The power and value of placebo and nocebo in painful osteoarthritis

The Nocebo Effect: A Bias in Clinical Practice-An Ethical Approach

BACKGROUND

The nocebo effect is often disregarded in medical practice and is certainly much less known than the placebo effect, although, in reality, both can influence therapeutic decision making and the quality of life of patients. However, the nocebo effect raises a number of issues not only of a practical nature related to clinical activity but also ethical dilemmas related to the observance of the patient's autonomy, nonmaleficence, or informed consent and the information on which it is based.

AREAS OF UNCERTAINTY

The ethical dilemmas raised by the nocebo effect revolve around how informed consent can be achieved, the accuracy and volume of information that is transmitted to the patient, and how to report negative side effects of therapeutic treatment.

DATA SOURCES

In September 2023, a narrative analysis of the literature was conducted using a combination of keywords such as nocebo, placebo, ethics, therapeutic relationship from PubMed, Scopus, Google Scholar, and so on, as well as from official documents developed at an international level (World Health Organization), for a period of 10 years (2012-2021).

RESULTS

Analyzing the articles that remarked upon the significant impact of ethics in nocebo research or in the therapeutic relationship, we can state that the existence of several relevant issues of interest have been detected regarding the ethical use of nocebo and its impact in research or in clinics and thus the need for proper knowledge and management of the impact of nocebo effects. The ethical paradox of obtaining informed consent with the 2 goals, first, the need for complete information and second, the preservation of the autonomy of the patient, respectively, that of "primum non-nocere" and of avoiding unnecessary harm by revealing probable adverse effects is a point of interest for numerous studies. The potential for a nocebo effect is present when we inform patients about the risks and benefits of treatment, there being a clear link between the moral and ethical duty to inform patients and the need to avoid situations that increase the nocebo impact on how the disease or the adverse effects of the treatment are perceived. Adapting information about the side effects of medicines should focus on ensuring a balance between transparency and caution, especially in patients with a high potential for nocebo effect.

CONCLUSIONS

The nocebo effect had for a long time been unknown or denied, although it can interfere with the results of the treatment used. As the nocebo phenomenon becomes increasingly known in medical practice, the clinical and ethical implications are identified by medical staff, and nocebo's adverse responses are no longer ignored.

GDF11 protects against mitochondrial-dysfunction-dependent NLRP3 inflammasome activation to attenuate osteoarthritis

INTRODUCTION

Osteoarthritis (OA) is a highly prevalent degenerative disease worldwide, and tumor necrosis factor (TNF-α) is closely associated with its development. Growth differentiation factor 11 (GDF11) has demonstrated anti-injury and anti-aging abilities in certain tissues; however, its regulatory role in OA remains unclear and requires further investigation.

OBJECTIVES

To identify whether GDF11 can attenuate osteoarthritis. To exploring the the potential mechanism of GDF11 in alleviating osteoarthritis.

METHODS

In this study, we cultured and stimulated mouse primary chondrocytes with or without TNF-α, analyzing the resulting damage phenotype through microarray analysis. Additionally, we employed GDF11 conditional knockout mice OA model to examine the relationship between GDF11 and OA. To investigate the target of GDF11's function, we utilized NLRP3 knockout mice and its inhibitor to verify the potential involvement of the NLRP3 inflammasome.

RESULTS

Our in vitro experiments demonstrated that endogenous overexpression of GDF11 significantly inhibited TNF-α-induced cartilage matrix degradation and inflammatory expression in chondrocytes. Furthermore, loss of GDF11 led to NLRP3 inflammasome activation, inflammation, and metabolic dysfunction. In an in vivo surgically induced mouse model, intraarticular administration of recombinant human GDF11 alleviated OA pathogenesis, whereas GDF11 conditional knockout reversed this effect. Additionally, findings from the NLRP3-knockout DMM mouse model revealed that GDF11 exerted its protective effect by inhibiting NLRP3.

