Gaps in appropriate use of treatment strategies in osteoarthritis

Exploring heterogeneity in coxarthrosis medication use patterns before total hip replacement: a State Sequence Analysis

OBJECTIVE

Evidence of geographical variation in total hip replacement (THR) and deviations from treatment guidelines persists. In this exploratory study, we aim to gain an in-depth understanding of patients' healthcare trajectories by identifying and visualising medication use patterns in coxarthrosis patients before surgery. We examine their association with patient characteristics and THR, and compare them with recommendations on mild analgesics, opioid prescription and exhaustion of conservative therapy.

METHODS

In this exploratory study, we apply State Sequence Analysis (SSA) on German health insurance data (2012-2015). We analyse a cohort of coxarthrosis patients, half of whom underwent THR after a 1 year observation period and half of whom did not undergo surgery until at least 1 year after the observation period. Hierarchical states are defined based on prescriptions. We construct sequences, calculate sequence similarity using optimal matching and identify medication use patterns via clustering. Patterns are visualised, descriptive statistics are presented and logistic regression is employed to investigate the association of medication patterns with subsequent THR.

RESULTS

Seven distinct medication use patterns are identified, correlating strongly with patient characteristics and subsequent THR. Two patterns leading to THR demonstrate exhaustion of pharmacological therapy. Opioid use is concentrated in two small patterns with low odds for THR. The most frequent pattern lacks significant pharmacological therapy.

CONCLUSIONS

This SSA uncovers heterogeneity in medication use patterns before surgery in coxarthrosis patients. Cautious opioid handling and adherence to a stepped prescription approach are observed, but many patients display low medication therapy usage and lack evidence of exhausting conservative options before surgery.

Pre-exercise and acute movement-evoked pain trajectories during a 24-week outdoor walking program for knee osteoarthritis (WALK)

Objectives

Exploring (1) pre-exercise and acute movement-evoked pain (AMEP) during an outdoor walking program in individuals with knee osteoarthritis (OA); and (2) comparing baseline physical performance and AMEP flares initiated by walking between participants with either a higher or lower attendance rate.

Methods

Individuals with knee OA were prescribed a 24-week walking program, including one unsupervised walk and two supervised walk classes per week. Participants self-reported knee pain on a numerical rating scale (NRS; 0-10) before and after each supervised class. Mixed-effects models were used to investigate trajectories over time for pre-exercise pain and AMEP change (post-minus pre-exercise pain; positive value indicates flare-up). Baseline physical performance (6 tests) and AMEP flares were compared between participants with higher (attending ≥70% of supervised classes) and lower attendance rates.

Results

Of 24 participants commencing the program, 7 (29%) withdrew. Over 24 weeks, pre-exercise pain improved by 1.20 NRS (95% CI -1.41 to -0.99), with estimated largest per class improvements during the first 8 weeks (-0.05 (-0.06 to -0.03) and plateauing around 20-weeks. The AMEP was estimated to improve by 0.19 NRS (95% CI -0.38 to -0.004) over 24-weeks, with improvements plateauing around 12-weeks. Participants with lower attendance (n ​= ​11) scored poorer on all physical performance tests and experienced a slight increase in AMEP during the first two weeks of the program.

Conclusions

Participants improved in pre-exercise pain and AMEP in the first 20 and 12 weeks, respectively. Despite supervision, physical performance and AMEP flares may have contributed to lower attendance.

Trial registration number

12618001097235.

Telehealth-Supported Exercise or Physical Activity Programs for Knee Osteoarthritis: Systematic Review and Meta-Analysis

BACKGROUND

The integration of telehealth-supported programs in chronic disease management has become increasingly common. However, its effectiveness for individuals with knee osteoarthritis (KOA) remains unclear.

OBJECTIVE

This study aimed to assess the effectiveness of telehealth-supported exercise or physical activity programs for individuals with KOA.

METHODS

A comprehensive literature search encompassing Embase, MEDLINE, CENTRAL, Web of Science, PubMed, Scopus, PEDro, GreyNet, and medRxiv from inception to September 2023 was conducted to identify randomized controlled trials comparing telehealth-supported exercise or physical activity programs to a control condition for KOA. Data were extracted and qualitatively synthesized across eligible studies, and a meta-analysis was performed to evaluate the effects. The study was reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020.

