Exercise and osteoarthritis: an update

Central aspects of pain associated with physical activity: results from the Investigating Musculoskeletal Health and Wellbeing cohort

Background

Knee pain reduces activity, while inactivity can increase pain. The central nervous system modulates both pain and activity. The 8-item Central Aspects of Pain (CAP) questionnaire measures self-reported symptoms associated with current and future knee pain severity and psychophysical evidence of central pain sensitivity. The objective was to explore associations between CAP and physical inactivity in people with knee pain.

Methods

Participants from the Investigating Musculoskeletal Health and Wellbeing cohort who reported their knee as their most troublesome joint with numerical rating scale pain severity ≥1/10 completed questionnaires at baseline and 12 months addressing demographic and clinical characteristics, CAP questionnaire, and physical inactivity (Frail Non-Disabled questionnaire item). Chi-squared, correlations and multivariable logistic regression were performed.

Results

Seven hundred twenty-two participants provided baseline data and 404 longitudinal data. Higher baseline CAP scores were associated with higher baseline pain severity {OR: 1.25 (95% confidence interval [CI]: 1.02-1.53); P = 0.032} and physical inactivity (OR: 1.18 [95% CI: 1.11-1.25]; P < 0.001). Increasing CAP scores over 12 months were associated with becoming physically inactive (OR: 1.16 [95% CI: 1.01-1.32]; P = 0.032). The effects of CAP on physical inactivity were not fully explained by pain severity nor by any single characteristic of widespread pain distribution, emotional or cognitive factors, sleep disturbance, or fatigue.

Conclusion

Central aspects of pain questionnaire displays cross-sectional and longitudinal associations with physical inactivity. Central nervous system manifestations of pain appear to link pain with physical activity and may be more important than pain severity.

Obesity and the Development of Arthritis Among Adults in the United States Using NHANES Data

Background

The alarming increase in the prevalence of obesity and arthritis in America in recent times is concerning both in terms of the deleterious health effects on the individuals and economic cost. The wear and tear on the musculoskeletal and the inflammatory effects of obesity may be the reasons for the rise in arthritis among individuals with obesity.

Objective

To investigate the association between obesity and the development of arthritis among adults in the United States.

Design

A total of 17 016 participants were included from the 2012 to 2018 National Health and Nutrition Examination Survey (NHANES). Most of the participants were aged 30 years and above (79.7%). The racial distribution included 64.0% Non-Hispanic whites, 15.3% Hispanics, 11.4% Non-Hispanics blacks, and 9.4% from all other races.

Methods

Obesity was defined as a body mass index (BMI) > 30 kg/m², and the outcome variable of interest, arthritis status, was self-reported. Survey weighted logistic regression was performed to calculate the odds ratio (OR) and 95% confidence interval controlling for potential confounding factors.

Result

Nearly 40% of all participants were individuals with obesity, and 27.5% reported having some form of arthritis. The risk of developing arthritis was higher in individuals with obesity (OR: 1.55, 95% CI: 1.35-1.80), women (OR: 1.94, 95%CI: 1.66-2.28), and individuals 30 years or older (OR: 10.81, 95% CI: 6.36-18.37) with non-Hispanic whites being the most affected race. The C-reactive protein (CRP) and white blood cell count (WBC) levels were higher in all individuals with obesity even though there was no statistical difference between individuals with obesity with and without arthritis.

Conclusions

Obesity substantially heightens the risk of developing arthritis due to the mechanical stress on weight-bearing joints and subsequent chronic-low level inflammation contributing to disease progression.

Correlation between the Altered Gut Microbiome and Lifestyle Interventions in Chronic Widespread Pain Patients: A Systematic Review

Background: Lifestyle interventions have a direct impact on the gut microbiome, changing its composition and functioning. This opens an innovative way for new therapeutic opportunities for chronic widespread patients. Purpose: The goal of the present study was to evaluate a correlation between lifestyle interventions and the gut microbiome in patients with chronic widespread pain (CWP). Methods: The systematic review was conducted until January 2023. Pain and microbiome were the two keywords selected for this revision. The search was conducted in PubMed, Chochrane, PEDro and ScienceDirect, where 3917 papers were obtained. Clinical trials with lifestyle intervention in CWP patients were selected. Furthermore, these papers had to be related with the gut microbiome, excluding articles related to other types of microbiomes. Results: Only six articles were selected under the eligibility criteria. Lifestyle interventions were exercise, electroacupuncture and ingesting a probiotic. Conclusions: Lifestyle intervention could be a suitable choice to improve the gut microbiome. This fact could be extrapolated into a better quality of life and lesser levels of pain.

