Effect of cane use on bone marrow lesion volume in people with medial tibiofemoral knee osteoarthritis: randomized clinical trial

Advances in the pathology and treatment of osteoarthritis

BACKGROUND

Osteoarthritis (OA), a widespread degenerative joint disease, predominantly affects individuals from middle age onwards, exhibiting non-inflammatory characteristics. OA leads to the gradual deterioration of articular cartilage and subchondral bone, causing pain and reduced mobility. The risk of OA increases with age, making it a critical health concern for seniors. Despite significant research efforts and various therapeutic approaches, the precise causes of OA remain unclear.

AIM OF REVIEW

This paper provides a thorough examination of OA characteristics, pathogenic mechanisms at various levels, and personalized treatment strategies for different OA stages. The review aims to enhance understanding of disease mechanisms and establish a theoretical framework for developing more effective therapeutic interventions.

KEY SCIENTIFIC CONCEPTS OF REVIEW

This review systematically examines OA through multiple perspectives, integrating current knowledge of clinical presentation, pathological mechanisms, and associated signaling pathways. It assesses diagnostic methods and reviews both pharmacological and surgical treatments for OA, as well as emerging tissue engineering approaches to manage the disease. While therapeutic strategies such as exercise, anti-inflammatory drugs, and surgical interventions are employed to manage symptoms and modify joint structure, none have been able to effectively halt OA's advancement or achieve long-lasting symptom relief. Tissue engineering strategies, such as cell-seeded scaffolds, supportive matrices, and growth factor delivery, have emerged as promising approaches for cartilage repair and OA treatment. To combat the debilitating effects of OA, it is crucial to investigate the molecular basis of its pathogenesis and seek out innovative therapeutic targets for more potent preventive and treatment strategies.

The future of in-field sports biomechanics: wearables plus modelling compute real-time in vivo tissue loading to prevent and repair musculoskeletal injuries

This paper explores the use of biomechanics in identifying the mechanistic causes of musculoskeletal tissue injury and degeneration. It appraises how biomechanics has been used to develop training programmes aiming to maintain or recover tissue health. Tissue health depends on the functional mechanical environment experienced by tissues during daily and rehabilitation activities. These environments are the result of the interactions between tissue motion, loading, biology, and morphology. Maintaining health of and/or repairing musculoskeletal tissues requires targeting the "ideal" in vivo tissue mechanics (i.e., loading and deformation), which may be enabled by appropriate real-time biofeedback. Recent research shows that biofeedback technologies may increase their quality and effectiveness by integrating a personalised neuromusculoskeletal modelling driven by real-time motion capture and medical imaging. Model personalisation is crucial in obtaining physically and physiologically valid predictions of tissue biomechanics. Model real-time execution is crucial and achieved by code optimisation and artificial intelligence methods. Furthermore, recent work has also shown that laboratory-based motion capture biomechanical measurements and modelling can be performed outside the laboratory with wearable sensors and artificial intelligence. The next stage is to combine these technologies into well-designed easy to use products to guide training to maintain or recover tissue health in the real-world.

Evaluation and management of knee osteoarthritis

Knee osteoarthritis (KOA) significantly contributes to the global disability burden, with its incidence expected to escalate by 74.9% by 2050. The urgency to comprehend and tackle this condition is critical, necessitating an updated and thorough review of KOA. A systematic review up to February 26, 2024, has elucidated the principal aspects of KOA's pathogenesis, risk factors, clinical manifestations, and contemporary management paradigms. The origins of KOA are intricately linked to mechanical, inflammatory, and metabolic disturbances that impair joint function. Notable risk factors include age, obesity, and previous knee injuries. Diagnosis predominantly relies on clinical assessment, with radiographic evaluation reserved conditionally. The significance of rehabilitation assessments, informed by the International Classification of Functioning, Disability, and Health framework, is highlighted. Treatment strategies are diverse, prioritizing nonpharmacological measures such as patient education, exercise, and weight management, with pharmacological interventions considered adjuncts. Intra-articular injections and surgical options are contemplated for instances where conventional management is inadequate. KOA stands as a predominant disability cause globally, characterized by a complex etiology and profound effects on individuals' quality of life. Early, proactive management focusing on nonpharmacological interventions forms the cornerstone of treatment, aiming to alleviate symptoms and enhance joint function. This comprehensive review underscores the need for early diagnosis, individualized treatment plans, and the integration of rehabilitation assessments to optimize patient outcomes. Further research is needed to refine prevention strategies and improve management outcomes for KOA patients.