RESULTS

In total, 23 studies met eligibility criteria, with 20 included in the meta-analysis. Results showed that telehealth-supported exercise or physical activity programs reduced pain (g=-0.39; 95% CI -0.67 to -0.11; P<.001), improved physical activity (g=0.13; 95% CI 0.03-0.23; P=.01), and enhanced physical function (g=-0.51; 95% CI -0.98 to -0.05; P=.03). Moreover, significant improvements in quality of life (g=0.25; 95% CI 0.14-0.36; P<.001), self-efficacy for pain (g=0.72; 95% CI 0.53-0.91; P<.001), and global improvement (odds ratio 2.69, 95% CI 1.41-5.15; P<.001) were observed. However, self-efficacy for physical function (g=0.14; 95% CI -0.26 to 0.53; P=.50) showed insignificant improvements. Subgroup analyses based on the World Health Organization classification of digital health (pain: χ22=6.5; P=.04 and physical function: χ22=6.4; P=.04), the type of teletechnology in the intervention group (pain: χ24=4.8; P=.31 and function: χ24=13.0; P=.01), and active or inactive controls (pain: χ21=5.3; P=.02 and physical function: χ21=3.4; P=.07) showed significant subgroup differences.

CONCLUSIONS

Telehealth-supported exercise or physical activity programs might reduce knee pain and improve physical activity, physical function, quality of life, self-efficacy, and global improvement in individuals with KOA. Future research should consider longer implementation durations and assess the feasibility of incorporating wearables and standardized components into large-scale interventions to evaluate the effects.

TRIAL REGISTRATION

PROSPERO CRD42022359658; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=359658.

Fibrotic pathways and fibroblast-like synoviocyte phenotypes in osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis, characterized by osteophyte formation, cartilage degradation, and structural and cellular alterations of the synovial membrane. Activated fibroblast-like synoviocytes (FLS) of the synovial membrane have been identified as key drivers, secreting humoral mediators that maintain inflammatory processes, proteases that cause cartilage and bone destruction, and factors that drive fibrotic processes. In normal tissue repair, fibrotic processes are terminated after the damage has been repaired. In fibrosis, tissue remodeling and wound healing are exaggerated and prolonged. Various stressors, including aging, joint instability, and inflammation, lead to structural damage of the joint and micro lesions within the synovial tissue. One result is the reduced production of synovial fluid (lubricants), which reduces the lubricity of the cartilage areas, leading to cartilage damage. In the synovial tissue, a wound-healing cascade is initiated by activating macrophages, Th2 cells, and FLS. The latter can be divided into two major populations. The destructive thymocyte differentiation antigen (THY)1─ phenotype is restricted to the synovial lining layer. In contrast, the THY1+ phenotype of the sublining layer is classified as an invasive one with immune effector function driving synovitis. The exact mechanisms involved in the transition of fibroblasts into a myofibroblast-like phenotype that drives fibrosis remain unclear. The review provides an overview of the phenotypes and spatial distribution of FLS in the synovial membrane of OA, describes the mechanisms of fibroblast into myofibroblast activation, and the metabolic alterations of myofibroblast-like cells.

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis: 2023 update

INTRODUCTION

Hip and knee osteoarthritis (OA) are increasingly common with a significant impact on individuals and society. Non-pharmacological treatments are considered essential to reduce pain and improve function and quality of life. EULAR recommendations for the non-pharmacological core management of hip and knee OA were published in 2013. Given the large number of subsequent studies, an update is needed.

METHODS

The Standardised Operating Procedures for EULAR recommendations were followed. A multidisciplinary Task Force with 25 members representing 14 European countries was established. The Task Force agreed on an updated search strategy of 11 research questions. The systematic literature review encompassed dates from 1 January 2012 to 27 May 2022. Retrieved evidence was discussed, updated recommendations were formulated, and research and educational agendas were developed.

RESULTS

The revised recommendations include two overarching principles and eight evidence-based recommendations including (1) an individualised, multicomponent management plan; (2) information, education and self-management; (3) exercise with adequate tailoring of dosage and progression; (4) mode of exercise delivery; (5) maintenance of healthy weight and weight loss; (6) footwear, walking aids and assistive devices; (7) work-related advice and (8) behaviour change techniques to improve lifestyle. The mean level of agreement on the recommendations ranged between 9.2 and 9.8 (0-10 scale, 10=total agreement). The research agenda highlighted areas related to these interventions including adherence, uptake and impact on work.

