Effect of glycosaminoglycan polysulfate on chondromalacia patellae. A placebo-controlled 1-year study

Medical Interventions for Patellofemoral Pain and Patellofemoral Osteoarthritis: A Systematic Review

Patellofemoral pain (PFP) and patellofemoral osteoarthritis (PFOA) are common, persistent conditions that may lie along a pathological spectrum. While evidence supports exercise-therapy as a core treatment for PFP and PFOA, primary care physicians commonly prescribe medication, or refer for surgical consults in persistent cases. We conducted a systematic review of medical interventions (pharmaceutical, nutraceutical, and surgical) for PFP and PFOA to inform primary care decision making. Methods: Following protocol registration, we searched seven databases for randomized clinical trials of our target interventions for PFP and PFOA. Our primary outcome was pain. We assessed risk of bias, calculated standardized mean differences (SMDs) and determined the level of evidence for each intervention. Results: We included 14 publications investigating pharmaceutical or nutraceutical interventions, and eight publications investigating surgical interventions. Two randomized control trials (RCTs) provided moderate evidence of patellofemoral arthroplasty having similar pain outcomes compared to total knee arthroplasty in isolated PFOA, with SMDs ranging from −0.3 (95% CI −0.8, 0.2, Western Ontario McMaster Pain Subscale, 1 year post-surgery) to 0.3 (−0.1, 0.7, SF-36 Bodily Pain, 2 years post-surgery). Remaining studies provided, at most, limited evidence. No efficacy was demonstrated for oral nonsteroidal anti-inflammatories or arthroscopic surgery. Conclusions: Pharmaceutical and nutraceutical prescriptions, and surgical referrals are currently being made with little supporting evidence, with some interventions showing limited efficacy. This should be considered within the broader context of evidence supporting exercise-therapy as a core treatment for PFP and PFOA.

Intra-Articular Injections for Joint Disease in Horses

Lameness remains an important source of reduced performance in many types of horses. Pain referable to joints is among the most common causes, and intra-articular injections remain a common and important means of addressing lameness referable to joints in horses.

Pharmacotherapy for patellofemoral pain syndrome

BACKGROUND

Patellofemoral pain syndrome (PFPS) is common among adolescents and young adults. It is characterised by pain behind or around the patella and crepitations, provoked by ascending or descending stairs, squatting, prolonged sitting with flexed knees, running and cycling. The symptoms impede function in daily activities or sports. Pharmacological treatments focus on reducing pain symptoms (non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids), or restoring the assumed underlying pathology (compounds containing glucosamine to stimulate cartilage metabolism, anabolic steroids to increase bone density of the patella and build up supporting muscles). In studies, drugs are usually applied in addition to exercises aimed at building up supporting musculature.

OBJECTIVES

This review aims to summarise the evidence of effectiveness of pharmacotherapy in reducing anterior knee pain and improving knee function in people with PFPS.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group and Cochrane Rehabilitation and Related Therapies Field trials registers, the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003), PEDro (up to January 2004), MEDLINE (1966 to January 2004), EMBASE (1988 to January 2004), and CINAHL (1982 to January 2004).

SELECTION CRITERIA

Controlled trials (randomised or not) comparing pharmacotherapy with placebo, different types of pharmacotherapy, or pharmacotherapy to other therapies for people with PFPS.

DATA COLLECTION AND ANALYSIS

The literature search yielded 780 publications. Eight trials were included, of which three were of high quality. Data were analysed qualitatively using best evidence synthesis, because meta-analysis was impeded by differences in route of administration of drugs, care programs and outcome measures.

