Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled 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.

Functional Capacity and Quality of Life in Elderly Patients With Knee Osteoarthritis

BACKGROUND

Knee Osteoarthritis (KOA) can cause considerable impairment of functional capacity and quality of life (QoL), especially in elderly individuals.

OBJECTIVES

To evaluate the impact of KOA on the functional capacity and QoL of elderly patients and to identify the factors associated with their impairment.

METHODS

This was a cross-sectional study including patients aged 65 years or more with primary KOA. Functional capacity was assessed using the WOMAC index and QoL using the WHOQOL-OLD instrument. The p significance level was set at 0.05.

RESULTS

Fifty patients were included, 3 men and 47 women, with a mean age of 71.9 ± 6.3 years. The mean WOMAC total score was 49.2 ± 21.7, WOMAC pain 12 ± 5.2, WOMAC function 33.4 ± 15.2 and WOMAC stiffness 4 ± 2.6. Factors associated with better functional capacity were the use of analgesics, functional rehabilitation and physical activity. The mean WOQOL-OLD total score was 84.2 ± 13.4. The autonomy and intimacy dimensions had the highest scores (92.1 ± 13.8 and 91.3 ± 16.5 respectively). The death and dying dimension had the lowest score (69.9 ± 37.1). Factors associated with a poor QoL were diabetes, unilateral involvement, duration of KOA, absence of analgesic treatment and the absence of physical activity. Functional limitation was significantly associated with poorer QoL.

CONCLUSION

In our study, KOA was found to be associated with impaired functional capacity and QoL among elderly patients. Comorbidities, inadequate use of analgesics and lack of physical activity seem to be determining factors contributing to this impairment.

Recommendations from the French Societies of Rheumatology and Physical Medicine and Rehabilitation on the non-pharmacological management of knee osteoarthritis

BACKGROUND

Although non-pharmacological therapies for knee osteoarthritis (OA) are essential pillars of care, they are often poorly considered and inconsistently applied.

OBJECTIVES

Under the umbrella of the French Society of Rheumatology (SFR) and the French Society of Physical Medicine and Rehabilitation (SOFMER), we aimed to establish consensual recommendations for the non-pharmacological management of people with knee OA.

METHODS

A group of fellows performed a systematic literature review on the efficacy and safety of non-pharmacological modalities (up to October 2021). The fellows then took part in discussions with a multidisciplinary group of experts to draft a list of recommendations. The list was then submitted to an independent reading committee who rated their level of agreement with each recommendation. Each recommendation was assigned a strength of recommendation and a level of evidence.

RESULTS

Five general principles were unanimously accepted: (A) the need to combine non-pharmacological and pharmacological measures; (B) the need for personalized management; (C) the need to promote adherence; (D) the need for adapted physical activity; and (E) the need for person-centered education. Specific positive or negative recommendations were defined for 11 modalities: (1) unloading knee brace; (2) kinesiotaping or knee sleeves; (3) shoes and/or insoles; (4) using a cane; (5) physical exercise program; (6) joint mobilization; (7) electro- or thermo-therapy; (8) acupuncture; (9) weight loss; (10) thermal spa therapy; and (11) workplace accommodation.

CONCLUSIONS

These SFR/SOFMER recommendations provide important and consensual knowledge to assist health professionals in decision-making for non-pharmacological treatments for knee OA.

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.

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.

Lower Extremity Assistive Devices (LEADs): A Contemporary Literature Review

Lower extremity ambulatory assistive devices (LEADs) are important augments that provide mobility and stability when weightbearing is restricted in the setting of injury, surgery, or balance disorders. In order to optimize patient safety and function when prescribing these devices, it is essential for the orthopaedic surgeon to have a firm understanding of their specific indications, proper fitting, energy demand, biomechanical advantages, and potential complications. Comprehension of normal gait cadence, identification of the functional deficit present and knowledge of available options will assist in safely prescribing the proper device. Over the last decade, newer alternatives to traditional LEADs (canes, crutches, walkers) have become available, including the rolling knee scooter and hands-free single crutch. These have been developed to improve mobility and independence; however, it is necessary to appreciate their limitations when prescribing them to patients. This review will provide an update on normal and pathologic gait biomechanics as well as the most common types of LEADs currently available to the orthopaedic surgeon, their indications, important considerations, proper fitting, associated energy expenditure, and complications.

Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine

Knee osteoarthritis (KOA) is a common geriatric disease in middle-aged and elderly people. Its main pathological characteristics are articular cartilage degeneration, changes in subchondral bone reactivity, osteophyte formation at joint edges, synovial disease, ligament relaxation or contracture, and joint capsular contracture. The prevalence rate of symptomatic KOA in middle-aged and elderly people in China is 8.1%, and this is increasing. The main clinical manifestations of this disease are pain and limited activity of the knee joint, which seriously affect the quality of life of patients and may cause disability, posing a huge burden on society and the economy. Although the pathogenesis of KOA is not clear, the treatment of KOA is diverse, and Chinese medicine, which mainly relies on plant-based natural products, has a relatively stable and reliable curative effect. This guideline aims to emphasize the evidence-based staging and stepped treatment of KOA and the therapeutic effect of integrative medicine based on traditional Chinese medicine on KOA. We make recommendations that include the adoption of manual therapy, acupuncture, external application of herbs, herbal plasters, exercise therapy, and other integrative medicine based on traditional Chinese medicine. Users of the above guidelines are most likely to include clinicians and health managers in healthcare settings.

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.

Exploring experiences with telehealth-delivered allied healthcare services for people with permanent and significant disabilities funded through a national insurance scheme: a qualitative study examining challenges and suggestions to improve services

OBJECTIVES

In people with a disability, or their caregivers, who reported suboptimal experiences, the objectives were to explore: (1) challenges with telehealth-delivered allied health services during the COVID-19 pandemic and (2) suggestions to improve such services.

DESIGN

Qualitative study based on an interpretivist paradigm and a phenomenological approach.