CONCLUSION

These findings demonstrate the ability of GDF11 to suppress TNF-α-induced inflammation and cartilage degeneration by preventing mitochondrial dysfunction and inhibiting NLRP3 inflammasome activation, suggesting its potential as a promising therapeutic drug for osteoarthritis.

Methodological Flaws in Meta-Analyses of Clinical Studies on the Management of Knee Osteoarthritis with Stem Cells: A Systematic Review

(1) Background: Conclusions of meta-analyses of clinical studies may substantially influence opinions of prospective patients and stakeholders in healthcare. Nineteen meta-analyses of clinical studies on the management of primary knee osteoarthritis (pkOA) with stem cells, published between January 2020 and July 2021, came to inconsistent conclusions regarding the efficacy of this treatment modality. It is possible that a separate meta-analysis based on an independent, systematic assessment of clinical studies on the management of pkOA with stem cells may reach a different conclusion. (2) Methods: PubMed, Web of Science, and the Cochrane Library were systematically searched for clinical studies and meta-analyses of clinical studies on the management of pkOA with stem cells. All clinical studies and meta-analyses identified were evaluated in detail, as were all sub-analyses included in the meta-analyses. (3) Results: The inconsistent conclusions regarding the efficacy of treating pkOA with stem cells in the 19 assessed meta-analyses were most probably based on substantial differences in literature search strategies among different authors, misconceptions about meta-analyses themselves, and misconceptions about the comparability of different types of stem cells with regard to their safety and regenerative potential. An independent, systematic review of the literature yielded a total of 183 studies, of which 33 were randomized clinical trials, including a total of 6860 patients with pkOA. However, it was not possible to perform a scientifically sound meta-analysis. (4) Conclusions: Clinicians should interpret the results of the 19 assessed meta-analyses of clinical studies on the management of pkOA with stem cells with caution and should be cautious of the conclusions drawn therein. Clinicians and researchers should strive to participate in FDA and/or EMA reviewed and approved clinical trials to provide clinically and statistically valid efficacy.

Emerging and New Treatment Options for Knee Osteoarthritis

Osteoarthritis (OA) is the most prevalent type of arthritis worldwide, resulting in pain and often chronic disability and a significant burden on healthcare systems globally. Non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, intra-articular corticosteroid injections are of little value in the long term, and opioids may have ominous consequences. Radiotherapy of knee OA has no added value. Physical therapy, exercises, weight loss, and lifestyle modifications may give pain relief, improve physical functioning and quality of life. However, no single treatment has regenerating potential for damaged articular cartilage. Due to a better understanding of osteoarthritis, innovative new treatment options have been developed. In this narrative review, we focus on emerging OA knee treatments, relieving symptoms, and regenerating damaged articular cartilage that includes intra-articular human serum albumin, conventional disease-modifying anti-rheumatic drugs (DMARDs), lipid-lowering agents (statin), nerve growth factors antagonists, bone morphogenetic protein, fibroblast growth factors, Platelet-Rich Plasma (PRP), Mesenchymal Stem Cells (MSC), exosomes, interleukin-1 blockers, gene-based therapy, and bisphosphonate.

Exploring changes, and factors associated with changes, in behavioural determinants from a low-cost, scalable education intervention about knee osteoarthritis: An observational cohort study

OBJECTIVE

To explore the relationships between participant characteristics, perceptions of a short educational video about osteoarthritis and its management, and immediate changes in behavioural determinants for effective self-management behaviours.

METHODS

Seventy-eight participants with knee OA (77% female, mean age 63.0 ± 8.7) watched the 9-min video that included evidence-based content and was designed to foster empowerment to self-manage effectively. Data were collected by online questionnaire at baseline and immediately after watching the video. Associations were tested between baseline health and information processing characteristics (health literacy, need for cognition), perceptions of the video (enjoyment, helpfulness, believability, novelty and relevance) and pre-post changes in behavioural determinants (self-efficacy for managing arthritis, attitude to self-management or 'activation', and importance/confidence for physical activity).