MAIN RESULTS

Four trials (163 participants) studied the effect of NSAIDs. Aspirin compared to placebo in a high quality trial produced no significant differences in clinical symptoms and signs. Naproxen produced significant short term pain reduction when compared to placebo, but not when compared to diflunisal. Laser therapy to stimulate blood flow in tender areas led to more satisfied participants than tenoxicam, though not significantly. Two high quality RCTs (84 participants) studied the effect of glycosaminoglycan polysulphate (GAGPS). Twelve intramuscular injections in six weeks led to significantly more participants with a good overall therapeutic effect after one year, and to significantly better pain reduction during one of two activities. Five weekly intra-articular injections of GAGPS and lidocaine were compared with intra-articular injections of saline and lidocaine or no injections, all with concurrent quadriceps training. Injected participants showed better function after six weeks, though only the difference between GAGPS injected participants and non-injected participants was significant. The differences had disappeared after one year. One trial (43 participants) found that intramuscular injections of the anabolic steroid nandrolone phenylpropionate significantly improved both pain and function compared to placebo injections.

REVIEWERS' CONCLUSIONS

There is only limited evidence for the effectiveness of NSAIDs for short term pain reduction in PFPS. The evidence for the effect of glycosaminoglycan polysulphate is conflicting and merits further investigation. The anabolic steroid nandrolone may be effective, but is too controversial for treatment of PFPS.

Structure-modifying agents for osteoarthritis: an update

The terms "chondroprotective" and "structure-modifying" were coined to identify a class of drugs capable of preventing, stabilizing, or repairing joint damage caused by osteoarthritis. The method of reference for evaluating structure-modifying effects in knee or hip osteoarthritis is the measurement of joint space loss on serial plain radiographs. Joint space width can be measured manually or by a computer. Several radiological techniques have been described for measuring joint space width in the medial femorotibial compartment of the knee and the superolateral part of the hip. Most studies of potentially structure-modifying effects evaluated slow-acting drugs for osteoarthritis, which are currently used for their delayed symptomatic effect in osteoarthritis. Although most of these agents have shown promising effects in vitro, none has been proven to produce clinically meaningful structure-modifying effects in humans with osteoarthritis.

Systematic review of the quality of randomized controlled trials for patellofemoral pain syndrome

STUDY DESIGN

Systematic review of the literature.

OBJECTIVES

To develop a grading scale to judge the quality of randomized clinical trials (RCTs) and conduct a systematic review of the published RCTs that assess nonoperative treatments for patellofemoral pain syndrome (PFPS).

BACKGROUND

Systematic reviews of the quality and usefulness of clinical trials allow for efficient synthesis and dissemination of the literature, which should facilitate clinicians' efforts to incorporate principles of evidence-based practice in the clinical decision-making process.

METHODS AND MEASURES

Using a scale based on criteria in the Cochrane Collaboration Handbook, we sought to critically appraise the methodology used in RCTs related to the nonoperative management of PFPS, synthesize and interpret our results, and report our findings in a user-friendly fashion. A scale to assess the methodological quality of trials was designed and pilot tested for its content and reliability. Published RCTs identified during a literature search were then selected and rated by 6 raters. We used predefined cutoff scores to identify specific weaknesses in the clinical research process that need to be improved in future clinical trials.

RESULTS

The quality scale we developed was demonstrated to be sufficiently reliable to warrant interpretation of the reviewers' findings. The percentage of trials that met a minimum level of quality for each specific criterion ranged from a low of 25% for the adequacy of the description of the randomization procedure to a high of 95% for the description and standardization of the intervention.

CONCLUSIONS

Based on the results of trials exhibiting a sufficient level of quality, treatments that were effective in decreasing pain and improving function in patients with PFPS were acupuncture, quadriceps strengthening, the use of a resistive brace, and the combination of exercises with patellar taping and biofeedback. The use of soft foot orthotics in patients with excessive foot pronation appeared useful in decreasing pain. In addition, at a short-term follow-up, patients who received exercise programs were discharged earlier from physical therapy. Unfortunately, most RCTs reviewed contained qualitative flaws that bring the validity of the results into question, thus diminishing the ability to generalize the results to clinical practice. These flaws were primarily in the areas of randomization procedures, duration of follow-up, control of cointerventions, assurance of blinding, accountability and proper analysis of dropouts, number of subjects, and the relevance of outcomes. Also, given the limited number of high-quality clinical trials, recommendations about supporting or refuting specific treatment approaches may be premature and can only be made with caution.