SETTING

Participants who accessed allied healthcare via telehealth during the pandemic.

PARTICIPANTS

Data saturation was achieved after 12 interviews. The sample comprised three people with permanent or significant disabilities, and nine carers/partners/family members of people with permanent or significant disabilities, who were funded by the Australian National Disability Insurance Scheme and had suboptimal experiences with telehealth. Semistructured one-on-one interviews explored experiences with telehealth and suggestions on how such services could be improved. An inductive thematic analysis was performed.

RESULTS

Six themes relating to the first study objective (challenges with telehealth) were developed: (1) evoked behavioural issues in children; (2) reliant on caregiver facilitation; (3) inhibits clinician feedback; (4) difficulty building rapport and trust; (5) lack of access to resources and (6) children disengaged/distracted. Five themes relating to the second study objective (suggestions to improve telehealth services) were developed: (1) establish expectations; (2) increase exposure to telehealth; (3) assess suitability of specific services; (4) access to support workers and (5) prepare for telehealth sessions.

CONCLUSIONS

Some people with permanent and significant disabilities who accessed allied healthcare via telehealth during the pandemic experienced challenges, particularly children. These unique barriers to telehealth need customised solutions so that people with disabilities are not left behind when telehealth services become more mainstream. Increasing experience with telehealth, setting expectations before consultations, supplying resources for therapy and assessing the suitability of clients for telehealth may help overcome some of the challenges experienced.

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

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

Applications of Wearable Technology in a Real-Life Setting in People with Knee Osteoarthritis: A Systematic Scoping Review

With the growing number of people affected by osteoarthritis, wearable technology may enable the provision of care outside a traditional clinical setting and thus transform how healthcare is delivered for this patient group. Here, we mapped the available empirical evidence on the utilization of wearable technology in a real-world setting in people with knee osteoarthritis. From an analysis of 68 studies, we found that the use of accelerometers for physical activity assessment is the most prevalent mode of use of wearable technology in this population. We identify low technical complexity and cost, ability to connect with a healthcare professional, and consistency in the analysis of the data as the most critical facilitators for the feasibility of using wearable technology in a real-world setting. To fully realize the clinical potential of wearable technology for people with knee osteoarthritis, this review highlights the need for more research employing wearables for information sharing and treatment, increased inter-study consistency through standardization and improved reporting, and increased representation of vulnerable populations.

Targeted treatment for osteoarthritis: drugs and delivery system

The management of osteoarthritis (OA) is a clinical challenge due to the particular avascular, dense, and occluded tissue structure. Despite numerous clinical reports and animal studies, the pathogenesis and progression of OA are still not fully understood. On the basis of traditional drugs, a large number of new drugs have been continuously developed. Intra-articular (IA) administration for OA hastens the development of targeted drug delivery systems (DDS). OA drugs modification and the synthesis of bioadaptive carriers contribute to a qualitative leap in the efficacy of IA treatment. Nanoparticles (NPs) are demonstrated credible improvement of drug penetration and retention in OA. Targeted nanomaterial delivery systems show the prominent biocompatibility and drug loading-release ability. This article reviews different drugs and nanomaterial delivery systems for IA treatment of OA, in an attempt to resolve the inconsonance between in vitro and in vivo release, and explore more interactions between drugs and nanocarriers, so as to open up new horizons for the treatment of OA.

Impact of walking aids on estimating physical activity using a tri-axial accelerometer in frail older adults

Objectives

This study aimed to compare the estimation error of physical activity level (PAL) estimated using a tri-axial accelerometer between an independent walking group and an assisted walking group with walking aids.

Methods

Subjects were 6 older adults who could walk independently and 10 older adults requiring walking assistance during gait. Total energy expenditure (TEE) was measured using the doubly labelled water (DLW) method over 2 weeks and PAL was calculated as the measured TEE divided by the basal metabolic rate measured using indirect calorimetry (PAL_DLW). The participants wore a tri-axial accelerometer (Active style Pro HJA-750C) on the waist simultaneously as the DLW period, and the estimated PAL was derived from it (PAL_ACC).

Results

The median PAL estimation error in the assisted walking group was −0.30 kcal/day (range: −0.77 to −0.01 kcal/day) and more underestimated than that in the independent walking group (p=0.02). The estimation error of PAL_ACC was significantly correlated with PAL_DLW (r=−0.80, p<0.01).

Conclusions

Using the accelerometer, PAL was underestimated for older adults who used walking aids but not for those who walked independently under free-living conditions.

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.

The effect of curcumin ointment on knee pain in older adults with osteoarthritis: a randomized placebo trial

Background

Some studies have shown the effect of oral administration of curcumin on knee pain. However, limited studies are available on the effect of topical curcumin. This study aimed to investigate the effect of curcumin ointment on knee pain in older adults with osteoarthritis.

Methods

This double-blind randomized placebo trial was conducted on 72 older adults with knee pain associated with osteoarthritis. The subjects were randomly assigned into an intervention and a placebo group to apply either curcumin 5% ointment or Vaseline ointment twice daily for 6 weeks. Using a Visual Analog Scale, the severity of knee pain was measured at the beginning of the study, at the end of the fourth and sixth week. Data were analyzed using descriptive and inferential methods.

Results

The mean baseline knee pain intensity was not significantly different between the two groups (P = 0.15). The mean pain intensity was significantly lower in the intervention group than in the placebo group at the third measurement (P = 0.02). The repeated-measures analysis showed that over time, the curcumin significantly decreased the mean pain intensity in the intervention group (P = 0.001). The mixed model showed an absolute difference of 1.133 (i.e. 11.33 mm) score which signifies a medium effect size and that the patient in the intervention group achieved the minimal clinically important difference.

Conclusion

Topical administration of curcumin 5% ointment can significantly reduce knee pain in older adults with knee osteoarthritis. Curcumin ointment can be used as an alternative treatment in older adults with knee pain associated with osteoarthritis.