CONCLUSIONS

The 2023 updated recommendations were formulated based on research evidence and expert opinion to guide the optimal management of hip and knee OA.

Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines

OBJECTIVE

To evaluate the quality of clinical practice guidelines (CPGs) for interventions in management of osteoarthritis (OA) and to provide a synthesis of high-quality CPG recommendations.

METHODS

Five databases (OvidSP Medline, Cochrane, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, and the Physiotherapy Evidence Database [PEDro]) and 4 online guideline repositories were searched. CPGs for the management of OA were included if they were 1) written in English and published from January 2015 to February 2022, focused on adults age ≥18 years, and met the criteria of a CPG as defined by the Institute of Medicine; and 2) were rated as high quality on the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. CPGs for OA were excluded if they were available via institutional access only, only addressed recommendations for the system/organization of care and did not include interventional management recommendations, and/or included other arthritic conditions.

RESULTS

Of 20 eligible CPGs, 11 were appraised as high quality and included in the synthesis. Of interest were the hip, knee, hand, and glenohumeral joints and/or polyarticular OA. Consistent recommendations were that care should be patient centered and include exercise, education, and weight loss (where appropriate). Nonsteroidal antiinflammatory drugs and surgical interventions were recommended for disabling OA that had not improved with nonsurgical care. Hand orthoses should be recommended for patients with hand OA.

CONCLUSION

This synthesis of high-quality CPGs for OA management offers health care providers with clear, simple guidance of recommended OA care to improve patient outcomes.

Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative

OBJECTIVE

To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA).

DESIGN

We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7.

RESULTS

A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics.

CONCLUSION

The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Rehabilitation interventions in osteoarthritis

The goals of the management of osteoarthritis (OA) are to relieve joint pain and stiffness, maintain or increase joint mobility and stability, improve activities and participation, and enhance quality of life. The first step in the management is to make a comprehensive holistic assessment to understand the impact of the disease on the individual. Then, an individualized management plan can be set via a shared-decision making process between the patient and the clinician taking into account all components of functioning affected by the disease. Rehabilitation interventions serve as the basis of OA management whereas pharmacological modalities are usually administered for additional symptom control. This study aimed to overview the rehabilitation interventions used for people with OA with an update of the recent evidence. First, core management approaches that include patient education, physical activity and exercises, and weight loss were addressed; then adjunctive treatments including biomechanical interventions (e.g. orthoses, assistive devices) and physical modalities were overviewed.

A pilot randomized controlled trial evaluating outdoor community walking for knee osteoarthritis: walk

OBJECTIVES

To determine the feasibility of a randomized controlled trial (RCT) examining outdoor walking on knee osteoarthritis (KOA) clinical outcomes and magnetic resonance imaging (MRI) structural changes.

METHOD

This was a 24-week parallel two-arm pilot RCT in Tasmania, Australia. KOA participants were randomized to either a walking plus usual care group or a usual care control group. The walking group trained 3 days/week. The primary outcome was feasibility assessed by changes being required to the study design, recruitment, randomization, program adherence, safety, and retention. Exploratory outcomes were changes in symptoms, physical performance/activity, and MRI measures.

RESULTS

Forty participants (mean age 66 years (SD 1.4) and 60% female) were randomized to walking (n = 24) or usual care (n = 16). Simple randomization resulted in a difference in numbers randomized to the two groups. During the study, class sizes were reduced from 10 to 8 participants to improve supervision, and exclusion criteria were added to facilitate program adherence. In the walking group, total program adherence was 70.0% and retention 70.8% at 24 weeks. The walking group had a higher number of mild adverse events and experienced clinically important improvements in symptoms (e.g., visual analogue scale (VAS) knee pain change in the walking group: - 38.7 mm [95% CI - 47.1 to - 30.3] versus usual care group: 4.3 mm [- 4.9 to 13.4]).

CONCLUSIONS

This study supports the feasibility of a full-scale RCT given acceptable adherence, retention, randomization, and safety, and recruitment challenges have been identified. Large symptomatic benefits support the clinical usefulness of a subsequent trial.

