Development of multinational definitions of minimal clinically important improvement and patient acceptable symptomatic state in osteoarthritis

Digitally delivered education and exercises for patients with hand osteoarthritis-An observational study

Hand osteoarthritis (OA) is a common form of OA, for which education and exercise are considered the first-line treatment. The aim of the present study was to examine pain and perceived hand function in participants following 3 months of digitally delivered first-line treatment for hand OA. Three-hundred-and-seventy-nine of 846 participants with clinical signs and symptoms of hand OA completed the study. The digital hand OA treatment program consists of video instructed daily exercises and patient education through text lessons. Pain (NRS, 0 no pain, 10 worst) was the primary outcome, and stiffness (NRS) and the Functional Index for Hand OsteoArthritis (FIHOA, 0 best, 30 worst) were among secondary outcomes. The McNemar test and linear mixed effect regression model were used to assess the changes in outcomes from baseline to 3-month. After three months, the digitally delivered program was associated with a significant decrease in pain intensity (mean change -1.30 (95% CI -1.49, -1.12)) and hand stiffness (mean change -0.81 (95% CI -1.02, -0.60)) but no conclusive changes in the FIHOA scores (mean change 0.3 (95% CI -0.2, 0.7)). The results agree with reports on face-to-face delivered first-line treatment for hand OA suggesting that digital treatment is a viable treatment option in patients with hand OA.

An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery

Background

This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes.

Methods

A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed.

Results

In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles.

Conclusions

There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.

Methotrexate to treat hand osteoarthritis with synovitis (METHODS): an Australian, multisite, parallel-group, double-blind, randomised, placebo-controlled trial

BACKGROUND

Hand osteoarthritis is a disabling condition with few effective therapies. Hand osteoarthritis with synovitis is a common inflammatory phenotype associated with pain. We aimed to examine the efficacy and safety of methotrexate at 6 months in participants with hand osteoarthritis and synovitis.

METHODS

In this multisite, parallel-group, double-blind, randomised, placebo-controlled trial, participants (aged 40-75 years) with hand osteoarthritis (Kellgren and Lawrence grade ≥2 in at least one joint) and MRI-detected synovitis of grade 1 or more were recruited from the community in Melbourne, Hobart, Adelaide, and Perth, Australia. Participants were randomly assigned (1:1) using block randomisation, stratified by study site and self-reported sex, to receive methotrexate 20 mg or identical placebo orally once weekly for 6 months. The primary outcome was pain reduction (measured with a 100 mm visual analogue scale; VAS) in the study hand at 6 months assessed in the intention-to-treat population. Safety outcomes were assessed in all randomly assigned participants. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000877381).

FINDINGS

Between Nov 22, 2017, and Nov 8, 2021, of 202 participants who were assessed for eligibility, 97 (48%) were randomly assigned to receive methotrexate (n=50) or placebo (n=47). 68 (70%) of 97 participants were female and 29 (30%) were male. 42 (84%) of 50 participants in the methotrexate group and 40 (85%) of 47 in the placebo group provided primary outcome data. The mean change in VAS pain at 6 months was -15·2 mm (SD 24·0) in the methotrexate group and -7·7 mm (25·3) in the placebo group, with a mean between-group difference of -9·9 (95% CI -19·3 to -0·6; p=0·037) and an effect size (standardised mean difference) of 0·45 (0·03 to 0·87). Adverse events occurred in 31 (62%) of 50 participants in the methotrexate group and 28 (60%) of 47 participants in the placebo group.

INTERPRETATION

Treatment of hand osteoarthritis and synovitis with 20 mg methotrexate for 6 months had a moderate but potentially clinically meaningful effect on reducing pain, providing proof of concept that methotrexate might have a role in the management of hand osteoarthritis with an inflammatory phenotype.

FUNDING

National Health and Medical Research Council of Australia.

Novel Tools to Approach and Measure Outcomes in Patients with Fractures

Upper extremity fractures are prevalent and pose a great burden to patients and society. In the US alone, the annual incidence of upper extremity fractures is 67.6 fractures per 10,000 persons. While the majority of patients with upper extremity fractures demonstrate satisfactory outcomes when treated appropriately (the details of which are discussed in prior articles), the importance of follow-up and outcome measurement cannot be understated. Outcome measurement allows for accountability and improvement in clinical outcomes and research. The purpose of this article is to describe recent advances in methods and tools for assessing clinical and research outcomes in hand and upper extremity care. Three specific advances that are broadly changing the landscape of follow-up care of our patients include: 1) telemedicine, 2) patient-reported outcome measurement, and 3) wearables/remote patient monitoring.

Associations between pain sensitization and measures of physical function in people with hand osteoarthritis: Results from the Nor-Hand study

OBJECTIVE

To examine whether pain sensitization is associated with hand and lower extremity function in people with hand osteoarthritis (OA) in the Nor-Hand study.

DESIGN

Pain sensitization was assessed by pressure pain thresholds (PPTs) and temporal summation (TS). Hand function was assessed by Australian/Canadian Osteoarthritis Hand Index (AUSCAN) (range: 0-36), grip strength and Moberg pick-up test, and lower extremity function was assessed by Western Ontario and McMaster Universities Osteoarthritis Index (range: 0-68), 30-s chair stand test, and 40-m walk test. We examined whether sex-standardized PPT and TS values were cross-sectionally associated with measures of physical function using linear regression analyses. Beta coefficients were presented per sex-specific standard deviation of PPT and TS. The mediating effect of pain was examined by causal-inference based mediation analysis.

RESULTS

In 206 participants, higher PPTs at/near the hand, indicative of less peripheral and/or central pain sensitization, were associated with greater grip strength and better self-reported hand function (beta for PPT at finger joint on AUSCAN function: -1.41, 95% CI -2.40, -0.42). Higher PPTs at/near the hand, near the knee and at trapezius were associated with lower extremity function, although not statistically significant for all outcomes. Self-reported pain severity mediated the effect of PPT on self-reported function. TS was not associated with hand or lower extremity function.

CONCLUSION

Peripheral sensitization, and possibly central sensitization, was associated with impaired function. Effects of PPTs on self-reported function were mediated by self-reported pain, whereas there might be a direct effect of sensitization or effects through other mediators on performance-based function.

Glucagon-like peptide-1 receptor agonists as a disease-modifying therapy for knee osteoarthritis mediated by weight loss: findings from the Shanghai Osteoarthritis Cohort

OBJECTIVE

Obesity is a risk factor for knee osteoarthritis (KOA) development and progression. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are indicated for type 2 diabetes mellitus (T2DM) and obesity. However, whether KOA patients can benefit from GLP-1RA therapies has not been sufficiently investigated, especially in the long term.

METHODS

The Shanghai Osteoarthritis Cohort study is a prospective, observational, multicentre study of >40 000 adults with clinically diagnosed osteoarthritis aged >45 years in Shanghai. We identified all KOA participants with comorbid T2DM enrolled from 1 January 2011 to 1 January 2017. Primary outcome was incidence of knee surgery after enrolment. Secondary outcomes included pain-relieving medication use, number of intra-articular therapies, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and medial femorotibial joint cartilage thickness. To evaluate the effects of GLP-1RA, we performed before-and-after comparison and comparison with participants who had no GLP-1RA exposure.

RESULTS

For an intergroup comparison (non-GLP-1RA vs GLP-1RA), more weight loss (adjusted mean difference in weight change from baseline -7.29 kg (95% CI -8.07 to -6.50 kg), p<0.001) and lower incidence of knee surgery (93/1574 (5.9%) vs 4/233 (1.7%), adjusted p=0.014) were observed in the GLP-1RA group. Statistically significant differences in mean change from baseline for the WOMAC total and pain subscale scores were observed (adjusted mean difference in WOMAC total score -1.46 (95% CI -2.84 to -0.08), p=0.038; adjusted mean difference in WOMAC pain subscore -3.37 (95% CI -5.79 to -0.94), p=0.007). Cartilage-loss velocity of the medial femorotibial joint was significantly lower in the GLP-1RA group postadjustment for baseline characteristics (adjusted mean difference -0.02 mm (95% CI -0.03 to -0.002 mm), p=0.004). For the before-and-after comparison within the GLP-1RA group, we observed a significant decrease of symptom-relieving medication consumption and cartilage loss velocity of medial femorotibial joint (after-treatment vs before-treatment: -0.03±0.05 vs -0.05±0.07 mm/year, p<0.001). The association between GLP-1RA exposure and decreased incidence of knee surgery was mediated by weight reduction (mediation proportion: 32.1%), instead of glycaemic control (too small to calculate).

CONCLUSION

With sufficient treatment duration, GLP-1RA therapies might be disease-modifying for KOA patients with comorbid T2DM, possibly mediated by weight loss. Further investigation is needed to elucidate effects of GLP-1RA on disease process, joint structure and patient-reported outcomes of osteoarthritis.

EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis

RATIONALE

Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS.

DESIGN

Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method.

RESULTS

The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus.

CONCLUSION

These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.

Minimal important change and difference for knee osteoarthritis outcome measurement tools after non-surgical interventions: a systematic review

OBJECTIVES

To systematically review and provide estimates of the minimal important change (MIC) and difference (MID) for outcome tools in people with knee osteoarthritis (OA) after non-surgical interventions. Design A systematic review.

DATA SOURCES

MEDLINE, CINAHL, Web of Science, Scopus and Cochrane databases were searched up to 21 September 2021.

ELIGIBILITY CRITERIA

We included studies that calculated MIC and MID using any calculation method including anchor, consensus and distribution methods, for any knee OA outcome tool after non-surgical interventions.

DATA EXTRACTION AND SYNTHESIS

We extracted reported MIC, MID and minimum detectable change (MDC) estimates. We used quality assessment tools appropriate to the studies' methods to screen out low-quality studies. Values were combined to produce a median and range, for each method.

RESULTS

Forty-eight studies were eligible (anchor-k=12, consensus-k=1 and distribution-k=35). MIC values for 13 outcome tools including Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, activities of daily living (ADL), quality of life (QOL) and Western Ontario and McMaster Universities Arthritis Index (WOMAC)-function were estimated using 5 high-quality anchor studies. MID values for 23 tools including KOOS-pain, ADL, QOL and WOMAC-function, stiffness and total were estimated using 6 high-quality anchor studies. One moderate quality consensus study reported MIC for pain, function and global assessment. MDC values from distribution method estimates for 126 tools including KOOS-QOL and WOMAC-total were estimated using 38 good-to-fair-quality studies.

