSION

This study demonstrates that triazole 1.1 reduces oxycodone's reinforcing effects and enhances oxycodone-induced antinociception to degrees that are comparable to typical KOR agonists. Given triazole 1.1's mild adverse-effect profile, developing MOR-KOR agonist combinations from the triazole 1.1 series may render new pain therapeutics with reduced abuse liability.

Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis

OBJECTIVE

To assess the effectiveness and safety of different preparations and doses of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol for knee and hip osteoarthritis pain and physical function to enable effective and safe use of these drugs at their lowest possible dose.

DESIGN

Systematic review and network meta-analysis of randomised trials.

DATA SOURCES

Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, regulatory agency websites, and ClinicalTrials.gov from inception to 28 June 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials published in English with ≥100 patients per group that evaluated NSAIDs, opioids, or paracetamol (acetaminophen) to treat osteoarthritis.

OUTCOMES AND MEASURES

The prespecified primary outcome was pain. Physical function and safety outcomes were also assessed.

REVIEW METHODS

Two reviewers independently extracted outcomes data and evaluated the risk of bias of included trials. Bayesian random effects models were used for network meta-analysis of all analyses. Effect estimates are comparisons between active treatments and oral placebo.

RESULTS

192 trials comprising 102 829 participants examined 90 different active preparations or doses (68 for NSAIDs, 19 for opioids, and three for paracetamol). Five oral preparations (diclofenac 150 mg/day, etoricoxib 60 and 90 mg/day, and rofecoxib 25 and 50 mg/day) had ≥99% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. Topical diclofenac (70-81 and 140-160 mg/day) had ≥92.3% probability, and all opioids had ≤53% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. 18.5%, 0%, and 83.3% of the oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of dropouts due to adverse events. 29.8%, 0%, and 89.5% of oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of any adverse event. Oxymorphone 80 mg/day had the highest risk of dropouts due to adverse events (51%) and any adverse event (88%).

CONCLUSIONS

Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs for pain and function in patients with osteoarthritis. However, these treatments are probably not appropriate for patients with comorbidities or for long term use because of the slight increase in the risk of adverse events. Additionally, an increased risk of dropping out due to adverse events was found for diclofenac 150 mg/day. Topical diclofenac 70-81 mg/day seems to be effective and generally safer because of reduced systemic exposure and lower dose, and should be considered as first line pharmacological treatment for knee osteoarthritis. The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO number CRD42020213656.

High-Frequency Impulse Therapy for Treatment of Chronic Back Pain: A Multicenter Randomized Controlled Pilot Study

Purpose

This study aims to examine high-frequency impulse therapy (HFIT) impact on pain and function among patients undergoing care for chronic low back pain (CLBP).

Methods

A pilot randomized-controlled trial of HFIT system versus sham was conducted across 5 orthopedic and pain center sites in California, USA. Thirty-six patients seeking clinical care for CLBP were randomized. Primary outcome was function measured by the Six Minute Walk Test (6MWT). Secondary outcomes were function (Timed Up and Go [TUG] and Oswestry Disability Index [ODI]), pain (Numerical Rating Scale [NRS]), quality of life (Patient Global Impression of Change [PGIC]), and device use. Patients were assessed at baseline and every week for 4 weeks of follow-up. Mann–Whitney U-test was used to analyze changes in each outcome. Repeated measures ANOVA was used to assess the effect of treatment over time.

Results

The average age of subjects was 53.9 ± 15.7 (mean ± SD) years, with 12.1 ± 8.8 years of chronic low back pain. Patients who received an HFIT device had a significantly higher 6MWT score at weeks 2 [Cohen’s d (95% CI): 0.33 (0.02, 0.61)], 3 [0.32 (0.01, 0.59)] and 4 [0.31 (0.01, 0.60)], respectively, as compared to their baseline scores (p < 0.05). Patients in the treatment group had significantly lower TUG scores at week 3 [0.30 (0.04, 0.57)] and significantly lower NRS scores at weeks 2 [0.34 (0.02, 0.58)] and 4 [0.41 (0.10, 0.67)] (p < 0.05).

Conclusion

A larger-scale RCT can build on the findings of this study to test whether HFIT is effective in reducing pain and improving function in CLBP patients. This study shows encouraging evidence of functional improvement and reduction in pain in subjects who used HFIT. The efficacy and minimally invasive nature of HFIT is anticipated to substantially improve the management of CLBP patients.

Is There Any Role for Opioids in the Management of Knee and Hip Osteoarthritis? A Systematic Review and Meta-Analysis

OBJECTIVE

Opioids have long been prescribed for chronic pain conditions, including osteoarthritis (OA). However, there is little information about their temporal efficacy, or differences in efficacy and safety between opioids with strong versus weak/intermediate μ opioid receptor-binding affinity. To explore these research questions, we conducted a systematic review and meta-analyses of randomized controlled trials (RCTs) conducted in patients with knee and/or hip OA.

METHODS

We searched Medline, Embase, PubMed Central, and the Cochrane Central Register of Controlled Trials from inception to December 2019 and sought unpublished data. Placebo-controlled RCTs of oral opioids in patients with knee and/or hip OA were included. Standardized mean differences (SMDs) were calculated for pain and function at 2, 4, 8, and 12 weeks. Subgroup analyses for strong and weak/intermediate opioids were conducted. Meta-regression was performed to assess the impact of dosage (morphine equivalency) on pain relief. Risk ratios were calculated for safety at the final follow-up.