TRIAL REGISTRATION NUMBER

12618001097235. Key Points • This pilot study is the first to investigate the effects of an outdoor walking program on knee osteoarthritis clinical outcomes and MRI joint structure, and it indicates that a full-scale RCT is feasible. • The outdoor walking program (plus usual care) resulted in large improvements in self-reported knee osteoarthritis symptoms compared to usual care alone. • The study identified recruitment challenges, and the manuscript explores these in more details and provides recommendations for future studies.

Primary care physicians' perceptions of the utility of novel education materials for patients with knee osteoarthritis

PURPOSE

To support primary care physicians (PCPs) and their patients with knee osteoarthritis (OA), we created a series of evidence-based whiteboard educational videos for patients with knee OA. In a previous study we piloted these videos with patients to understand their acceptability and impact. The purpose of this study was to explore PCPs' perspectives to understand the utility of novel patient education videos to support management.

MATERIALS AND METHOD

We conducted a qualitative descriptive study using semi-structured interviews of newly practicing and resident PCPs after watching a series of patient education videos. A thematic analysis approach was used combining both inductive and research question driven coding, category formation, and theme identification.

RESULTS

Ten participants were included. Barriers to optimal management were identified including the challenge of patient adherence and access to non-operative treatments. PCPs indicated that the videos would support their management of patients with knee OA by (1) supporting credibility and building trust with their patient, (2) reinforcing patient understanding, and (3) enhancing their own management of patients.

CONCLUSION

Future implementation of these resources with attention to barriers that may limit uptake is necessary and may optimize management of knee OA in primary care.IMPLICATIONS FOR REHABILITATIONThe provision of patient educational materials may support patient buy-in regarding appropriate management, enhance patient understanding, and improve physicians' future practice.Viewing these videos could potentially improve physicians' future resource use, recommendation of non-operative treatments, and the quality of their total knee replacement referrals, which has benefits to both the patient and the healthcare system.Perceived barriers to implementing evidence-based recommendations may pose a challenge for patients and clinicians and should be considered to help facilitate the uptake of educational interventions.

Comparing Video-Based, Telehealth-Delivered Exercise and Weight Loss Programs With Online Education on Outcomes of Knee Osteoarthritis : A Randomized Trial

BACKGROUND

Scalable knee osteoarthritis programs are needed to deliver recommended education, exercise, and weight loss interventions.

OBJECTIVE

To evaluate two 6-month, telehealth-delivered exercise programs, 1 with and 1 without dietary intervention.

DESIGN

3-group, parallel randomized (5:5:2) trial. (Australian New Zealand Clinical Trials Registry: ACTRN12618000930280).

SETTING

Australian private health insurance members.

PARTICIPANTS

415 persons with symptomatic knee osteoarthritis and a body mass index between 28 and 40 kg/m2 who were aged 45 to 80 years.

INTERVENTION

All groups received access to electronic osteoarthritis information (control). The exercise program comprised 6 physiotherapist consultations via videoconference for exercise, self-management advice, and behavioral counseling, plus exercise equipment and resources. The diet and exercise program included an additional 6 dietitian consultations for a ketogenic very-low-calorie diet (2 formulated meal replacements and a low-carbohydrate meal daily) followed by a transition to healthy eating, as well as nutrition and behavioral resources.

MEASUREMENTS

Primary outcomes were changes in knee pain (numerical rating scale [NRS] of 0 to 10, higher indicating worse) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]; scale, 0 to 68, higher indicating worse) at 6 months (primary time point) and 12 months. Secondary outcomes were weight, physical activity, quality of life, mental health, global change, satisfaction, willingness to have surgery, orthopedic appointments, and knee surgery.

RESULTS

A total of 379 participants (91%) provided 6-month primary outcomes, and 372 (90%) provided 12-month primary outcomes. At 6 months, both programs were superior to control for pain (between-group mean difference in change on NRS: diet and exercise, -1.5 [95% CI, -2.1 to -0.8]; exercise, -0.8 [CI, -1.5 to -0.2]) and function (between-group mean difference in change on WOMAC: diet and exercise, -9.8 [CI, -12.5 to -7.0]; exercise, -7.0 [CI, -9.7 to -4.2]). The diet and exercise program was superior to exercise (pain, -0.6 [CI, -1.1 to -0.2]; function, -2.8 [CI, -4.7 to -0.8]). Findings were similar at 12 months.

LIMITATION

Participants and clinicians were unblinded.