CONCLUSION

Median MIC, MID and MDC estimates were reported for outcome tools in people with knee OA after non-surgical interventions. The results of this review clarify the current understanding of MIC, MID and MDC in the knee OA population. However, some estimates suggest considerable heterogeneity and require careful interpretation.

PROSPERO REGISTRATION NUMBER

CRD42020215952.

Colchicine twice a day for hand osteoarthritis (COLOR): a double-blind, randomised, placebo-controlled trial

BACKGROUND

Colchicine has been suggested for osteoarthritis treatment, but evidence is contradictory. We aimed to investigate colchicine's efficacy and safety compared with placebo in people with hand osteoarthritis.

METHODS

In this single-centre, double-blind, randomised, placebo-controlled trial we recruited adults with symptomatic hand osteoarthritis and finger pain of at least 40 mm on a 100 mm visual analogue scale from an outpatient clinic in Denmark. The hand with the most severe finger pain at inclusion was the target hand. Participants were randomly assigned (1:1) to 0·5 mg colchicine or placebo taken orally twice a day for 12 weeks, stratified by BMI (≥30 kg/m2), sex, and age (≥75 years). Participants, outcome assessors, and data analysts were masked to treatment allocation. The primary endpoint was change from baseline to week 12 in target hand finger pain, assessed on a 100 mm visual analogue scale with a pre-specified minimal clinically important difference of 15 mm, in the intention-to-treat population. Safety was assessed at week 12 in the intention-to-treat population. The study was registered with ClinicalTrials.gov, NCT04601883, and with EudraCT, 2020-002803-20.

FINDINGS

Between Jan 15, 2021, and March 3, 2022, 186 people were screened for eligibility, and 100 were randomly assigned to receive colchicine (n=50) or placebo (n=50). Participants had a mean age of 70·9 (SD 7·5) years, 69 (69%) of 100 were women and 31 (31%) were men. All participants completed the study. The mean change from baseline to week 12 in finger pain were -13·9 mm (SE 2·8) in the colchicine group and -13·5 mm (2·8) in the placebo group, with a between-group difference (colchicine vs placebo) of -0·4 mm (95% CI -7·6 to 6·7; p=0·90). In the colchicine group, there were 76 adverse events in 36 (72%) of 50 participants and one serious adverse advent (migraine attack leading to hospital admission). In the placebo group, there were 42 adverse events in 22 (44%) of 50 participants and two serious adverse events (cholecystitis and elevated alanine aminotransferase concentrations, in the same patient).

INTERPRETATION

In people with painful hand osteoarthritis, treatment with 0·5 mg of colchicine twice day for 12 weeks did not effectively relieve pain, and treatment with colchicine was associated with more adverse events.

FUNDING

The Oak Foundation, IMK Almene Fond, Minister Erna Hamilton's Scholarship for Science and Art, AP Moller and Wife Chastine McKinney Moller's Foundation for Medical Science Advancement, The Danish Medical Association, the Velux Foundation, Aase and Ejnar Danielsen's Foundation, and Director Emil C Hertz and Wife Inger Hertz's foundation.

The effects of a mobile app-delivered intervention in people with symptomatic hand osteoarthritis: a pragmatic randomized controlled trial

BACKGROUND

Exercise therapy, self-management and education are recommended interventions for hand osteoarthritis (OA), but new delivery systems are needed to solve lack of adherence.

AIM

To determine the effects on hand function and pain related measures of a mobile app-delivered intervention, compared with usual care, in patients with symptomatic hand OA.

DESIGN

A pragmatic, multicenter, two-group parallel randomized controlled trial.

SETTING

Community health centers in rural southern Spain.

POPULATION

Eighty-three participants with unilateral or bilateral symptomatic hand OA were proposed to participate, and finally 74 were included and randomized.

METHODS

Participants received a home multimodal treatment (exercise, education, and self-management recommendations) with the CareHand mobile app or usual care (written exercises) over 12 weeks. Monthly telephone calls were performed to monitor adherence. The primary outcome was hand physical function (Australian/Canadian Hand Osteoarthritis Index, AUSCAN) at 3- and 6-months. Secondary measures included hand pain intensity and morning stiffness, upper limb function, hand dexterity, and grip and pinch strength.

RESULTS

The CareHand group showed significant within-group changes in hand function at 6-months (-3.0, 95% CI -5.1 to -0.9 vs. usual care: -0.9, 95% CI -3.3 to 1.5). Neither group showed improvements in hand function at 3-months (CareHand: -1.5, 95% CI -3.1 to 0.1; usual care: -0.5, 95% CI -2.7 to 1.7). For the secondary outcomes, the CareHand group showed better results on upper limb function both at 3- and 6-months, and on pain both at 1- and 3-months compared to usual care group. Linear regression models indicated that baseline scores of pain intensity, hand status, and upper limb function were associated with a greater improvement in hand pain and physical function.

CONCLUSIONS

A mobile app-delivered intervention is effective for improving hand function, and better than usual care for upper limb function and pain. Further research is warranted to understand the impact of mobile health (mHealth) in people with hand OA.

CLINICAL REHABILITATION IMPACT

mHealth interventions are a feasible and secure multimodal delivery approach in older adults with hand OA in rural primary care setting. Baseline pain and upper limb function might predict functional hand outcomes.

Harmonising knee pain patient-reported outcomes: a systematic literature review and meta-analysis of Patient Acceptable Symptom State (PASS) and individual participant data (IPD)

OBJECTIVE

In order to facilitate data pooling between studies, we explored harmonisation of patient-reported outcome measures (PROMs) in people with knee pain due to osteoarthritis or knee trauma, using the Patient Acceptable Symptom State scores (PASS) as a criterion.

METHODS

We undertook a systematic literature review (SLR) of PASS scores, and performed individual participant data (IPD) analysis of score distributions from concurrently completed PROM pairs. Numerical rating scales (NRS), visual analogue scales, KOOS and WOMAC pain questionnaires were standardised to 0 to 100 (worst) scales. Meta-regression explored associations of PASS. Bland Altman plots compared PROM scores within individuals using IPD from WebEx, KICK, MenTOR and NEKO studies.

RESULTS

SLR identified 18 studies reporting PASS in people with knee pain. Pooled standardised PASS was 27 (95% CI: 21 to 35; n = 6,339). PASS was statistically similar for each standardised PROM. Lower PASS was associated with lower baseline pain (β = 0.49, P = 0.01) and longer time from treatment initiation (Q = 6.35, P = 0.04). PASS scores were lowest in ligament rupture (12, 95% CI: 11 to 13), but similar between knee osteoarthritis (31, 95% CI: 26 to 36) and meniscal tear (27, 95% CI: 20 to 35). In IPD, standardised PROMs each revealed similar group mean scores, but scores within individuals diverged between PROMs (LoA between -7 to -38 and +25 to 52).

CONCLUSION

Different standardised PROMs give similar PASS thresholds in group data. PASS thresholds may be affected more by patient and treatment characteristics than between PROMs. However, different PROMs give divergent scores within individuals, possibly reflecting different experiences of pain.

The disability associated with hand osteoarthritis is substantial in a cohort of post-menopausal women: the QUALYOR study

OBJECTIVES

Our primary aims were to assess current prevalence of HOA and the disability associated with this condition, in the group usually most affected, i.e., women older than 55.

METHODS

We performed hand radiographs, clinical examination, grip strength measurement, AUSCAN and COCHIN questionnaires in a cohort of postmenopausal women aged at least 55. Radiographic hand OA (RHOA) was defined as at least 2 affected joints among 30, grading 2 or more using the Kellgren Lawrence score but without any HOA symptom. Symptomatic HOA (OA ACR) was defined according to ACR criteria for hand OA. Moderate to severe symptomatic HOA was defined as having OA ACR and AUSCAN total score of >43/100.

RESULTS

We enrolled 1,189 participants. The mean age was 71.7 years. Inter-reader reliability of radiographs reading was good (ICC = 0.86) and intra-reader reliability was excellent (ICC = 0.97). Among the 1,189 women, 333 (28.0%) had RHOA, 482 (40.5%) patients fulfilled the ACR criteria for symptomatic HOA and 82 of these (17% of OA ACR population) had moderate to severe symptomatic HOA. The prevalence of symptomatic erosive osteoarthritis was 11.8%. Mean AUSCAN and Cochin scores were higher and grip strength lower in patients with symptomatic HOA compared to patient without HOA. Differences were more noticeable in patients with moderate to severe HOA.

CONCLUSIONS

We have assessed disability associated with HOA in greater detail than previously and found that a third of postmenopausal women had RHOA, two fifths had symptomatic HOA and one sixth of symptomatic patients had moderate to severe HOA related disability and a tenth had symptomatic erosive osteoarthritis, representing a substantial burden of disease in our population-based cohort.

Infection after total joint replacement of the hip and knee: research programme including the INFORM RCT

Background

People with severe osteoarthritis, other joint conditions or injury may have joint replacement to reduce pain and disability. In the UK in 2019, over 200,000 hip and knee replacements were performed. About 1 in 100 replacements becomes infected, and most people with infected replacements require further surgery.

Objectives

To investigate why some patients are predisposed to joint infections and how this affects patients and the NHS, and to evaluate treatments.

Design

Systematic reviews, joint registry analyses, qualitative interviews, a randomised controlled trial, health economic analyses and a discrete choice questionnaire.

Setting

Our studies are relevant to the NHS, to the Swedish health system and internationally.

Participants

People with prosthetic joint infection after hip or knee replacement and surgeons.

Interventions

Revision of hip prosthetic joint infection with a single- or two-stage procedure.

Main outcome measures

Long-term patient-reported outcomes and reinfection. Cost-effectiveness of revision strategies over 18 months from two perspectives: health-care provider and Personal Social Services, and societal.

Data sources

National Joint Registry; literature databases; published cohort studies; interviews with 67 patients and 35 surgeons; a patient discrete choice questionnaire; and the INFORM (INFection ORthopaedic Management) randomised trial.

Review methods

Systematic reviews of studies reporting risk factors, diagnosis, treatment outcomes and cost comparisons. Individual patient data meta-analysis.

