The association between reduced knee joint proprioception and medial meniscal abnormalities using MRI in knee osteoarthritis: results from the Amsterdam osteoarthritis cohort

BACKGROUND

Osteoarthritis (OA) of the knee is characterized by pain and activity limitations. In knee OA, proprioceptive accuracy is reduced and might be associated with pain and activity limitations. Although causes of reduced proprioceptive accuracy are divergent, medial meniscal abnormalities, which are highly prevalent in knee OA, have been suggested to play an important role. No study has focussed on the association between proprioceptive accuracy and meniscal abnormalities in knee OA.

OBJECTIVE

To explore the association between reduced proprioceptive accuracy and medial meniscal abnormalities in a clinical sample of knee OA subjects.

METHODS

Cross-sectional study in 105 subjects with knee OA. Knee proprioceptive accuracy was assessed by determining the joint motion detection threshold in the knee extension direction. The knee was imaged with a 3.0 T magnetic resonance (MR) scanner. Number of regions with medial meniscal abnormalities and the extent of abnormality in the anterior and posterior horn and body were scored according to the Boston-Leeds Osteoarthritis Knee Score (BLOKS) method. Multiple regression analyzes were used to examine whether reduced proprioceptive accuracy was associated with medial meniscal abnormalities in knee OA subjects.

RESULTS

Mean proprioceptive accuracy was 2.9° ± 1.9°. Magnetic resonance imaging (MRI)-detected medial meniscal abnormalities were found in the anterior horn (78%), body (80%) and posterior horn (90%). Reduced proprioceptive accuracy was associated with both the number of regions with meniscal abnormalities (P < 0.01) and the extent of abnormality (P = 0.02). These associations were not confounded by muscle strength, joint laxity, pain, age, gender, body mass index (BMI) and duration of knee complaints.

CONCLUSION

This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee OA. The study highlights the importance of meniscal abnormalities in understanding reduced proprioceptive accuracy in persons with knee OA.

Alterations in mucosal neuropeptides in patients with irritable bowel syndrome and ulcerative colitis in remission: a role in pain symptom generation?

BACKGROUND

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by chronic abdominal pain. The transient receptor potential vanilloid 1 (TRPV1) channel, which is involved in visceral pain signalling, has been shown to be up-regulated in IBS. Activation of TRPV1 leads to the release of neuropeptides, such as somatostatin and substance P (SP). We hypothesized that increased pain perception in IBS could be explained by increased transcription in TRPV1 and/or altered levels of neuropeptides. We therefore assessed the transcription of TRPV1 and the mucosal concentration of somatostatin and SP in IBS in comparison to healthy volunteers and patients with ulcerative colitis (UC) in remission as disease controls, and to ascertain their relationship to pain symptoms.

METHOD

Sigmoid colonic mucosal samples were collected from 12 patients with IBS, 34 patients with UC in remission and 9 healthy volunteers, in which groups TRPV1 mRNA levels were determined using quantitative polymerase chain reaction and neuropeptide concentrations by radioimmunoassay. Pain symptom intensity was determined by questionnaires.

RESULTS

Transcription of TRPV1 as well as the concentration of neuropeptides were significantly higher in IBS, but only the former correlated with pain symptom severity.

CONCLUSION

Increased transcription of TRPV1 may provide a possible explanation for pain generation in IBS. While the neuropeptides SP and somatostatin were both found to be increased in IBS, these changes are not sufficient to explain pain generation. Pain generation in IBS is probably explained by a complex redundancy in the regulation of local nociceptive mechanisms, which remains a subject of intensive investigation.

[The aftermath of the reduction in inpatient care and treatment II: cross-sectional study relating to the health, the need for care, the quality of life, social functioning and the integration in society of chronic mental patients in Amsterdam]

BACKGROUND

The move from less hospital care to more community-based care was expected to have positive results for long-term mental patients. It was believed that independent living would improve the quality of life and promote better social functioning and better integration into society. The basic idea was that the needs of patients would be better served by outpatient care.

AIM

To map particulars relating to illness symptoms, functioning, care needs, quality of life, extent and features of the social network and social integration of a group of long-term psychiatric patients in Amsterdam 15 years after the closure of the Santpoort psychiatric hospital.

METHOD

Interviews and questionnaires were used to obtain information from a stratified sample of long-term mental patients in the care of the mental health organisations in Amsterdam.

RESULTS

323 patients and those who were treating them were interviewed. Most group members were fairly elderly and one-third suffered from schizophrenia. More than half of the group had long-term psychiatric problems. Most of the patients were in poor health, half of the group had somatic symptoms and a quarter abused alcohol or drugs. Patients and doctors had varying views on whether patients&rsquo; needs had been met. Patients had few social contacts. About one-third of these social contacts were with fellow-patients. Patients living independently caused few or no problems in the city. However, these patients were more often victim of discrimination, social exclusion and criminality.

CONCLUSION

Many patients with long-term mental illness considered their current quality of life to be reasonably good and were satisfied with the health care they received. However, the limited number of social contacts, inadequate integration into society and the poor health of many patients are matters that still give cause for concern.

The course of limitations in activities over 5 years in patients with knee and hip osteoarthritis with moderate functional limitations: risk factors for future functional decline

OBJECTIVE

To describe the course of limitations in activities over 5 years follow-up and identify predictors of future limitations in activities in elderly patients with osteoarthritis (OA) of the hip or knee with moderate functional limitations.

