A randomised controlled trial of tidal irrigation vs corticosteroid injection in knee osteoarthritis: the KIVIS Study

OBJECTIVES

Patients with knee osteoarthritis (OA) often suffer pain that is not fully controlled by analgesics and often require intra-articular therapies. The aim of this study was to compare the benefits of intra-articular corticosteroid injections (CSIs) and tidal irrigation (TI) in patients with OA of the knee.

METHODS

We performed a dual-centre, single blind, randomised, parallel group trial comparing TI and CSI. Patients with knee OA were randomised to either irrigation using a 3.2mm arthroscope under local anaesthesia or an intra-articular injection of 40 mg triamcinolone acetonide and 1% lidocaine. Patients were followed for 6 months. The primary outcome measure was the Western Ontario and McMaster Universities OA Index total pain score (visual analogue scale, VAS).

RESULTS

One hundred and fifty patients were recruited of whom 71 received TI and 79 CSI. In both treatment groups, over 80% of patients reported improvement at 2 and 4 weeks. After this time, the benefit of CSI decreased whereas that of TI was maintained: at 26 weeks the pain relief afforded by TI was significantly greater than that of CSI. At 26 weeks 29% of the CSI group reported improvement vs 64% of the TI group (P<0.001). Patients with a knee effusion responded better to both treatments, however, this was most apparent for CSI. Patients with less severe radiographic OA also obtained the greatest improvement from both treatments.

CONCLUSION

Both procedures lead to significant short-term pain relief of at least 4 weeks, however, TI displayed a significantly greater duration of benefit. Patients with effusions and milder radiographic change obtained the best response to treatment.

Urinary CTX-II and glucosyl-galactosyl-pyridinoline are associated with the presence and severity of radiographic knee osteoarthritis in men

OBJECTIVE

To investigate the association between biochemical markers of bone, cartilage, and synovial turnover with the presence and severity of knee osteoarthritis (OA) in men.

METHODS

176 men aged 59-70 years from the MRC Hertfordshire Cohort were studied. Weightbearing anteroposterior and lateral semiflexed radiographs were taken of both knees. A lifestyle questionnaire including basic demographic details and a questionnaire detailing knee pain was completed. This random sample was stratified based on the Kellgren and Lawrence (K&L) score, and the following biochemical markers were analysed: serum osteocalcin, serum C-terminal crosslinked telopeptide of type I collagen (CTX-I), urinary C-terminal crosslinked telopeptide of type II collagen (CTX-II), and urinary glucosyl-galactosyl-pyridinoline (Glc-Gal-Pyd).

RESULTS

Age, body mass index (BMI), social class, smoking, and alcohol consumption were similar across K&L grades. Only one subject had a grade 4 K&L score, and was amalgamated with grade 3 subjects. A strong significant association was found between the presence of knee OA and urinary CTX-II and urinary Glc-Gal-Pyd (p=0.0001 and p=0.009), which persisted after adjustment for age and BMI. A significant positive association was also found between urinary CTX-II and urinary Glc-Gal-Pyd and the severity of K&L grade, joint space narrowing, and osteophytes scores, which persisted after adjustment for age and BMI. No associations between the presence and severity of knee OA were found for serum CTX-I or serum osteocalcin.

CONCLUSIONS

Urinary CTX-II and Glc-Gal-Pyd, but not systemic markers of bone turnover, are strongly associated with disease severity and the presence of OA at the tibiofemoral and patellofemoral joints in men.

Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus

OBJECTIVES

Exercise is an effective and commonly prescribed intervention for lower limb osteoarthritis (OA). Many unanswered questions remain, however, concerning the practical delivery of exercise therapy. We have produced evidence-based recommendations to guide health-care practitioners.

METHODS

A multidisciplinary guideline development group was formed from representatives of professional bodies to which OA is of relevance and other interested parties. Each participant contributed up to 10 propositions describing key clinical points regarding exercise therapy for OA of the hip or knee. Ten final recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of two categories: (1) strength of evidence and (2) strength of recommendation.

RESULTS

The first round of the Delphi process produced 123 propositions. This was reduced to 10 after four rounds. These related to aerobic and strengthening exercise, group versus home exercise, adherence, contraindications and predictors of response. The literature search identified 910 articles; 57 intervention trials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence to support each proposition is presented.

CONCLUSION

These are the first recommendations for exercise in hip and knee OA to clearly differentiate research evidence and expert opinion. Gaps in the literature are identified and issues requiring further study highlighted.

EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

OBJECTIVES

To update the EULAR recommendations for management of knee osteoarthritis (OA) by an evidence based medicine and expert opinion approach.

METHODS

The literature search and guidelines were restricted to treatments for knee OA pertaining to clinical and/or radiological OA of any compartment of the knee. Papers for combined treatment of knee and other types of OA were excluded. Medline and Embase were searched using a combination of subject headings and key words. Searches for those treatments previously investigated were conducted for January 1999 to February 2002 and for those treatments not previously investigated for 1966 to February 2002. The level of evidence found for each treatment was documented. Quality scores were determined for each paper, an effect size comparing the treatment with placebo was calculated, where possible, and a toxicity profile was determined for each treatment modality.

RESULTS

497 new publications were identified by the search. Of these, 103 were intervention trials and included in the overall analysis, and 33 treatment modalities were identified. Previously identified publications which were not exclusively knee OA in the initial analysis were rejected. In total, 545 publications were included. Based on the results of the literature search and expert opinion, 10 recommendations for the treatment of knee OA were devised using a five stage Delphi technique. Based on expert opinion, a further set of 10 items was identified by a five stage Delphi technique as important for future research.

CONCLUSION

The updated recommendations support some of the previous propositions published in 2000 but also include modified statements and new propositions. Although a large number of treatment options for knee OA exist, the evidence based format of the EULAR Recommendations continues to identify key clinical questions that currently are unanswered.

The use of conventional and complementary treatments for knee osteoarthritis in the community

OBJECTIVES

The aim of the survey was to assess the prevalence of clinically diagnosed knee osteoarthritis (OA) in two general practice populations in the Wessex region (practice A: a deprived urban population and practice B: an affluent rural population) and to assess both conventional and complementary therapy use in these two populations.

METHODS

All patients over 55 yr with a clinical diagnosis of knee OA, as identified from the practice computerized records, were sent a questionnaire about their knee pain and their use of conventional and complementary treatments.

RESULTS

A total of 4566 patients over 55 yr were registered in the two practices. Of these, 828 (18.13%) had a clinical diagnosis of knee OA and 240 (29%) patients were asymptomatic at the time of survey. Physiotherapy was under-utilized with only 13.1% of patients having received either hospital- or GP-based physiotherapy. There was a high prevalence of non-steroidal anti-inflammatory drug (NSAID) use, being significantly more in the affluent population (P < 0.05). In the affluent population there were statistically more social class groups 1-3a; statistically more NSAIDs, glucosamine and chondroitin sulphate were also used. The median amount spent on complementary medicine per month was 5.00 UK pounds, with the affluent population spending significantly more (P < 0.05).

CONCLUSIONS

In this population, physiotherapy is an under-utilized treatment for knee OA, in spite of its recommendation as first-line treatment in all guidelines. Complementary medicines and therapies are commonly used, particularly in affluent populations.

Epidemiology of osteoporosis

Osteoporosis is a major public health problem through its association with fracture. The problem may be alleviated substantially by appropriate early intervention before fracture occurs. This chapter discusses the epidemiology of osteoporosis and addresses the following questions: How should osteoporosis be defined? What is the incidence and prevalence of osteoporosis and fracture? Is there geographical variation in the occurrence of osteoporosis? What are the risk factors for osteoporosis and do they explain the occurrence of osteoporosis and osteoporotic fracture?

A community-based study of chronic fatigue syndrome

BACKGROUND

Most previous estimates of the prevalence of chronic fatigue syndrome (CFS) have derived largely from treated populations, and have been biased by differential access to health care treatment linked with sex, ethnic identification, and socioeconomic status.

OBJECTIVE

To assess the point prevalence of CFS in an ethnically diverse random community sample.

DESIGN AND PARTICIPANTS

A sample of 28,673 adults in Chicago, Ill, was screened by telephone, and those with CFS-like symptoms were medically evaluated. MAIN OUTCOME MEASURES AND ANALYSES: Self-report questionnaires, psychiatric evaluations, and complete medical examinations with laboratory testing were used to diagnose patients with CFS. Univariate and multivariate statistical techniques were used to delineate the overall rate of CFS in this population, and its relative prevalence was subcategorized by sex, ethnic identification, age, and socioeconomic status.

RESULTS

There was a 65.1% completion rate for the telephone interviews during the first phase of the study. Findings indicated that CFS occurs in about 0.42% (95% confidence interval, 0.29%-0.56%) of this random community-based sample. The highest levels of CFS were consistently found among women, minority groups, and persons with lower levels of education and occupational status.