Integrative Korean medicine treatment for inpatients with osteoarthritis of the knee: An observational study

The use of integrative Korean medicine treatment (IKMT) for patients with knee osteoarthritis (OA) has been reported previously; however, to date, no studies have investigated the long-term prognosis of these patients following IKMT for primary knee OA. We aimed to examine the long-term effects of IKMT in patients diagnosed with primary knee OA and receiving IKMT during hospitalization. This retrospective observational study, complemented by a follow-up survey, included patients with primary knee OA who received IKMT during hospitalization across 7 Korean medicine hospitals. The primary outcome was the Numerical Rating Scale knee-pain score, whereas the secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EuroQol-5 dimension-5 level questionnaire (EQ-5D-5L), and Patient Global Impression of Change scores. Patients were evaluated at admission, discharge, and during follow-up. Of the 180 included patients, 81 responded to the survey. Compared with the corresponding values at admission, the Numerical Rating Scale score decreased by 2.44 (2.08-2.81) points at discharge and 1.89 (1.5-2.26) points at follow-up. Additionally, compared with their scores at admission, the WOMAC score decreased by 17.20 (13.68-20.71) points at discharge and 25.74 (22.22-29.26) points at follow-up, whereas the EuroQol-5 dimension-5 level questionnaire score improved by -0.15 (-0.18 to -0.12) points at discharge and -0.12 (-0.15 to -0.09) points at follow-up. The patients expressed high satisfaction with pharmacopuncture (65.4%), acupuncture (54.03%), physical therapy (35.8%), and herbal medicine (34.6%). Regarding Patient Global Impression of Change, 96.30% of the patients reported improvement. IKMT was effective in improving pain, functional disability, and quality of life in patients with primary knee OA. Its effects were maintained throughout the long-term follow-up period, and physical functions continuously improved.

Toe-in and toe-out gait retraining interventions to reduce proxy measures of medial knee joint load in people with medial knee osteoarthritis: Protocol for a randomised placebo-controlled trial

OBJECTIVE

Our primary aim is to determine the effect of a six-week toe-in, toe-out and active placebo gait retraining program on proxy measures of medial knee joint load and varus thrust in people with medial knee osteoarthritis. Our secondary aim is to determine the intervention effects on patient reported outcomes and physical function and determine if changes are maintained at three-months follow-up.

METHODS

We will conduct a three-arm randomised placebo-controlled trial. Ninety participants with medial knee osteoarthritis will be randomised and stratified via varus thrust status (presence/absence) to: toe-in, toe-out or placebo gait retraining (an intervention that does not change proxy measures of medial knee joint load). The intervention involves weekly clinician-supervised sessions with biofeedback, knee osteoarthritis education, motor learning and behaviour change principles, and daily gait retraining practice. Primary outcomes are proxy measures of medial knee joint load: knee adduction moment (early- and late-stance peaks and impulse), and varus thrust (presence/absence). Secondary outcomes include pain, physical function, medication and health care utilisation, quality of life, work ability, treatment blinding, intervention credibility and other biomechanical outcomes. Assessment timepoints are at baseline, six weeks (post intensive training), and three-months following the six-week intervention.

CONCLUSION

Our trial will determine whether toe-in or toe-out gait retraining is most effective at reducing proxy measures of medial knee joint load and varus thrust in people with medial knee osteoarthritis. This study will also evaluate if toe-in or toe-out gait retraining interventions are superior at improving pain, physical function and quality of life compared to placebo.

CLINICAL TRIAL REGISTRATION

This clinical trial protocol is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12621000414819).

Chinese guidelines for the rehabilitation treatment of knee osteoarthritis: An CSPMR evidence-based practice guideline

BACKGROUND

Knee osteoarthritis (KOA) is the most common degenerative joint disease in China, causing a huge economic burden on patients, families, and society. Standardized KOA rehabilitation treatment is an important means to prevent and treat the disease and promote the development of high-quality medical services. This guideline is updated on the basis of the 2016 and 2019 editions.

METHODS

Clinical questions regarding rehabilitation assessment and treatment were selected through clinical questions screening and deconstruction, and multiple rounds of Delphi questionnaire consultation. The International Classification of Functioning, Disability and Health (ICF) was used as the theoretical framework, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to grade the quality of evidence and recommendations.

RESULTS

The reporting of this guideline followed the standard of Reporting Items for Practice Guidelines in Healthcare (RIGHT). Taking into account patients' preferences and values and the needs of Chinese clinical practice, a total of 11 clinical questions and 28 recommendations were established. The clinical questions were grouped into two categories: KOA assessment (body function, body structure, activity and participation, quality of life, and environmental factors and clinical outcomes assessment, resulting in 9 recommendations) and KOA treatment (health education, therapeutic exercise, therapeutic modalities, occupational therapy, assistive devices, and regenerative rehabilitation approaches, resulting in 19 recommendations).