RESULTS

All behavioural determinants improved immediately after watching the video. Positive perceptions were associated with greater improvements in self-efficacy for arthritis (Spearman's rho, ρ = 0.26-0.47). Greater perceived relevance was associated with increased self-rated importance of being physically active (ρ = 0.43). There were small positive associations between health literacy domains related to health information and positive viewer perceptions of the video. People with higher need for cognition may achieve greater improvement in confidence to be physically active (ρ = 0.27).

CONCLUSION

The educational video may help achieve outcomes important for increasing self-management behaviours in people with knee osteoarthritis. Positive perceptions appear to be important in achieving these improvements. People with lower health literacy and lower need for cognition may respond less well to this information about knee osteoarthritis delivered in this way.

Glycitin Suppresses Cartilage Destruction of Osteoarthritis in Mice

Osteoarthritis (OA), a chronic joint disease, is characterized by cartilage surface erosion, subchondral bone rebuilding, and formation of osteophytes. To date, the nosogenesis and underlying mechanisms of OA have not yet been elucidated. However, it is widely accepted that TNF-α is a crucial cytokine in the development of OA. Glycitin, a natural isoflavone extracted from legumes, affects physiological reactions and pathological responses. Recently, the anti-inflammatory effect of glycitin has been reported. However, the function of glycitin in cartilage degeneration in OA remains to be investigated. In the current study, primary murine chondrocytes were isolated and stimulated by TNF-α to evaluate the anti-inflammatory effects and protective function of glycitin in chondrocytes. In vivo, the ACLT mouse model, a frequently-used OA model, was used to further examine the therapeutic role of glycitin in cartilage degeneration and inflammation in OA. Consequently, glycitin functions were examined both in vivo and in vitro. Moreover, the underlying mechanism of action of glycitin was investigated and was found to involve the NF-κB signaling pathway. Collectively, this study suggests that glycitin can be potentially used for the treatment of joint degenerative diseases, including OA.

Exploring patient views of empathic optimistic communication for osteoarthritis in primary care: a qualitative interview study using vignettes

Background

Osteoarthritis (OA) causes pain and disability. An empathic optimistic consultation approach can improve patient quality of life, satisfaction with care, and reduce pain. However, expressing empathic optimism may be overlooked in busy primary care consultations and there is limited understanding of patients’ views about this approach.

Aim

To explore patients’ perspectives on clinician communication of empathy and optimism in primary care OA consultations.

Design & setting

Vignette study with qualitative semi-structured interviews. Purposefully sampled patients (n = 33) aged >45 years with hip or knee OA from GP practices in Wessex (Hampshire, Dorest, Wiltshire, and Somerset).

Method

Fifteen participants watched two filmed OA consultations with a GP, and 18 participants read two case vignettes. In both formats, one GP depicted an empathic optimistic approach and one GP had a ‘neutral’ approach. Semi-structured interviews were conducted with all participants and analysed using thematic analysis.

Results

Patients recognised that empathic communication enhanced interactions, helping to engender a sense of trust in their clinician. They felt it was acceptable for GPs to convey optimism only if it was realistic, personalised, and embedded within an empathic consultation. Discussing patients’ experiences and views with them, and conveying an accurate understanding of these experiences improves the credibility of optimistic messages.

Conclusion

Patients value communication with empathy and optimism, but it requires a fine balance to ensure messages remain realistic and trustworthy. Increased use of a realistic optimistic approach within an empathic consultation could enhance consultations for OA and other chronic conditions, and improve patient outcomes. Digital training to help GPs implement these findings is being developed.