Effects of Patient Education on Pain and Function and Its Impact on Conservative Treatment in Elderly Patients with Pain Related to Hip and Knee Osteoarthritis: A Systematic Review

(1) Background: Patient education (PE), exercise therapy, and weight management are recommended as first-line interventions for hip and knee osteoarthritis (OA). Evidence supporting the effectiveness of exercise therapy and weight management in people with lower-limb OA has been synthesized in recent studies. However, according to the Osteoarthritis Research Society International, PE is often considered a standard of care and the inclusion of this as a first-line intervention for people with knee OA in clinical practice guidelines is often supported by limited evidence. The aim of this review is to evaluate the effects of PE on pain and function and how it impacts on conservative treatment. (2) Methods: This is a literature review of studies investigating the effect of patient education on pain and function and its impact on conservative treatment in elderly patients with pain related to hip and knee OA. PRISMA guidelines were followed during the design, search, and reporting stages of this review. The search was carried out in the PubMed database. (3) Results: A total of 1732 studies were detected and analyzed by performing the proposed searches in the detailed database. After removing duplicates and analyzing the titles and abstracts of the remaining articles, 20 studies were ultimately selected for this review. Nineteen of these twenty articles showed positive results in pain or function in patients with pain related to hip and knee OA. (4) Conclusions: PE seems to be effective in reducing pain and improving function in patients with pain related to hip and knee OA. Furthermore patient education seems to positively impact the conservative treatment with which it can be associated.

The Efficacy of Harpagophytum procumbens (Teltonal) in Patients with Knee Osteoarthritis: A Randomized Active-Controlled Clinical Trial

Purpose

The high prevalence of knee osteoarthritis (KOA) is a major cause of disability among elders. NSAIDs are recommended to reduce KOA patients' symptoms, but their adverse side effects limit their consumption. In this study, we evaluated the effectiveness of Harpagophytum procumbens compared to a routine NSAID (meloxicam) on pain reduction and functional improvement of KOA patients. Patients and Methods. Sixty patients aged 40–60 years, with painful knee osteoarthritis (grades 1-2 of Kellgren–Lawrence scale) for at least one month, were randomized into two groups with different routine medication periods. Group A consisted of daily administration of two Harpagophytum procumbens (Teltonal) tablets (2∗480 mg) for one month, and group B consisted of daily administration of meloxicam (15 mg) for ten days. The visual analogue scale (VAS), Western Ontario McMaster University Osteoarthritis Index (WOMAC), Oxford Knee Scale (OKS), and patient satisfaction were evaluated at the baseline and after 2, 4, and 8 weeks.

Results

There were no statistically significant differences between demographic characteristics, pain intensity, and function scores before the treatment. VAS, OKS, and WOMAC scores improved in both groups (p < 0.001) over time, but no significant superiority was shown; after 8 weeks: VAS (Teltonal (4.80 ± 1.80) vs. meloxicam (5.06 ± 1.43)), OKS (34.06 ± 4.38, 34.00 ± 7.87, Teltonal vs. meloxicam, respectively), and WOMAC scores (25.73 ± 10.11 Teltonal vs. 26.20 ± 13.94, meloxicam).

Conclusion

Teltonal is an effective and safe treatment in patients with mild KOA in the short term. However, no significant superiority was shown in using Teltonal or meloxicam, in people who cannot take NSAIDs, it can be a good alternative, although difference in medication periods should be considered.

People Prefer to Continue with Painful Activities Even if They Lead to Earlier Surgery

BACKGROUND

The degree to which physical activity results in arthritis progression is unknown, but it probably is less than most people believe. But the belief that painful activity is harmful has notable associations both with greater pain intensity and greater activity intolerance among people seeking care for painful conditions such as osteoarthritis. If there were evidence that people not seeking care would prefer to accommodate a painful cherished activity, even if such accommodation is harmful, this might remind surgeons that many people seeking their care also hold this value. Care strategies could be designed to help people reconnect with this value by guiding them to an appropriate weighting of the potential benefits and the potential harms of painful activity.