Trial registration

Retrospectively registered in the Iranian Registry of Clinical Trials (IRCT) (IRCT20100403003618N6, 2019-03-08), https://en.irct.ir/trial/37155

Nonpharmacological and nonsurgical approaches in OA

Osteoarthritis (OA) is a chronic, disabling, and common disease. Nonpharmacological and nonsurgical treatments are seen as the core treatments for OA. This paper presents an overview of the recommendations from international guidelines on nonpharmacological and nonsurgical interventions. Education, advice, or information about the etiology, progression, prognosis, and treatment options of OA are recommended to be an ongoing and integral part of care. Weight loss (if overweight) is an important core treatment in knee and hip OA. Exercise is a key core treatment in knee, hip, and hand OA and should be considered regardless of age, structural disease severity, functional status, pain levels, or the presence of comorbidities. Walking aids/devices are recommended for both hip and knee OA, while orthoses are recommended for patients with carpometacarpal (CMC) joint OA. Trained healthcare providers with the skills to provide the core treatments are essential. In addition, there should be a proactive management from the first consultation for OA symptoms. Tools for such proactive management and for better uptake of the core interventions are discussed.

Home-based management of knee osteoarthritis during COVID-19 pandemic: literature review and evidence-based recommendations

Purpose

To provide evidence-based recommendations for patients with severe knee osteoarthritis (OA), who had their knee surgery postponed due to the COVID-19 pandemic.

Methods

PubMed/Medline, Scopus and Cochrane Central databases were systematically reviewed for studies reporting outcomes of home-based treatments for knee OA. Due to between-study differences in treatment strategy and reporting methods the results were not pooled and findings of the current review were presented in a narrative manner.

Results

The comprehensive literature search yielded 33 eligible studies that were included in this review. Management is performed at home and consists of exercise, proper nutrition, physical therapy and use of corrective and assistive orthotics. Virtual education on self-management strategies should be part of coping with knee OA. Initiating an exercise programme involving gymnastics, stretching, home cycling and muscle strengthening is highly recommended. Obese patients are encouraged to set weight loss goals and adopt a healthy diet. Potential benefits but weak evidence has been shown for the use of knee braces, sleeves, foot orthotics or cushioned footwear. Walking aids may be prescribed, when considered necessary, along with the provision of instructions for their use.

Conclusion

When bridging the time to rescheduled surgery, it is essential to use appropriate home-based tools for the management of knee OA if pain is to be reduced and need for analgesics or opioid use is to be diminished while maintaining or even improving the functioning and avoiding further limitation of range of motion and subsequent muscular atrophies. Finally, none of these treatments may completely substitute for the life-changing effect of a total knee arthroplasty in patients with severe knee OA. Hence, the subsequent goal is to gradually and safely reinstate elective surgery.

Combined effect of laser acupuncture and electroacupuncture in knee osteoarthritis patients: A protocol for a randomized controlled trial

BACKGROUND

Knee osteoarthritis (KOA) is a common degenerative joint disorder that affects 250 million people globally. KOA can lead to disability and is often associated with cardiovascular disease, poor quality of life, and mortality. The most common treatment for KOA is non-steroidal anti-inflammatory drug administration. However, the analgesic effect is limited and often accompanied by multiple side effects. Hence, many KOA patients opt for complementary and alternative medicine. Acupuncture is one of the most popular complementary treatments with great analgesic effect and minimal side effect. Electroacupuncture (EA) and laser acupuncture (LA) have been known to reduce pain in KOA patients. However, to date, no study has assessed the benefits of combining these two therapies.

METHODS

Fifty participants diagnosed with KOA, aged 50 years or older, and with consistent knee pain for more than 3 months were recruited and randomly assigned to the treatment group (EA plus LA) or control group (EA plus sham LA without laser output). All subjects in the treatment group will undergo a combined EA and LA treatment thrice a week for 4 weeks. The acupuncture will be performed on GB33, GB34, SP9, SP10, and ST36 sites. The treatment group will receive acupuncture with a transcutaneous electrical nerve stimulator at GB33, GB34, SP9, and SP10 sites and with LA at EX-LE5, ST35, and BL40 sites. The subjects in the control group will undergo the same treatment modality as the treatment group, except these subjects will not be exposed to laser output. Outcome measurements will include visual analog scale, Western Ontario McMaster Universities Osteoarthritis Index, Knee injury and osteoarthritis outcome, body composition analysis, knee range of motion, quadriceps muscle stiffness, one-leg standing with eyes open test, and the 30-s chair stand test before and after 4 weeks of intervention.

OBJECTIVES

This protocol aims to investigate the combined effect of EA and LA in KOA patients.

Contralateral canes for knee osteoarthritis

Introduction

Knee osteoarthritis is a relevant health problem given its high prevalence and associated disability. Within the non-pharmacological management alternatives, the use of canes has been proposed, however, there is no consensus in the literature regarding its indication.

Methods

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

Results and conclusions

We identified three systematic reviews including four studies overall, of which one was randomized trials. We conclude that the use of a contralateral cane in patients with knee osteoarthritis probably reduces pain. In addition, it could slightly increase function, but the certainty of the evidence is low.

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

OBJECTIVE

To evaluate effects of daily cane use for 3 months on medial tibiofemoral bone marrow lesion (BML) volumes in people with medial tibiofemoral osteoarthritis (OA).

DESIGN

In this randomized controlled trial (RCT), 79 participants with medial tibiofemoral OA were randomized to either a cane group (using a cane whenever walking) or control group (not using any gait aid) for 3 months. The cane group received a single training session by a physiotherapist, using a biofeedback cane to teach optimal technique and body weight support and motor learning principles to facilitate retention of learning. The primary outcome was change in total medial tibiofemoral BML volume (per unit bone volume) measured from magnetic resonance imaging (MRI) at 3 months. Secondary outcomes were BML volumes (per unit bone volume) of the medial tibia and femur, and patient-reported outcomes of overall knee pain, knee pain on walking, physical function, perceived global symptom changes and health-related quality of life. MRI analyses were performed by a blinded assessor.