The effects of patients' expectations on surgery outcome in total hip and knee arthroplasty: a prognostic factor meta-analysis

Patients' expectations are among the most frequently studied psychological prognostic factors in total knee and hip arthroplasty (TKA/THA). So far, however, evidence on the effect of patients' preoperative expectations on surgery outcome is inconclusive. Heterogeneity of expectation constructs and the use of psychometrically not evaluated measurement instruments have constituted major obstacles for the integration of the current literature. Using a theory-based model of expectation constructs , this meta-analysis set out to disentangle the conflicting results in the current literature. Systematic literature searches yielded k = 46 studies (N = 10,465) that reported associations of preoperative expectations with postoperative pain, functioning and disability, and satisfaction. Random effects meta-analysis revealed a robust small association (r = .16; 95% CI .13, .19) between patients' positive preoperative expectations and better postoperative outcomes. This effect did not differ between THA and TKA, different outcome categories and different follow-up periods. Studies using psychometrically evaluated expectation measures reported significantly higher effects (r = .19; 95% CI .16, .22). Whether this effect varies among different expectation constructs remains unclear. High-quality studies using validated, multidimensional expectation measures are needed to further understand the role of different expectation constructs in THA and TKA surgery.

Intra-articular injection with Autologous Conditioned Plasma does not lead to a clinically relevant improvement of knee osteoarthritis: a prospective case series of 140 patients with 1-year follow-up

Background and purpose - Platelet-rich plasma (PRP) is broadly used in the treatment of knee osteoarthritis, but clinical outcomes are highly variable. We evaluated the effectiveness of intra-articular injections with Autologous Conditioned Plasma (ACP), a commercially available form of platelet-rich plasma, in a tertiary referral center. Second, we aimed to identify which patient factors are associated with clinical outcome. Patients and methods - 140 patients (158 knees) with knee osteoarthritis (Kellgren and Lawrence grade 0-4) were treated with 3 intra-articular injections of ACP. The Knee Injury and Osteoarthritis Outcome Score (KOOS), pain (Numeric Rating Scale; NRS), and general health (EuroQol 5 Dimensions; EQ5D) were assessed at baseline and 3, 6, and 12 months' follow-up. The effect of sex, age, BMI, Kellgren and Lawrence grade, history of knee trauma, and baseline KOOS on clinical outcome at 6 and 12 months was determined using linear regression. Results - Mean KOOS increased from 37 at baseline to 44 at 3 months, 45 at 6 months, and 43 at 12 months' follow-up. Mean NRS-pain decreased from 6.2 at baseline to 5.3 at 3 months, 5.2 at 6 months, and 5.3 at 12 months. EQ5D did not change significantly. There were no predictors of clinical outcome. Interpretation - ACP does not lead to a clinically relevant improvement (exceeding the minimal clinically important difference) in patients suffering from knee osteoarthritis. None of the investigated factors predicts clinical outcome.

What Physiotherapists Specialized in Orthopedic Manual Therapy Know About Nocebo-Related Effects and Contextual Factors: Findings From a National Survey

Objective

The aim of this study was to investigate the knowledge of orthopedic manual therapists (OMTs) regarding context factors (CFs) capable of triggering nocebo effects during the treatment and how this knowledge is related to their socio-demographic features.

Design

A cross-sectional online survey.

Setting

National.

Main Outcome Measures

A 20 items questionnaire composed by open-ended and closed single-choice questions was administered to explore: (a) socio-demographic variables (10 questions); (b) the relation between different CFs and nocebo-related effects (2 questions); and (c) the knowledge of participants about nocebo-related effects and how they managed them in the clinical practice (8 questions).

Participants

1288 OMTs were recruited from the database of the Master in Rehabilitation of Musculoskeletal Disorders (MRDM) of the University of Genova from March to May 2019. Inclusion criteria were: (a) to possess a valid email account; (b) to understand and use as a native language the Italian; (c) to be graduated as OMTs; and (d) to be employed as physiotherapists specialized-OMTs during the survey.