Patellofemoral pain syndrome in the female athlete

Although PFS will continue to be a therapeutic challenge, the prognosis for most female athletes is good, especially if they are motivated and compliant with their treatment program. Particularly in women, care should be taken to avoid placing too much emphasis on biomechanical variants that may not be clinically significant or correctable because such findings can reinforce a feeling that "nothing can be done." In many cases, muscle dysfunction and repetitive loading of the patellofemoral joint rather than fixed biomechanical factors contribute to the development of PFS. Nonetheless, the importance of a detailed biomechanical assessment on physical examination must not be neglected, particularly in athletes who are not improving with conservative treatment and who may become surgical candidates. A practical initial treatment program for most athletes with nontraumatic PFS begins with relative rest, quadriceps strengthening, and stretching of tight myotendinous units. The introduction of NSAIDs, orthoses, taping, knee sleeves, and more specific rehabilitative exercises should be an individualized decision based on physical findings, past treatment results, and athletic expectations. Surgical referral should be considered in cases of PFS or patellar instability refractory to prolonged maximal nonoperative treatment.

Acupuncture treatment of patellofemoral pain syndrome

OBJECTIVE

To evaluate the effect of acupuncture treatment in patellofemoral pain syndrome.

DESIGN

A controlled trial where patients were randomly assigned either to acupuncture treatment or no treatment. Evaluation of the result was blinded.

SETTING

An acupuncture/physiotherapy treatment practice in Bergen, Norway.

SUBJECTS

A total of 75 patients with patellofemoral pain syndrome were included, of whom 44 were female.

INTERVENTION

Individualized acupuncture treatment twice weekly for 4 weeks.

MAIN OUTCOME MEASURE

Patients were followed for 1 year with the Cincinnati Knee Rating System (CKRS) scale as the main outcome measure. Other tests used were the Stairs-Hopple test, quadriceps atrophy, and evaluating level pain after activity by a visual analogue scale.

RESULTS

At inclusion patients, aged 18-45 (mean 31.0) years, reported persistent pain on activity (mean 6.6 years) and at rest (mean 4.3 years). CRS scores at baseline were similar (acupuncture group 58.0 versus no treatment group 56.1). At 12 months there was a significant difference in the CRS score between the groups (acupuncture 75.2 versus no treatment 61.7, p = 0.005). When analyzing for worst case, the difference persisted (68.1 versus 54.4, p = 0.03). Results were then dichotomized as to whether the patient was cured or not at 12 months. A patient was defined as cured if he/she scored "slight" or "none" on the "pain" or "limitation to activity" subscales. The Number Necessary to Treat (NNT) to cure one patient was NNT = 3.0 for the CRS pain subscale and NNT = 3.7 for the CRS function subscale.

CONCLUSION

We conclude that acupuncture may be an alternative treatment for patellofemoral pain syndrome.

Patellofemoral pain syndrome. A critical review of the clinical trials on nonoperative therapy

Many therapies have been advocated for treating patellofemoral pain, which suggests little consensus on optimal treatment. We reviewed the high-quality evidence for successful treatment of patellofemoral syndrome based on successful outcome information. To achieve this goal, we undertook a systematic search and critical appraisal of the literature on patellofemoral pain syndrome. Our definition of patellofemoral pain syndrome was broad and included patients with cartilage damage. We found five randomized controlled trials and some follow-up studies. The prognoses for most new cases of patellofemoral pain syndrome are good, although a proportion of patients with this syndrome will have persistent symptoms. Quadriceps muscle exercises were effective in treating this condition, and knee braces were not. Both prostheses and intramuscular glycosaminoglycan polysulfate had encouraging results for patients; however, these results need confirmation. There were many studies of biomechanics, which indicates that there is an assumption that an alteration of abnormal biomechanics would result in clinical benefit. Studies are needed that place more emphasis on the therapeutic benefit. There is limited evidence on which to base therapy, and there needs to be more high-quality research. Studies need to be longer, account for factors that predispose the patients, and have a more standardized means of assessing outcomes.