QUESTIONS/PURPOSES

(1) What degree of harm (measured as a decrease in the number of years before reconstructive surgery) are people willing to trade to continue a cherished activity? (2) What factors are associated with the chosen number of years? (3) What percentage of patients is willing to trade harm to the joint (presented as surgery 3 years earlier) to continue their cherished activity? (4) What factors are associated with the choice to trade harm for continued activity?

METHODS

We performed an online, survey-based, time trade-off experiment using a crowdsourcing website that allows users to pay volunteers to complete surveys. The survey was closed when the prespecified number of surveys was obtained. The experiment measured personal and psychological factors associated with the willingness to accommodate harmful painful activity to continue cherished activities among people not currently troubled by the condition, an approach favored in trade-off studies. Large crowdsourcing survey studies may not represent the general population, but they have sufficient diversity to determine factors associated with responses. Participants (539 total, 289 men and 250 women with a mean age of 33 ± 11 years) completed validated measures of symptoms of anxiety and depression, activity tolerance, an 11-point ordinal measure of pain intensity, and three validated questionnaires addressing common misconceptions about pain. To answer our first and second questions, we calculated the harm (measured as a decrease in the number of years before reconstructive surgery) that people were willing to trade to continue their cherished activity, and then we used multiple linear regression to identify factors associated with the number of years. To answer the third and fourth questions, we calculated the percentage of patients who would choose to trade harm to the joint (surgery 3 years earlier) to continue their cherished activity and then we used multiple logistic regression to identify factors associated with the choice to trade harm for activity.

RESULTS

Participants were willing to trade harm in the form of more rapid disease progression leading to surgery a mean of 4.5 ± 3.6 years earlier to continue a cherished activity. Controlling for personal and psychological factors, a greater number of years people were willing to trade was associated with slightly greater bodily pain intensity (r = 0.11; p = 0.01). Seventy-six percent (410 of 539) of participants were willing to trade harm in the form of needing surgery 3 years earlier to continue their cherished activity. Controlling for personal and psychological factors, a choice to trade earlier surgery for continued activity was associated with an income greater than USD 50,000 per year (odds ratio 2.07 [95% confidence interval 1.17 to 3.65]; p = 0.01) and greater fear of painful movement (OR 1.07 [95% CI 1.01 to 1.15]; p = 0.04).

CONCLUSION

People are relatively willing to accommodate pain to continue a cherished activity, even if it causes harm.

CLINICAL RELEVANCE

Musculoskeletal specialists can incorporate strategies to help people seeking care to revitalize their inherent level of willingness to accommodate painful activity. One strategy might be to attend to an appropriate weighting of the potential benefits and the potential harms of painful activity.

LEVEL OF EVIDENCE

Level II, prognostic study.

Influence of Isometric Exercise Combined With Electromyostimulation on Inflammatory Cytokine Levels, Muscle Strength, and Knee Joint Function in Elderly Women With Early Knee Osteoarthritis

Background and Objectives: Muscle strengthening exercise is suggested to beneficial for patients with knee osteoarthritis (OA) and electrical muscular stimulation is reported to be effective in improvement of muscle strength. This study examined whether isometric exercise combined with whole body-electromyostimulation (WB-EMS) can improve serum cytokine levels, muscle strength, and knee function in elderly women with early knee OA.

Materials and Methods: This randomized controlled study included 75 participants assigned into three groups: the control group (CON), isometric exercise group (ISOM), and isometric exercise and electromyostimulation group (ISOM + EMS). The two exercise groups performed their respective programs for 8 weeks, 3 days a week, 30 min a day. The main exercises for both groups were performed continuously during the 20 min in an alternation of a 6-s contraction with a 4-s break. At pre- and post-intervention, anthropometric variables, muscle strength, Knee Injury and Osteoarthritis Outcome Score (KOOS), and blood sampling for biomarkers including interleukin-6, tumor necrosis factor-α, C-reactive protein, and resistin were performed.

Results: All variables at pre-intervention showed no significant differences among the three groups. However, there were significant differences between groups for body composition, muscle strength, KOOS subscale scores, and biomarkers. ISOM + EMS group resulted in a significant reduction in body weight, fat mass, fat percentage, inflammatory cytokine levels, and increased muscle strength. An ISOM + EMS group had the best KOOS score among all groups.