CONCLUSION

Telehealth-delivered exercise and diet programs improved pain and function in people with knee osteoarthritis and overweight or obesity. A dietary intervention conferred modest additional pain and function benefits over exercise.

PRIMARY FUNDING SOURCE

Medibank, the Medibank Better Health Foundation Research Fund, and a National Health and Medical Research Council Centre of Research Excellence.

Exploring views of orthopaedic surgeons, rheumatologists and general practitioners about osteoarthritis management

BACKGROUND

Delivery of recommended treatments for hip and knee osteoarthritis (OA) is known to be discordant with guideline recommendations. However, professional views related to OA management across medical and surgical disciplines are not well understood. The aim of this study was to explore the views of medical professionals about management of hip and knee OA.

METHODS

Qualitative study. Semistructured individual interviews were conducted with orthopaedic surgeons, rheumatologists and general practitioners routinely involved in the management of OA. Interviews were audiotaped, transcribed, member-checked, coded and thematically analysed.

RESULTS

Fifteen medical professionals were interviewed. Three main themes were: (i) recognition of the importance of nonsurgical management of hip and knee OA, focussed on self-management, exercise-therapy, weight management and analgesia; (ii) joint replacement being considered the 'last resort' for end stage disease not responding to nonsurgical management; and (iii) determination of management 'success' through patient perceptions was more common than the use of validated instruments. Views on management broadly converged across disciplines, except for the role of joint replacement, considered an adjunct in the overall management of OA by rheumatologists and as a definitive cure by orthopaedic surgeons.

CONCLUSIONS

Aligning with current guidelines, medical professionals recognised the importance of nonsurgical management focussed on exercise-therapy for hip and knee OA, and concurred that joint replacement surgery should be a last resort. A focus on patient education was less prominent, which along with implementation of validated outcome measures in routine medical practice, may require greater health system support.

Physical Therapy Use and Associated Factors in Adults with and without Osteoarthritis-An Analysis of the Population-Based German Health Update Study

BACKGROUND

Physical therapy (PT) is recommended as first-line management for osteoarthritis (OA). The purpose of this study was to assess the PT use among adults with OA and those without (Non-OA) and subsequently identify associated factors among these populations.

METHODS

This cross-sectional study obtained national data from the population-based German Health Update (GEDA2014/2015-EHIS) study containing 24,016 participants aged 18 years and older. Analyses were stratified by sex, age, socioeconomic status (SES), residence, smoking behavior, body mass index, pain and general health. Multivariate regression analysis was conducted to evaluate factors associated with PT use within the past 12 months.

RESULTS

PT was used more frequently in the OA population compared with the Non-OA population (35.8% vs. 18.7%). In both populations, women, participants with high SES, residence in Eastern Germany, severe pain, poor general health and non-smokers received PT more frequently. Multivariate analysis confirmed these findings, in addition to people aged 80 years and older. The influence of SES was higher among OA participants.

CONCLUSION

The underutilization of PT in OA patients (35.8%) was particularly evident among males, people with a low SES and those being older than 60 years, which aids to develop strategies increasing PT use towards guideline-oriented OA management.

Return to work and productivity loss after surgery: A health economic evaluation

BACKGROUND

We aimed to identify preoperative psychosocial factors associated with return-to-work (RTW) and the associated cost of productivity loss due to work absenteeism following surgery. Research demonstrates a high economic burden from productivity loss after surgery, but the comparative cost of productivity loss relative to income across different operations has not been examined.

MATERIALS AND METHODS

A mixed surgical cohort recruited for a randomized controlled trial were prospectively followed for up to two years following surgery with daily phone assessments to three months, weekly assessments thereafter to six months, then monthly assessments thereafter to determine RTW status, opioid use and pain.

RESULTS

183 of 207 (88.3%) patients in paid employment prior to surgery, who provided at least one day of follow-up, were included in this analysis. The average cost of productivity loss due to work absenteeism was $13 761 (median $9064). Patients who underwent total knee replacement incurred the highest income loss. Medical claims filed before surgery were significantly associated with relative income loss (AOR 5.09; 95% CI 1.73-14.96; p < 0.01) and delayed postoperative RTW. Elevated preoperative PTSD symptoms were associated with delayed RTW (HR 0.78; 95%CI 0.63-0.96; p-value = 0.02) while male gender (HR 1.63; 95%CI 1.11-2.38; p-value = 0.01) was associated with faster postoperative RTW.