CONCLUSION

This is the first evidence-based guideline for KOA rehabilitation in China utilizing the ICF framework. This guideline provides key guidance for developing systematic, standardized, and precise rehabilitation protocols for KOA across various healthcare settings.

Maintaining soldier musculoskeletal health using personalised digital humans, wearables and/or computer vision

OBJECTIVES

The physical demands of military service place soldiers at risk of musculoskeletal injuries and are major concerns for military capability. This paper outlines the development new training technologies to prevent and manage these injuries.

DESIGN

Narrative review.

METHODS

Technologies suitable for integration into next-generation training devices were examined. We considered the capability of technologies to target tissue level mechanics, provide appropriate real-time feedback, and their useability in-the-field.

RESULTS

Musculoskeletal tissues' health depends on their functional mechanical environment experienced in military activities, training and rehabilitation. These environments result from the interactions between tissue motion, loading, biology, and morphology. Maintaining health of and/or repairing joint tissues requires targeting the "ideal" in vivo tissue mechanics (i.e., loading and strain), which may be enabled by real-time biofeedback. Recent research has shown that these biofeedback technologies are possible by integrating a patient's personalised digital twin and wireless wearable devices. Personalised digital twins are personalised neuromusculoskeletal rigid body and finite element models that work in real-time by code optimisation and artificial intelligence. Model personalisation is crucial in obtaining physically and physiologically valid predictions.

CONCLUSIONS

Recent work has shown that laboratory-quality biomechanical measurements and modelling can be performed outside the laboratory with a small number of wearable sensors or computer vision methods. The next stage is to combine these technologies into well-designed easy to use products.

Synovitis mediates the association between bone marrow lesions and knee pain in osteoarthritis: data from the Foundation for the National Institute of Health (FNIH) Osteoarthritis Biomarkers Consortium

OBJECTIVES

Although subchondral bone marrow lesions (BMLs) and synovitis have been well acknowledged as important sources of pain in knee osteoarthritis (KOA), it is unclear if synovitis plays the mediating role in the relationship between BMLs and knee pain.

METHODS

We analyzed 600 subjects with magnetic resonance imaging (MRI) in the Foundation for National Institutes of Health Osteoarthritis Biomarkers Consortium (FNIH) cohort at baseline and 24-month. BMLs and synovitis were measured according to the MRI Osteoarthritis Knee Score (MOAKS) scoring system. BMLs were scored in five subregions. A summary synovitis score of effusion and Hoffa-synovitis was calculated. Knee pain was evaluated using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Linear regression models were applied to analyze the natural direct effect (NDE) of BMLs and synovitis with knee pain, respectively, and natural indirect effect (NIE) mediated by synovitis.

RESULTS

590 participants (58.8% females, with a mean age of 61.5) were included in the present analyses. For NDE, knee pain was cross-sectionally associated with medial femorotibial BMLs (β = 0.23, 95% CI: 0.09, 0.38) and synovitis (β = 0.40, 95% CI: 0.20, 0.60). Longitudinal associations retained significant [medial femorotibial BMLs (β = 0.37, 95% CI: 0.21, 0.53); synovitis (β = 0.72, 95% CI: 0.45, 0.99)]. In the NIE analyses, synovitis mediated the association between medial femorotibial BML and knee pain at baseline (β = 0.051, 95% CI: 0.01, 0.09) and over 24 months (β = 0.079, 95% CI: 0.023, 0.15), with the mediating proportion of 17.8% and 22.4%, respectively.

CONCLUSION

Synovitis partially mediates the association between medial femorotibial BMLs and knee pain.

Management of Knee Osteoarthritis: What Internists Need to Know

Knee osteoarthritis (OA) is a common and morbid condition. No disease-modifying therapies exist; hence the goals of current treatment are to palliate pain and to retain function. OA pain is significantly influenced by the placebo effect. Nonpharmacologic interventions are essential and have been shown to improve outcomes. Canes, unloading braces, and therapeutic heating/cooling may be valuable. Pharmacotherapy options include topical and oral nonsteroidal anti-inflammatory drugs, duloxetine, and periodic intra-articular glucocorticoids and hyaluronans. Opioids, intra-articular stem cells, and platelet-rich plasma are not recommended. Novel targets such as nerve growth factor are under investigation and may be approved soon for OA pain.

The association between change in bone marrow lesion size and change in tibiofemoral cartilage volume and knee symptoms

OBJECTIVE

To describe the association between change in subchondral bone marrow lesions (BMLs) and change in tibiofemoral cartilage volume and knee symptoms in patients with symptomatic knee OA.

