The role of thermal balneotherapy in the treatment of obese patient with knee osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis clinically characterized by joint pain, functional limitation, and reduced quality of life. Several studies have shown a clear link between obesity and higher risk of knee OA. According to the multifactorial OA pathogenesis, the management of this condition requires a multidisciplinary approach. The objective of this study is to evaluate hydrokinesitherapy effects in thermal setting in obese patients with knee OA. Fifty-three patients were assessed for eligibility, of which 33 refused the treatment, while 10 patients dropped out after the enrollment for personal reasons or inability to adhere to the program. Ten patients (8 females, 2 males, mean age of 59.4 years) with obesity (range BMI 30-45 kg/m2) and knee OA (II-III grade of Kellgren-Lawrence scale) treated with hydrokinetic therapy in thermal water (two sessions per week for 8 consecutive weeks) completed the study. Primary outcome measure was pain (VAS). Secondary outcomes were clinical knee evaluation (range of motion-ROM, lower-limb muscle strength), WOMAC, and Lequesne Algofunctional Index. Patellar tendon and peri-articular soft tissue ultrasound evaluation and gait analysis at baseline (T0), at the end of treatment (T1), and at 6 months of follow-up (T2) were performed. Significant decrease on VAS pain during walking on a flat surface and going up/down stairs was reached from baseline at T1 (p = 0.0039; p = 0.0098) and was maintained at T2 (p = 0.00954) exclusively for VAS pain during walking on a flat surface. WOMAC score showed a significant reduction between T0 and T1 (p = 0.0137) and between T0 and T2 (p = 0.006438), as ROM evaluations. Kinematic path assessment did not show significant results in individual gait steps, except for the space-time variables of the average speed and the values of ground reaction force (GRF) obtained with force platforms. Hydrokinesitherapy in thermal environment in obese patients with knee OA may determine pain relief, joint function improvement, and walking speed increase until 6 months of follow-up.

Reliability of a device for the knee and ankle isometric and isokinetic strength testing in older adults

Background

Lower extremity muscle mass, strength, power, and physical performance are critical determinants of independent functioning in later life. Isokinetic dynamometers are becoming very common in assessing different features of muscle strength, in both research and clinical practice; however, reliability studies are still needed to support the extended use of those devices.

Objective

The purpose of this study is to assess the test-retest reliability of knee and ankle isokinetic and isometric strength testing protocols in a sample of older healthy subjects, using a new and untested isokinetic multi-joint evaluation system.

Methods

Sixteen male and fourteen female older adults (mean age 65.2 ± 4.6 years) were assessed in two testing sessions. Each participant performed a randomized testing procedure that includes different isometric and isokinetic tests for knee and ankle joints.

Results

All participants concluded the trial safety and no subject reported any discomfort throughout the overall assessment. Coefficients of correlation between measures were calculated showing moderate to strong effects among all test-retest assessments and paired-sample t test showed only one significant difference (p<0.05) in the maximal isokinetic bilateral knee flexion torque.

Conclusions

The multi-joint evaluation system for the assessment of knee and ankle isokinetic and isometric strength provided reliable test-retest measures in healthy older adults.

Level of evidence

Ib.

I performed experiments and I have results. Wow, and now?

Writing a scientific article is not an easy task, but it is definitely a great satisfaction to be able to conclude and publish it. Indeed, each publication is a service we make to the entire scientific community and to the advancement of science even before our personal career. There is and there will not be a final book/article for writing a scientific paper. Therefore, some knowledge is a decisive factor to increase the chances of our work being accepted by a specialized scientific journal. The purpose of this editorial is to trace an ideal path, based on our personal experience, useful to properly structure a scientific article, from bibliographic research to cover letter. Articles should not be written in a polished way to gratify one's own ego, but they must be written for anyone who can read and understand them.

LEVEL OF EVIDENCE

V.

I.S.Mu.L.T. first-time patellar dislocation guidelines

Primary traumatic patellar dislocation is common, particularly in young active individuals. A consensus on its management is still lacking. The present work provides easily accessible guidelines to be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, to improve the quality of care and rationalize the use of resources.

LEVEL OF EVIDENCE

Ia.

Conservative management of tendinopathies around hip

BACKGROUND

The anatomy of hip is widely complex and several anatomical structures interact and contribute to its functioning. For position and role, hip and the surrounding tendons, which have their insertion around, are overstressed and often overloaded, especially in athletes. This could lead to the developing of several tendinopathies, among which the differential diagnosis is often complicated. Many conservative treatments are used in clinical practice, while actually, no defined conservative protocol is recommended.