Results

In registry analyses, about 0.62% and 0.75% of patients with hip and knee replacement, respectively, had joint infection requiring surgery. Rates were four times greater after aseptic revision. The costs of inpatient and day-case admissions in people with hip prosthetic joint infection were about five times higher than those in people with no infection, an additional cost of > £30,000. People described devastating effects of hip and knee prosthetic joint infection and treatment. In the treatment of hip prosthetic joint infection, a two-stage procedure with or without a cement spacer had a greater negative impact on patient well-being than a single- or two-stage procedure with a custom-made articulating spacer. Surgeons described the significant emotional impact of hip and knee prosthetic joint infection and the importance of a supportive multidisciplinary team. In systematic reviews and registry analyses, the risk factors for hip and knee prosthetic joint infection included male sex, diagnoses other than osteoarthritis, high body mass index, poor physical status, diabetes, dementia and liver disease. Evidence linking health-care setting and surgeon experience with prosthetic joint infection was inconsistent. Uncemented fixation, posterior approach and ceramic bearings were associated with lower infection risk after hip replacement. In our systematic review, synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy for prosthetic joint infection. Systematic reviews and individual patient data meta-analysis showed similar reinfection outcomes in patients with hip or knee prosthetic joint infection treated with single- and two-stage revision. In registry analysis, there was a higher rate of early rerevision after single-stage revision for hip prosthetic joint infection, but, overall, 40% fewer operations are required as part of a single-stage procedure than as part of a two-stage procedure. The treatment of hip or knee prosthetic joint infection with early debridement and implant retention may be effective in > 60% of cases. In the INFORM randomised controlled trial, 140 patients with hip prosthetic joint infection were randomised to single- or two-stage revision. Eighteen months after randomisation, pain, function and stiffness were similar between the randomised groups (p = 0.98), and there were no differences in reinfection rates. Patient outcomes improved earlier in the single-stage than in the two-stage group. Participants randomised to a single-stage procedure had lower costs (mean difference –£10,055, 95% confidence interval –£19,568 to –£542) and higher quality-adjusted life-years (mean difference 0.06, 95% confidence interval –0.07 to 0.18) than those randomised to a two-stage procedure. Single-stage was the more cost-effective option, with an incremental net monetary benefit at a threshold of £20,000 per quality-adjusted life-year of £11,167 (95% confidence interval £638 to £21,696). In a discrete choice questionnaire completed by 57 patients 18 months after surgery to treat hip prosthetic joint infection, the most valued characteristics in decisions about revision were the ability to engage in valued activities and a quick return to normal activity.

Limitations

Some research was specific to people with hip prosthetic joint infection. Study populations in meta-analyses and registry analyses may have been selected for joint replacement and specific treatments. The INFORM trial was not powered to study reinfection and was limited to 18 months’ follow-up. The qualitative study subgroups were small.

Conclusions

We identified risk factors, diagnostic biomarkers, effective treatments and patient preferences for the treatment of hip and knee prosthetic joint infection. The risk factors include male sex, diagnoses other than osteoarthritis, specific comorbidities and surgical factors. Synovial fluid alpha-defensin and leucocyte esterase showed high diagnostic accuracy. Infection is devastating for patients and surgeons, both of whom describe the need for support during treatment. Debridement and implant retention is effective, particularly if performed early. For infected hip replacements, single- and two-stage revision appear equally efficacious, but single-stage has better early results, is cost-effective at 18-month follow-up and is increasingly used. Patients prefer treatments that allow full functional return within 3–9 months.

Future work

For people with infection, develop information, counselling, peer support and care pathways. Develop supportive care and information for patients and health-care professionals to enable the early recognition of infections. Compare alternative and new treatment strategies in hip and knee prosthetic joint infection. Assess diagnostic methods and establish NHS diagnostic criteria.

Study registration

The INFORM randomised controlled trial is registered as ISRCTN10956306. All systematic reviews were registered in PROSPERO (as CRD42017069526, CRD42015023485, CRD42018106503, CRD42018114592, CRD42015023704, CRD42017057513, CRD42015016559, CRD42015017327 and CRD42015016664).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 10. See the NIHR Journals Library website for further project information.

Identification of Symptom Phenotypes of Hand Osteoarthritis Using Hierarchical Clustering: Results From the DIGICOD Cohort

OBJECTIVE

We aimed to delineate phenotypes in hand osteoarthritis (HOA) based on cardinal symptoms (pain, functional limitation, stiffness, and aesthetic discomfort).

METHODS

With data from the Digital Cohort Design (DIGICOD), we performed a hierarchical agglomerative clustering analysis based on Australian/Canadian Osteoarthritis Hand Index (AUSCAN) subscores for pain, physical function, stiffness, and visual analog scale for aesthetic discomfort. Kruskal-Wallis and post hoc analyses were used to assess differences between clusters.

RESULTS

Among 389 patients, we identified 5 clusters: cluster 1 (n = 88) and cluster 2 (n = 91) featured low and mild symptoms; cluster 3 (n = 80) featured isolated aesthetic discomfort; cluster 4 (n = 42) featured a high level of pain, stiffness, and functional limitation; and cluster 5 (n = 88) had the same features as cluster 4 but with high aesthetic discomfort. For clusters 4 and 5, AUSCAN pain score was >41 of 100, representing only one-third of our patients. Aesthetic discomfort (clusters 3 and 5) was significantly associated with erosive HOA and a higher number of nodes. The highly symptomatic cluster 5 was associated but not significantly with metabolic syndrome, and body mass index and C-reactive protein level did not differ among clusters. Symptom intensity was significantly associated with joint destruction as well as with physical and psychological burden. Patients' main expectations differed among clusters, and function improvement was the most frequent expectation overall.

CONCLUSION

The identification of distinct clinical clusters based on HOA cardinal symptoms suggests previously undescribed subtypes of this condition, warranting further study of biological characteristics of such clusters, and opening a path toward phenotype-based personalized medicine in HOA.

Is high intensity laser therapy more effective than other physical therapy modalities for treating knee osteoarthritis? A systematic review and network meta-analysis

Background

The use of physical therapy modalities, especially high intensity laser therapy (HILT), for individuals with knee osteoarthritis (KOA) is still controversial.

Objective

To compare the effects of HILT to other physical therapy modalities on symptoms and function in individuals with KOA.

Methods

Six databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, and PEDro) were searched in March 2022. Included studies were randomized controlled trials involving HILT conducted on individuals with KOA. The end-trial weighted mean difference (WMD) and standard deviations (SD) with 95% confidence intervals (CI) were analyzed.

Results

Ten studies with 580 participants were obtained, of which nine were included in the final network meta-analysis. In terms of relieving pain, HILT demonstrated the highest probability of being among the most effective treatments, with surface under the cumulative ranking (SUCRA) = 100%, and compared to a control (placebo laser or exercise or a combination of both) on the visual analog scale (VAS) for pain it demonstrated significant benefits (WMD 1.66, 95% CI 1.48–1.84). For improving self-reported function, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores, the HILT SUCRA value led with 98.9%. When individuals with KOA were treated by HILT, the improvement in stiffness was statistically significant (WMD 0.78, 95% CI 0.52–1.04) but the amount of improvement was smaller than the minimal clinically important difference (MCID).

Conclusion

The current evidence suggests that HILT may be more effective than other physical therapy modalities for improving pain and function in individuals with KOA. For improving stiffness, however, it may not be clinically effective.

Systematic review registration

[https://www.researchregistry.com], identifier [1148].

Krill oil improved osteoarthritic knee pain in adults with mild to moderate knee osteoarthritis: a 6-month multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Osteoarthritis (OA) is a major cause of chronic pain and disability worldwide. Treatment generally focuses on symptom relief through nonsteroidal anti-inflammatory drugs (NSAIDs) and analgesics, which may incur side effects. Krill oil, rich in anti-inflammatory long-chain (LC) omega-3 ( ω-3) PUFAs and astaxanthin, may be a safe and effective alternative treatment.

OBJECTIVES

This study sought to investigate the effects of a commercially available krill oil supplement on knee pain in adults with mild to moderate knee OA. Secondary outcomes were knee stiffness; physical function; NSAID use; Omega-3 Index; and lipid, inflammatory, and safety markers.

METHODS

Healthy adults (n = 235, 40-65 y old, BMI >18.5 to <35 kg/m2), clinically diagnosed with mild to moderate knee OA, regular knee pain, and consuming <0.5 g/d LC ω-3 PUFAs, participated in a 6-mo double-blind, randomized, placebo-controlled, multicenter trial. Participants consumed either 4 g krill oil/d (0.60 g EPA/d, 0.28 g DHA/d, 0.45 g astaxanthin/d) or placebo (mixed vegetable oil). Knee outcomes were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) numeric scale (normalized to scores of 0-100). Outcomes were assessed at baseline, 3 mo, and 6 mo.

RESULTS

Omega-3 Index increased with the krill oil supplement compared with placebo (from 6.0% to 8.9% compared with from 5.5% to 5.4%, P < 0.001). Knee pain score improved in both groups with greater improvements for krill oil than for placebo (difference in adjusted mean change between groups at 6 mo: -5.18; 95% CI: -10.0, -0.32; P = 0.04). Knee stiffness and physical function also had greater improvements with krill oil than with placebo (difference in adjusted mean change between groups at 6 mo: -6.45; 95% CI: -12.1, -0.9 and -4.67; 95% CI: -9.26, -0.05, respectively; P < 0.05). NSAID use, serum lipids, and inflammatory and safety markers did not differ between groups.

CONCLUSIONS

Krill oil was safe to consume and resulted in modest improvements in knee pain, stiffness, and physical function in adults with mild to moderate knee OA.This trial was registered at clinicaltrials.gov as NCT03483090.

Evaluation of the PROMIS Upper Extremity Against Validated Patient-Reported Outcomes in Patients With Early Carpometacarpal Osteoarthritis

PURPOSE

Internal consistency, construct, and criterion validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) v1.2 were evaluated in patients with early-stage carpometacarpal (CMC) osteoarthritis (OA). We hypothesized that in patients with early CMC OA, PROMIS UE scores would: (1) be lower than those in asymptomatic controls; (2) correlate with established patient-reported outcomes; (3) correlate with pinch and grip strengths; and (4) not correlate with radiographic disease progression.