RESULTS

A total of 18 RCTs (9,283 participants) were included. Opioids demonstrated small benefits on pain at each time point, with SMDs ranging from -0.28 (95% confidence interval [95% CI] -0.38, -0.17) to -0.19 (95% CI -0.29, -0.08); similar effects were observed for function. Strong opioids demonstrated consistently inferior efficacy and overall worse safety than weak/intermediate opioids. Meta-regression revealed that incremental pain relief achieved beyond 20-50-mg doses was not substantial in the context of increased safety risks.

CONCLUSION

Opioids provide minimal relief of OA symptoms within a 12-week period, and they are known to cause discomfort in a majority of patients. Clinicians and policy makers should reconsider the utility of opioids in the management of OA.

Current therapeutic approaches in the management of hemophilia-a consensus view by the Romanian Society of Hematology

Hemophilia A (HA) and hemophilia B (HB) are rare disorders, being caused by the total lack or under-expression of two factors from the coagulation cascade coded by genes of the X chromosome. Thus, in hemophilic patients, the blood does not clot properly. This results in spontaneous bleeding episodes after an injury or surgical intervention. A patient-centered regimen is considered optimal. Age, pharmacokinetics, bleeding phenotype, joint status, adherence, physical activity, personal goals are all factors that should be considered when individualizing therapy. In the past 10 years, many innovations in the diagnostic and treatment options were presented as being either approved or in development, thus helping clinicians to improve the standard-of-care for patients with hemophilia. Recombinant factors still remain the standard of care in hemophilia, however they pose a challenge to treatment adherence because they have short half-life, which where the extended half-life (EHL) factors come with the solution, increasing the half-life to 96 hours. Gene therapies have a promising future with proven beneficial effects in clinical trials. We present and critically analyze in the current manuscript the pros and cons of all the major discoveries in the diagnosis and treatment of HA and HB, as well as identify key areas of hemophilia research where improvements are needed.

Nortriptyline for pain in knee osteoarthritis: a double-blind randomised controlled trial in New Zealand general practice

BACKGROUND

Osteoarthritis (OA) of the knee is a common cause of chronic pain. Analgesics that are currently available have limited efficacy and may be poorly tolerated. Tricyclic antidepressants are used as analgesics for other chronic conditions, but they have not been evaluated as analgesics in OA.

AIM

To investigate the analgesic efficacy of nortriptyline in people with knee OA.

DESIGN AND SETTING

A two-arm, parallel-group, 1:1, double-blind, randomised, placebo-controlled trial in Christchurch, New Zealand.

METHOD

Participants were recruited from orthopaedic outpatient clinics, primary care, and through public advertising. Adults with knee OA and a pain score of ≥20 points on the 50-point Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale were randomised to receive either nortriptyline or identical placebo for 14 weeks. The primary outcome was knee pain at 14 weeks measured using the WOMAC pain subscale. Secondary outcomes included: function; stiffness; non-steroidal anti-inflammatory drug, opioid, and/or paracetamol use; each participant's global assessment; and adverse effects at 14 weeks.

RESULTS

Of the 205 randomised participants, 201 (98.0%) completed follow-up at 14 weeks. The baseline-adjusted mean WOMAC pain subscale score at week 14 was 6.2 points lower (95% confidence interval = -0.26 to 12.6, P = 0.06) in the nortriptyline arm versus the placebo arm. Differences in secondary outcomes generally favoured the nortriptyline arm, but were small and unlikely to be clinically relevant. However, the following were all more commonly reported by participants taking nortriptyline than those taking a placebo: dry mouth (86.9% versus 51.0%, respectively, P<0.001), constipation (58.6% versus 30.4%, respectively, P<0.001), and sweating (31.3% versus 20.6%, respectively, P = 0.033).

CONCLUSION

This study suggests nortriptyline does not significantly reduce pain in people with knee OA. The adverse effect profile was as expected.

The prevalence of and exact indications for daily opioid use among aged home care clients with and without dementia

Background

The increasing trend of opioid use for non-malignant pain among older people has raised concerns about whether opioids are used for appropriate indications. On the other hand, pain in patients with dementia may be undertreated.

Aims

To examine the prevalence of and indications for daily opioid use among home care clients, and to determine opioid use differs between those with and without dementia.

Methods

All home care clients aged ≥ 65 years using opioids daily (n = 282) were identified based on their first Resident Assessment Instrument–Home Care assessment in 2014. Exact indications for opioid use, the opioid substance used, the median duration of use, and changes in opioid medication within 12 months from study entry were obtained from the electronic medical records.

Results

The prevalence of daily opioid use was 9.3%, and the median duration of use before the study entry was 357 days (interquartile range 126–719 days). The majority of clients continued to use opioids daily during the follow-up year. Vertebral osteoporotic fractures (21.6%), degenerative spinal disorders (20.9%), and osteoarthritis (20.6%) were the most common indications for opioid use. Buprenorphine was used more frequently in persons with dementia, but otherwise there were no differences between those with and without dementia.

Discussion and conclusions

Home care clients use opioids for long periods of time for pain related mostly to musculoskeletal disorders, although the effectiveness of long-term opioid use is not clear. The lack of effective or suitable options for management of pain might explain the situation.

Future projections of opioid use and cost in patients with chronic osteoarthritis pain in Spain

BACKGROUND

Opioids are widely used in moderate-to-severe chronic pain which is non-responsive to standard analgesics. Prescriptions have increased in Europe in the last decade, although remain lower than in USA. This work projected the future utilization and costs of opioids in chronic osteoarthritis (OA) pain in the Spanish National Health System (NHS).

