Decreased Pain and Improved Dynamic Knee Instability Mediate the Beneficial Effect of Wearing a Soft Knee Brace on Activity Limitations in Patients With Knee Osteoarthritis

Cerebral Mechanism of Tuina on the Descending Pain Inhibitory System in Knee Osteoarthritis: Protocol for a Randomized Controlled Trial

BACKGROUND

Knee osteoarthritis (KOA) is reputedly the most common musculoskeletal disease of the lower limbs and the main cause of pain and disability among older individuals. Pain is the most significant and widespread symptom of KOA. The descending pain inhibitory system has a cardinal role in normal pain consciousness, and its malfunction may be one of the pathophysiological mechanisms in KOA. Crucially, the rostral ventromedial medulla (RVM) and periaqueductal gray (PAG), as important components of the descending pain inhibitory system, directly modulate the activity of the spinal neurons involved in pain transmission. Tuina, a manual therapy, is effective and safe for reducing clinical symptoms of KOA; however, the mechanism that influences pain through the descending pain inhibitory system in KOA is unclear.

OBJECTIVE

This study aims to investigate the modulatory implications of Tuina on the RVM and PAG, which have critical roles in the descending pain inhibitory system in patients with KOA.

METHODS

This randomized controlled parallel trial will be conducted at the Tuina Clinic of the Third Affiliated Hospital of Henan University of Chinese Medicine (Zhengzhou, China). Patients with KOA will be randomly assigned (1:1) to 6 weeks of health education or Tuina. All patients in both groups will accept a resting-state functional magnetic resonance scan at the beginning and end of the experiment, and the resting-state functional connectivity and the voxel-based morphometry analysis will be performed to detect the RVM and PAG function and structure changes. The clinical outcome assessments will be (1) the pressure pain thresholds, (2) the Numerical Rating Scale, (3) the Hamilton Depression Scale (HAMD), and (4) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Considering that this trial is a study of resting-state functional magnetic resonance imaging technology, resting-state functional connectivity and voxel-based morphometry are the primary outcomes, and clinical outcome assessments are secondary outcomes. Adverse events will be documented and assessed throughout. All main analyses will be carried out on the basis of the intention-to-treat principle. The outcome evaluators and data statisticians will be masked to the treatment group assignment to reduce the risk of bias.

RESULTS

This trial was approved by the ethics committee of the Third Affiliated Hospital of Henan University of Chinese Medicine. Enrollment began in December 2023, and the results of this trial are expected to be submitted for publication in May 2025.

CONCLUSIONS

This trial will identify a possible relationship between function and structure changes of RVM and PAG and the improvement of clinical variables, elucidating the effect of Tuina on the descending pain inhibitory system of patients with KOA. This trial will provide much-needed knowledge for Tuina for patients with KOA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300070289; https://www.chictr.org.cn/showproj.html?proj=182570.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52820.

Factors associated with pain pressure threshold in both local and remote sites in knee osteoarthritis

BACKGROUND

Knee osteoarthritis (KOA) is a prevalent condition, and its most frequent symptom is pain that often leads to disability. Pain sensitization is a core feature of KOA, and it can be measured through quantitative sensory testing protocols such as pain pressure threshold (PPT). However, there is a lack of understanding about the factors that may influence changes in PPTs in the KOA population.

OBJECTIVE

To explore the clinical and functional factors associated with PPTs in a sample of people with chronic KOA pain and to compare models of local (knees) and remote (thenar regions) sites.

DESIGN

Cross-sectional analysis of a prospective cohort.

SETTING

Primary care in public institution.

PARTICIPANTS

113 adults with KOA.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

Multivariable regression analyses evaluating demographic, clinical, and functional variables that could be associated with local and remote PPTs (main outcomes) were performed.

RESULTS

Both thenar region (adjusted-R2 : 0.29) and knee (adjusted-R2 : 0.45) models had the same significant negative association with being a female, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain levels (thenar: β: -0.15, p = .002; knee: β: -0.2, p < .001), and the 10-Meter Walking Test (thenar: β: -0.05, p = .038; knee: β: -0.08, p = .004). A small significant positive association with depressive symptoms was identified in both models, which acted as a confounder for WOMAC pain and was likely affected by unmeasured confounders.

CONCLUSIONS

PPTs in KOA pain are associated with functional outcomes such as the 10-Meter Walking Test and activity-related pain intensity; thus more disability is associated with smaller pain thresholds. Similarity between models may suggest central sensitization.

The effect of orthosis management on joint instability in knee joint disease: A systematic review

INTRODUCTION

Joint instability is a common finding of clinical importance in patients with knee disease. This literature review aimed to examine the evidence regarding the effect of orthosis management on joint instability in knee joint disease.