METHODS

This is a review article. The aim of this manuscript is to evaluate the current evidences about the effectiveness of conservative management in hip tendinopathies.

CONCLUSION

Conservative treatment is effective in the management of hip tendinopathies and may be considered the first-line approach for patients affected. However, there is lack of evidences about which is the most effective treatment. Exercise therapy seems to provide long-term pain relief, but the literature is still lacking about the correct type, dose, posology, intensity of exercise prescribed. Further studies about different local approaches, as PRP or hyaluronic acid injections, may be encouraged.

LEVEL OF EVIDENCE

I.

Efficacy of eccentric exercise in lower limb tendinopathies in athletes

Tendinopathies are among the most frequent sport injuries, therefore their correct treatment is a crucial issue in sports medicine practice. In most of the cases, these multifactorial conditions are related to overuse and characterized by activity-induced pain, local tenderness and swelling. Although tendinopathies are common, their treatment is not easy. Currently, it is generally accepted that their management should include early functional exercises. Eccentric exercise (EE) is considered a fundamental therapeutic resource, especially for the treatment of Achilles and patellar tendinopathies. This article focuses on the use of EE for the treatment and prevention of the lower limb tendinopathies, evaluates the existing programs and their efficacy, and reviews the possible mechanisms of the healing process and the action of EE on tendon structure. EE-based treatments are useful to improve symptoms and function in lower limb tendinopathies, but more evidence is still required to devise an adequate dose-response model and to determine their long-term effects.

Interrelationship between temporomandibular joint osteoarthritis (OA) and cervical spine pain: Effects of intra-articular injection with hyaluronic acid

OBJECTIVE

The aim of this study was to evaluate cervical spine pain and function after five sessions of viscosupplementation with hyaluronic acid (HA) in patients with temporomandibular joint (TMJ) osteoarthritis.

METHODS

Forty-nine patients, (79% females, aged between 43-81 years), affected by TMJ osteoarthritis and concurrent cervical spine pain and limited function were recruited. All patients underwent a cycle of five weekly arthrocenteses and viscosupplementation with 1 ml of medium molecular weight HA according to the single-needle arthrocentesis technique. Outcome variables were TMJ pain (VAS), cervical active ranges of motion, cervical disability (NPDS), and presence of painful palpation sites. Assessments were carried out at baseline and at one, three and six months after the end of treatment protocol.

RESULTS

A significant reduction over time was shown both in TMJ pain levels and in NPDS values with respect to baseline (p < 0.001). Most parameters of active cervical range of motion showed an improvement with time. Benefits remained stable throughout six months after the viscosupplementation protocol.

CONCLUSIONS

A protocol of TMJ intra articular arthrocentesis and viscosupplementation improved cervical function and reduced disability in patients with concurrent cervical spine pain. These findings add to the complex amount of literature on the relationship between temporomandibular disorders and cervical spine disorders.

Efficacy of betamethasone valerate medicated plaster on painful chronic elbow tendinopathy: a double-blind, randomized, placebo-controlled trial

OBJECTIVE

to investigate the efficacy and safety of a medicated plaster containing betamethasone valerate (BMV) 2.25 mg in patients with chronic elbow tendinopathy.

METHODS

randomized, double-blind, placebo-controlled study with assignment 2:2:1:1 to BMV medicated plaster applied daily for 12 hours, daily for 24 hours or matched placebo. 62 patients aged ≥18 years with chronic lateral elbow tendinopathy were randomized. The primary efficacy variable was pain reduction (VAS) at day 28. Secondary objectives included summed pain intensity differences (SPID), overall treatment efficacy and tolerability.

RESULTS

mean reduction in VAS pain score at day 28 was greater in both BMV medicated plaster groups, -39.35±27.69 mm for BMV12-h and -36.91±32.50 mm for BMV24-h, than with placebo, -20.20±27.32 mm. Considering the adjusted mean decreases, there was a statistically significant difference between BMV12-h and placebo (p=0.0110). Global pain relief (SPID) and overall treatment efficacy were significantly better with BMV. BMV and placebo plasters had similar local tolerability and there were few treatment-related adverse events.

CONCLUSIONS

BMV plaster was significantly more effective than placebo at reducing pain in patients with chronic elbow tendinopathies. The BMV plaster was safe and well tolerated.

Hyaluronic acid intra-articular injection and exercise therapy: effects on pain and disability in subjects affected by lower limb joints osteoarthritis. A systematic review by the Italian Society of Physical and Rehabilitation Medicine (SIMFER)

BACKGROUND

It is debated whether intra-articular viscosupplementation with hyaluronic acid (HA) can lead to improvements in subjects with osteoarthritis (OA) undergoing physical and rehabilitative interventions.