Results

791 responses were received (61.4%); 473 of them were male (59.8%), with an average age of 31.0 ± 7.1 years. OMTs defined nocebo-related effects as the psychosocial context effects around therapy and patient with specific biological bases (72.2%). OMTs know that their clinical practice is pervaded by nocebo-related effects (42.5%), triggered by CFs. Participants communicated nocebo-related effects balancing the positive features of the therapy with the negative ones (50.9%), during the decision of the therapeutic plan (42.7%). They reported associative learning as the main mechanism involved in nocebo-related effects (28.8%). OMTs taught and trained patient’s strategies to manage nocebo-related effects (39.6%) through an evaluation and correction of patient’s anxieties, doubts and expectations (37.7%). OMTs most frequently considered themselves to have a “medium” education about nocebo-related effects (48.2%) and that their management should be taught during bachelor (78.6%).

Conclusion

OMTs believed that nocebo-related effects were present in their clinical practice and that they can be triggered by CFs.

Effectiveness of Health-Led Cognitive Behavioral-Based Group Therapy on Pain, Functional Disability and Psychological Outcomes among Knee Osteoarthritis Patients in Malaysia

Background: Psychosocial interventions for patients with osteoarthritis (OA) of the knee to reduce pain and improve physical and psychological functioning are still lacking in Malaysia. Methods: A parallel-group unblinded randomized controlled trial involving 300 patients was conducted in two hospital orthopedics clinics in Malaysia. Patients were randomly assigned to receive cognitive behavioral-based group therapy (n = 150) or no further intervention (n = 150). The primary outcome was the change from baseline in knee pain as determined by the Knee injury and Osteoarthritis Outcome Score (KOOS) at 6 months. The data collected were analyzed by covariate-adjusted mixed design repeated measures analysis of variance. All analyses were performed under the terms of intention-to-treat. Results: At 6 months, mean change from baseline in the KOOS knee pain score was 0.6 points (95% CI −1.73 to 2.94) in the control group and 8.9 points (95% CI 6.62 to 11.23) (denoting less knee pain intensity) in the intervention group (significant treatment effect p < 0.0001). Patients treated with such an approach also experienced significant improvement in functional ability when performing activities of daily living and had improved ability to cope with depression, anxiety and pain catastrophizing. Conclusion: The intervention module delivered by healthcare professionals had a sustained effect on knee OA pain and functionality over 6 months, thereby leading to an overall improvement in psychological well-being, thus benefitting most of the Malaysian knee OA patients.

Nocebo phenomena may be enhanced in aging: Implications for clinical practice

Nocebo effects, denoting unfavourable outcomes after a medical intervention because of negative expectations rather than a direct pharmacologic action, are an important cause of dropout from clinical trials and non-adherence to medication, and may be especially pertinent for older adults. Several characteristics of aging individuals and their medical care have a potential to augment nocebo susceptibility, such as depression and anxiety, neurodegenerative diseases and chronic pain states, adverse healthcare experiences, generic drug use, age-related stereotypes, and strained patient-physician communication. Nocebo-related research in older adults is hindered by under-representation in clinical trials, medical complexity of geriatric patients, and lack of validated tools to accurately assess susceptibility and efficacy of preventive efforts.

A critical overview of the current myofascial pain literature - January 2020

We are starting 2020 with 6 basic research studies, 9 review articles, 14 dry needling/injection studies, and one manual therapy paper for a total of 30 new papers. Topics range from studies on mechanisms, inflammatory mediators in myofascial pain, fascia, screening, Platelet-rich plasma intramuscular injections, and temporal summation to clinical studies on patients with tension-type headache, chronic pelvic pain, knee osteoarthritis, plantar fasciitis, generalized musculoskeletal pain, neck pain, breast cancer, tendinopathies, thoracic outlet syndrome, and canine dry needling, among others.

Anxiety and Osteoarthritis Disability: Updated Overview and Commentary

Introduction:

Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.

Objective:

In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.

Methods:

Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.

Results:

Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.

Conclusion:

This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.