METHODS

Patients with early CMC OA (modified Eaton stage 0 or 1) and matched asymptomatic control patients completed the PROMIS UE, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation at 2 time points. The PROMIS UE's internal consistency was evaluated by Cronbach's alpha, construct validity by Spearman correlation coefficients among the patient-reported outcome measures, and criterion validity using measures of strength. A floor or ceiling effect was indicated if more than 15% of patients achieved the lowest or highest possible score.

RESULTS

The PROMIS UE had high internal consistency. Patients with early CMC OA had a lower score than healthy controls (average, 42 vs 54, respectively). We observed moderate to high correlations between the PROMIS UEv1.2, Australian and Canadian Osteoarthritis Hand Index, and Patient-Rated Wrist-Hand Evaluation and good criterion validity when compared to key pinch and grip strengths. The PROMIS UE did not correlate to radiographic disease severity.

CONCLUSIONS

The PROMIS UE had a high correlation with Australian and Canadian Osteoarthritis Hand Index and a moderate correlation with Patient-Rated Wrist-Hand Evaluation. The PROMIS UE had high internal consistency and good criterion validity.

CLINICAL RELEVANCE

The PROMIS UE is a valid assessment for disability in patients with early CMC OA and can serve as a clinical adjunct to an outcome assessment.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

Minimal important difference and patient acceptable symptom state for the Numerical Rating Scale (NRS) for pain and the Patient-Rated Wrist/Hand Evaluation (PRWHE) for patients with osteoarthritis at the base of thumb

Background

The Numerical Rating Scale (NRS) and Patient-rated wrist/hand evaluation (PRWHE) are patient-reported outcomes frequently used for evaluating pain and function of the wrist and hand. The aim of this study was to determine thresholds for minimal important difference (MID) and patient acceptable symptom state (PASS) for NRS pain and PRWHE instruments in patients with base of thumb osteoarthritis.

Methods

Fifty-two patients with symptomatic base of thumb osteoarthritis wore a splint for six weeks before undergoing trapeziectomy. NRS pain (0 to 10) and PRWHE (0 to 100) were collected at the time of recruitment (baseline), after splint immobilization prior to surgery, and at 3, 6, 9 and 12 months after surgery. Four anchor-based methods were used to determine MID for NRS pain and PRWHE: the receiver operating characteristics (ROC) curve, the mean difference of change (MDC), the mean change (MC) and the predictive modelling methods. Two approaches were used to determine PASS for NRS pain and PRWHE: the 75^th percentile and the ROC curve methods. The anchor question for MID was the change perceived by the patient compared with baseline; the anchor question for PASS was whether the patient would be satisfied if the condition were to stay similar. The correlation between the transition anchor at baseline and the outcome at all time points combined was calculated using the Spearman’s rho analysis.

Results

The MID for NRS pain was 2.5 using the ROC curve method, 2.0 using the MDC method, 2.8 using the MC method, and 2.5 using the predictive modelling method. The corresponding MIDs for PRWHE were 22, 24, 10, and 20. The PASS values for NRS pain and PRWHE were 2.5 and 30 using the ROC curve method, and 2.0 and 22 using the 75th percentile method, respectively. The area under curve (AUC) analyses showed excellent discrimination for all measures.

Conclusion

We found credible MID estimates for NRS and PRWHE (including its subscales), although the MID estimates varied depending on the method used. The estimates were 20-30% of the range of scores of the instruments. The cut-offs for MID and PASS showed good or excellent discrimination, lending support for their use in future studies.

Trial registration

This clinimetrics study was approved by the Helsinki University ethical review board (HUS1525/2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01600-1.

Multimodal prediction of pain and functional outcomes 6 months following total knee replacement: a prospective cohort study

BACKGROUND

Knee osteoarthritis (OA) is among the most common and disabling persistent pain conditions, with increasing prevalence and impact around the globe. In the U.S., the rising prevalence of knee OA has been paralleled by an increase in annual rates of total knee arthroplasty (TKA), a surgical treatment option for late-stage knee OA. While TKA outcomes are generally good, post-operative trajectories of pain and functional status vary substantially; a significant minority of patients report ongoing pain and impaired function following TKA. A number of studies have identified sets of biopsychosocial risk factors for poor post-TKA outcomes (e.g., comorbidities, negative affect, sensory sensitivity), but few prospective studies have systematically evaluated the unique and combined influence of a broad array of factors.

METHODS

This multi-site longitudinal cohort study investigated predictors of 6-month pain and functional outcomes following TKA. A wide spectrum of relevant biopsychosocial predictors was assessed preoperatively by medical history, patient-reported questionnaire, functional testing, and quantitative sensory testing in 248 patients undergoing TKA, and subsequently examined for their predictive capacity.

RESULTS

The majority of patients had mild or no pain at 6 months, and minimal pain-related impairment, but approximately 30% reported pain intensity ratings of 3/10 or higher. Reporting greater pain severity and dysfunction at 6 months post-TKA was predicted by higher preoperative levels of negative affect, prior pain history, opioid use, and disrupted sleep. Interestingly, lower levels of resilience-related "positive" psychosocial characteristics (i.e., lower agreeableness, lower social support) were among the strongest, most consistent predictors of poor outcomes in multivariable linear regression models. Maladaptive profiles of pain modulation (e.g., elevated temporal summation of pain), while not robust unique predictors, interacted with psychosocial risk factors such that the TKA patients with the most pain and dysfunction exhibited lower resilience and enhanced temporal summation of pain.

CONCLUSIONS

This study underscores the importance of considering psychosocial (particularly positively-oriented resilience variables) and sensory profiles, as well as their interaction, in understanding post-surgical pain trajectories.

Open-Label Pilot Study of a Single Intra-Articular Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid (HANOX-M-XL) for the Treatment of the First Metatarsophalangeal Osteoarthritis (Hallux Rigidus): The REPAR Trial

Purpose:

The purpose of this study was to obtain information on safety and short-term efficiency of a single intra-articular injection of mannitol-modified cross-linked hyaluronic acid (HANOX-M-XL) in patients with painful first metatarsophalangeal joint osteoarthritis (1stMTPJ-OA).

Methods:

The study involved an observational, single-arm, prospective multicentre trial, with a 3-month follow-up. Inclusion criteria were patients with symptomatic 1st MTPJ-OA not relieved by analgesics and / or non-steroidal-anti-inflammatory drugs and / or foot orthotic. All patients received a single, imaging-guided intra-articular (IA) injection of 1 mL of HANOX-M-XL in the 1st MTPJ. The primary outcome was the change in pain between the date of injection and month 3. The secondary outcomes were the patient assessment of effectiveness, the decrease in painkiller use and the influence of the radiographic score on the clinical efficacy.

Results:

Sixty-five participants (72.3% women, mean age = 60) were included in the trial. Coughlin-Shurnas radiological grade was 1 in 28 patients, 2 in 29, and 3 in 6. At baseline and month 3, the average pain (0-10) was 6.5 ± 1.8 and 2.8 ± 2.3, respectively. The change in pain score was highly significant (−3.1 ± 2.9; P < .0001). At baseline there was no statistically difference in pain between the radiological stages (P = .69). At endpoint, the average pain score was 2.0 ± 1.9 in x-ray stage 1, 3.1 ± 2.3 in stage 2 and 3.3 ± 2.4 in stage 3 (P = .001). Mild to moderate adverse reactions were reported by 15 patients. All were a transient increase of the hallux pain that occurred immediately and up to 6 hours after injection and resolved in 1 to 7 days.

Conclusion:

This pilot study suggests that a single IA injection of HANOX-M-XL is safe and mainly benefits patients with mild moderate 1st MTPJ-OA. Further randomized controlled trials are necessary to confirm these preliminary encouraging results.

Efficacy of mud plus bath therapy as compared to bath therapy in osteoarthritis of hands and knees: a pilot single-blinded randomized controlled trial

The primary objective of this study was to assess the efficacy of mud plus bath therapy in comparison to bath therapy alone in hand and knee osteoarthritis (HOA and KOA). We conducted a single-blinded randomized controlled trial (RCT). Patients were randomly assigned to either mud plus bath therapy (group 1) or balneotherapy (group 2). The primary outcome was a change in AUSCAN questionnaire for HOA and in WOMAC for KOA at month 12. Evaluations were performed at baseline (B), immediately after the interventions (week 2, W2) and after 3 (M3), 6 (M6), 9 (M9) and 12 (M12) months. 37 patients with KOA and 52 with HOA were randomized in the study. In HOA patients, AUSCAN pain improved more in group 1 compared to group 2 at M3, M6 and M12 (p<0.001, p=0.001 and p=0.038, respectively). AUSCAN stiffness improved more in group 1 at M3 (p=0.001). AUSCAN function improved more at M3, M6, M9 and M12 (p=0.001, p=0.001, p=0.014 and p=0.018, respectively). Regarding, KOA, WOMAC function decreased more prominently in group 1 compared to group 2 at M9 (p=0.007). The absolute values of WOMAC function at M6 and M9 were lower in group 1 compared to group 2 (p=0.029 and p=0.001, respectively). WOMAC pain absolute values were lower in group 1 at W2 (p=0.044) and at M9 (p=0.08). We conducted a RCT on the efficacy of mud plus balneotherapy over balneotherapy alone in HOA and KOA. We found that mud plus balneotherapy was more effective than balneotherapy alone on clinical outcomes of HOA. Differences in clinical outcomes of KOA were not significant, yet numerically higher.

Single and Composite Endpoints of Within-Patient Improvement in Symptoms: Pooled Tanezumab Data in Patients with Osteoarthritis

INTRODUCTION

Combining measures of key core domains (especially pain and function) into a composite endpoint that requires each patient to meet a threshold of improvement for each domain provides information on multiple aspects of osteoarthritis within individual patients. This pooled analysis of two phase 3 studies (NCT02697773, NCT02709486) explored single and composite endpoints for assessing within-patient improvement in knee or hip osteoarthritis symptoms following subcutaneous administration of tanezumab or placebo.

METHODS

Endpoints at week 16 included proportions of responders (≥ 30% improvement) in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain, WOMAC Physical Function, WOMAC Pain/Function composite, and weekly average pain; and patient acceptable symptom state (PASS) composite responders, minimal clinically important improvement (MCII) composite responders, Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) responders, and sustained weekly average pain responders.