METHODS

An epidemiological model was populated with the opioid dispensing trends from 2010 to 2019 using Spanish Medicinal Agency rates of opioid utilization in subjects over 18 years of age and the real-world OPIOIDS study to estimate chronic-OA-pain patients receiving opioids. A best-fitted trend analysis model was applied estimating the likely number of DHD (defined daily dose/1000 inhabitants per day) to calculate projected opioid utilization and costs for the period 2020-2029.

RESULTS

In 2010, an estimated 5.67 DHD were dispensed for the equivalent of 217,076 chronic OA pain patients per day [1.99 DHD, 76,084 refractory to non-steroidal anti-inflammatory drugs (NSAIDs)]. From these trends and OA prevalence, the projected number of DHDs is expected to increase more than threefold to 17.98 DHDs by the year 2029 for the equivalent of 727,356 chronic OA pain patients per day (8.18 DHD, 330,720 refractory to NSAIDs); 41.8% on strong opioids. The estimated cost was €116.9m (€45.0m in NSAID-refractory OA) in 2010 rising by 222% to €376.1m (€199.7m refractory to NSAIDs) by 2029.

CONCLUSION

Chronic-OA-pain-related opioid dispensing and costs to the NHS are set to increase more than threefold from 2010 to 2029 in Spain. Using opioids for OA pain is concerning given disease chronicity and other related costs not computed in these projections.

PLAIN LANGUAGE SUMMARY

• Opioids are widely used in chronic pain which is non-responsive to standard analgesics. Prescriptions have increased in Europe, although remain lower than in USA. Osteoarthritis (OA) is a degenerative joint disease usually accompanied by pain. Despite not recommended, opioids use in OA have been expanded because this health condition is increasing with ageing and, also, because physicians both primary and specialist boosted their use.• This study aimed to quantify the current burden of opioids used for chronic moderate-to-severe OA pain by estimating the number of defined daily doses per 1000 inhabitants per day (DHD) and associated costs, and to forecast the likely burden on the National Health System (NHS) in Spain for the years 2020-2029.• In 2010, an estimated 5.67 DHDs were dispensed for the equivalent of 217,076 chronic OA pain patients per day. From these trends, the projected number of DHDs is expected to increase more than threefold to 17.98 DHDs by the year 2029 for the equivalent of 727,356 chronic OA pain patients per day; 41.8% on strong opioids. The estimated cost was €116.9m in 2010 rising by 222% to €376.1m by 2029.• Chronic OA-pain-related opioid dispensing and costs to the NHS are set to increase substantially (threefold to more than fourfold) from 2010 to 2029 in Spain. Thus, using opioids for OA pain is concerning given disease chronicity, aging population and other related costs not computed in these projections. Our findings can inform payors and clinicians about ongoing discussions on appropriate analgesic management for longer-term OA pain, including resource requirements at a national level. Clinicians who prescribe opioids for OA pain should consider the potential implications of side effects such as sedation, cognitive deterioration, incremental need of caregivers, particularly in older people, and carefully consider the risk-benefit balance.

Expert consensus of the Chinese Association for the Study of Pain on pain treatment with the transdermal patch

Chronic pain lasting more than 3 mo, or even several years can lead to disability. Treating chronic pain safely and effectively is a critical challenge faced by clinicians. Because administration of analgesics through oral, intravenous or intramuscular routes is not satisfactory, research toward percutaneous delivery has gained interest. The transdermal patch is one such percutaneous delivery system that can deliver drugs through the skin and capillaries at a certain rate to achieve a systemic or local therapeutic effect in the affected area. It has many advantages including ease of administration and hepatic first pass metabolism avoidance as well as controlling drug delivery, which reduces the dose frequency and side effects. If not required, then the patch can be removed from the skin immediately. The scopolamine patch was the first transdermal patch to be approved for the treatment of motion sickness by the Food and Drug Administration in 1979. From then on, the transdermal patch has been widely used to treat many diseases. To date, no guidelines or consensus are available on the use of analgesic drugs through transdermal delivery. The pain branch of the Chinese Medical Association, after meeting and discussing with experts and based on clinical evidence, developed a consensus for promoting and regulating standard use of transdermal patches containing analgesic drugs.

Subchondral bone microenvironment in osteoarthritis and pain

Osteoarthritis comprises several joint disorders characterized by articular cartilage degeneration and persistent pain, causing disability and economic burden. The incidence of osteoarthritis is rapidly increasing worldwide due to aging and obesity trends. Basic and clinical research on osteoarthritis has been carried out for decades, but many questions remain unanswered. The exact role of subchondral bone during the initiation and progression osteoarthritis remains unclear. Accumulating evidence shows that subchondral bone lesions, including bone marrow edema and angiogenesis, develop earlier than cartilage degeneration. Clinical interventions targeting subchondral bone have shown therapeutic potential, while others targeting cartilage have yielded disappointing results. Abnormal subchondral bone remodeling, angiogenesis and sensory nerve innervation contribute directly or indirectly to cartilage destruction and pain. This review is about bone-cartilage crosstalk, the subchondral microenvironment and the critical role of both in osteoarthritis progression. It also provides an update on the pathogenesis of and interventions for osteoarthritis and future research targeting subchondral bone.

Knee osteoarthritis: key treatments and implications for physical therapy

BACKGROUND

Knee osteoarthritis (OA) is a chronic progressive disease that imparts a substantial socioeconomic burden to society and healthcare systems. The prevalence of knee OA has dramatically risen in recent decades due to consistent increases in life expectancy and obesity worldwide. Patient education, physical exercise, and weight loss (for overweight or obese individuals) constitute the first-line knee OA treatment approach. However, less than 40% of patients with knee OA receive this kind of intervention. There is an unmet need for healthcare professionals treating individuals with knee OA to understand the current recommended treatment strategies to provide effective rehabilitation.