An Exploration of Knowledge and Attitudes of Medical Students and Rheumatologists to Placebo and Nocebo Effects: Threshold Concepts in Clinical Practice

INTRODUCTION

Understanding placebo and nocebo responses (context/meaning effects [CMEs]) is fundamental to physician agency. Specific instruction in CMEs is often lacking in medical education. Patient-practitioner interactions may challenge medical students' understanding of biomedical causality and the nexus between this, practical ethics and professionalism across various conceptual and applied aspects of CMEs. This study compared the corpus of knowledge and phronesis related to CMEs between Australian graduate medical students and rheumatologists to gain a sophisticated understanding of this relationship to inform curriculum development.

METHOD

In 2013 and 2014, the authors surveyed third-year medical students undertaking a graduate programme in an Australian medical school and Australian rheumatologists to ascertain their understanding of placebo and nocebo responses. The survey ascertained (1) the alignment of the respondents' understanding of CMEs with accepted facts and concepts; (2) opinions on the ethical status of CMEs; and (3) responses to 2 scenarios designed to explore matters of biomedical causality, practical ethics and professionalism.

RESULTS

There were 88 completed surveys returned, 53 rheumatologists and 35 students. Similar proportions within each group identified CMEs, with most (n = 79/88 [89.8%]) correctly recognising a placebo (rheumatologists: 50 [94.3%], students: 29 [82.9%]) and approximately three-quarters (n = 65/88 [73.9%]) correctly recognising nocebo effects (rheumatologists: 39 [73.6%], students: 26 [74.3%]). Statistically significant differences between practitioners and students were observed in relation to the following: placebo responders and placebo responsiveness; placebos as a 'diagnostic tool'; placebos usage in clinical practice and research, and nocebo effects.

CONCLUSIONS

Physicians require an awareness of CMEs and the fact that they arise from and influence the effective agency of health care professionals. Curricular emphasis is needed to permit an honest assessment of the components that influence when, how and why patient outcomes arise, and how one's agency might have neutral or negative effects but could be inclined towards positive and away from negative patient outcomes.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

Short-term cryotherapy did not substantially reduce pain and had unclear effects on physical function and quality of life in people with knee osteoarthritis: a randomised trial

OBJECTIVE

Does short-term cryotherapy improve pain, function and quality of life in people with knee osteoarthritis (OA)?

DESIGN

Randomised controlled trial with concealed allocation, blinded assessment of some outcomes, and intention-to-treat analysis.

PARTICIPANTS

People living in the community with knee OA.

INTERVENTIONS

The experimental group received cryotherapy, delivered as packs of crushed ice applied to the knee with mild compression. The control group received the same regimen but with sham packs filled with sand. The interventions were applied once a day for 4 consecutive days.

OUTCOME MEASURES

Participants were assessed at baseline and on the day after the 4-day intervention period. The primary outcome was pain intensity according to a visual analogue scale. Secondary outcomes were baseline to post-intervention changes according to the Western Ontario and McMaster Universities Osteoarthritis, Knee injury and Osteoarthritis Outcome; Timed Up and Go test; and 30-Second Chair to Stand test.

RESULTS

Sixty participants were randomised into the experimental group (n = 30) or the control group (n = 30). Twenty-nine participants from each group completed the trial. The mean between-group difference in change in pain severity was -0.8 cm (95% CI -1.6 to 0.1), where negative values favour the experimental group. This result did not reach the nominated smallest worthwhile effect of 1.75 cm. The secondary outcomes had less-precise estimates, with confidence intervals that spanned worthwhile, trivial and mildly harmful effects.

CONCLUSION

Short-term cryotherapy was not superior to a sham intervention in terms of relieving pain or improving function and quality of life in people with knee OA. Although cryotherapy is considered to be a widely used resource in clinical practice, this study does not suggest that it has an important short-term effect, when compared with a sham control, as a non-pharmacological treatment for people with knee osteoarthritis.