Conclusion: Isometric exercise combined with WB-EMS resulted in the best overall improvements in knee function and alleviating the pain and symptoms of patients with early knee OA. Further, reduced levels of inflammatory cytokines were observed. These non-pharmacologic, non-invasive interventions should be considered by healthcare specialists for elderly patients with early knee OA.

Opioid Use Disorder Is Associated with an Increased Risk of Infection after Total Joint Arthroplasty: A Large Database Study

BACKGROUND

Recent studies have shown that patients with opioid use disorder have impaired immunity. However, few studies with large patient populations have evaluated the risks of surgical site infection (SSI) and prosthetic joint infection (PJI) with opioid use disorder after total joint arthroplasty (TJA), and there is a lack of evidence for revision TJA in particular.

QUESTIONS/PURPOSES

Are patients with opioid use disorder who undergo (1) primary THA, (2) primary TKA, (3) revision THA, or (4) revision TKA at a higher risk of experiencing SSIs 90 days after surgery or PJIs 2 years after surgery than those who do not have opioid use disorder?

METHODS

All primary and revision TJAs performed between 2005 and 2014 were identified from the Medicare Analytical Files of the PearlDiver Supercomputer using ICD-9 codes. This database is one of the largest nationwide databases; it comprehensively and longitudinally tracks patients based on all insurance claims rather than particular hospital visits, and has a low error rate (estimated at 1.3%). Boolean command operators were used to form a study group of patients with a history of opioid use disorder before surgery. ICD-9 diagnosis codes 304.00 to 304.02 and 305.50 to 305.52 were used to identify patients with opioid use disorder. Study group patients were matched 1:1 to control participants without opioid use disorder undergoing TJA, according to age, sex, and comorbidity burden (Elixhauser comorbidity index [ECI]). The ECI is comprised of 31 different comorbidities and can be used for large administrative databases. The query yielded a study population of 54,332 patients: 14,944 undergoing primary THA (opioid use disorder: n = 7472), 23,680 undergoing primary TKA (opioid use disorder: n = 11,840), 8116 undergoing revision THA (opioid use disorder: n = 4058), and 7592 undergoing revision TKA (opioid use disorder: n = 3796). The primary outcomes analyzed were SSI at 90 days and PJI at 2 years postoperatively, which were identified with ICD-9 codes. Logistic regression analyses were performed to calculate the risk that an infection would develop in a patient with opioid use disorder compared with the matched control patients without opioid use disorder.

RESULTS

Patients with opioid use disorder undergoing primary THA had an increased risk of SSI at 90 days (OR 1.85 [95% CI 1.51 to 2.25]; p < 0.001) and PJI at 2 years (OR 1.66 [95% CI 1.42 to 1.93]; p < 0.001). Compared with matched controls, opioid use disorder patients undergoing primary TKA had an increased risk of SSI at 90 days (OR 1.72 [95% CI 1.46 to 2.02]; p < 0.001) and PJI at 2 years (OR 1.31 [95% CI 1.16 to 1.47]; p < 0.001). Similarly, for revision THAs, there was an increase in 90-day SSIs (OR 1.89 [95% CI 1.53 to 2.32]; p < 0.001) and 2-year PJIs (OR 4.24 [95% CI 3.67 to 4.89]; p < 0.001). The same held for revision TKAs for 90-day SSIs (OR 1.88 [95% CI 1.53 to 2.29]; p < 0.001) and 2-year PJIs (OR 4.94 [95% CI 4.24 to 5.76]; p < 0.001).

CONCLUSIONS

After accounting for age, sex, and comorbidity burden, these results revealed that patients with opioid use disorder undergoing TJA were at increased risk of having SSIs and PJIs. Based on these findings, healthcare systems and/or administrators should recognize the increased associated PJI and SSI risks in patients with opioid use disorder and enact clinical policies that reflect these associated risks. Additionally, these findings should encourage surgeons to pursue multidisciplinary approaches to help patients reduce their opioid consumption before their arthroplasty procedure.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Exploring the relationship between chronic pain and cortisol levels in subjects with osteoarthritis: results from a systematic review of the literature

OBJECTIVE

Several reports in the literature have identified an association between cortisol levels and the presence of chronic pain in conditions such as rheumatoid arthritis, low back pain or whiplash. In contrast, few have examined the association of cortisol and pain in people with osteoarthritis (OA). The purpose of this systematic review was to verify the association between cortisol and pain in the OA population.