OBJECTIVE

To guide physical therapists in their clinical decision making by summarizing the safest and most efficacious treatment options currently available, and by delineating the most traditional outcome measures used in clinical research for knee OA.

CONCLUSION

There is a need for healthcare providers to abandon low-quality and ineffective treatments and educate themselves and their patients about the current best evidence-based practices for knee OA.

Clinical and technical factors associated with knee radiofrequency ablation outcomes: a multicenter analysis

BACKGROUND

There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome.

METHODS

We retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions.

RESULTS

The overall rate of a positive response was 61.1% (95% CI 55.2% to 67.0%). In univariable analysis, larger electrode size (p=0.01), repeated lesions (p=0.02), having>80% pain relief during the prognostic block (p=0.02), not being on opioids (p=0.04), having no coexisting psychiatric condition (p=0.02), having a lower baseline pain score (p=0.01) and having >3 nerves targeted (p=0.02) were associated with a positive outcome. In multivariate logistic analysis, being obese (OR 3.68, 95% CI 1.66 to 8.19, p=0.001), not using opioids (OR 0.35, 95% CI 0.16 to 0.77, p=0.009), not being depressed (OR 0.29, 95% CI 0.10 to 0.82, p=0.02), use of cooled RFA (OR 3.88, 95% CI 1.63 to 9.23, p=0.002) and performing multiple lesions at each neural target (OR 15.88, 95% CI 4.24 to 59.50, p<0.001) were associated with positive outcome.

CONCLUSIONS

We identified multiple clinical and technical factors associated with treatment outcome, which should be considered when selecting patients for RFA treatment and in the design of clinical trials.

Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis

OBJECTIVE

While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.

METHODS

A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.

RESULTS

In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02).

CONCLUSION

Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.

Multimodal Treatment Patterns for Osteoarthritis and Their Relationship to Patient-Reported Pain Severity: A Cross-Sectional Survey in the United States

Purpose

The purpose of this study was to assess how patient-reported pain is related to osteoarthritis (OA) treatment patterns in routine clinical practice.

Patients and Methods

Data were collected between February and May 2017 from 153 United States (US) primary care physicians, rheumatologists, and orthopedic surgeons. Each invited up to nine consecutive patients to rate their OA pain in the last week. Physicians provided demographic, clinical, and treatment information for patients, including nonpharmacologic therapies ever recommended, currently recommended over-the-counter (OTC) medications, and currently and ever prescribed medications for the management of OA. Findings for patients with mild (0─3), moderate (4─6), and severe current pain (7─10) were compared using appropriate statistics.

Results

Among the 841 patients (61% female; mean 65 years; 57% knee OA), 45% reported mild, 36% moderate, and 19% severe current OA pain. Current treatment modalities differed by pain severity (P<0.05). Most patients (70%) had been recommended nonpharmacologic therapy and 40% were currently recommended OTC medications. More patients with moderate (81%) or severe pain (78%) currently received prescription medications, with or without nonpharmacologic therapy, versus those with mild pain (67%). Overall, 47% of patients currently received just one prescription drug, while 49% had received one prescription drug ever. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common current (58%) and ever received (88%) prescriptions. Current NSAID prescriptions were not associated with pain severity. Acetaminophen recommendations, opioid prescriptions (current and ever), and multiple prescription medications tried were numerically highest in the severe pain group (all P<0.05 by pain severity). In all groups, >80% of treatment switches were due to lack of efficacy.

Conclusion

Real-life treatment patterns for OA in the US are significantly associated with current patient-reported pain. Combining nonpharmacologic and pharmacologic treatments is common but higher pain ratings are associated with multiple failed prescription treatments. Current use of acetaminophen and opioids, but not NSAIDs, increases alongside pain severity.

Intra-Articular Injection of Amniotic Membrane and Umbilical Cord Particulate for the Management of Moderate to Severe Knee Osteoarthritis

Objective

To evaluate the long-term benefit of a single injection of amniotic membrane/umbilical cord (AM/UC) particulate in patients with moderate to severe knee osteoarthritis (OA).

Methods

A single-center, investigator-initiated, retrospective study of patients who received intra-articular injection of 100 mg lyophilized and micronized AM/UC for radiographically confirmed, Kellgren–Lawrence (KL) grade 3 or 4 symptomatic knee OA. Data regarding demographics, OA severity, comorbidities, treatment regimens, complications, and patient-reported outcomes were collected and assessed. Patient Global Impression of Change (PGIC) was assessed on a 7-point scale, and Global Perceived Improvement (GPI), expressed as percent improvement relative to baseline, was used to further quantify the degree of symptomatic change. Clinically important response to treatment was assessed at 12 months using simplified OMERACT–OARSI responder criteria.

Results

A total of 42 patients with KL grade 3 (36%) and 4 (64%) knee OA were included for analysis. Prior to injection, patient-rated pain was 6.6 ± 1.5 out of 10 (median: 7, range: 3–10) despite prior treatment with oral/topical NSAIDs (62%) and intra-articular injection(s) of corticosteroids (57%) and/or hyaluronic acid (48%). Twelve months following AM/UC injection, 31 patients (74%) reported significant clinical improvement via PGIC, and the OMERACT–OARSI treatment response rate was 81% (34/42). GPI of pain and function was 62 ± 24%, 69 ± 27%, 69 ± 27%, and 64 ± 31% at 1, 3, 6, and 12 months, respectively. Symptomatic improvement was maintained for an average duration of 12.1 ± 4.5 months (median: 12, range: 3–22). One patient developed swelling in the knee within 36 hours of injection. No other adverse events or complications were reported.