METHODS

The detailed protocol for this study was published in the International Prospective Register of Systematic Reviews in the field of health and social welfare (CRD 42022335360). A literature search was conducted on May 2023, using the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Physiotherapy Evidence Database (PEDro), and Institute of Electrical and Electronics Engineers (IEEE) Xplore. A secondary search was manually conducted using Google Scholar to address publication bias. Each database search strategy was described, and the search was conducted by independent reviewers.

RESULTS

A total of 281 studies were retrieved, 11 articles were included in the systematic review. Of the 11 articles selected, the number of included diseases was 2 for osteoarthritis, 7 for anterior cruciate ligament injuries, and 3 for posterior cruciate ligament injuries. In result, orthosis management may improve self-reported instability and functional assessment in patients with osteoarthritis, anterior cruciate ligament injury, and posterior cruciate ligament injury. However, an objective evaluation of anatomical instability did not indicate an improvement in joint instability.

CONCLUSION

The effects of orthosis management on knee instability might improve physical function and self-reported instability.

The Effectiveness of Tuina in Relieving Pain, Negative Emotions, and Disability in Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of Tuina in relieving the pain, negative emotions, and disability of patients with knee osteoarthritis (KOA).

DESIGN

Single-center, parallel, randomized controlled trial.

SETTING

Shanghai Guanghua Integrated Chinese and Western Medicine Hospital, Shanghai, China.

SUBJECTS

Adult patients with KOA who were able to speak Chinese and self-report symptoms were eligible.

METHODS

A total of 104 patients were randomly allocated to receive the 6-week treatment of Tuina (Tuina group) or celecoxib (celecoxib group). Data on pain, negative emotions, and disability were collected at baseline, at week 2, 4, and 6, and follow-up (1 month after the last treatment). The primary outcomes were the pressure pain thresholds. The secondary outcomes were: (1) numerical rating scale at rest and with movement; (2) Hamilton Anxiety Scale; (3) Hamilton Depression Scale; (4) Western Ontario and McMaster Universities Osteoarthritis Index; and (5) clinical effective rate. The adverse events of the trial were evaluated.

RESULTS

In total, 99 patients completed the follow-up. Generalized linear mixed models were constructed to analyse the between-group differences. Statistically significant differences were found in the interaction effects (P < .05). In evaluating the group effect, statistical differences were found at week 6 and follow-up (P < .05). Further, all variables showed a time effect (P < .05). A statistical difference in the clinical effective rate was found between the Tuina and celecoxib groups (P < .05).

CONCLUSIONS

Tuina produced superior effects for pain, negative emotions, and disability over time, as compared to celecoxib in patients with KOA.

Effect of low-level laser therapy plus exercise therapy on pain, range of motion, muscle strength, and function in knee osteoarthritis - a systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is commonly associated with multiple musculoskeletal impairments.

OBJECTIVE

The purpose of this review was (1) to investigate the effectiveness of LLLT plus ET on pain, ROM, muscle strength, and function in KOA immediately after therapy and (2) whether the effectiveness of LLLT plus ET could be sustained at follow-up (4 - 32 weeks).

METHODS

Six databases were systematically searched upto December 2021 to find relevant articles. Included studies were RCTs written in English, which compared LLLT plus ET with placebo LLLT plus ET in KOA. Three independent reviewers extracted data and assessed the quality of included studies. Standard mean difference (SMD) was used in meta-analysis using random effect model.

RESULT

Of the 6307 articles, 14 RCTs (820 patients) met the inclusion criteria. The results demonstrated that there was a significant difference in pain immediately after therapy (SMD: -0.58, p = 0.001) and at follow-up (SMD: -1.35, p = 0.05) in LLLT plus ET group. There were no significant differences in knee ROM, muscle strength, and knee function outcomes immediately and at follow-up.

CONCLUSION

Our findings indicate that LLLT plus ET could be considered to alleviate pain in the KOA. LLLT reduces pain at 4-8J with a wavelength of 640-905nm per point applied for 10-16 sessions at a frequency of 2 sessions/week. An exercise therapy program at prescribed dosage involving major muscle groups might help. However, LLLT plus ET is no more effective than placebo LLLT plus ET in improving ROM, muscle strength, and function in KOA.

Effect of Knee Orthosis and Kinesio Taping on Clinical and Neuromuscular Outcomes in Patients with Knee Osteoarthritis: A Randomized Clinical Trial

Objectives

Impaired proprioception and muscle weakness may not only be a consequence of knee osteoarthritis (OA) but also part of its pathogenesis. Thus, the enhancement of quadriceps strength and proprioceptive accuracy can play a pivotal role in the management of knee OA. This study aimed to investigate the effects of Kinesio tape and flexible knee orthosis in terms of clinical and neuromuscular outcomes in patients with knee OA.