RESULTS

Pooled population comprised 1545 patients. Of patients who had a ≥ 30% improvement in WOMAC Pain and/or WOMAC Physical Function, 88.5% were WOMAC Pain/Function composite responders, 7.0% were WOMAC Pain (but not Function) responders, and 4.4% were WOMAC Function (but not Pain) responders. Of weekly average pain responders, 43.1% were PASS composite responders. Odds ratios (tanezumab 2.5 mg and 5 mg groups, respectively, vs placebo) were 1.75 and 1.86 (WOMAC Pain/Function composite responders), 1.41 and 1.65 (weekly average pain responders), 1.60 and 1.73 (PASS composite responders), 1.52 and 1.68 (MCII composite responders), 1.75 and 1.88 (OMERACT-OARSI responders), and 1.85 and 1.48 (sustained weekly average pain responders). Subgroup analyses suggested a greater magnitude of effect for patients with a knee index joint compared with hip on some endpoints.

CONCLUSION

Responders on single pain endpoints were in many cases also responders on function or composite endpoints. Separation of tanezumab from placebo was similar and consistent across single and composite endpoints.

Core outcome measurement instrument selection for physical function in hand osteoarthritis using the OMERACT Filter 2.1 process

OBJECTIVE

Physical function is one of the Outcome Measures in Rheumatology (OMERACT) core outcome domains for hand osteoarthritis studies. Our aim was to select appropriate instrument(s) to measure this domain, as part of the development of a core outcome measurement set.

METHODS

Following the OMERACT Filter 2.1 instrument selection process, the (function subscale of) the Australian/Canadian Hand Osteoarthritis Index (AUSCAN), Functional Index for Hand Osteoarthritis (FIHOA) and Michigan Hand Outcomes Questionnaire (MHQ) were assessed for domain match, feasibility, truth and discrimination. Data gathered from available literature, working group and patient surveys, and additional analyses in two hand osteoarthritis cohorts were used to inform a consensus process. Results were summarized in Summary of Measurements Properties tables and reviewed by the OMERACT technical advisory group.

RESULTS

MHQ passed the assessment of domain match and feasibility by the working group and patient research partners. For AUSCAN important limitations in feasibility were noted, but domain match was good. FIHOA did not pass the assessment and was not taken through the follow-up assessment. Based on published literature, reliability and construct/longitudinal validity of both MHQ and AUSCAN fulfilled OMERACT standards. While clinical trial discrimination and thresholds of meaning were good for AUSCAN, results for MHQ were ambiguous.

CONCLUSION

MHQ was provisionally endorsed as OMERACT core outcome measure for the core domain physical function. While AUSCAN may have better metric properties than MHQ, it received provisional endorsement as a second measure of function due to important feasibility issues. A research agenda to merit full endorsement was set.

Factors Associated With Functional Decline in Hand and Hip/Knee Osteoarthritis After One Year: Data From a Population-Based Study

OBJECTIVE

To investigate factors that together with hand or hip/knee osteoarthritis (OA) could contribute to functional decline over a year's time in elderly individuals.

METHODS

The data of 1,886 individuals between ages 65 and 85 years in a prospective, observational population-based study with 12-18 months of follow-up in the context of the European Project on Osteoarthritis were analyzed. The outcome measures were self-reported hand and hip/knee functional decline, evaluated using a minimum clinically important difference of 4 on the Australian/Canadian Hand OA Index and of 2 on the Western Ontario and McMaster Universities Osteoarthritis Index hip/knee physical function subscales, both normalized to 0-100. Using regression models adjusted for sex, age, country, and education level, the baseline factors considered were clinical hand or hip/knee OA, pain, analgesic/antiinflammatory medications, comorbidities, social isolation, income, walking time, grip strength, physical activity time, and medical/social care.

RESULTS

After a year, 453 participants were identified as having worse hand functionality and 1,389 as not worse. Hand OA, anxiety, walking time, and grip strength were risk factors for hand functional decline; pain was a confounder of the effect of hand OA. Analgesic/antiinflammatory medications mediated the combined effect of hip/knee OA plus pain on functional decline in the 554 individuals classified as having worse hip/knee functionality and the 1,291 persons who were not worse. Peripheral artery disease, obesity, and cognitive impairment were other baseline risk factors.

CONCLUSION

Study findings showed that together with emotional status and chronic physical and cognitive conditions, OA affects hand and hip/knee functional decline.

The Development of Disease-Modifying Therapies for Osteoarthritis (DMOADs): The Evidence to Date

Osteoarthritis (OA) is a complex heterogeneous articular disease with multiple joint tissue involvement of varying severity and no regulatory-agency-approved disease-modifying drugs (DMOADs). In this review, we discuss the reasons necessitating the development of DMOADs for OA management, the classifications of clinical phenotypes or molecular/mechanistic endotypes from the viewpoint of targeted drug discovery, and then summarize the efficacy and safety profile of a range of targeted drugs in Phase 2 and 3 clinical trials directed to cartilage-driven, bone-driven, and inflammation-driven endotypes. Finally, we briefly put forward the reasons for failures in OA clinical trials and possible steps to overcome these barriers.

Long-term structural and symptomatic effects of intra-articular sprifermin in patients with knee osteoarthritis: 5-year results from the FORWARD study

OBJECTIVE

The FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) trial assessed efficacy and safety of the potential disease-modifying osteoarthritis drug (DMOAD) sprifermin in patients with knee osteoarthritis. Here, we report 5-year efficacy and safety results.

METHODS

Patients were randomised to intra-articular sprifermin 100 µg or 30 µg every 6 months (q6mo) or 12 months, or placebo, for 18 months. The primary analysis was at year 2, with follow-up at years 3, 4 and 5. Additional post hoc exploratory analyses were conducted in patients with baseline minimum radiographic joint space width 1.5-3.5 mm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain 40-90, a subgroup at risk (SAR) of progression.

RESULTS

378 (69%) patients completed the 5-year follow-up. A significant dose-response in total femorotibial joint cartilage thickness with sprifermin (trend test, p<0.001) and a 0.05 mm mean difference with sprifermin 100 µg q6mo versus placebo (95% CI 0.00 to 0.10; p=0.015) were sustained to year 5. WOMAC pain scores improved ~50% from baseline in all groups. No patient in the 100 µg q6mo group had replacement of the treated knee. 96%-98% of patients receiving sprifermin and 98% placebo reported adverse events, most were mild or moderate and deemed unrelated to treatment. Adverse event-related study withdrawals were <10%. Differentiation in WOMAC pain between sprifermin 100 µg q6mo and placebo in the SAR (n=161) at year 3 was maintained to year 5 (-10.08; 95% CI -25.68 to 5.53).

CONCLUSION

In the longest DMOAD trial reported to date, sprifermin maintained long-term structural modification of articular cartilage over 3.5 years post-treatment. Potential translation to clinical benefit was observed in the SAR.

TRIAL REGISTRATION NUMBER

NCT01919164.

The effects of sprifermin on symptoms and structure in a subgroup at risk of progression in the FORWARD knee osteoarthritis trial

OBJECTIVE

To assess pain outcomes and cartilage thickness change in a subgroup at risk (SAR) of further progression in the FORWARD trial of knee osteoarthritis patients treated with sprifermin.

METHODS

Patients were randomised 1:1:1:1:1 to: sprifermin 100 µg every 6 months (q6mo), 100 µg q12mo, 30 µg q6mo, 30 µg q12mo, or placebo for 18 months. SAR was defined as baseline medial or lateral minimum joint-space width (mJSW) 1.5-3.5 mm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score 40-90 units. Follow-up to 3 years was included in the analysis. Treatment benefit was explored by repeated measures, linear dose-effect trends by timepoint.

RESULTS

The SAR comprised 161 (29%) of 549 patients. Mean difference (95% CI) in WOMAC pain at year 3 for sprifermin 100 µg q6mo vs placebo SAR was -8.75 (-22.42, 4.92) for SAR vs 0.97 (-6.22, 8.16) for the intent-to-treat population. SAR placebo patients lost more cartilage over 2 years than the modified ITT (mITT) placebo arm (mean change from baseline, mm [SD]: -0.05 [0.10] vs -0.02 [0.07]). Net total femorotibial joint thickness gain with sprifermin 100 µg q6mo (adjusted mean difference from placebo [95% CI] was similar in the SAR and in the mITT group: 0.06 [0.01, 0.11] vs 0.05 [0.03, 0.07]).

CONCLUSIONS

Selection for low mJSW and moderate-to-high pain at baseline resulted in more rapid disease progression and demonstrated translation of structure modification (with maintained net benefit on total cartilage thickness) into symptomatic benefit. This subgroup may represent a target population for future trials.

CLINICAL TRIAL REGISTRATION

NCT01919164.

The presence of erosive joints is a strong predictor of radiological progression in hand osteoarthritis: results of a 2-year prospective follow-up of the Liège Hand Osteoarthritis Cohort (LIHOC)

Background

This study measured the magnitude and determinants of clinical and radiological progression in patients with hand osteoarthritis (HOA) over a 2-year prospective follow-up to gain a greater understanding of the disease time course.

Methods

Two hundred three consecutive outpatients diagnosed with HOA were followed for 2 years (183 women, median age 69 years). Pain and function were evaluated using the Australian/Canadian Osteoarthritis Hand Index (AUSCAN), and clinical examination recorded the number of painful/swollen joints and nodes. X-rays were scored using Kellgren-Lawrence (KL) and Verbruggen-Veys scales. Clinical progression was defined as deterioration in AUSCAN ≥ the minimal clinically important difference. Radiographic progression was defined as (a) one new erosive/remodeled joint, (b) progression of ≥ one anatomical stage in one joint, or (c) change in KL total score above the smallest detectable difference. Logistic regression was performed to determine whether patient characteristics influenced clinical and radiological progression.