RESULTS

Seventy-eight participants (99%) completed the primary outcome. Mean (standard deviation) daily cane use was 2.3 (1.7) hours over 3 months. No evidence of between-group differences was found for change in total medial tibiofemoral BML volume (mean difference: -0.0010 (95% confidence intervals: -0.0022, 0.0003)). Most secondary outcomes showed minimal differences between groups.

CONCLUSION

Daily use of a cane during walking for 3 months aiming to reduce knee joint loading did not change medial tibiofemoral BML volumes compared to no use of gait aids.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry (ACTRN12614000909628).

The walking cane length influences the postural sway of community-dwelling older women

BACKGROUND

Mobility-related problems in older people may be relieved by the use of walking canes. However, the influence of the cane length on the postural stability of cane users has not been explored.

OBJECTIVE

The objective of this study is to examine the influence of a single-point cane with different lengths on the postural sway of regular cane users, older women during two stance positions, with feet parallel and semi-tandem stance.

METHODS

Eighteen older women, who used a single-point walking cane for at least 6 months, stood on a force plate with feet parallel or in semitandem position for 40 s. They always used a cane that was adjusted to one of three different lengths resulting from the distance between the wrist crease and the floor, named WF, or this distance plus 7.5 or 10 cm. Amplitude and speed of the centre of pressure (COP) and its components (rambling and trembling) in the anterior-posterior and medial-lateral directions and mean vertical force applied to the cane were compared across cane lengths.

RESULTS

The amplitude and velocity of COP, rambling and trembling increased with the cane length. This effect was observed for the anterior-posterior with the feet parallel and in the medial-lateral direction with the semi-tandem position. More force was applied on the shorter cane (WF) in semitandem position.

CONCLUSION

Longer canes increased the postural sway in the older women and restricted the body weight loaded on the cane. Improper cane length influences the postural sway particularly in a semitandem stance of regular cane users. This may cause a negative impact on postural stability required in daily life activities. The current findings may contribute to the prescription of this assistive device for older adults.

Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review

Background

Lower limb osteoarthritis (OA) causes high levels of individual pain and disability and is an increasing socio-economic burden to global healthcare systems. Physical Activity interventions are commonly provided by physiotherapists to help patients with lower limb OA manage their clinical symptoms.

Objective

To identify and evaluate the effectiveness of behavioural change techniques (BCTs) within physiotherapy interventions to increase physical activity (PA) adherence in patients with lower limb OA.

Design

A systematic review was conducted, following Cochrane guidelines according to a published and registered protocol (CRD42016039932). Two independent researchers conducted searches, determined eligibility, assessed risk of bias (Cochrane tool), intervention fidelity (NIHBCC checklist), and coded randomised controlled trials (RCTs) for BCTs (V1 taxonomy). BCT effectiveness ratios were calculated and RCT risk of bias and intervention fidelity were summarised narratively.

Data sources

A highly sensitive search strategy was conducted on Medline, Embase, PsycINFO, CENTRAL, CINAHL and PEDro and grey literature databases from inception to January 2^nd, 2018. Reference lists of included RCTs and relevant articles were reviewed, and a citation search was conducted using Web of Science.

Eligibility criteria for selecting studies

RCTs that evaluated the effectiveness of a physiotherapy intervention that incorporated ≥1 BCT that promoted home or community-based PA adherence in patients with lower limb osteoarthritis.

Results

Twenty-four RCTs (n = 2366 participants) of variable risk of bias (RoB) (5 low; 7 moderate; 12 high) and poor intervention reporting from 10 countries were included. Heterogeneity of intervention BCTs and PA adherence outcome measures precluded meta-analysis. Thirty-one distinct BCTs were identified in 31 interventions across RCTs. In general, BCTs demonstrated higher effectiveness ratios for short-term and long-term PA adherence compared with medium-term outcomes. The BCTs ‘behavioural contract’, ‘non-specific reward’, ‘patient-led goal setting’ (behaviour), ‘self-monitoring of behaviour’, and ‘social support (unspecified) demonstrated the highest effectiveness ratios across time points to promote PA adherence.

Conclusions

BCTs demonstrate higher short and long-term than medium-term effectiveness ratios. Further research involving low RoB RCTs incorporating transparently reported interventions with pre-specified BCTs aimed at optimising lower limb OA patient PA adherence is required.

The use of functional performance tests by primary health-care providers to determine walking ability with and without awalking device in community-dwelling elderly

Background: Primary health-care (PHC) providers are important for community involvement in health promotion and prevention efforts, particularly today that the number of elderly is increasing dramatically. The use of a standard practical measure would help in promoting the effectiveness of referral and monitoring processes. Objectives: To investigate the use of functional performance tests in terms of the appropriate cutoff point to determine walking ability with and without a walking device in community-dwelling elderly, and reliability of the tests when used by PHC providers. Methods: Community-dwelling people aged 65 years or older who walked with or without a walking device (n = 309) were interviewed and assessed for information related to the use of a walking device in daily living. Then, they were randomly assessed for their functional ability using the Timed Up and Go Test (TUG), Five Times Sit-to-Stand Test (FTSST), and the 10-Meter Walk Test (10MWT). PHC providers, including a physical therapist, village health volunteer, and a caregiver, assessed 30 participants' functional performances, to address rater reliability of the tests. Results: The findings suggested that outcomes of the tests (TUG < 12 s, FTSST < 15 s, and 10MWT > 0.8 m/s) can indicate the ability of walking without a walking device of the participants. These tests could be used by PHC providers, except for the FTSST by a caregiver. Conclusions: The findings offer a clear cutoff point for promoting the involvement of PHC providers and the standardization of a screening, monitoring, and referral process among many clinical and community settings.

Body weight support through a walking cane in inexperienced users with knee osteoarthritis

BACKGROUND

Walking canes are a self-management strategy recommended for people with knee osteoarthritis (OA) by clinical practice guidelines. Ensuring that an adequate amount of body-weight support (%BWS) is taken through the walking cane is important as this reduces measures of knee joint loading.