Methods

This clinical trial was conducted on 56 patients with knee OA, randomly allocated to two groups: knee orthosis or Kinesio tape. The knee orthosis group wore a neoprene knee support for 4 weeks. For participants in the Kinesio tape group, tape was applied once a week, for 4 weeks. The primary outcomes were pain intensity and physical function evaluated through the visual analog scale and the Western Ontario and McMaster OA index. The secondary outcomes were concentric and isometric quadriceps strength, Joint Position Sense (JPS), Threshold to Detect Passive Motion (TTDPM), and force sense (FS), all measured by isokinetic dynamometry.

Results

All outcome measures were significantly improved in the orthosis group. The Kinesio tape group also demonstrated significant changes in all outcome measures except three proprioception components namely JPS (70° target), FS, and TTDPM. At the end of the fourth week, there were no significant between-group differences for measured parameters.

Conclusion

Wearing a flexible knee orthosis and/or Kinesio tape for 4 weeks significantly improved knee pain, physical function, and quadriceps strength. Although knee orthosis showed significant beneficial effects on various components of proprioception, there were no significant differences between the two groups at the end of the 4-week intervention.

Effect of compression by elastic bandages on pain and function in individuals with knee osteoarthritis: protocol of a randomised controlled clinical trial

INTRODUCTION

Although compression is used to control pain in knee osteoarthritis (KOA), its clinical application is poorly supported, and there is a lack of scientific evidence to support its clinical use. As a low-cost and accessible protocol, compression using elastic bands could be a non-pharmacological intervention to reduce pain and improve physical function in individuals with KOA. This study aims to evaluate the effects of compression on pain and function in individuals with KOA.

METHODS AND ANALYSIS

A randomised controlled clinical trial will be conducted. Individuals with KOA (n=90; both sexes; between 40 and 75 years old) will be allocated to three groups (n=30/group): compression (compression by the elastic bandage on the affected knee, once a day for 20 min, on four consecutive days); sham (same protocol, but the elastic band is placed around the affected knee without compression) and control (no intervention). The individuals in the three groups will be evaluated 1 day before the first intervention, 1 day after the last intervention, and at the 12th and 24th weeks after the end of the intervention. Pain intensity by the Visual Analogue Scale and pain scale from Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) will be the primary outcomes. The secondary variables will be physical function assessed by the WOMAC questionnaire and physical tests (step test; 30 s sit and stand test; 40 m accelerated walk test). The Global Rating of Change Scale (GRC) will also be applied to quantify the volunteers' perceived change.

ETHICS AND DISSEMINATION

The project was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (3955692). The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04724902.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Efficacy and safety of focused low-intensity pulsed ultrasound versus pulsed shortwave diathermy on knee osteoarthritis: a randomized comparative trial

The aim of this study was to compare the efficacy and safety of focused low-intensity pulsed ultrasound (FLIPUS) with pulsed shortwave diathermy (PSWD) in subjects with painful knee osteoarthritis (OA). In a prospective randomized trial, 114 knee OA patients were randomly allocated to receive FLIPUS or PSWD therapy. The primary outcome was the change from baseline in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores. Secondary outcomes included the numerical rating scale (NRS) for pain assessment, time up and go (TUG) test, active joint range of motion (ROM) test, and Global Rating of Change (GRC) scale. Data were collected at baseline, 12 days, 12 weeks and 24 weeks. Patients receiving FLIPUS therapy experienced significantly greater improvements in the WOMAC total scores than patients receiving PSWD therapy at 12 days (mean difference, - 10.50; 95% CI - 13.54 to - 7.45; P = 0.000). The results of the NRS, TUG test, ROM test and GRC scale showed that participants treated with FLIPUS reported less pain and better physical function and health status than those treated with PSWD at 12 days (P = 0.011, P = 0.005, P = 0.025, P = 0.011, respectively). Furthermore, patients in the FLIPUS group showed significant improvements in the WOMAC total scores and NRS scores at 12 weeks (mean difference, - 7.57; 95% CI - 10.87 to - 4.26; P = 0.000 and - 1.79; 95% CI - 2.11 to - 1.47, respectively) and 24 weeks (mean difference, - 6.96; 95% CI - 10.22 to - 3.71; P = 0.000 and - 1.37; 95% CI - 1.64 to - 0.96; P = 0.000, respectively) of follow-up. There were no adverse events during or after the interventions in either group. This study concluded that both FLIPUS and pulsed SWD are safe modalities, and FLIPUS was more effective than PSWD in alleviating pain and in improving dysfunction and health status among subjects with knee OA in the short term.Trial registration: Chinese Clinical Trial Registry, ChiCTR2000032735. Registered 08/05/2020, http://www.chictr.org.cn/showproj.aspx?proj=53413 .