Results

After 2 years, all radiographic scores deteriorated significantly in the study population (p <  0.05), and the number of proximal and distal interphalangeal nodes was significantly higher (p <  0.01). The AUSCAN, number of painful joints at rest or at pressure, number of swollen joints, and pain measure on a visual analog scale remained unchanged. At the individual level, the number of patients with clinically meaningful progression ranged from 25 to 42% (clinical progression) and from 22 to 76% (radiological progression). The only significant predictor of worsening of total AUSCAN was AUSCAN pain subscale < 74.5 (odds ratio [OR] 1.02 [1.01, 1.03]; p <  0.01). The presence of ≥ four swollen joints (OR 2.78 [1.21, 6.39]; p = 0.02) and erosive osteoarthritis (OR 13.23 [5.07, 34.56]; p <  0.01) at baseline predicted a new erosive joint. A meaningful change in KL was more frequent with painful joints at baseline (OR 3.43 [1.68, 7.01]; p <  0.01).

Conclusions

Evidence of radiological progression over 2 years was observed in patients with HOA in the LIHOC population even without clinical worsening of disease. For individual patients, baseline pain level is predictive for clinical progression and the presence of erosive or swollen joints are significant predictors of radiological progression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-020-02390-x.

Attainment of the Patient-acceptable Symptom State in 548 patients with rheumatoid arthritis: Influence of demographic factors

OBJECTIVES

To explore the clinical and socio-demographic factors associated with Patient Acceptable Symptom Status (PASS) in Rheumatoid Arthritis (RA).

METHODS

In a post-hoc analyses of a cross-sectional study, RA patients from 11 countries were included. PASS was assessed as acceptable/not acceptable status by the patient. Variables collected included socio-economic (gender, age and country gross domestic product (GDP) per capita) and clinical variables: DAS28-3vESR (28 joint counts and Erythrocyte Sedimentation Rate), the patient-reported Rheumatoid Arthritis Impact of Disease (RAID) score and its seven domains (scored 0 to 10). Patients in PASS or not were compared through univariable tests and factors associated with PASS assessed by multivariable forward conditional logistic regression. A similar analysis was performed in the subgroup patients in DAS28 remission (n=168).

RESULTS

A total of 548 patients were included: 80.5% female, mean (±SD) age 55.8±12.8years, disease duration 13.6±10.6 years, DAS28 3.6±1.5. Overall, 360 (65.7%) considered themselves to be in PASS. Independent factors positively associated with being in PASS were age>50 years [odds ratio, OR 1.67; (95% confidence Interval: 1.04-2.67)], a lower DAS28 [OR: 1.28 (1.08-1.52)], lower pain [OR:1.45 (1.27-1.64)] and better emotional well-being [OR:1.28 (1.13-1.45)]. Among patients in remission, being in PASS was positively associated with less severe pain [OR: 2.50 (1.79-3.84)], age>50 years [OR 3.30 (1.03 to10.87)] and living in a country of the low GDP category [OR: 5.08; (1.34-19.23)].

CONCLUSIONS

Being in PASS is related to many factors besides disease activity, including age, perceived impact of the disease and national GDP.

TKA patients experience less improvement than THA patients at 3 and 12 months after surgery. A retrospective observational cohort study

PURPOSE

To investigate whether WOMAC scores changes after THA or TKA are gender and joint specific.

METHODS

Retrospective cohort study. The data of 855 THA and 684 TKA patients were analyzed.

RESULTS

Follow-up time (p < 0.001), gender (p < 0.001), joint (p < 0.001), and interaction FU by joint (p < 0.001) had significant effects on WOMAC total and sub-scores. Patients after TKA perceived less improvement in all dimensions in comparison to THA patients (p < 0.001).

CONCLUSION

WOMAC score changes after THA or TKA are joint-specific. Patients after TKA perceived less improvement. These results can be used to adjust patients' expectations.

Defining Minimum Clinically Important Changes for the Patient Activity Scale II

OBJECTIVE

To define the minimum clinically important improvement (MCII) and minimum clinically important worsening (MCIW) for the Patient Activity Scale II (PAS-II; range 0-10), a recommended patient-reported outcome measuring rheumatoid arthritis disease activity.

METHODS

Data were taken from Forward, The National Databank for Rheumatic Diseases, from four 6-month data collection periods. Both anchor-based and distribution-based methods were used to estimate the MCII and MCIW. Anchor-based analyses used comparisons of pain and general health to the previous 6 months. Distribution-based analyses used 0.5 and 0.35 SDs. We stratified analyses based on the PAS-II score (above/below 3.7), hypothesizing that the MCII and MCIW would depend on the baseline score. To assess construct validity, we evaluated the odds of achieving the MCII in patients receiving new therapies.

RESULTS

In the overall sample, for pain and general health anchor questions, the MCIW was 0.50 and 0.55, respectively. The MCII was defined as 0.39 and 0.45, respectively, for pain and general health. The MCIW for anchor-based methods among participants with low disease activity was 1.10 (1.09/1.11 [pain/general health]), while the MCII for those with moderate-to-high disease activity was 1.09 (1.15/1.02 [pain/general health]). Distribution-based methods for 0.5 and 0.35 SD were 1.08 and 0.76, respectively, for pain and general health. There was fair-to-excellent agreement with clinically important differences in assessments of pain and disability. Patients receiving new treatments had 30% greater odds of achieving the MCII.

CONCLUSION

The minimum important change in PAS-II score was approximately 0.5. Among participants with a moderate-to-high PAS-II score , the MCII was 1.1, and among participants with low disease activity, the MCIW was 1.1.

Estimation of Minimally Important Differences and Patient Acceptable Symptom State Scores for the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form in Rheumatoid Arthritis

OBJECTIVE

Studies have supported the validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI) scale in rheumatoid arthritis (RA). Here, we characterize minimally important differences (MIDs) and patient acceptable symptom state (PASS) values.

METHODS

PROMIS PI scores were collected in four periods at 6-month intervals from patients with RA (n > 3200 per period). Both anchor- and distribution-based methods estimated MIDs. Anchors were pain comparisons, pain interference, and general health. Time responses for each anchor-response group (four administrations, each with three change periods) were averaged. The mean changes of the "somewhat worse" and "somewhat better" groups were used as estimates for MID for worsening and improvement, respectively. Distribution-based MID analyses used standardized error of measurement (SEM) and SD. PASS was estimated with the question "If your health was to remain for the rest of your life as it has been in the past 48 hours, would this be acceptable?" MIDs and PASS values were also estimated by baseline pain levels.

RESULTS

Anchor-based methods yielded estimates of 1.65 to 1.84 for worsening and -1.29 to -1.73 for improvement. The SEM estimate was 1.84. The PASS estimate for the entire group was 41.6. Substantial differences in MIDs and PASS were noted among baseline pain groups.

CONCLUSION

The best estimate of a group-level MID was approximately 2 points, similar to MIDs suggested in other conditions. The PASS value for the entire group was almost an SD better than the population mean. Results should enhance use of PROMIS PI in RA by facilitating interpretation of scores and changes.

The relationship between patient acceptable symptom state and disease activity in patients with psoriatic arthritis

OBJECTIVES

The Psoriatic Arthritis Disease Activity Score (PASDAS) and Disease Activity Index for Psoriatic Arthritis (DAPSA) are composite PsA disease activity measures. We sought to identify the PASDAS and DAPSA cut-off points consistent with patient acceptable symptom state (PASS), the threshold of symptoms beyond which patients consider themselves well, and examine PASS across published PASDAS and DAPSA thresholds for low, moderate and high disease activity.

METHODS

We used a standard protocol including physician assessment and patient-reported outcomes to prospectively record measures required to calculate PASDAS and DAPSA. We identified PASS thresholds for the PASDAS and DAPSA using receiver operating characteristics curve analyses. We assessed the frequency of reporting acceptable symptom state across disease activity thresholds for PASDAS and DAPSA scores.

RESULTS

A total of 229 patients (58.5% male, mean age 55.5 years, mean disease duration 17.1 years) were recruited. The PASS threshold for the PASDAS was 3.79 [area under the curve (AUC) 0.86, sensitivity 0.75, specificity 0.82] and for the DAPSA was 11.10 (AUC 0.91, sensitivity 0.89, specificity 0.82). With the PASDAS, 90% of patients defined as having low disease activity considered their symptom state acceptable, compared with 55% and 17% among those with moderate and high disease activity, respectively. With the DAPSA, 98% of patients in disease remission considered their symptom state acceptable compared with 85, 22 and 18% among those with low, moderate and high disease activity, respectively.

CONCLUSION

We have defined PASS thresholds for PASDAS and DAPSA. The PASDAS target for low disease activity and DAPSA targets of low disease activity or remission align well with PASS.

Determining the Patient Acceptable Symptomatic State for Patients Undergoing Arthroscopic Partial Meniscectomy in the Knee

BACKGROUND

Arthroscopic partial meniscectomy is one of the most common procedures in orthopaedic surgery. The patient acceptable symptomatic state (PASS), which defines a level of symptoms above which patients consider themselves well, remains to be well-defined in this population.

PURPOSE

Using an anchor-based approach, our goal was to determine the 1-year PASS for the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee (IKDC) Subjective Knee Form, the Western Ontario Meniscal Evaluation Tool (WOMET), and the Marx Activity Scale (MAS) in patients who were treated with partial knee meniscectomy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A consecutive series of patients with knee meniscal tears and a Kellgren-Lawrence grade of 0 to 2 treated with arthroscopic partial meniscectomy were eligible. The KOOS (0-100), IKDC (0-100), WOMET (0-100), and MAS (0-16) were administered at baseline and 12 months postoperatively. An external anchor question at 1 year postoperatively was used to determine PASS values. A receiver operating characteristic curve (ROC) analysis was used to determine the PASS value at which patients considered their status to be satisfactory.

RESULTS

The study included 110 patients (mean ± SD age, 53.8 ± 12.0 years), 57.3% were male, and the follow-up rate was 82%. In total, 70% of patients had an Outerbridge arthroscopic grade of 2 or lower. Based on ROC analysis, the 1-year postoperative PASS values (sensitivity, specificity) were 64.3 (47.8, 100.0) for KOOS Symptoms, 81.6 (71.6, 100.0) for KOOS Pain, 82.4 (82.1, 86.4) for KOOS Function in Daily Living, 71.0 (62.7, 81.8) for KOOS Function in Sport and Recreation, 51.0 (83.6, 95.5) for KOOS Knee-Related Quality of Life, 56.2 (82.1, 100.0) for IKDC, 58.5 (79.1, 100.0) for WOMET, and 7.0 (44.8, 68.2) for MAS. Baseline scores did not affect the PASS threshold across the different instruments. However, patients with higher baseline scores were more likely to achieve the PASS for the KOOS Symptoms (odds ratio [OR], 2.808; P = .047), IKDC (OR, 4.735; P = .006), and WOMET (OR, 2.985; P = .036). Age, sex, and cartilage status were not significantly related to the odds of achieving the PASS for any of the patient-reported outcome measures.