RESEARCH QUESTION

1) How much body weight support do people with knee OA place through a cane? 2) Do measures of body weight support increase following a brief simple training session?

METHODS

Seventeen individuals with knee pain who had not used a walking cane before were recruited. A standard-grip aluminum cane was then used for 1 week with limited manufacturer instructions. Following this, participants were evaluated using an instrumented force-measuring cane to assess body weight support (% total body weight) through the cane. Force data were recorded during a 430-metre walk undertaken twice; once before 10 min of cane training administered by a physiotherapist, and once immediately after training. Measures of BWS (peak force, average force, impulse equal to the average cane force times duration, and cane-ground contact duration) were extracted. Using bathroom scales, training aimed to take at least 10% body weight support through the cane.

RESULTS

Before training, the average peak BWS was 7.2 ± 2.5% of total body weight. Following 10 min of training, there was a significant increase in average peak BWS by 28%, average BWS by 25%, and BWS impulse by 54% (p < 0.05). However, individual BWS responses to training were variable. Duration of cane placement increased by 22% after training (p = 0.02). Timing of peak BWS through the cane occurred at 51% of contact phase before training, and at 53% after training (p = 0.05).

SIGNIFICANCE

A short training session can increase the transfer of body weight through a walking cane. However, more sophisticated feedback may be needed to achieve target levels of BWS.

Advances in rheumatology practice in Brazil

Despite resilient inequities, Brazil has seen progressive improvement in health care in the last 25 years. Infectious diseases rendered place to chronic non-communicable diseases as a major cause of death. Existence of traditional schools of medicine and training services in rheumatology helped form a reasonable number of specialists, though irregular distribution due to the economic issues favoring their clustering in major cities. The Brazilian Society of Rheumatology provides continued medical education, helps training rheumatologists, family physicians and other health professionals and has worked to publish national recommendations for the diagnosis and treatment of major rheumatic diseases. Access to medications and health care facilities is provided for most patients, free of direct charge, including biologics. Specialized services for autoimmune and rare diseases, including pediatric rheumatology and autoinflammatory diseases, have improved, particularly in developed centers of the southern best developed parts of the country. A major unmet need is the lack of access to non-pharmacological treatment modalities. In this article, we will summarize some of the strengths and points that need improvement to enhance access to the rheumatological health care in Brazil.

Outpatient management of knee osteoarthritis

Osteoarthritis of the knee is a common disease that causes significant disability. Most patients can be managed conservatively in the outpatient setting. A small minority require surgery. The cornerstones of treatment are weight loss, exercise and analgesia. Walking aids, medial patellar taping, acupuncture and transcutaneous electrical nerve stimulation are useful management adjuncts. Current evidence does not support routine prescription of glucosamine and chondroitin supplements. Early consultation with an orthopaedic surgeon should be made when conservative measures fail.

[The feasibility of the application of cryotherapy and radonotherapy for the treatment of the patients presenting with osteoarthritis]

Osteoarthritis (OA) is currently considered to be one of the most widespread diseases. Its main clinical symptoms include pain and dysfunction of joints. In the present review of the foreign and domestic literature, the questions of pathogenesis and risk factors underlying the development of osteoarthritis are discussed. The understanding of OA pathogenesis have altered essentially in the recent years which made necessary the search for the novel approaches to the treatment of this pathology. According to the modern views of OA origin and progression, its therapy should be based on the application of the combination of medicamentous and non-medicamentous modalities including, in particular, collective and individual activities focused on the implementation of the programs of therapeutic physical training as an obligatory component of ОА prophylaxis and treatment. The present review gives evidence of the feasibility of the application of the methods of cryotherapy and radonotherapy for the management of the patients suffering from osteoarthritis. It is emphasized that many recent publications report extensive investigations of the clinical and pathogenetic aspects of the application of these methods for the combined regenerative treatment of the patients presenting with gonarthrosis. The influence of cryotherapy and radonotherapy on the neuroendocrine and immune systems is discussed with special reference to the possibility of regulation of the metabolic processes and retardation of inflammation. It is concluded that the introduction of the above methods into the compulsory individual program for the regenerative treatment of patients presenting with osteoarthritis is pathologically substantiated since it greatly contributes to the reduction of pain and retardation of the progress of the disease. The main pharmaceutical preparations for the OA treatment remain to be slow-acting symptomatic medicines possessed of the chondro-protective effect.

Impact of Traumatic Lower Extremity Injuries Beyond Acute Care: Movement-Based Considerations for Resultant Longer Term Secondary Health Conditions

Significance: Advances in field-based trauma care, surgical techniques, and protective equipment have collectively facilitated the survival of a historically large number of service members (SMs) following combat trauma, although many sustained significant composite tissue injuries to the extremities, including limb loss (LL) and limb salvage (LS). Beyond the acute surgical and rehabilitative efforts that focus primarily on wound care and restoring mobility, traumatic LL and LS are associated with several debilitating longer term secondary health conditions (e.g., low back pain [LBP], osteoarthritis [OA], and cardiovascular disease [CVD]) that can adversely impact physical function and quality of life. Recent Advances: Despite recent advancements in prosthetic and orthotic devices, altered movement and mechanical loading patterns have been identified among persons with LL and salvage, which are purported risk factors for the development of longer term secondary musculoskeletal conditions and may limit functional outcomes and/or concomitantly impact cardiovascular health. Critical Issues: The increased prevalence of and risk for LBP, OA, and CVD among the relatively young cohort of SMs with LL and LS significantly impact physiological and psychological well-being, particularly over the next several decades of their lives. Future Directions: Longitudinal studies are needed to characterize the onset, progression, and recurrence of health conditions secondary to LL and salvage. While not a focus of the current review, detailed characterization of physiological biomarkers throughout the rehabilitation process may provide additional insight into the current understanding of disease processes of the musculoskeletal and cardiovascular systems.