AIM

To assess the effects of intra-articular viscosupplementation on disability in subjects with OA undergoing physical and rehabilitative interventions. Information on pain and quality of life were also collected.

METHODS

The databases of PubMed, Medline, EMbase and CINAHL were searched for English language full-text randomized controlled trials comparing intra-articular viscosupplementation alone or associated with physical and rehabilitative interventions to viscosupplementation alone, shame treatment, waiting lists, and any type of rehabilitative interventions. Methodological quality of each study was assessed by using the Physiotherapy Evidence Database (PEDro) Scale.

RESULTS

A total of 115 references were retrieved, and 8 studies were selected. Three trials compared HA injection and physical therapy in knee OA, with disability and pain improvements in all studies, and between-group differences in favor of physical therapy in two studies; two trials compared HA injection and home exercises in knee OA, with improvements in pain, disability and quality of life in all studies, without between-group differences; two trials compared HA injection plus physical therapy agents and exercises to exercises plus physical therapy agents in knee OA, with improvements in disability and pain in both studies, and between-group differences in favor of the inclusion HA in one study; one trial compared HA injection and home exercises in ankle OA, with improvements in disability and pain in both arms without between-group differences.

CONCLUSION

Physical therapy agents seemed to have greater effects than intra-articular viscosupplementation on disability and pain. In the other cases both intra-articular viscosupplementation and physical and rehabilitative interventions seemed to be equally effective in improving disability, pain, and quality of life in subjects with knee and ankle OA.

CLINICAL REHABILITATION IMPACT

A treatment model associating intra-articular viscosupplementation to physical and rehabilitative interventions seems promising but more high quality RCTs are needed before it can be suggested.

Muscles, Ligaments and Tendons Journal - Basic principles and recommendations in clinical and field Science Research: 2016 Update

The proper design and implementation of a study as well as a balanced and well-supported evaluation and interpretation of its main findings are of crucial importance when reporting and disseminating research. Also accountability, funding acknowledgement and adequately declaring any conflict of interest play a major role in science. Since the Muscles, Ligaments and Tendons Journal (MLTJ) is committed to the highest scientific and ethical standards, we encourage all Authors to take into account and to comply, as much as possible, to the contents and issues discussed in this official editorial. This could be useful for improving the quality of the manuscripts, as well as to stimulate interest and debate and to promote constructive change, reflecting upon uses and misuses within our disciplines belonging to the field of "Clinical and Sport - Science Research".

Hormones and tendinopathies: the current evidence

BACKGROUND

Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions.

SOURCES OF DATA

Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

AREAS OF AGREEMENT

In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances.

AREAS OF CONTROVERSY

Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons.

GROWING POINTS

The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases.

AREAS TIMELY FOR DEVELOPING RESEARCH

The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed.

The Role of Detraining in Tendon Mechanobiology

Introduction: Several conditions such as training, aging, estrogen deficiency and drugs could affect the biological and anatomo-physiological characteristics of the tendon. Additionally, recent preclinical and clinical studies examined the effect of detraining on tendon, showing alterations in its structure and morphology and in tenocyte mechanobiology. However, few data evaluated the importance that cessation of training might have on tendon. Basically, we do not fully understand how tendons react to a phase of training followed by sudden detraining. Therefore, within this review, we summarize the studies where tendon detraining was examined.

Materials and Methods: A descriptive systematic literature review was carried out by searching three databases (PubMed, Scopus and Web of Knowledge) on tendon detraining. Original articles in English from 2000 to 2015 were included. In addition, the search was extended to the reference lists of the selected articles. A public reference manager (www.mendeley.com) was adopted to remove duplicate articles.

Results: An initial literature search yielded 134 references (www.pubmed.org: 53; www.scopus.com: 11; www.webofknowledge.com: 70). Fifteen publications were extracted based on the title for further analysis by two independent reviewers. Abstracts and complete articles were after that reviewed to evaluate if they met inclusion criteria.

Conclusions: The revised literature comprised four clinical studies and an in vitro and three in vivo reports. Overall, the results showed that tendon structure and properties after detraining are compromised, with an alteration in the tissue structural organization and mechanical properties. Clinical studies usually showed a lesser extent of tendon alterations, probably because preclinical studies permit an in-depth evaluation of tendon modifications, which is hard to perform in human subjects. In conclusion, after a period of sudden detraining (e.g., after an injury), physical activity should be taken with caution, following a targeted rehabilitation program. However, further research should be performed to fully understand the effect of sudden detraining on tendons.