CONCLUSION

These findings allow researchers and clinicians to determine whether partial meniscectomy is meaningful to patients at the individual level and will be helpful for responder analysis in future trials related to the treatment of meniscal abnormality.

Efficacy and safety of the first-in-class imidazoline-2 receptor ligand CR4056 in pain from knee osteoarthritis and disease phenotypes: a randomized, double-blind, placebo-controlled phase 2 trial

OBJECTIVE

CR4056 is a selective imidazoline-2 (I2) receptor ligand with potent analgesic activity in animal pain models. This proof-of-concept study tested CR4056 efficacy and safety in patients with knee osteoarthritis (OA) and different phenotypes.

DESIGN

This is a multicenter, randomized, double-blind, placebo-controlled trial. Knee OA patients with moderate to severe pain received CR4056 (women 100 mg bid; men 200 mg bid) or placebo (both genders) for 14 days. The primary outcome was the change in WOMAC pain score (0-100 scale) compared to placebo, analyzed in the intention-to-treat population and pre-defined OA phenotypes.

RESULTS

213 patients were treated with CR4056 (92 women; 52 men) or placebo (69 overall). After 14 days, median WOMAC pain improvements were 10 points on placebo and 14, 20 and 16 in women, men, and pooled CR4056 groups (P = 0.184, 0.030 and 0.070 vs placebo, respectively). Pre-specified subgroup analysis in the metabolic OA phenotype (BMI ≥ 27.5 kg/m², N = 156) showed statistically significant differences in all CR4056-treated groups vs placebo of 12-18 points. Conversely, there were too few patients with a neuropathic or inflammatory phenotype for a meaningful analysis. CR4056 was well tolerated; the most common adverse event was mild headache.

CONCLUSIONS

Although the primary endpoint was met in males only, this exploratory phase 2 trial shows that CR4056 might be an effective analgesic against knee OA pain, especially in overweight patients representing the metabolic OA phenotype. These findings, along with the broad-spectrum analgesic activity of CR4056 in animal models, warrant further clinical investigation in OA and other pain conditions.

CLINICAL TRIAL REGISTRATION NUMBER

EudraCT 2015-001136-37.

Defining the Minimal Clinically Important Difference in Athletes Undergoing Arthroscopic Correction of Sports-Related Femoroacetabular Impingement: The Percentage of Possible Improvement

BACKGROUND

Measures of clinically meaningful improvement in patient-reported outcomes within orthopaedics are becoming a minimum requirement to establish the success of an intervention.

PURPOSE

To (1) define the minimal clinically important difference (MCID) at 2 years postoperatively in competitive athletes undergoing hip arthroscopic surgery for symptomatic, sports-related femoroacetabular impingement utilizing existing anchor- and distribution-based methods and (2) derive a measure of the MCID using the percentage of possible improvement (POPI) method and compare against existing techniques.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

There were 2 objective outcome measures-the modified Harris Hip Score (mHHS) and 36-Item Short Form Health Survey (SF-36)-administered at baseline and 2 years postoperatively. External anchor questions were used to determine the MCID through mean change, mean difference, and receiver operating characteristic (ROC) techniques. Distribution-based calculations consisted of 0.5 SD, effect size, and standard error of measurement techniques. The POPI was calculated alongside each technique as an achieved percentage change of maximum available improvement for each athlete relative to the individual baseline score. The impact of the preoperative baseline score on the MCID was assessed by assigning athletes to groups determined by baseline percentiles. Statistical analysis was performed, with P < .05 considered significant.

RESULTS

There were 576 athletes (96% male; mean age, 25.9 ± 5.7 years). The MCID score change (and POPI) for the mHHS and SF-36 ranged from 2.4 to 16.7 (21.6%-63.6%) and from 3.3 to 24.9 (22.1%-57.4%), respectively. The preoperative threshold value for achieving the ROC-determined MCID was 80.5 and 86.5 for the mHHS and 70.1 and 72.4 for the SF-36 for the patient-reported outcome measure (PROM) score- and POPI-calculated MCID, respectively. Through the commonly used mean change method, 40.0% (mHHS) and 42.4% (SF-36) of athletes were unable to achieve the MCID because of high baseline scores and PROM ceiling effects compared with 0% when the POPI technique was used. A highly significant difference for the overall MCID was observed between preoperative baseline percentile groups for the mHHS (P = .014) and SF-36 (P = .004) (improvement in points), while there was no significant difference between groups for either the mHHS (P = .487) or SF-36 (P = .417) using the POPI technique.

CONCLUSION

The MCID defined by an absolute value of improvement was unable to account for postoperative progress in a large proportion of higher functioning athletes. The POPI technique negated associated ceiling effects, was unrestricted by the baseline score, and may be more appropriate in quantifying clinically important improvement.

Estimates of Responsiveness, Minimally Important Differences, and Patient Acceptable Symptom State in Five Patient-Reported Outcomes Measurement Information System Short Forms in Systemic Lupus Erythematosus

OBJECTIVE

Examinations of Patient-Reported Outcomes Measurement Information System (PROMIS) measures in adult systemic lupus erythematosus (SLE) have provided support for their cross-sectional validity in SLE. We estimated responsiveness to change, meaningful changes (minimally important differences [MIDs]), and the patient acceptable symptom state (PASS) for five PROMIS short forms to facilitate longitudinal use and interpretation of PROMIS scales in SLE.

METHODS

Data from five administrations of PROMIS short forms in the FORWARD SLE cohorts were used. Pearson correlation coefficients were used to assess associations between changes in PROMIS measures and changes in anchor measures for responsiveness analyses. Worse, same, or better groups were defined for each anchor. Differences in PROMIS scores were calculated for each consecutive PROMIS administration; mean changes in PROMIS scores of individuals in the worse, same, and better groups were calculated. Both anchor-based and distribution-based methods were used to estimate MIDs. PASS was defined as the 75th-percentile positive score among those who considered their health to be acceptable or who were somewhat or very satisfied with their health.

RESULTS

All PROMIS short forms showed adequate responsiveness to changes in related patient-reported outcomes. However, only the fatigue and pain interference scales were responsive to self-reported SLE activity. Taking into account all methods, we estimated MIDs for each scale to be approximately two points. All PASS values were better than the population mean T-score of 50.

CONCLUSION

These results support use and further study of PROMIS short forms in SLE and should facilitate interpretation of PROMIS scores and changes.

Biomarkers in Painful Symptomatic Knee OA Demonstrate That MRI Assessed Joint Damage and Type II Collagen Degradation Products Are Linked to Disease Progression

Background

Osteoarthritis (OA) is the most prevalent arthritis worldwide, but the evolution of pain in relation to joint damage and biochemical markers are not well understood. We evaluated the relation between clinical pain measures and evoked pain in relation to structural damage and biochemical biomarkers in knee OA.

Methods

A cross-sectional study in people with knee OA and healthy controls was conducted. A total of 130 participants with advanced OA requiring total knee replacement (TKR) (n = 78), mild OA having standard care (n = 42) and non-OA controls (n = 6), with four drop-outs were assessed. Pain scoring was performed by the Western Ontario and McMaster Universities OA Index (WOMAC_P) and the Visual Analog Scale (VAS). Pain sensitization was assessed by pain pressure thresholds (PPTs). Knee magnetic resonance imaging (MRI) assessed joint damage using the MRI Knee OA Score (MOAKS). Overall MOAKS scores were created for bone marrow lesions (BMLs), cartilage degradation (CD), and effusion/Hoffa synovitis (tSyn). Type II collagen cleavage products (CTX-II) were determined by ELISA.

Results

The advanced OA group had a mean age of 68.9 ± 7.7 years and the mild group 63.1 ± 9.6. The advanced OA group had higher levels of pain, with mean WOMAC_P of 58.8 ± 21.7 compared with the mild OA group of 40.6 ± 26.0. All OA subjects had pain sensitization by PPT compared with controls (p < 0.05). WOMAC_P correlated with the total number of regions with cartilage damage (nCD) (R = 0.225, p = 0.033) and total number of BMLs (nBML) (R = 0.195, p = 0.065) using body mass index (BMI), age, and Hospital Anxiety and Depression Scale (HADS) as covariates. Levels of CTX-II correlated with tSyn (R = 0.313, p = 0.03), nBML (R = 0.252, p = 0.019), number of osteophytes (R = 0.33, p = 0.002), and nCD (R = 0.218, p = 0.042), using BMI and age as covariates. A multivariate analysis indicated that BMI and HADS were the most significant predictors of pain scores (p < 0.05).

Conclusion

People with both mild and advanced OA show features of pain sensitization. We found that increasing MRI-detected joint damage was associated with higher levels of CTX-II, suggesting that increasing disease severity can be assessed by MRI and CTX-II biomarkers to evaluate OA disease progression.

Clinical thresholds of symptoms for deciding on surgery for trapeziometacarpal osteoarthritis

The severity of preoperative symptoms at which patients are likely to achieve a minimal important change and patient acceptable symptom state after surgery may help the decision to perform surgery for trapeziometacarpal osteoarthritis. The study objective was to define these thresholds for pain at rest and during activities as well as for the brief Michigan Hand Outcomes Questionnaire. One hundred and fifty-one patients were examined before surgery and 3, 6 and 12 months after surgery. The minimal important change after surgery was 1.9, 3.9 and 16 scores for pain at rest, pain during activities and the brief Michigan Hand Outcomes Questionnaire, respectively. The respective patient acceptable symptom state values were 1.5, 2.5 and 70 after surgery. Our results show that patients with baseline pain values between 3.5 and 5.5 at rest, between 6.5 and 7.5 during activities and a presurgery brief Michigan Hand Outcomes Questionnaire score of about 47, have the greatest chance of achieving a relevant symptom change and an acceptable symptom state. The information from this study may help surgeons in deciding the surgical indications and help patients in their expectation in symptom relief after surgery. Level of evidence: IV.

Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

Low-level laser therapy (LLLT) is not recommended in major knee osteoarthritis (KOA) treatment guidelines. We investigated whether a LLLT dose-response relationship exists in KOA.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eligible articles were identified through PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials on 18 February 2019, reference lists, a book, citations and experts in the field.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We solely included randomised placebo-controlled trials involving participants with KOA according to the American College of Rheumatology and/or Kellgren/Lawrence criteria, in which LLLT was applied to participants' knee(s). There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

The included trials were synthesised with random effects meta-analyses and subgrouped by dose using the World Association for Laser Therapy treatment recommendations. Cochrane's risk-of-bias tool was used.

RESULTS

22 trials (n=1063) were meta-analysed. Risk of bias was insignificant. Overall, pain was significantly reduced by LLLT compared with placebo at the end of therapy (14.23 mm Visual Analogue Scale (VAS; 95% CI 7.31 to 21.14)) and during follow-ups 1-12 weeks later (15.92 mm VAS (95% CI 6.47 to 25.37)). The subgroup analysis revealed that pain was significantly reduced by the recommended LLLT doses compared with placebo at the end of therapy (18.71 mm (95% CI 9.42 to 27.99)) and during follow-ups 2-12 weeks after the end of therapy (23.23 mm VAS (95% CI 10.60 to 35.86)). The pain reduction from the recommended LLLT doses peaked during follow-ups 2-4 weeks after the end of therapy (31.87 mm VAS significantly beyond placebo (95% CI 18.18 to 45.56)). Disability was also statistically significantly reduced by LLLT. No adverse events were reported.

CONCLUSION

LLLT reduces pain and disability in KOA at 4-8 J with 785-860 nm wavelength and at 1-3 J with 904 nm wavelength per treatment spot.

PROSPERO REGISTRATION NUMBER

CRD42016035587.

Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With Osteoarthritis: The FORWARD Randomized Clinical Trial

IMPORTANCE

Sprifermin is under investigation as a disease-modifying osteoarthritis drug.

OBJECTIVE

To evaluate the effects of sprifermin on changes in total femorotibial joint cartilage thickness in the more symptomatic knee of patients with osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) was a 5-year, dose-finding, multicenter randomized clinical trial conducted at 10 sites. Eligible participants were aged 40 to 85 years with symptomatic, radiographic knee osteoarthritis and Kellgren-Lawrence grade 2 or 3. Enrollment began in July 2013 and ended in May 2014; the last participant visit occurred on May 8, 2017. The primary outcome at 2 years and a follow-up analysis at 3 years are reported.

INTERVENTIONS

Participants were randomized to 1 of 5 groups: intra-articular injections of 100 μg of sprifermin administered every 6 months (n = 110) or every 12 months (n = 110), 30 μg of sprifermin every 6 months (n = 111) or every 12 months (n = 110), or placebo every 6 months (n = 108). Each treatment consisted of weekly injections over 3 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was change in total femorotibial joint cartilage thickness measured by quantitative magnetic resonance imaging at 2 years. The secondary end points (of 15 total) included 2-year change from baseline in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The minimal clinically important difference (MCID) is unknown for the primary outcome; for total WOMAC score in patients with hip and knee osteoarthritis, the absolute MCID is 7 U (95% CI, 4 to 10 U) and the percentage MCID is 14% (95% CI, 9% to 18%).

RESULTS

Among 549 participants (median age, 65.0 years; 379 female [69.0%]), 474 (86.3%) completed 2-year follow-up. Compared with placebo, the changes from baseline to 2 years in total femorotibial joint cartilage thickness were 0.05 mm (95% CI, 0.03 to 0.07 mm) for 100 μg of sprifermin administered every 6 months; 0.04 mm (95% CI, 0.02 to 0.06 mm) for 100 μg of sprifermin every 12 months; 0.02 mm (95% CI, -0.01 to 0.04 mm) for 30 μg of sprifermin every 6 months; and 0.01 mm (95% CI, -0.01 to 0.03 mm) for 30 μg of sprifermin every 12 months. Compared with placebo, there were no statistically significant differences in mean absolute change from baseline in total WOMAC scores for 100 μg of sprifermin administered every 6 months or every 12 months, or for 30 μg of sprifermin every 6 months or every 12 months. The most frequently reported treatment-emergent adverse event was arthralgia (placebo: n = 46 [43.0%]; 100 μg of sprifermin administered every 6 months: n = 45 [41.3%]; 100 μg of sprifermin every 12 months: n = 50 [45.0%]; 30 μg of sprifermin every 6 months: n = 40 [36.0%]; and 30 μg of sprifermin every 12 months: n = 48 [44.0%]).

CONCLUSIONS AND RELEVANCE

Among participants with symptomatic radiographic knee osteoarthritis, the intra-articular administration of 100 μg of sprifermin every 6 or 12 months vs placebo resulted in an improvement in total femorotibial joint cartilage thickness after 2 years that was statistically significant, but of uncertain clinical importance; there was no significant difference for 30 μg of sprifermin every 6 or 12 months vs placebo. Durability of response also was uncertain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01919164.

Illness perceptions and their association with 2 year functional status and change in patients with hand osteoarthritis

Objective

To investigate the association between illness perceptions and disability both cross-sectionally and over 2 years in patients with hand OA.

Methods

Illness perceptions and self-reported disability were assessed at baseline and after 2 years in 384 patients with primary hand OA (mean age 61 years, 84% women, n = 312 with follow-up) with the Illness Perception Questionnaire - Revised (IPQ-R), Functional Index for Hand OA, Australian/Canadian Hand OA Index and HAQ. Risk ratios for high disability (highest quartile) at both time points were estimated for tertiles of IPQ-R dimensions, using Poisson regression. The mean IPQ dimension change difference between patients with and without disability progression (change Functional Index for Hand OA ⩾ 1, Australian/Canadian Hand OA Index > 1.4, HAQ > 0.22) was estimated with linear regression. Analyses were adjusted for age, Doyle index and baseline score.

Results

At baseline, stronger negative illness perceptions were associated with high disability. Baseline illness perceptions were also associated with high disability after 2 years, although adjustment made apparent that these associations were confounded by baseline disability status. Most illness perceptions changed over 2 years; understanding increased, OA was regarded as more chronic and fewer emotions and consequences and less personal and treatment control were experienced. The 2 year change in disability was different between patients with and without progression for the illness perceptions of more perceived consequences, symptoms, treatment control and emotions.

Conclusion

Illness perceptions seemed to be implicated in disability and its progression. Our results suggest that interventions could focus on improving baseline disability, potentially using illness perceptions to accomplish this goal.

Minimal clinically important decline in physical function over one year: EPOSA study

BACKGROUND

The Australian/Canadian hand Osteoarthritis Index (AUSCAN) and the Western Ontario and McMaster Universities knee and hip Osteoarthritis Index (WOMAC) are the most commonly used clinical tools to manage and monitor osteoarthritis (OA). Few studies have as yet reported longitudinal changes in the AUSCAN index regarding the hand. While there are published data regarding WOMAC assessments of the hip and the knee, the two sites have always evaluated separately. The current study therefore sought to determine the minimal clinically important difference (MCID) in decline in the AUSCAN hand and WOMAC hip/knee physical function scores over 1 year using anchor-based and distribution-based methods.

METHODS

The study analysed data collected by the European Project on Osteoarthritis, a prospective observational study investigating six adult cohorts with and without OA by evaluating changes in the AUSCAN and WOMAC physical function scores at baseline and 12-18 months later. Pain and stiffness scores, the performance-based grip strength and walking speed and health-related quality of life measures were used as the study's anchors. Receiver operating characteristic curves and distribution-based methods were used to estimate the MCID in the AUSCAN and WOMAC physical function scores; only the data of those participants who possessed paired (baseline and follow up-measures) AUSCAN and WOMAC scores were included in the analysis.

RESULTS

Out of the 1866 participants who were evaluated, 1842 had paired AUSCAN scores and 1845 had paired WOMAC scores. The changes in the AUSCAN physical function score correlated significantly with those in the AUSCAN pain score (r = 0.31). Anchor- and distribution-based approaches converged identifying 4 as the MCID for decline in the AUSCAN hand physical function. Changes in the WOMAC hip/knee physical function score were significantly correlated with changes in both the WOMAC pain score (r = 0.47) and the WOMAC stiffness score (r = 0.35). The different approaches converged identifying two as the MCID for decline in the WOMAC hip/knee physical function.

CONCLUSIONS

The most reliable MCID estimates of decline over 1 year in the AUSCAN hand and WOMAC hip/knee physical function scores were 4 and 2 points, respectively.

Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial

BACKGROUND

Conditioned pain modulation (CPM) is impaired in people with chronic pain such as knee osteoarthritis (KOA). The purpose of this randomized, controlled clinical trial was to investigate whether strong electroacupuncture (EA) was more effective on chronic pain by strengthening the CPM function than weak EA or sham EA in patients with KOA.

METHODS

In this multicenter, three-arm parallel, single-blind randomized controlled trial, 301 patients with KOA were randomly assigned. Patients were randomized into three groups based on EA current intensity: strong EA (> 2 mA), weak EA (< 0.5 mA), and sham EA (non-acupoint). Treatments consisted of five sessions per week, for 2 weeks. Primary outcome measures were visual analog scale (VAS), CPM function, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Three hundred one patients with KOA were randomly assigned, among which 271 (90.0%) completed the study (mean age 63.93 years old). One week of EA had a clinically important improvement in VAS and WOMAC but not in CPM function. After 2 weeks treatment, EA improved VAS, CPM, and WOMAC compared with baseline. Compared with sham EA, weak EA (3.8; 95% CI 3.45, 4.15; P < .01) and strong EA (13.54; 95% CI 13.23, 13.85; P < .01) were better in improving CPM function. Compared with weak EA, strong EA was better in enhancing CPM function (9.73; 95% CI 9.44, 10.02; P < .01), as well as in reducing VAS and total WOMAC score.

CONCLUSION

EA should be administered for at least 2 weeks to exert a clinically important effect on improving CPM function of KOA patients. Strong EA is better than weak or sham EA in alleviating pain intensity and inhibiting chronic pain.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trial Registry ( ChiCTR-ICR-14005411 ), registered on 31 October 2014.