REGISTRATION

NCT02725047.

Nocebos in rheumatology: emerging concepts and their implications for clinical practice

Nocebo effects are noxious reactions to therapeutic interventions that occur because of negative expectations of the patient. In the past decade, neurobiological data have revealed specific neural pathways induced by nocebos (that is, interventions that cause nocebo effects), as well as the associated mechanisms and predisposing factors of nocebo effects. Epidemiological data suggest that nocebos can have a notable effect on medication adherence, clinical outcomes and health-care policy. Meta-analyses of randomized controlled trials (RCTs) of patients with rheumatic and musculoskeletal diseases (RMDs) indicate that withdrawal of treatment by placebo-arm participants owing to adverse events is common; a proportion of these events could be nocebo effects. Moreover, in large-scale, open-label studies of patients with RMDs who transition from bio-originator to biosimilar therapeutics, biosimilar retention rates were much lower than in previous double-blind switch RCTs. This discrepancy suggests that in addition to the lack of response in some patients because of intrinsic differences between the drugs, nocebos might have an important role in low biosimilar retention, thus increasing the need for awareness and early identification of nocebo effects by rheumatologists and allied health-care professionals.

Effectiveness of Therapeutic Ultrasound on Clinical Parameters and Ultrasonographic Cartilage Thickness in Knee Osteoarthritis: A Double-Blind Trial

Objective:

A double-blind placebo-controlled randomized study was conducted to assess the effectiveness of therapeutic ultrasound (US) in knee OA.

Patients and Methods:

Thirty-three patients (mean age 54.7 ± 14.7) were randomized to receive either continuous US (n = 15) or sham US (n = 18) as a placebo. Continuous ultrasonic waves with 1 MHZ frequency and 1 watt/cm² power were applied for 5 min for 10 sessions. The primary outcome was pain on movement assessed by visual analog scale (VAS). The secondary outcomes were WOMAC scores and measurements of distal femoral cartilage thickness by imaging US.

Results:

Both groups showed reduced knee pain on movement following intervention. The VAS measurements improved significantly both in the treatment and the placebo group patients (P < 0.05 and P < 0.05). WOMAC scores improved statistically significant in all domains (pain, stiffness, physical function, and total score) in the treatment group (P < 0.05). All domains of WOMAC score showed statistically significant change when compared with the placebo group (P < 0.05). There was no change in the cartilage thickness measurements of medial femoral condyle, lateral femoral condyle, and intercondylar area in both groups after intervention.

Conclusion:

Results suggest that US is effective treatment modality in pain relief and improvement of function in patients with knee OA; however, US had no effect on cartilage repair.

Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain

Placebo and nocebo effects are embodied psycho-neurobiological responses capable of modulating pain and producing changes at different neurobiological, body at perceptual and cognitive levels. These modifications are triggered by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare providers, such as healing rituals and signs. The CFs directly impact on the quality of the therapeutic outcome: a positive context, that is a context characterized by the presence of positive CFs, can reduce pain by producing placebo effects, while a negative context, characterized by the presence of negative CFs, can aggravate pain by creating nocebo effects. Despite the increasing interest about this topic; the detailed study of CFs as triggers of placebo and nocebo effects is still lacked in the management of musculoskeletal pain.

Increasing evidence suggest a relevant role of CFs in musculoskeletal pain management. CFs are a complex sets of internal, external or relational elements encompassing: patient’s expectation, history, baseline characteristics; clinician’s behavior, belief, verbal suggestions and therapeutic touch; positive therapeutic encounter, patient-centered approach and social learning; overt therapy, posology of intervention, modality of treatment administration; marketing features of treatment and health care setting. Different explanatory models such as classical conditioning and expectancy can explain how CFs trigger placebo and nocebo effects. CFs act through specific neural networks and neurotransmitters that were described as mediators of placebo and nocebo effects.