Conclusion

Intra-articular injection of AM/UC particulate may be effective in alleviating pain and improving function in patients with moderate to severe knee OA, with the potential to delay total knee replacement for up to 12 months.

Controlling the "Opioid Epidemic": A Novel Chemical Entity (NCE) to Reduce or Supplant Opiate Use for Chronic Pain

We report on the ongoing project “A Novel Therapeutic to Ameliorate Chronic Pain and Reduce Opiate Use.” Over 100 million adults in the U.S. suffer from intermittent or constant chronic pain, and chronic pain affects at least 10% of the world’s population. The primary pharmaceuticals for treatment of chronic pain have been natural or synthetic opioids and the use of opioids for pain treatment has resulted in what has been called an “epidemic” of opioid abuse, addiction and lethal overdoses. We have, through a process of rational drug design, generated a novel chemical entity (NCE) and have given it the name Kindolor. Kindolor is a non-opiate, non-addicting molecule that was developed specifically to simultaneously control the aberrant activity of three targets on the peripheral sensory system that are integral in the development and propagation of chronic pain. In our initial preclinical studies, we demonstrated the efficacy of Kindolor to reduce or eliminate chronic pain in five animal models. The overall goal of the project is to complete the investigational new drug (IND)-enabling preclinical studies of Kindolor, and once IND approval is gained, we will proceed to the clinical Phase Ia and 1b safety studies and a Phase 2a efficacy study. The work is in its second year, and the present report describes progress toward our overall goal of bringing our compound to a full Phase 2 ready stage.

Guidelines for the diagnosis and treatment of osteoarthritis in China (2019 edition)

Osteoarthritis (OA) is a degenerative disease of middle-aged and elderly people, contributed a higher burden of disease in China and the world. In 2017, under the support of the Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association. The objective was to develop an evidence-based diagnosis and treatment guideline for OA in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2018CN028). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the OA diagnosis, disease risks monitoring and evaluate, treatment purpose and physical, medical and surgical interventions. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of OA.

Patients use fewer analgesics following supervised exercise therapy and patient education: an observational study of 16 499 patients with knee or hip osteoarthritis

OBJECTIVES

To investigate changes in analgesic use before and after supervised exercise therapy and patient education in patients with knee or hip osteoarthritis (OA).

METHODS

We recruited 16 499 of 25 933 eligible patients (64%; mean age 64.9; SD 9.6; 73% women) from the Good Life with osteoArthritis in Denmark (GLA:D) registry. Change in proportions of analgesic users (categorised according to analgesic risk profile; opioids > non-steroidal anti-inflammatory drugs > paracetamol) was assessed from before to after an 8-week supervised exercise therapy and patient education programme targeting knee or hip OA pain and functional limitations.

RESULTS

Patients reported 13.2 mm (95% CI 12.8 to 13.6) less pain (visual analogue scale 0-100 mm) at follow-up compared with baseline. The proportion of analgesic users reduced from 62.2% (95% CI 61.5 to 63.0) at baseline to 44.1% (95% CI 43.3 to 44.9) at follow-up (absolute change: 18.1% (95% CI 17.3 to 19.0)). Among patients using analgesics at baseline, 52% changed to a lower risk analgesic or discontinued analgesic use. The proportion of opioid users after the exercise therapy was 2.5% (95% CI 2.1 to 2.9) lower than baseline; this represents a relative reduction of 36%.

CONCLUSION

Among patients with knee or hip OA using analgesics, more than half either discontinued analgesic use or shifted to lower risk analgesics following an 8-week structured exercise therapy and patient education programme (GLA:D). These data encourage randomised controlled trial evaluation of whether supervised exercise therapy, combined with patient education, can reduce analgesic use, including opioids, among patients with knee and hip OA pain.

A Real-World Study Using Claims Data to Evaluate Possible Failure of Opioid Treatment Regimens Among Patients with Hip and/or Knee Osteoarthritis in the US

Background

Although opioids may be used in the management of pain in patients with osteoarthritis (OA), there is a dearth of real-world data characterizing opioid regimen failure in these patients.

Objective

Using claims data, this study explored measures that may be potentially indicative of opioid treatment failure and the association of such potential failure with health care resource utilization (HRU) and costs.

Patients and Methods

Using a national employer-sponsored insurance claims database covering the years 2011–2016, this retrospective longitudinal study identified adults with hip/knee osteoarthritis who filled ≥1 opioid prescription (index event) and had continuous health plan enrollment 6 months pre- and ≥12 months post-index. Index opioid regimen intensity was defined in the 3-month post-index period by frequency, average daily dose, and duration of action. Possible index opioid regimen failure was defined as an increase in opioid regimen intensity, addition of a non-opioid pain medication, joint surgery, or opioid-abuse-related events. One-year follow-up HRU and costs were compared between those with possible treatment failure and those without.

Results

Among 271,512 OA patients (61.5% knee; 11.1% hip; 27.4% both), 34.9% met the definition of possible index opioid regimen failure within a year: increased regimen intensity (16.1%), joint surgery (14.0%), addition of non-opioid pain medication (11.4%), and opioid-abuse-related events (1.9%). Rates of possible failure generally increased with higher index regimen intensity. Compared with those who did not fail, those who potentially failed their index treatment regimen had significantly higher HRU (P<0.001), and all-cause ($36,699 vs $15,114) and osteoarthritis-related costs ($17,298 vs $1,967) (both P<0.0001).