CONCLUSIONS

Chronic fatigue syndrome is a common chronic health condition, especially for women, occurring across ethnic groups. Earlier findings suggesting that CFS is a syndrome primarily affecting white, middle-class patients were not supported by our findings.

Monitoring and assessing symptoms of chronic fatigue syndrome: use of time series regression

Chronic Fatigue Syndrome's principal symptoms are severe and include prolonged fatigue and a number of other minor symptoms. Behavioral data collection methods were used in a case study to show some of the benefits that can be derived from monitoring symptoms hourly and daily. Using time series regression, several statistically significant correlates of fatigue were found both within days and between days. Perceived energy, physical exertion, and mental exertion were significantly related to fatigue in both analyses. Collection of such data may help resolve a number of theoretical and methodological problems in research on the Chronic Fatigue Syndrome.

Chronic fatigue syndrome: assessing symptoms and activity level

Current approaches to the diagnosis and assessment of Chronic Fatigue Syndrome (CFS) rely primarily on scales that measure only the occurrence of various symptoms related to CFS. Such approaches do not provide information on either the severity of symptoms or on fluctuations in symptom severity and activity level that occur over time. As a result, these measures do not reflect the complexities and the interrelations among symptoms. By obscuring the fluctuating nature of CFS and its high variability, current assessment procedures may prevent health care professionals from understanding the complexities of this disease. The present study provides two CFS case studies to illustrate the advantages of using self-reporting rating scales in combination with a device used to measure the frequency and intensity of activity. The implications of this assessment system, which captures the symptom dynamics and variability involved in CFS, are discussed.

Coming out for lesbian women: its relation to anxiety, positive affectivity, self-esteem, and social support

The present study investigated relations between lesbians' disclosure of their sexual orientation and psychological adjustment. The 499 participants responded to a questionnaire assessing level of self-disclosure, sources of social support, forms of socializing, self-description of sexual orientation, and length of self-identification as a lesbian. The more widely a woman disclosed her sexual orientation the less anxiety, more positive affectivity, and greater self-esteem she reported. Degree of disclosure to family, gay and lesbian friends, straight friends, and co-workers was related to overall level of social support, with those who more widely disclosed reporting greater levels of support. Participants who more widely disclosed their sexual orientation were less likely to engage in anonymous socializing, had a larger percentage of lesbian friends, and were more involved in the gay and lesbian community. Path analyses revealed a mediating effect of social reactions (both initial and current) on the relation between identity development and self-disclosure.

Politics, science, and the emergence of a new disease. The case of chronic fatigue syndrome

Chronic fatigue syndrome (CFS) emerged as a diagnostic category during the last decade. Initial research suggested that CFS was a relatively rare disorder with a high level of psychiatric comorbidity. Many physicians minimized the seriousness of this disorder and also interpreted the syndrome as being equivalent to a psychiatric disorder. These attitudes had negative consequences for the treatment of CFS. By the mid-1990s, findings from more representative epidemiological studies indicated considerably higher CFS prevalence rates. However, the use of the revised CFS case definition might have produced heterogeneous patient groups, possibly including some patients with pure psychiatric disorders. Social scientists have the expertise to more precisely define this syndrome and to develop appropriate and sensitive research strategies for understanding this disease.

Politics, science, and the emergence of a new disease. The case of chronic fatigue syndrome

Chronic fatigue syndrome (CFS) emerged as a diagnostic category during the last decade. Initial research suggested that CFS was a relatively rare disorder with a high level of psychiatric comorbidity. Many physicians minimized the seriousness of this disorder and also interpreted the syndrome as being equivalent to a psychiatric disorder. These attitudes had negative consequences for the treatment of CFS. By the mid-1990s, findings from more representative epidemiological studies indicated considerably higher CFS prevalence rates. However, the use of the revised CFS case definition might have produced heterogeneous patient groups, possibly including some patients with pure psychiatric disorders. Social scientists have the expertise to more precisely define this syndrome and to develop appropriate and sensitive research strategies for understanding this disease.

Clinical interventions by psychologists with lesbians and gay men

A questionnaire that assesses methods of intervention with, and attitudes toward, lesbians and gay men was completed by 139 clinical psychologists. None claimed to use aversion techniques to change sexual orientation. Eleven percent reported use of alternative methods (e.g., psychoanalytic techniques) to change sexual orientation, whereas 5.8% supported the use of aversion therapy for this purpose. Viewing homosexuality as "unacceptable" predicted both the use of alternative therapies and support of aversion therapy to change sexual orientation.