Physical Function Assessment of a Mayan Population Living With Osteoarthritis: The Importance of Considering Different Aspects of Functioning

Objectives:

To assess the physical function of people living with osteoarthritis in a Maya-Yucateco rural community from 3 perspectives and explore factors associated with the presence of disability.

Design:

Physical function and social, physical, psychological, and behavioral factors were evaluated in all adults detected with hand, hip, and/or knee osteoarthritis (n = 144) through a Community-Oriented Program for the Control of Rheumatic Diseases–based census in the Mayan community of Chankom, Yucatán. All cases fulfilled the American College of Rheumatology criteria. Physical function was assessed from 3 perspectives: hypothetical or “what people think they can do” (Health Assessment Questionnaire-Disability Index [HAQ-DI]), experimental or “what people could do in standardized conditions” (6-minute walk test [6MWT] + the Functional Dexterity Test) and enacted or “what people actually do” (personal care, work, and leisure activities’ self-report).

Results:

About 80% of participants reported “mild” disability (HAQ-DI ≤ 1) in the hypothetical function perspective, whereas average experimental function scores were low (6MWT: 206 m, Functional Dexterity Test: 64 seconds), and 78% of participants reported problems with enacted function (ie, work). Pain was significantly associated with disability in the hypothetical perspective (odds ratio [OR] = 3 [95% confidence interval [CI]: 1-4]); levels of wealth (β = 5 [95% CI: 1-9]) and muscle strength (β = 54 [95% CI: 20-87]) were significantly associated with functioning in the experimental perspective; and lower levels of self-efficacy (OR = 12 [95% CI: 6-27]) and physical activity (OR = 12 [95% CI: 6-27]) were significantly associated with work disability in the enacted function perspective.

Conclusions:

People living with osteoarthritis in Chankom show important issues when assessing physical function at the experimental and enacted perspectives, which could have been overlooked if only the hypothetical perspective was considered. Different factors were associated with different physical function perspectives and all should be addressed to decrease disability in this community.

The influence of the crutch setup on stability and weight-bearing parameters in post total hip replacement surgery patients during quiet standing

PURPOSE

The purpose of this study is to evaluate the influence of the crutch setup on standing, in post total hip replacement (THR) surgery patients.

MATERIALS AND METHODS

Thirty patients after THR were randomly assigned to walking with the elbow flexed (EF) or elbow straight (ES) crutch setup. Subjects were asked to stand on a force platform in a comfortable position with the crutch positioned on the unaffected side, facing forward for 10 seconds. Centre of pressure total path and maximal excursion were evaluated in both medio-lateral and anterior-posterior planes. Difference in the asymmetry of left/right acromial height, measured with and without the crutch, was calculated (ACdiff). Percentage of body weight borne by the crutch (Fcr), symmetry (SIload) between operated and healthy limbs loading during the trial, together with shoulder forces and moments were measured.

RESULTS

No significant differences between the two groups (p > .05) were found for stability parameters. ACdiff, Fcr and shoulder load increased significantly (p < .05) in EF group compared to ES group. In addition leg loading symmetry was significantly reduced in the EF group.

CONCLUSIONS

The present study showed that the ES setup reduced the force borne by the crutch, the load on the shoulder joint and it minimized postural and loading asymmetries when compared to EF setup. Conversely, postural stability was not influenced by the crutch setup. Implications for Rehabilitation Static posture and weight-bearing parameters are influenced by crutch setup during quiet standing. Crutch setup does not influence postural stability. Adjusting the crutch according to the elbow straight setup reduces the force borne by the crutch and the asymmetry in lower limbs loading. Forces and moments at the shoulder joint were reduced for the elbow straight setup group.

Impact of Cane Use on Bone Marrow Lesion Volume in People With Medial Knee Osteoarthritis (CUBA Trial)

BACKGROUND

No effective cure exists for knee osteoarthritis (OA). Low-burden self-management strategies that can slow disease progression are needed. Bone marrow lesions (BMLs) are a source of knee pain and accelerate cartilage loss. Importantly, they may be responsive to biomechanical off-loading treatments.

OBJECTIVE

The study objective is to investigate whether, in people with medial tibiofemoral OA, daily cane use for 12 weeks reduces the volume of medial tibiofemoral BMLs and improves pain, physical function, and health-related quality of life.

DESIGN

This study will be an assessor-masked, 2-arm, parallel-group, multisite randomized controlled trial.

SETTING

The community will serve as the setting for this study.

PARTICIPANTS

The study participants will be people who are 50 years old or older and have medial tibiofemoral OA and at least 1 medial tibiofemoral BML.

INTERVENTION

The participants will be allocated to either the cane group (using a cane daily whenever walking for 12 weeks) or the control group (not using any gait aid for 12 weeks).

MEASUREMENTS

Outcomes will be measured at baseline and 13 weeks. The primary outcome will be total medial tibiofemoral BML volume measured from magnetic resonance imaging. Secondary outcomes will include BML volume of the medial tibia and/or femur, knee pain overall and on walking, physical function, participant-perceived global change, and health-related quality of life. Additional measures will include physical activity, cointerventions, adverse events, participation, participant demographics, cane training process measures and feasibility, barriers to and facilitators of cane use, and loss to follow-up.

LIMITATIONS

People who are morbidly obese will not be included because of difficulties with magnetic resonance imaging.

CONCLUSIONS

The findings of this study will help to determine whether cane use can alter disease progression in people with medial tibiofemoral OA and/or influence clinical symptoms. This study may directly influence clinical guidelines for the management of knee OA.