METHODS

In total, 251 participants (mean 61.7 years, 51% female) were included. Tibiofemoral cartilage volume was measured at baseline and 24 months, and BML size at baseline, 6 and 24 months. Knee pain and function scores were evaluated at baseline, 6 and 24 months. Change in total and compartment-specific BML size was categorized according to the Least Significance Criterion. Linear mixed-effects models were used to evaluate the associations of change in BMLs over 6 and 24 months with change in cartilage volume over 24 months and knee symptoms over 6 and 24 months.

RESULTS

Total BML size enlarged in 26% of participants, regressed in 31% and remained stable in 43% over 24 months. Compared with stable BMLs in the same compartment, enlarging BMLs over 24 months were associated with greater cartilage loss (difference: -53.0mm3, 95% CI: -100.0, -6.0), and regressing BMLs were not significantly associated with reduced cartilage loss (difference: 32.4mm3, 95% CI: -8.6, 73.3) over 24 months. Neither enlargement nor regression of total BML size over 6 and 24 months was associated with change in knee pain and function over the same time intervals.

CONCLUSIONS

In subjects with symptomatic knee osteoarthritis and BMLs, enlarging BMLs may lead to greater cartilage loss but regressing lesions are not associated with reduced cartilage loss while neither is associated with change in knee symptoms.

Management of Knee Osteoarthritis: What Internists Need to Know

Knee osteoarthritis (OA) is a common and morbid condition. No disease-modifying therapies exist; hence the goals of current treatment are to palliate pain and to retain function. OA is significantly influenced by the placebo effect. Nonpharmacologic interventions are essential and have been shown to improve outcomes. Canes, unloading braces, and therapeutic heating/cooling may be valuable. Pharmacotherapy options include topical and oral nonsteroidal anti-inflammatory drugs, duloxetine, and periodic intra-articular glucocorticoids and hyaluronans. Opioids, intra-articular stem cells, and platelet-rich plasma are not recommended. Novel targets such as nerve growth factor are under investigation and may be approved soon for OA pain.

Osteoarthritis year in review 2020: imaging

This narrative "Year in Review" highlights a selection of articles published between January 2019 and April 2020, to be presented at the OARSI World Congress 2020 within the field of osteoarthritis (OA) imaging. Articles were obtained from a PubMed search covering the above period, utilizing a variety of relevant search terms. We then selected original and review studies on OA-related imaging in humans, particularly those with direct clinical relevance, with a focus on the knee. Topics selected encompassed clinically relevant models of early OA, particularly imaging applications on cruciate ligament rupture, as these are of direct clinical interest and provide potential opportunity to evaluate preventive therapy. Further, imaging applications on structural modification of articular tissues in patients with established OA, by non-pharmacological, pharmacological and surgical interventions are summarized. Finally, novel deep learning approaches to imaging are reviewed, as these facilitate implementation and scaling of quantitative imaging application in clinical trials and clinical practice. Methodological or observational studies outside these key focus areas were not included. Studies focused on biology, biomechanics, biomarkers, genetics and epigenetics, and clinical studies that did not contain an imaging component are covered in other articles within the OARSI "Year in Review" series. In conclusion, exciting progress has been made in clinically validating human models of early OA, and the field of automated articular tissue segmentation. Most importantly though, it has been shown that structure modification of articular cartilage is possible, and future research should focus on the translation of these structural findings to clinical benefit.

A novel walking cane with haptic biofeedback reduces knee adduction moment in the osteoarthritic knee

Knee osteoarthritis is a leading cause of ambulatory disability in adults. The most prescribed mobility aid, the walking cane, is often underloaded and therefore fails to reduce knee joint loading and provide symptomatic relief. For this study, a novel walking cane with haptic biofeedback was designed to improve cane loading and reduce the knee adduction moment (KAM). To determine; 1) the short-term efficacy of a novel walking cane using haptic biofeedback to encourage proper cane loading and 2) the effects of the novel cane on KAM. Cane loading and KAM, peak knee adduction moment (PKAM), and knee adduction angular impulse (KAAI)) while walking were calculated under five conditions: 1) naïve, 2A) after scale training (apply 20%BW to cane while standing, using a beam scale), 2B) scale recall (attempt to load the cane to 20%BW), 3A) after haptic training (vibrotactile biofeedback delivered when target cane load achieved), and 3B) haptic recall (attempt to load the cane to 20%BW with vibrotactile biofeedback delivered). Compared to the naïve condition all interventions significantly increased cane loading and reduced PKAM and KAAI. No differences between haptic recall and scale recall condition were observed. The haptic biofeedback cane was shown to be an effective and simple way to increase cane loading and reduced knee loading. Haptic biofeedback and scale training were equally effective at producing immediate short-term improvements in cane loading and knee loading. Future studies should examine the long-term effects of scale training and canes with haptic biofeedback on knee joint health, pain, and osteoarthritis disease progression.