Diagnostic and quantitative arthroscopy: quantitative arthroscopy

Arthroscopy still remains the 'gold standard' for the assessment of articular cartilage and synovium because it provides direct and magnified evaluation of these anatomical structures. Thus, alongside the use of arthroscopy as a diagnostic or therapeutic procedure in knee disorders, a further function of knee arthroscopy, performed under local anaesthesia on an outpatient basis, has been proposed: the monitoring and follow-up of knee chondropathy and synovitis conducted for research purposes on patients suffering from knee osteoarthritis or chronic synovitis. This function is used in order (1) to evaluate the natural history of these diseases, (2) to assess 'de visu' the effect on chondral or synovial lesions of medical treatments or surgical interventions, and (3) to validate non-invasive imaging techniques such as plain radiographs or magnetic resonance imaging. The development of this arthroscopic outcome measurement of chondropathy and synovitis required the establishment and validation of systems for scoring the severity of chondral and synovial lesions. The author reviews both earlier and newer arthroscopic classifications and underlines the need for a quantitative description of cartilage and synovial abnormalities, either global and based on the investigator's overall assessment by using a visual analogue scale of severity, or, more analytically, taking into account the baseline parameters of the lesions, i.e. depth/intensity, extent and location.

Achilles tendon injuries in athletes

Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies. The majority of Achilles tendon injuries from sport occur in males, mainly because of their higher rates of participation in sport, but also with tendinopathies a gender difference is probably indicated. Athletes in running sports have a high incidence of Achilles tendon overuse injuries. About 75% of total and the majority of partial tendon ruptures are related to sports activities usually involving abrupt repetitive jumping and sprinting movements. Mechanical factors and a sedentary lifestyle play a role in the pathology of these injuries. Achilles tendon overuse injuries occur at a higher rate in older athletes than most other typical overuse injuries. Recreational athletes with a complete Achilles tendon rupture are about 15 years younger than those with other spontaneous tendon ruptures. Following surgery, about 70 to 90% of athletes have a successful comeback after Achilles tendon injury. Surgery is required in about 25% of athletes with Achilles tendon overuse injuries and the frequency of surgery increases with patient age and duration of symptoms as well as occurrence of tendinopathic changes. However, about 20% of injured athletes require a re-operation for Achilles tendon overuse injuries, and about 3 to 5% are compelled to abandon their sports career because of these injuries. Myotendineal junction pain should be treated conservatively. Partial Achilles tendon ruptures are primarily treated conservatively, although the best treatment method of chronic partial rupture seems to be surgery. Complete Achilles tendon ruptures of athletes are treated surgically, because this increases the likelihood of athletes reaching preinjury activity levels and minimises the risk of re-ruptures. Marked forefoot varus is found in athletes with Achilles tendon overuse injuries, reflecting the predisposing role of ankle joint overpronation. Athletes with the major stress in lower extremities have often a limited range of motion in the passive dorsiflexion of the ankle joint and total subtalar joint mobility, which seems to be predisposing factor for these injuries. Various predisposing transient factors are found in about one-third of athletes with Achilles tendon overuse injuries; of these, traumatic factors (mostly minor injuries) predominate. The typical histological features of chronically inflamed paratendineal tissue of the Achilles tendon are profound proliferation of loose, immature connective tissue and marked obliterative and degenerative alterations in the blood vessels. These changes cause continuing leakage of plasma proteins, which may have an important role in the pathophysiology of these injuries. The chronically inflamed paratendineal tissues of the Achilles tendon do not seem to have enough capacity to form mature connective tissue.