CONCLUSION

Surgery places a high economic burden on individuals due to postoperative productivity loss. Multidisciplinary approaches, such as pathways, that facilitate the operation and recovery may mitigate the economic consequences for patients, employers, and the healthcare system.

Trends in management of hip and knee osteoarthritis in general practice in Australia over an 11-year window: a nationwide cross-sectional survey

Background

We aimed to describe trends in knee and hip OA management by general medical practitioners (GPs) in Australia.

Methods

We analysed cross-sectional survey data from the Bettering the Evaluation and Care of Health (BEACH) program (1,000 randomly-selected GPs annually recording 100 consecutive patient encounters) over two periods: Period one April 1, 2005-March 31, 2010 and period two April 1, 2010-March 31, 2016. This included data from 10,738 GPs and 1,073,800 patient encounters with 6,565 GPs and 9,196 patient encounters for hip/knee OA. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates.

Findings

Rate of knee OA problems managed by GPs increased in period two (7•1 (6•9-7•4) vs 6•2 (95% CI 6•0-6•5) per 1,000 all encounters), with a similar trend for hip OA. Encounter rates rose for some subgroups but remained stable for vulnerable subgroups. Although use of Medicare chronic disease management items, referral to allied health professionals and advice/education and lifestyle management (knee OA) increased, rates remained low. Use of MRI imaging rose. Overall medication rates were stable but substantially higher than non-pharmacological treatments. Declining reliance on non-steroidal anti-inflammatory drugs and glucosamine and increased reliance on paracetamol (knee OA) and opioids were demonstrated.

Interpretation

GPs in Australia are more frequently managing knee and hip OA. While small changes in GP management actions occured, rates of recommended first-line non-pharmacological treatments remained low and imaging, medications, and surgical referral rates high. Strategies are needed to optimise lifestyle management and reduce low-value care, with attention to healthcare disparities.

Funding

Funding was provided for this report by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Translational Research in Musculoskeletal Pain (#1079078).

Hydrogen sulfide inhibits endoplasmic reticulum stress through the GRP78/mTOR pathway in rat chondrocytes subjected to oxidative stress

The activation of oxidative stress is a primary cause of chondrocyte apoptosis in osteoarthritis (OA). The 78‑kDa glucose‑regulated protein (GRP78)/mammalian target of rapamycin (mTOR) signaling pathway has been demonstrated to be linked with the endoplasmic reticulum (ER) and autophagy. Hydrogen sulfide (H2S) has been reported to exert antioxidant effects. The present study investigated oxidative stress levels via 2',7'‑dichlorofluorescin diacetate and MitoSOX staining, apoptosis rates via flow cytometry and the expression levels of ER stress‑related proteins in GYY4137 (donor of H2S)‑treated chondrocytes (CHs). CHs were isolated from the bilateral hip joints of male rats to examine mitochondrial permeability transition pore opening‑ and mTOR signaling pathway‑related proteins. The results demonstrated that tert‑Butyl hydroperoxide (TBHP) increased CH apoptosis, and treatment with GYY4137 ameliorated TBHP‑mediated the generation of ROS and CH apoptosis. Moreover, TBHP‑treated CHs displayed elevated ER stress sensor expression levels and apoptotic rates; however, the TBHP‑induced protein expression levels were decreased following GYY4137 treatment. In the present study, treatment with either GYY4137 or transfection with GRP78 siRNA both suppressed the activation of p‑P70S6k and p‑mTOR. H2S played an important role in regulating ER stress in TBHP‑stimulated CHs. GYY4137 promoted autophagy, which was accompanied by the inhibition of ER stress. On the whole, the present study demonstrates that TBHP‑induced oxidative stress stimulates ER interactions and CH apoptosis, which are suppressed by exogenous H2S via modulating the GRP78/mTOR signaling pathway.