Available findings suggest a relevant clinical role and impact of CFs. They should be integrated in the clinical reasoning to increase the number of treatment solutions, boosts their efficacy and improve the quality of the decision-making. From a clinical perspective, the mindful manipulation of CFs represents a useful opportunity to enrich a well-established therapy in therapeutic setting within the ethical border. From a translational perspective, there is a strong need of research studies on CFs close to routine and real-world clinical practice in order to underline the uncertainty of therapy action and help clinicians to implement knowledge in daily practice.

Pharmaceutical-grade Chondroitin sulfate is as effective as celecoxib and superior to placebo in symptomatic knee osteoarthritis: the ChONdroitin versus CElecoxib versus Placebo Trial (CONCEPT)

OBJECTIVES

Chondroitin sulfate 800 mg/day (CS) pharmaceutical-grade in the management of symptomatic knee osteoarthritis consistent with the European Medicines Agency guideline.

METHODS

A prospective, randomised, 6-month, 3-arm, double-blind, double-dummy, placebo and celecoxib (200 mg/day)-controlled trial assessing changes in pain on a Visual Analogue Scale (VAS) and in the Lequesne Index (LI) as coprimary endpoints. Minimal-Clinically Important Improvement (MCII), Patient-Acceptable Symptoms State (PASS) were used as secondary endpoints.

RESULTS

604 patients (knee osteoarthritis) diagnosed according to American College of Rheumalogy (ACR) criteria, recruited in five European countries and followed for 182 days. CS and celecoxib showed a greater significant reduction in pain and LI than placebo. In the intention-to-treat (ITT) population, pain reduction in VAS at day 182 in the CS group (-42.6 mm) and in celecoxib group (-39.5 mm) was significantly greater than the placebo group (-33.3 mm) (p=0.001 for CS and p=0.009 for celecoxib), while no difference observed between CS and celecoxib. Similar trend for the LI, as reduction in this metric in the CS group (-4.7) and celecoxib group (-4.6) was significantly greater than the placebo group (-3.7) (p=0.023 for CS and p=0.015 for celecoxib), no difference was observed between CS and celecoxib. Both secondary endpoints (MCII and PASS) at day 182 improved significantly in the CS and celecoxib groups. All treatments demonstrated excellent safety profiles.

CONCLUSION

A 800 mg/day pharmaceutical-grade CS is superior to placebo and similar to celecoxib in reducing pain and improving function over 6 months in symptomatic knee osteoarthritis (OA) patients. This formulation of CS should be considered a first-line treatment in the medical management of knee OA.

Nocebo effects in clinical studies: hints for pain therapy

INTRODUCTION

Nocebo-induced algesic responses occurring within clinical contexts present a challenge for health care practitioners working in the field of pain medicine.

OBJECTIVES

Following the recent research on algesic nocebo effects, the scope of this review is to develop ethically acceptable strategies to help avoid, or at least reduce, nocebo responses within clinical settings.

METHODS

We reviewed relevant clinical studies that depict how patient-practitioner interactions may contribute to the reduction of nocebo responses.

RESULTS

A strong algesic nocebo effect may adversely impact a patient's condition by causing decreases in both the efficacy and effectiveness of interventions, as well as by promoting treatment nonadherence and discontinuation. These effects may be triggered through multiple channels and can lead to significant alterations in a patient's perception of pain, consequently producing a weakening of the specific positive effects of pharmacological, psychological, or physical pain-management interventions.

CONCLUSION

To minimize nocebo effects in clinical settings, we identified and discussed five contextual aspects relevant to the treatment of patients with chronic pain: (1) negative patient-clinician communication and interaction during treatment; (2) emotional burden of patients during treatment with analgesic medication; (3) negative information provided via informational leaflets; (4) cued and contextual conditioning nocebo effects; and (5) patient's lack of positive information. Through an understanding of these elements, many preventive and ethically acceptable clinical actions can be taken to improve multidisciplinary pain treatment outcomes.