Osteoarthritis

Osteoarthritis (OA) is the most common joint disorder, is associated with an increasing socioeconomic impact owing to the ageing population and mainly affects the diarthrodial joints. Primary OA results from a combination of risk factors, with increasing age and obesity being the most prominent. The concept of the pathophysiology is still evolving, from being viewed as cartilage-limited to a multifactorial disease that affects the whole joint. An intricate relationship between local and systemic factors modulates its clinical and structural presentations, leading to a common final pathway of joint destruction. Pharmacological treatments are mostly related to relief of symptoms and there is no disease-modifying OA drug (that is, treatment that will reduce symptoms in addition to slowing or stopping the disease progression) yet approved by the regulatory agencies. Identifying phenotypes of patients will enable the detection of the disease in its early stages as well as distinguish individuals who are at higher risk of progression, which in turn could be used to guide clinical decision making and allow more effective and specific therapeutic interventions to be designed. This Primer is an update on the progress made in the field of OA epidemiology, quality of life, pathophysiological mechanisms, diagnosis, screening, prevention and disease management.

A smart cane with vibrotactile biofeedback improves cane loading for people with knee osteoarthritis

Nine million adults have symptomatic knee osteoarthritis (OA) in the U.S. and almost half of those people have a walking aid such as a cane. Proper cane loading (e.g. 15% body weight [BW]) can reduce knee loading and may slow OA progression. The purpose of this study was to investigate the efficacy of a novel smart cane with vibrotactile biofeedback that aims to facilitate increased cane loading. Ten subjects with knee OA performed a 50 m hallway walk test under four conditions: 1) naïve, 2) conventional cane with verbal instruction, 3) smart cane, and 4) conventional cane post smart cane. The cane load (% BW; mean ± 1 standard deviation) for the four conditions was 9.0 ± 1.9 (naïve), 12.7 ± 2.6 (conventional cane), 17.6 ± 2.4 (smart cane), and 15.6 ±3.1 (conventional cane post smart cane). These results indicate that the smart cane's vibrotactile biofeedback helped the users achieve the target cane loading of 15% BW or more as compared to naïve or verbal instruction alone. After using the smart cane, conventional cane loading was higher than the naïve and verbal instruction conditions demonstrating a potential smart cane training effect. Long term increased cane loading may reduce knee pain and improve joint function.

Pain Relief for an Osteoarthritic Knee in the Elderly: A Practical Guide

In view of the increasing prevalence of knee osteoarthritis (OA) in the population worldwide, optimal management is critical to decrease the burden of this condition and minimize disability and personal suffering. Current care is based on a sequence of non-pharmacological, pharmacological, and surgical modalities, targeted to improving pain and function in the elderly population. The aim of this article is to provide a practical view of the efficacy of therapeutic options available along with clinically relevant considerations on the management of knee OA in this demographic group.

Long-term use of minimal footwear on pain, self-reported function, analgesic intake, and joint loading in elderly women with knee osteoarthritis: A randomized controlled trial

BACKGROUND

Efforts have been made to retard the progressive debilitating pain and joint dysfunction in patients with knee osteoarthritis. We aimed to evaluate the therapeutic effect of a low-cost minimalist footwear on pain, function, clinical and gait-biomechanical aspects of elderly women with knee osteoarthritis.

METHODS

Throughout a randomized, parallel and controlled clinical trial, fifty-six patients with medial knee osteoarthritis were randomly allocated to an intervention (n=28) or control group (n=28), and assessed at baseline and after three and six months. The intervention involved wearing Moleca(®) footwear for at least 6h/day, 7 days/week, over 6 months. The pain subscale of the Western Ontario and McMaster Universities Osteoarthritis Index was the primary outcome. The secondary outcomes were the other subscales, Lequesne score, distance walked in 6 min, knee oedema and effusion, knee adduction moment and paracetamol intake. Intention-to-treat analysis was performed using two-way casewise ANOVA (< .05) and Cohen's d coefficient.

FINDINGS

Intervention group showed improvement in pain (effect size: 1.41, p<.001), function (effect size: 1.22, p=.001), stiffness (effect size: 0.76, p=.001), Lequesne score (effect size: 1.07, p<.001), and reduction by 21.8% in the knee adduction moment impulse (p=.017) during gait wearing Moleca(®). The analgesic intake was lower in the intervention group.

INTERPRETATION

The long-term use of Moleca(®) footwear relieves pain, improves self-reported function, reduces the knee loading while wearing Moleca(®), refrains the increase of analgesic intake in elderly women with knee osteoarthritis and can be considered as a conservative mechanical treatment option. ClinicalTrials.gov (NCT01342458).

Comparison of Two Methods for Estimating Adjustable One-Point Cane Length in Community-Dwelling Older Adults

BACKGROUND AND PURPOSE

Our aim is to estimate inter-observer reliability, test-retest reliability, anthropometric and biomechanical adequacy and minimal detectable change when measuring the length of single-point adjustable canes in community-dwelling older adults.

METHODS

There are 112 participants in the study. They are men and women, aged 60 years and over, who were attending an outpatient community health centre. An exploratory study design was used. Participants underwent two assessments within the same day by two independent observers and by the same observer at an interval of 15-45 days. Two measures were used to establish the length of a single-point adjustable cane: the distance from the distal wrist crease to the floor (WF) and the distance from the top of the greater trochanter of the femur to the floor (TF). Each individual was fitted according to these two measures, and elbow flexion angle was measured.

RESULTS AND DISCUSSION

Inter-observer reliability and the test-retest reliability were high in both TF (ICC^3.1  = 0.918 and ICC^2.1  = 0.935) and WF measures (ICC^3.1  = 0.967 and ICC^2.1  = 0.960). Only 1% of the individuals kept an elbow flexion angle within the standard recommendation of 30° ± 10° when the cane length was determined by the TF measure, and 30% of the participants when the cane was determined by the WF measure. The minimal detectable cane length change was 2.2 cm.

CONCLUSION

Our results suggest that, even though both measures are reliable, cane length determined by WF distance is more appropriate to keep the elbow flexion angle within the standard recommendation. The minimal detectable change corresponds to approximately a hole in the cane adjustment. Copyright © 2015 John Wiley & Sons, Ltd.