Conclusion

Among OA patients treated with opioids, approximately one-third may fail their index opioid regimen within a year and incur significantly higher HRU and costs than those without. Further research is needed to validate these findings with clinical outcomes.

Effect of Biomechanical Footwear on Knee Pain in People With Knee Osteoarthritis: The BIOTOK Randomized Clinical Trial

IMPORTANCE

Individually calibrated biomechanical footwear therapy may improve pain and physical function in people with symptomatic knee osteoarthritis, but the benefits of this therapy are unclear.

OBJECTIVE

To assess the effect of a biomechanical footwear therapy vs control footwear over 24 weeks of follow-up.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at a Swiss university hospital. Participants (N = 220) with symptomatic, radiologically confirmed knee osteoarthritis were recruited between April 20, 2015, and January 10, 2017. The last participant visit occurred on August 15, 2017.

INTERVENTIONS

Participants were randomized to biomechanical footwear involving shoes with individually adjustable external convex pods attached to the outsole (n = 111) or to control footwear (n = 109) that had visible outsole pods that were not adjustable and did not create a convex walking surface.

MAIN OUTCOMES AND MEASURES

The primary outcome was knee pain at 24 weeks of follow-up assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscore standardized to range from 0 (no symptoms) to 10 (extreme symptoms). The secondary outcomes included WOMAC physical function and stiffness subscores and the WOMAC global score, all ranging from 0 (no symptoms) to 10 (extreme symptoms) at 24 weeks of follow-up, and serious adverse events.

RESULTS

Among the 220 randomized participants (mean age, 65.2 years [SD, 9.3 years]; 104 women [47.3%]), 219 received the allocated treatment and 213 (96.8%) completed follow-up. At 24 weeks of follow-up, the mean standardized WOMAC pain subscore improved from 4.3 to 1.3 in the biomechanical footwear group and from 4.0 to 2.6 in the control footwear group (between-group difference in scores at 24 weeks of follow-up, -1.3 [95% CI, -1.8 to -0.9]; P < .001). The results were consistent for WOMAC physical function subscore (between-group difference, -1.1 [95% CI, -1.5 to -0.7]), WOMAC stiffness subscore (between-group difference, -1.4 [95% CI, -1.9 to -0.9]), and WOMAC global score (between-group difference, -1.2 [95% CI, -1.6 to -0.8]) at 24 weeks of follow-up. Three serious adverse events occurred in the biomechanical footwear group compared with 9 in the control footwear group (2.7% vs 8.3%, respectively); none were related to treatment.

CONCLUSIONS AND RELEVANCE

Among participants with knee pain from osteoarthritis, use of biomechanical footwear compared with control footwear resulted in an improvement in pain at 24 weeks of follow-up that was statistically significant but of uncertain clinical importance. Further research would be needed to assess long-term efficacy and safety, as well as replication, before reaching conclusions about the clinical value of this device.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02363712.

Which Nonsurgical Treatments Do Patients Believe Are Most Effective for Hip and Knee Arthritis?

BACKGROUND

The purpose of this study was to determine which nonsurgical treatments patients believe are most effective for managing pain secondary to hip and knee arthritis.

METHODS

Five hundred sixty-five consecutive patients were administered an anonymous questionnaire developed in consultation with a center with expertise in survey design. Statistical analyses included Student t-test, Fisher Exact, Wilcoxon Rank-Sum test, and generalized cost-effectiveness analysis.

RESULTS

Four hundred thirty-six patients completed the questionnaire (response rate 77.2%). Opioids (52 of 118; 44.1%), prescription nonsteroidal anti-inflammatory drugs (NSAIDs) (67 of 200; 33.5%), and corticosteroid injections (87 of 260; 33.5%) were reported as most effective. Stem cell and platelet-rich plasma injections were selected by three of 12 (25.0%) and three of 15 patients (19.5%), respectively, and physical therapy (PT) by 50 of 257 patients (19.5%). Twenty-five percent of respondents received opioids, commonly prescribed by primary care providers (48.2%) and orthopaedic surgeons (39.5%). Opioid use correlated with lower patient-reported effectiveness of PT, NSAIDs, and corticosteroid injections (P < 0.05). The highest cost-effectiveness ratios were NSAIDs, opioids, and acetaminophen (2.2, 3.7, 4.0, and 5.4, respectively). The lowest cost-effectiveness ratios were stem cell injections, platelet-rich plasma injections, and PT (1966.7, 520.8, and 138.6, respectively).

CONCLUSIONS

The nonsurgical treatments that are reported by patients to be most effective are oftentimes the least expensive.

Biological Regeneration of Articular Cartilage in an Early Stage of Compartmentalized Osteoarthritis: 12-Month Results

BACKGROUND

Biological regeneration in an early stage of osteoarthritis (OA) is an important clinical challenge. An early-stage compartmentalized OA model was used to evaluate different biological regeneration techniques.

HYPOTHESIS

Biological regeneration in an early stage of compartmentalized OA is possible.

STUDY DESIGN

Controlled laboratory study.