Sonoelastography in the diagnosis of tendinopathies: an added value

BACKGROUND

sonoelastography helps in the detection of abnormalities not yet evident on B-mode exam.

METHODS

in this observational study, we report a collection of cases of symptomatic patients without alterations at ultrasound imaging but with evidence of pathological findings at sonoelastography. Patients, with clinical history suggestive for tendinopathies or surgically treated, and negative at the ultrasound exam, were submitted to sonoelastography. Out of 846, 632 patients with positive ultrasound exam were excluded. Sonoelastography was therefore performed in the remaining 214.

RESULTS

the examination was positive in 168 cases: 78 patients were affected with shoulder diseases, while elbow pathology was observed in 31 subjects; patellar, Achilles and plantar fascia disorders were reported in 19, 27, and 13 patients, respectively.

CONCLUSION

sonoelastography can reveal tendon abnormalities of clinical relevance in a high percentage of cases, where the ultrasound exam was negative, making the method a complementary tool to ultrasound evaluation.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Heterotopic ossification following hip arthroplasty: a comparative radiographic study about its development with the use of three different kinds of implants

Background

Our purpose was to record the incidence of heterotopic ossification (HO) following hip replacement by different variables to identify patient groups that are likely to develop HO in the absence of a prophylactic protocol.

Methods

Radiographically, we studied 651 patients having undergone hip joint replacement, evaluating three kinds of implants: ceramic-ceramic-coupled total hip replacement (THR), TriboFit^® with polycarbonate urethane-ceramic coupling and endoprosthesis. Each patient was analysed for HO development by age, gender, diagnosis, presence of previous ossifications, surgical approach and kind of implant. Within the population that developed HO, data were assessed for correlation with severity of ossification graded according to Brooker classification.

Results

The overall incidence of HOs was 59.91 %. The factors increasing their incidence in the univariate analysis were as follows: lower age of the patients with HO (mean 77.6 years, p = 0.0018) than those subjects who did not develop HO (mean 80.2 years); male gender (64.4 %, p = 0.1011); diagnosis of coxarthrosis (72.7 %, p = 0.0001) compared to femur neck fracture (55.9 %, p = 0.0001); presence of previous HO (76.2 %, p = 0.0260); lateral approach (65.5 %) as opposed to anterior-lateral approach (55.6 %, p = 0.0163); and ceramic-ceramic THR (68.1 %) and TriboFit^® (67.0 %) compared to endoprosthesis (51.3 %, p = 0.0001).

During multivariate analysis, the presence of HO after previous hip surgery (p = 0.0324) and the kind of implant (p = 0.0004) showed to be independent risk factors for the development of HO. Analysing the population that developed HO, we found that the severity of ossification by Brooker classification was influenced by gender (p = 0.0478) and kind of implant (p = 0.0093).

Conclusions

In agreement with the literature, our radiographic study confirms the following risk factors of HO development in absence of any prophylactic treatment: male gender, diagnosis of coxarthrosis compared to femur neck fracture, previous HO, surgical approach and kind of implant. In particular, Hardinge-Bauer and Watson-Jones surgical approaches, characterized by a wide exposure of the coxofemoral joint, and ceramic-ceramic THR and TriboFit^® implants significantly increase the development of HO.

Hyaluronic acid injections protect patellar tendon from detraining-associated damage

INTRODUCTION

Having previously demonstrated that detraining affects patellar tendon (PT) proteoglycan content and collagen fiber organization, we undertook the present study with two aims: to improve knowledge on the adaptation of PT and its enthesis to detraining from a histological and histomorphometric point of view, and to investigate the hypothesis that repeated peri-patellar injections of hyaluronic acid (HA) on detrained PT may reduce and limit detrained associated-damage.

METHODS

Twenty-four male Sprague-Dawley rats were divided into 3 groups: Untrained (n=6), Trained (n=6) (10 wks-treadmill) and Detrained (n=12). In the detrained rats, the left tendon was untreated while the right tendon received repeated peri-patellar injections of either HA or saline (NaCl). Structure and morphology of PTs (modified Movin score, tear density, collagen type I and III) and enthesis (cell morphology, chondrocyte cluster formation, tidemark integrity, matrix staining and vascularization) were evaluated.

RESULTS

The left PT and enthesis of the Detrained groups showed altered structure and morphology with the highest Movin score values, the highest percentage of collagen III and the lowest of collagen I; the lowest score values were observed in the Trained and Detrained-HA groups. Detrained-NaCl PTs showed the highest collagen III and the lowest collagen I values with respect to Detrained-HA PTs.