Nomogram in Knee Instability: 3D Gait Analysis of Knee Osteoarthritis Patients

BACKGROUND

Measures of knee stability by symptoms, physical examination, and imaging do not accurately reflect the condition of knee movement. Therefore, this study aimed to introduce a model for assessing knee stability during walking in patients with knee osteoarthritis (OA).

AIMS

Three dimensional(3D) gait analysis system was used to quantify the gait of patients and display the clinical diagnosis model of knee instability with nomogram to guide clinical diagnosis and treatment.

METHODS

This cross-sectional study performed a 3D gait analysis in 93 participants with knee OA and 40 healthy control subjects. Multiple linear regression analysis investigated the correlation between gait parameters and knee extension/flexion stability. The predicting models were built applied multinomial logistic regression analysis and calibration plot, C-index, decision curve analysis, bootstrapping validation were used to assess the predicting nomograms' clinical usefulness and internal validation.

RESULTS

Multiple linear regression analysis indicated knee extension stability was correlated with walking speed (β = 0.256, P = 0.006), knee extensor strength (β = -0.196, P = 0.03), static HKA (β = 0.218, P = 0.016), width of the femoral diaphysis (β = -0.282, P = 0.002) and WOMAC score (β = 0.281, P = 0.002); however, knee flexion stability was correlated with walking speed (β = 0.340, P < 0.001), knee flexor strength (β = -0.327, P < 0.001), posterior tibial slope (PTS) (β = 0.291, P < 0.001), knee flexion/extension range of motion (ROM) (β = 0.177, P = 0.018) and HSS score (β = -0.173, P = 0.028). We developed and internally validated a knee instability risk nomogram in patients with knee OA.

CONCLUSIONS

These results indicated that using the 3D motion analysis system is feasible to quantify knee instability. The current prediction models could serve as a reliable tool to quantify the possibility of knee instability in OA patients.

TRIAL REGISTRATION NUMBER TRN

ChiCTR2100051302; Date of registration: Sep 18, 2021; retrospectively registered.

Effects of Aquatic Exercises for Patients with Osteoarthritis: Systematic Review with Meta-Analysis

This systematic review examined papers published in Korean, English and newer publications that were not included in previous studies to assess the effect size of aquatic exercise-based interventions on pain, quality of life and joint dysfunction among patients with osteoarthritis. Six national and international databases were used to review literature (published up to 7 March 2019) on randomized controlled trials of aquatic exercise-based interventions in patients with osteoarthritis. For the 20 studies included, a meta-analysis showed that aquatic exercise produces 0.61-point reduction (n = 756; mean difference (MD) = −0.61; 95% confidence interval (CI): −0.90–−0.32) in pain compared with a control group, and aquatic exercise was effective in reducing pain (n = 315; MD = −0.28; 95% CI: −0.50–−0.05) compared with a land-based exercise group. Another meta-analysis showed that aquatic exercise produces 0.77-point improvement in quality of life (n = 279; MD = −0.77; 95% CI: −1.38–−0.15) compared with a control group. Finally, a meta-analysis showed that aquatic exercise produces 0.34-point reduction in joint dysfunction (n = 279; MD = −0.77; 95% CI: −1.38–−0.15) compared with a control group. For patients with osteoarthritis, aquatic-exercise-based interventions are effective for reducing pain and joint dysfunction and improving quality of life.

Factors Influencing Pain Management of Patients with Osteoarthritis: A Cross-Sectional Study

Background: Osteoarthritis (OA) is a complex disease associated with chronic pain. Many patients treat their joint pain at a symptomatic level with over-the-counter (OTC) pain medications, often without the knowledge of their physicians. The aim of this study was to provide physicians with data about osteoarthritic patients’ habits of pain management and to examine the explanatory factors of various ways of self-treatment. Methods: A cross-sectional study involving 189 patients with hip or knee OA and scheduled for joint replacement surgery was carried out. Participants filled out a self-administered questionnaire consisting of the Western Ontario and McMaster Universities Osteoarthritis Index and questions about their methods of alleviating pain. Results: 2.6% of patients did not use anything to alleviate their pain, while 63% practiced a non-pharmacological method. Diclofenac was the most frequently used drug, followed by ibuprofen. Profession had the greatest impact on medication habits; patients doing manual work were significantly more likely to take OTC non-steroidal anti-inflammatory drugs and use topical analgesics. Conclusions: Patients utilized a wide variety of pain management techniques. They seemed to use well-known painkillers, even if their side effects were less desirable. Such patients require comprehensive pain management, including educational and behavioural interventions, complemented by topical and oral medication.