Managing osteoarthritis

Management of osteoarthritis should be based on a combination of non-drug and drug treatments targeted towards prevention, modifying risk and disease progression. Obesity is the most important modifiable risk factor, so losing weight in addition to land- and water-based exercise and strength training is important. While paracetamol can be tried, guidelines recommend non-steroidal anti-inflammatory drugs as first-line treatment for osteoarthritis. If there are concerns about the adverse effects of oral treatment, particularly in older patients or those with comorbidities, topical non-steroidal anti-inflammatory drugs can be used. Glucosamine does not appear to be any better than placebo for pain. Its effect on the structural progression of disease when taken alone or in combination with chondroitin is uncertain. Fish oil has not been found to reduce the structural progression of knee arthritis. Surgical interventions should be avoided in the first instance, with arthroscopic procedures not showing benefit over sham procedures or optimised physical and medical therapy. Joint replacement surgery should be considered for severe osteoarthritis.

Effects of contralateral versus ipsilateral cane use on gait in people with knee osteoarthritis

OBJECTIVE

To compare the immediate effects of contralateral versus ipsilateral cane use on spatiotemporal gait parameters and peak vertical ground force in overweight or obese adults with symptomatic knee osteoarthritis (OA).

DESIGN

Prospective observational study.

SETTING

An academic tertiary Veterans Affairs Healthcare Center.

PARTICIPANTS

Thirty-eight overweight or obese subjects with symptomatic knee OA who had not used a cane for the past 30 days.

METHODS

Spatiotemporal gait data were obtained with an optical motion capture system while subjects walked without a cane, with a cane contralateral to the more painful lower limb, or with a cane ipsilateral to the more painful lower limb at self-selected speeds. An in-shoe dynamic pressure distribution system was used to measure the vertical ground reaction force.

MAIN OUTCOME MEASUREMENTS

Spatiotemporal measures of gait and peak vertical ground reaction force on both lower limbs were recorded for each walking condition: no cane, contralateral cane, and ipsilateral cane.

RESULTS

Walking with a cane either contralateral or ipsilateral to the more symptomatic limb led to significant reductions in gait velocity (14%-16%), cadence (12%-14%), and peak vertical ground reaction force (normalized for body weight; 11%-12%) on the more painful lower limb compared with walking unaided (P < .05). There were no significant differences in the peak vertical ground reaction force on either lower limbs when comparing walking with a cane contralateral to the more painful limb or walking with a cane ipsilateral to the more painful limb. Subjects also experienced a significant decrease in gait velocity with contralateral or ipsilateral cane use compared with walking without a cane; the lower walking speed was due to a decrease in cadence.

CONCLUSIONS

These results support the prescription of a single-point cane to offload a lower limb with painful knee OA by holding the cane either ipsilateral or contralateral to the more painful lower limb.

Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, and this widespread use is complicated by safety issues.

METHOD

A Literature review was conducted.

RESULTS

NSAIDs are a leading cause of drug-related morbidity, especially in the elderly and patients with comorbidities. Most adverse effects are related to generalized inhibition of the major targets of NSAIDs: cyclooxygenases I and II. These enzymes are not only involved in pain and inflammation pathogenesis but are also required in the gastrointestinal (GI) tract for mucosal protection and gut motility, and in the kidneys for functional integrity. Thus, the mechanisms of NSAID toxicity are well understood, but the consequences are largely uncontrolled in clinical practice. GI ulcers, including bleeding ulcers, may occur in several percent of all chronic unprotected, high-dose NSAID users. Renal side effects may precipitate renal failure, resulting in acute dialysis and chronic retention. This includes sodium retention, resulting in arterial hypertension, heart failure, and atherosclerotic events. Cardiovascular risk may be tripled by chronic high-dose NSAID use in long-term clinical trials though "real-life studies" indicate lower risk ratios. Off-target side effects include allergic reactions, drug-induced liver injury, and central nervous system effects.

CONCLUSIONS

Management of pain and inflammation must consider those risks and find alternative drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity. Alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies, need to be further utilized. The appalling equation "less pain-more deaths/morbidity" ultimately necessitates treatment optimization in the individual patient.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

OBJECTIVES

Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint.

METHODS

ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus.

RESULTS

Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated.

CONCLUSIONS

The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

OARSI guidelines for the non-surgical management of knee osteoarthritis

OBJECTIVE

To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide.

METHOD

Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores.

RESULTS

Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation).

CONCLUSION

These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.

Lateral trunk lean gait modification increases the energy cost of treadmill walking in those with knee osteoarthritis

OBJECTIVE

To compare the energy expenditure of increased lateral trunk lean walking - a suggested method of reducing medial compartment knee joint load - compared to normal walking in a population of older adults with medial knee osteoarthritis (OA).

METHOD

Participants completed two randomly-presented treadmill walking conditions: 15 min of normal walking or walking with ten degrees of peak lateral trunk lean. Lateral trunk lean angle was displayed in front of the participant in real-time during treadmill conditions. Energy expenditure (VO2 and METs), heart rate (HR), peak lateral trunk lean angle, knee pain and perceived exertion were measured and differences between conditions were compared using paired t-tests.

RESULTS

Twelve participants (five males, mean (standard deviation (SD)) age 64.1 (9.4) years, body mass index (BMI) 28.3 (4.9) kg/m²) participated. All measures were significantly elevated in the lateral trunk lean condition (P < 0.008), except for knee pain (P = 0.22). Oxygen consumption (VO2) was, on average 9.5% (95% CI 4.2-14.7%) higher, and HR was on average 5.3 beats per minute (95% CI 1.7-9.0 bpm) higher during increased lateral trunk lean walking.

CONCLUSION

Increased lateral trunk lean walking on a treadmill resulted in significantly higher levels of steady-state energy expenditure, HR, and perceived exertion, but no difference in knee pain. While increased lateral trunk lean has been shown to reduce biomechanical measures of joint loading relevant to OA progression, it should be prescribed with caution given the potential increase in energy expenditure experienced when it is employed.