METHODS

A 7-mm cartilage defect was surgically created in 24 sheep. After 3 months, by which time early OA had set in, the sheep were randomized into 4 different treatment groups and operated for the second time. One group (CONTROL) served as a long-term follow-up group for the further development of OA. The other 3 groups (regeneration groups) each underwent a different regeneration procedure after abrasion of the subchondral bone (defect size: 20 × 10 mm with a depth of 2.5 mm): spongialization alone (SPONGIO), spongialization followed by implantation of an unseeded hyaluronan matrix (MATRIX), or spongialization followed by implantation of a hyaluronan matrix seeded with autologous chondrocytes (MACT). Then, 12 months after the second operative procedure, the animals were euthanized and the defects subjected to macroscopic and histological grading. Historical 4-month data were compared with the 12-month results.

RESULTS

After 12 months of follow-up, advanced cartilage degeneration was observed in the CONTROL group. On the other hand, all regeneration groups improved significantly compared with the 4-month results using the Mankin score. Cartilage quality in the MACT group was significantly better than in the MATRIX group, as determined by the Mankin and the O'Driscoll scores.

CONCLUSION

There are no existing clinical options for preventing early OA from progressing to a severe disease. This study provides important information on how a surgical intervention can forestall the development of OA.

CLINICAL RELEVANCE

OA of the knee is very common. Total joint replacement is not an acceptable option for active patients. Biological regeneration in OA is successful for focal cartilage defects; however, a long-term follow-up for biological regeneration in OA is missing. It is essential to have long-term results for a regenerative procedure involving cartilage, which is a tissue with a very slow turnover.

Neighborhood built and social environment and meeting physical activity recommendations among mid to older adults with joint pain

Arthritis is a leading cause of disability in the United States, with the most efficacious treatments being physical activity (PA). Arthritis patients are less likely to meet PA recommendations and the neighborhood environment may play a role. This study examines the effect of neighborhood walkability and social cohesion on PA among arthritis patients in a sample of US adults. This cross-sectional study used 2015 National Health Interview Survey data. Eligible participants were age ≥45 years, had arthritis, recent leg-joint pain and complete data. Walkability was based on 6 questions regarding amenities and destinations that promote walking. Social cohesion was based on 4 validated questions. Meeting PA was defined as 150 min/week. Chi-squared testing and logistic regression determined associations between neighborhood environment and PA, including interaction between social cohesion and walkability. The final unweighted sample included 3,826 participants with mean age 64.6 years (SE = 0.26), 61.8% female and 78.1% non-Hispanic White. In adjusted, weighted analysis, not, slightly, and moderately-walkable neighborhoods all had lower odds of meeting PA recommendations verses highly-walkable neighborhood (OR = 0.61[95% CI 0.41–0.92], OR = 0.65[95% CI 0.50–0.85], OR = 0.75[95% CI 0.59–0.97], respectively). Social cohesion was independently associated with decreased odds of meeting PA guidelines (p = 0.003). No interaction with walkability was found (p = 0.405). Less than a highly-walkable neighborhood and lower social cohesion were independently associated with decreased odds of meeting PA recommendations among adults with arthritis and recent joint pain. Since walking is one of the most effective treatments for arthritis, clinicians should be sensitive to barriers patients may perceive to walking.

Computerised cognitive training for 12 or more weeks for maintaining cognitive function in cognitively healthy people in late life

BACKGROUND

Increasing age is associated with a natural decline in cognitive function and is the greatest risk factor for dementia. Cognitive decline and dementia are significant threats to independence and quality of life in older adults. Therefore, identifying interventions that help to maintain cognitive function in older adults or that reduce the risk of dementia is a research priority. Cognitive training uses repeated practice on standardised exercises targeting one or more cognitive domains and may be intended to improve or maintain optimal cognitive function. This review examines the effects of computerised cognitive training interventions lasting at least 12 weeks on the cognitive function of healthy adults aged 65 or older and has formed part of a wider project about modifying lifestyle to maintain cognitive function. We chose a minimum 12 weeks duration as a trade-off between adequate exposure to a sustainable intervention and feasibility in a trial setting.

OBJECTIVES

To evaluate the effects of computerised cognitive training interventions lasting at least 12 weeks on cognitive function in cognitively healthy people in late life.

SEARCH METHODS

We searched to 31 March 2018 in ALOIS (www.medicine.ox.ac.uk/alois), and we performed additional searches of MEDLINE, Embase, PsycINFO, CINAHL, ClinicalTrials.gov, and the WHO Portal/ICTRP (www.apps.who.int/trialsearch), to ensure that the search was as comprehensive and as up-to-date as possible to identify published, unpublished, and ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs, published or unpublished, reported in any language. Participants were cognitively healthy people, and at least 80% of the study population had to be aged 65 or older. Experimental interventions adhered to the following criteria: intervention was any form of interactive computerised cognitive intervention - including computer exercises, computer games, mobile devices, gaming console, and virtual reality - that involved repeated practice on standardised exercises of specified cognitive domain(s) for the purpose of enhancing cognitive function; the duration of the intervention was at least 12 weeks; cognitive outcomes were measured; and cognitive training interventions were compared with active or inactive control interventions.

DATA COLLECTION AND ANALYSIS

We performed preliminary screening of search results using a 'crowdsourcing' method to identify RCTs. At least two review authors working independently screened the remaining citations against inclusion criteria. At least two review authors also independently extracted data and assessed the risk of bias of included RCTs. Where appropriate, we synthesised data in random-effects meta-analyses, comparing computerised cognitive training (CCT) separately with active and inactive controls. We expressed treatment effects as standardised mean differences (SMDs) with 95% confidence intervals (CIs). We used GRADE methods to describe the overall quality of the evidence for each outcome.