Cartilage-targeting ultrasmall lipid-polymer hybrid nanoparticles for the prevention of cartilage degradation

Current drug delivery approaches for the treatment of cartilage disorders such as osteoarthritis (OA) remain inadequate to achieve sufficient drug penetration and retention in the dense cartilage matrix. Herein, we synthesize sub-30 nm lipid-polymer hybrid nanoparticles functionalized with collagen-targeting peptides for targeted drug delivery to the cartilage. The nanoparticles consist of a polymeric core for drug encapsulation and a lipid shell modified with a collagen-binding peptide. By combining these design features, the nanoparticles can penetrate deep and accumulate preferentially in the cartilage. Using MK-8722, an activator of 5'-adenosine monophosphate-activated protein kinase (AMPK), as a model drug, the nanoparticles can encapsulate the drug molecules in high capacity and release them in a sustained and controllable manner. When injected into the knee joints of the mice with collagenase-induced OA, the drug-loaded nanoparticles can effectively reduce cartilage damage and alleviate the disease severity. Overall, the ultrasmall targeted nanoparticles represent a promising delivery platform to overcome barriers of dense tissues for the treatment of various indications, including cartilage disorders.

Understanding the Impact of Sex and Gender in Osteoarthritis: Assessing Research Gaps and Unmet Needs

Osteoarthritis (OA) affects more than 300 million individuals globally, with higher prevalence in women than in men. In addition, OA affects women and men differently, with women demonstrating both increased disease severity and disability. The Society for Women's Health Research (SWHR) convened an interdisciplinary group of expert researchers and clinicians for a roundtable meeting to review the current state of the science on OA and to identify knowledge gaps in the scientific literature, especially as they relate to the topics of sex and gender. The current review summarizes discussions from the roundtable and prioritizes areas of need that warrant further attention in OA research, diagnosis, care, and education. Improvements in basic and clinical research, clinical practice, patient education, and policy are needed to allow for better understanding as to the pathogenesis of sex- and gender-related disparities in OA.

Hip and Knee Injuries

Hip and knee injuries are a common presenting concern for patients to a primary care office. This pathology represents a large differential and it can often be a diagnostic challenge for providers to determine the etiology of a patient's symptoms. This article discusses several of the most common causes for hip and knee pain while providing an evidence based review of physical examination maneuvers, imaging studies and treatment modalities to assist a primary care provider when encountering active patients with underlying hip or knee pain.

The Effect of the Phytocomplex Electrophoresis on the Clinical Symptomatology and Quality of Life of Patients with the Knee Joint Osteoarthritis

BACKGROUND:

Improving the effectiveness of rehabilitation of patients with osteoarthritis necessitates the use of drug electrophoresis with sinusoidal modulated currents (SMC-electrophoresis) in conjunction with drug therapy. The phytocomplex is proposed for electrophoresis composed of the compared, alfalfa and hops dry extract, containing flavonoids, coumestans, polysaccharides, steroids, essential amino acids, vitamins, mineral components and causing its possible use in osteoarthritis.

AIM:

The research aims to study the effect of the phytocomplex SMC-electrophoresis on the clinical symptoms and quality of life of patients with the knee joint osteoarthritis.

METHODS:

One hundred and eight patients were randomly distributed into 3 groups (n = 36). The phytocomplex SMC-electrophoresis was assigned to the first group, the amplipulse therapy (SMC) – to the second group, and the “basic” drug therapy – to the third group. The drug therapy of the patients of the third group was comparable with the drug treatment of those in the first two groups. The concentration of phytocomplex in the working solution was 10%. The electrotherapy was carried out in the aligned SMC mode in the first and fourth kind of works. Comparative indicators were as follows: WOMAC index, pain level on a visual analogue scale (VAS), Lequesne index, joint range of motion (JROM), articular and tendon indices, quality of life as per Health Assessment Questionnaire (HAQ).

RESULTS:

The use of the phytocomplex SMC-electrophoresis had a more pronounced positive effect on pain, knee joint function and quality of life of the patients compared with the treatment with drugs alone or using amplitude therapy. This was especially pronounced immediately after the rehabilitation. The analgesic effect was consistently maintained in the patients of the first group for up to 6 – 12 months, the second group – up to 3 – 6 months in terms of the level of pain according to the WOMAC and Lequesne indices, VAS, articular and tendon indices. Stable results have been obtained for improving the functions of the knee joint for up to 6 – 12 months using the phytocomplex SMC-electrophoresis as per the WOMAC and Lequesne indices. In the treatment by the phytocomplex SMC-electrophoresis, no side effects were registered.

CONCLUSION:

The obtained results give grounds for further research on the evaluation of the effectiveness of using the phytocomplex SMC-electrophoresis in microcirculatory disorders in the affected joint, for correcting connective tissue metabolism and electrolyte metabolism in the patients with the knee joint osteoarthritis.