DESIGN

The databases MEDLINE, CINAHL, EMBASE were searched systematically for human studies written in English up to December 2018. Two researchers screened titles and abstracts against predefined inclusion criteria; a third resolved discrepancies. Articles were included if they measured the cortisol levels in adults with pain in the OA population. Methodological quality was assessed using Methodological Index for non-randomized Studies (MINORS) score.

RESULTS

Seven studies reporting on 415 patients were included in this review. The MINORS scale yielded mean scores of 8.6 of 16 and 17.5 of 24, for the cohort and case-control studies respectively. In general, the studies were of poor quality. A discrepancy of noteworthy associations between cortisol level comparison and pain was found.

CONCLUSIONS

This study shows that there is a discrepancy in the relationship between cortisol and pain dependent on how and when cortisol is measured. Evidence from three low-quality studies suggest increased cortisol levels in patients with pain but the conclusions have a high risk of bias. It was not possible to make a quantitative analysis comparing the relationship between cortisol and pain in the OA population.

Effect Of E-OA-07 On Improving Joint Health And Mobility In Individuals With Knee Osteoarthritis: A Randomized, Double-Blind, Placebo-Controlled, Parallel Group Study

AIM

The aim of the present study was to evaluate the effect of E-OA-07 on individuals having osteoarthritis of the knee.

BACKGROUND

Lanconone® (E-OA-07) is a widely marketed dietary supplement which has been previously studied in different clinical settings for managing chronic joint pain. This was a confirmatory study planned at a lowered dose regimen with the purpose of improving compliance and reducing consumer cost.

METHODS

Male and female participants aged between 40 and 65 years, with history of joint pain for at least 3 years, were recruited. Knee joint dysfunction of grade II/III was radiographically characterized as per Kellgren-Lawrence system of classification. Enrolled participants were randomized to receive E-OA-07 at a dose of 1000 mg/day or placebo over a period of 8 weeks. The primary efficacy parameter was assessment of change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Whereas, the secondary parameters explored in the study included WOMAC subscales of stiffness and physical function, EQ-5D-5L questionnaire, systemic inflammatory marker (hs-CRP) and self-assessment of treatment satisfaction.

RESULTS

At the end of 8 weeks, joint pain severity as per WOMAC was found to be significantly reduced in the E-OA-07 group as compared to placebo (p<0.001). Similar improvement was observed in the subscales of stiffness and physical function which corresponds to significant improvement in the quality-of-life standards of E-OA-07 participants (p<0.001), reporting higher treatment satisfaction (p<0.001).

CONCLUSION

E-OA-07 at a dose of 1000 mg/day was able to significantly reduce joint pain and thereby improve joint mobility in study participants. At the end of the study period, there was a clinically relevant change of 45.55%, 45.91% and 38.19% for pain, stiffness and physical function, respectively. Moving forward, studies could be planned for understanding the cartilage regenerative properties of E-OA-07.

Effect of muscle strengthening on perceived pain and static knee angles in young subjects with patellofemoral pain syndrome

The purpose of this pilot study was to determine the effects of strength training of the knee muscles on perceived pain and static knee angles in young subjects with patellofemoral pain syndrome (PFPS). Ten patients, 100% female (mean age, 18.2±3.8 years), with unilateral PFPS (anterior knee pain for at least 3 months), received muscle strengthening of the hip and knee (10 sessions over a period of 3 weeks). The outcome measures were perceived pain (visual analogue scale, VAS) and static knee angles (knee rotation measurer). All measures were collected at pre-, postintervention, and at 1-month follow-up (VAS). Muscle strengthening reduced perceived pain after intervention in 90.8% in subjects and this result was maintained at 1-month follow-up (all, P=0.001). Regarding changes in static knee angles, no significant improvements were found in internal and external rotation; valgus and varus; flexion and recurvatum (all, P>0.05). There was no significant difference between the symptomatic and healthy sides (all, P>0.05). Analyses of the correlation coefficients indicated no significant associations between changes in perceived pain and static knee angles. The current study found that muscle strengthening addressed to the symptomatic knee reduced pain; however, perceived pain was not associated with static knee angles in young subjects with unilateral PFPS.