MAIN RESULTS

We identified eight RCTs with a total of 1183 participants. The duration of the interventions ranged from 12 to 26 weeks; in five trials, the duration of intervention was 12 or 13 weeks. The included studies had moderate risk of bias, and the overall quality of evidence was low or very low for all outcomes. We compared CCT first against active control interventions, such as watching educational videos. Negative SMDs favour CCT over control. Trial results suggest slight improvement in global cognitive function at the end of the intervention period (12 weeks) (standardised mean difference (SMD) -0.31, 95% confidence interval (CI) -0.57 to -0.05; 232 participants; 2 studies; low-quality evidence). One of these trials also assessed global cognitive function 12 months after the end of the intervention; this trial provided no clear evidence of a persistent effect (SMD -0.21, 95% CI -0.66 to 0.24; 77 participants; 1 study; low-quality evidence). CCT may result in little or no difference at the end of the intervention period in episodic memory (12 to 17 weeks) (SMD 0.06, 95% CI -0.14 to 0.26; 439 participants; 4 studies; low-quality evidence) or working memory (12 to 16 weeks) (SMD -0.17, 95% CI -0.36 to 0.02; 392 participants; 3 studies; low-quality evidence). Because of the very low quality of the evidence, we are very uncertain about the effects of CCT on speed of processing and executive function. We also compared CCT to inactive control (no interventions). We found no data on our primary outcome of global cognitive function. At the end of the intervention, CCT may lead to slight improvement in episodic memory (6 months) (mean difference (MD) in Rivermead Behavioural Memory Test (RBMT) -0.90 points, 95% confidence interval (CI) -1.73 to -0.07; 150 participants; 1 study; low-quality evidence) but can have little or no effect on executive function (12 weeks to 6 months) (SMD -0.08, 95% CI -0.31 to 0.15; 292 participants; 2 studies; low-quality evidence), working memory (16 weeks) (MD -0.08, 95% CI -0.43 to 0.27; 60 participants; 1 study; low-quality evidence), or verbal fluency (6 months) (MD -0.11, 95% CI -1.58 to 1.36; 150 participants; 1 study; low-quality evidence). We could not determine any effects on speed of processing because the evidence was of very low quality. We found no evidence on quality of life, activities of daily living, or adverse effects in either comparison.

AUTHORS' CONCLUSIONS

We found low-quality evidence suggesting that immediately after completion of the intervention, small benefits of CCT may be seen for global cognitive function when compared with active controls, and for episodic memory when compared with an inactive control. These benefits are of uncertain clinical importance. We found no evidence that the effect on global cognitive function persisted 12 months later. Our confidence in the results was low, reflecting the overall quality of the evidence. In five of the eight trials, the duration of the intervention was just three months. The possibility that more extensive training could yield larger benefit remains to be more fully explored. We found substantial literature on cognitive training, and collating all available scientific information posed problems. Duration of treatment may not be the best way to categorise interventions for inclusion. As the primary interest of older people and of guideline writers and policymakers involves sustained cognitive benefit, an alternative would be to categorise by length of follow-up after selecting studies that assess longer-term effects.

A Longitudinal Study of the Association of Opioid Use with Change in Pain Interference and Functional Limitations in a Nationally Representative Cohort of Adults with Osteoarthritis in the United States

Introduction

Real-world data are sparse on longitudinal associations of opioid use with pain interference with activities (PIA) and daily function with osteoarthritis (OA) in the USA.

Methods

Data from the 2010–2015 Medical Expenditure Panel Surveys were analyzed for community-dwelling adults with OA. Opioid use patterns were defined as persistent, intermittent, and no use. Evaluated outcomes were a change in PIA and functional limitations (activities of daily living [ADL], instrumental ADL [IADL], social and work activities, and cognitive function). Multivariable regression analyses explored the association of persistent/intermittent versus no opioid use with PIA and functional limitations. Results were weighted for the US population.

Results

Among 4172 patients (66.2% female, 80.8% white, mean age 61.7 years), 62.1% reported no PIA change at follow-up, 17.9% worsened, and 20.0% improved. Although 51.0–93.1% of patients reported no functional limitations, 3.8–13.1% worsened (1.1–11.3% improved). Relative to no opioid use, persistent users had higher odds of severe/extreme PIA (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.95–4.32; P < 0.001) and moderate PIA (AOR, 2.04; 95% CI, 1.31–3.20; P < 0.01) at follow-up. For patients with baseline functional limitations, persistent opioid users were more likely to report physical and work limitations at follow-up (both P < 0.05). For patients without baseline functional limitations, persistent opioid users had higher odds than those without use of reporting IADL, physical, social, and cognitive limitations at follow-up (all P < 0.05); intermittent users were more likely to report physical and social limitations (both P < 0.05).

Conclusions

Persistent opioid use for pain in patients with OA appeared to be associated with poorer PIA and functional outcomes, regardless of baseline functional status. These findings highlight the importance of patient-reported outcomes for opioid benefit–risk assessment and suggest the need for alternative analgesic approaches.

[The clinical status and treatment options for osteoarthritis in patients with frailty]

Aging is an independent risk factor for the development of many diseases and geriatric syndromes. Osteoarthritis (OA), as the most common joint disease in the elderly, can be attributed to age - associated conditions. And the most significant geriatric syndrome, which dramatically affects the management and prognosis of an elderly, is frailty. The review provides current information on the prevalence of OA and frailty, their clinical and prognostic significance, and also shows the mutually aggravating role of these two conditions. The difference between non - and medication management of patients with OA and frailty is emphasized.