CONCLUSION

This study strengthens previously published data showing the alteration in tendon and enthesis morphology due to discontinuation of training, and provides new data showing that treatment with HA is effective in the maintenance of the structural properties of PT and enthesis in Detrained rats. Such beneficial effects could play a significant role in the management of conservative and rehabilitation strategies in athletes that change type, intensity and duration of training.

Metabolic and cytoprotective effects of in vivo peri-patellar hyaluronic acid injections in cultured tenocytes

The purpose of this study was to investigate tenocyte mechanobiology after sudden-detraining and to examine the hypothesis that repeated peri-patellar injections of hyaluronic acid (HA) on detrained patellar tendon (PT) may reduce and limit detrained-associated damage in tenocytes. Twenty-four male Sprague-Dawley rats were divided into three groups: Untrained, Trained and Detrained. In the Detrained rats, the left tendon was untreated while the right tendon received repeated peri-patellar injections of either HA or saline (NaCl). Tenocyte morphology, metabolism and synthesis of C-terminal-propeptide of type I collagen, collagen-III, fibronectin, aggrecan, tenascin-c, interleukin-1β, matrix-metalloproteinase-1 and-3 were evaluated after 1, 3, 7 and 10 days of culture. Transmission-electronic-microscopy showed a significant increase in mitochondria and rough endoplasmic reticulum in cultured tenocytes from Detrained-HA with respect to those from Detrained-NaCl. Additionally, Detrained-HA cultures showed a significantly higher proliferation rate and viability, and increased synthesis of C-terminal-Propeptide of type I collagen, fibronectin, aggrecan, tenascin-c and matrix-metalloproteinase-3 with respect to Detrained-NaCl ones, whereas synthesis of matrix-metalloproteinase-1 and interleukin-1β was decreased. Our study demonstrates that discontinuing training activity in the short-term alters tenocyte synthetic and metabolic activity and that repeated peri-patellar infiltrations of HA during detraining allow the maintenance of tenocyte anabolic activity.

Morphological adaptation and protein modulation of myotendinous junction following moderate aerobic training

Myotendinous junction is the muscle-tendon interface through which the contractile force can be transferred from myofibrils to the tendon extracellular matrix. At the ultrastructural level, aerobic training can modify the distal myotendinous junction of rat gastrocnemius, increasing the contact area between tissues. The aim of this work is to investigate the correlation between morphological changes and protein modulation of the myotendinous junction following moderate training. For this reason, talin, vinculin and type IV collagen amount and spatial distribution were investigated by immunohistochemistry and confocal microscopy. The images were then digitally analyzed by evaluating fluorescence intensity. Morphometric analysis revealed a significant increased thickening of muscle basal lamina in the trained group (53.1 ± 0.4 nm) with respect to the control group (43.9 ± 0.3 nm), and morphological observation showed the presence of an electron-dense area in the exercised muscles, close to the myotendinous junction. Protein concentrations appeared significantly increased in the trained group (talin +22.2%; vinculin +22.8% and type IV collagen +11.8%) with respect to the control group. Therefore, our findings suggest that moderate aerobic training induces/causes morphological changes at the myotendinous junction, correlated to the synthesis of structural proteins of the muscular basal lamina and of the cytoskeleton.

Muscle Injuries: A Brief Guide to Classification and Management

Muscle injuries are frequent in athletes. Despite their high incidence, advances in clinical diagnostic criteria and imaging, their optimal management and rehabilitation strategies are still debated in literature. Furthermore, reinjury rate is high after a muscle lesion, and an improper treatment or an early return to sports can increase the rate of reinjury and complications. Most muscle injuries are managed conservatively with excellent results, and surgery is normally advocated only for larger tears. This article reviews the current literature to provide physicians and rehabilitation specialists with the necessary basic tools to diagnose, classify and to treat muscle injuries. Based on anatomy, biomechanics, and imaging features of muscle injury, the use of a recently reported new classification system is also advocated.

Impact of oestrogen deficiency and aging on tendon: concise review

The knowledge about tendons and tenocyte biological behaviour during aging and, especially, oestrogen deficiency is limited. Women differ from men with regard to muscle and tendon, most likely due to differences in sex hormones activity and tissue response. To-date the interest in metabolic factors that may induce tendon disorders is growing. The aim of this paper is to elucidate the current findings in the correlation between oestrogen deficiency, aging and tendon pathology and to encourage future researches to ameliorate assessment and management of tendinopathies in postmenopausal women.