The role of cartilage-derived antigens, pro-coagulant activity and fibrinolysis in the pathogenesis of osteoarthritis

Superficial fraying, splitting and fibrillation of articular cartilage as a consequence of ageing or mechanical injury is not always associated with joint pain. However, similar cartilage lesions accompanied by synovitis and engorgement of the subchondral vasculature generally is; the disorder being known as osteoarthritis (OA). In this hypothesis it is contended that the progression of early cartilage fibrillation to symptomatic OA arises as a consequence of the antigenic nature of cartilage components which when released into synovial fluid and the circulation can stimulate leukocytes (to a varying degree) to produce a number of factors some of which promote blood coagulation. While it is known that with ageing hyper-coagulation and plaque deposition is increased, the augmentation of this process by factors released by activated leukocytes is considered to exacerbate the problem. These haematological events may be particularly relevant in individuals whose leukocytes are hypersensitive to the cartilage-derived antigens, and whose fibrinolytic system is less capable of mobilizing the thrombi deposited in synovial tissues and the subchondral vascular tree.

Chondroscopy: a new method for scoring chondropathy

The purpose of this study was to evaluate the performance (simplicity, reproducibility, relevance) of chondroscopy as a method for evaluating cartilage damage. Chondroscopy consisted in endoscopic evaluation of the knee using a 2.7-mm Storz arthroscope under local anesthesia and recorded on videotape. Scoring of chondropathy was based on physician's overall assessment using a 100-mm-length visual analogue scale (VAS) and size and grade of cartilage lesions. Reproducibility was evaluated by variability (coefficient of variation [CV]) in the reading of chondroscopic evaluations of five patients five times by one physician and one time each by four different physicians. The correlations between scoring of chondropathy (VAS) and radiological articular joint space narrowing, demographic data (sex, age, weight), and disease characteristics (localization, etiology, activity) were studied in 84 outpatients fulfilling the American College of Rheumatology criteria for the diagnosis of osteoarthritis of the knee. The grade and size of the lesions were both correlated with the physician's overall assessment (r = 0.713 and r = 0.816, respectively). These two variables accounted for 72% of the variance of the VAS (multiple regression analysis). Intraobserver reproducibility was better than interobserver reproducibility (CV, 9% and 37%, respectively). There was a strong correlation between the scoring of chondropathy (VAS) and radiological joint space narrowing (r = .646, P < .0001). Moreover, in 17 of 33 patients without radiological joint space narrowing, VAS was > 20 mm. At variance, the body mass index was the single clinical variable found to correlate with the scoring of chondropathy (r = .282, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of intraarticular glycosaminoglycan polysulfate treatment on patellofemoral pain syndrome. A prospective, randomized double-blind trial comparing glycosaminoglycan polysulfate with placebo and quadriceps muscle exercises

OBJECTIVE

To compare the effects of intraarticular (IA) injections of glycosaminoglycan polysulfate (GAGPS) plus basic conservative treatment with the effects of placebo injections plus conservative treatment and with the effects of conservative treatment alone in patients with chronic patellofemoral pain syndrome (PFPS).

METHODS

We treated 53 patients who presented with chronic PFPS in 1 knee, according to 1 of the 3 protocols, in a prospective, randomized, double-blind study. Basic conservative treatment consisted of a 6-week program of quadriceps muscle exercise, elimination of symptom-producing activities, and oral doses of nonsteroidal antiinflammatory drugs. Physiologic saline served as placebo for injection. During the 6-week treatment period, 5 injections were given 1 week apart. Along with measurements of quadriceps strength, standardized subjective, functional, and clinical assessments were performed at presentation, after 6 weeks of treatment, and after 6 months.

RESULTS

Results at 6 months indicated that IA injections of GAGPS or saline did not result in significant improvement beyond the good results achieved by the basic conservative treatment alone. More than two-thirds of the patients in each group experienced complete recovery.

CONCLUSION

Neither the GAGPS injections nor the physiologic saline injections are more effective than conservative therapy in the treatment of chronic PFPS. Restoration of normal quadriceps muscle function to the affected knee seems to be crucial in treating PFPS.