METHOD

A longitudinal cohort study with 5 years follow-up was conducted. Patients (n=288) were recruited at rehabilitation centers and hospitals. The main outcome measures were self-reported and performance-based limitations in activities. Prognostic factors were demographic and clinical data, body functions, comorbidity, cognitive functioning, avoidance of activity and social support. Measurements were conducted at baseline, 1, 2, 3 and 5 years follow-up.

RESULTS

Both in patients with knee and hip OA, the course of limitations in activities remained fairly stable over a period of 5 years. Avoidance of activity, increased pain, more comorbidity, a higher age, a longer disease duration, a reduced muscle strength and range of joint motion at baseline predicted more future limitations in activities in patients with knee OA. In patients with hip OA, avoidance of activity, increased pain, more comorbidity, a higher age, a higher educational level and a reduced range of motion at baseline predicted more future limitations in activities.

CONCLUSIONS

The course of limitations in activities remains fairly stable over a period of 5 years in elderly patients with hip or knee OA. However, at individual level there is considerable variation. Predictors of more future limitations in activities include avoidance of activity, increased pain, higher morbidity count, reduced range of motion, and a higher age.

A multidisciplinary and multidimensional intervention for patients with hand osteoarthritis

Background: Although several guidelines recommend that treatment programmes in patients with hand osteoarthritis should be both multidisciplinary and multidimensional, currently no such treatment programme for hand osteoarthritis has been described. Therefore the aim of this study was to systematically develop a multidisciplinary and multidimensional non-pharmacological treatment programme and to give a detailed description on the content of this treatment programme.

Development of the treatment programme: The programme was developed in phases. In a preclinical theoretical phase, disease-specific problems, current evidence and the influence of patient characteristics on the benefit of interventions were explored. In a modelling phase, the treatment programme was designed.

Treatment programme: The programme contains an individual intake, four weekly nurse and occupational therapist-led group sessions and a booster session after six months. Treatment components of the programme are self-management, daily home exercises to enhance joint mobility and grip strength and education about ergonomic principles. The treatment programme is tailored to the needs of individual patients with hand osteoarthritis.

Conclusions: A non-pharmacological multidisciplinary and multidimensional treatment programme for patients with hand osteoarthritis was developed. Further research is necessary to investigate the effectiveness of this treatment programme. Currently, the programme is being evaluated in an ongoing randomized clinical trial.

Prevalence and risk factors for recurrence of depression five years after short term psychodynamic therapy

BACKGROUND

Follow-up research concerning the efficacy of treatment for depression is scarce and varies widely in clinical and methodological terms. Aim was to conduct a five-year follow-up study of recurrence of depression after short supportive Psychodynamic Treatment (PDT) alone or in combination with pharmacotherapy.

METHODS

Patients who had been treated five years previously for major depressive disorder in a randomised control trial comparing short supportive PDT alone or in combination with pharmacotherapy, were traced. Patients who completed treatment were included. Recurrent episodes in the past five years were identified using CIDI. Severity of symptoms after five years was measured with the Hamilton Rating Scale for Depression and sub-scales Depression, Anxiety and Somatisation of the self-report Symptom Checklist 90.

RESULTS

52 (37%) patients of the original sample were localised. 42% had suffered from one or more recurrences during the follow-up period. There was no significant difference between the group who had received psychotherapy and the group who had received combined therapy during the acute phase. Young women and patients with more residual depressive symptoms and less somatic symptoms directly after treatment, were more at risk for recurrence.

LIMITATIONS

Relatively small study population. Furthermore it was not known if patients received other treatment during the follow-up period.

CONCLUSIONS

The long-term efficacy of PDT (with or without antidepressants) seemed to be comparable with other psychotherapies for depression. But the high recurrence rate urges us to shift the focus of depression treatment to improving long-term outcome and to the prevention of recurrence, in particular for young women and patients with residual symptoms of depression.

Physiotherapy in hip and knee osteoarthritis: development of a practice guideline concerning initial assessment, treatment and evaluation

BACKGROUND

An update of a Dutch physiotherapy practice guideline in Hip and Knee Osteoarthritis (HKOA) was made, based on current evidence and best practice.

METHODS

A guideline steering committee, comprising 10 expert physiotherapists, selected topics concerning the guideline chapters: initial assessment, treatment and evaluation. With respect to treatment a systematic literature search was performed using various databases, and the evidence was graded (1-4). For the initial assessment and evaluation mainly review papers and textbooks were used. Based on evidence and expert opinion, recommendations were formulated. A first draft of the guideline was reviewed by 17 experts from different professional backgrounds. A second draft was field-tested by 45 physiotherapists.

RESULTS

In total 11 topics were selected. For the initial assessment, three recommendations were formulated, pertaining to history taking, red flags, and formulating treatment goals. Concerning treatment, 7 recommendations were formulated; (supervised) exercise therapy, education and self management interventions, a combination of exercise and manual therapy, postoperative exercise therapy and taping of the patella were recommended. Balneotherapy and hydrotherapy in HKOA, and thermotherapy, TENS, and Continuous Passive Motion in knee OA were neither recommended nor discouraged. Massage therapy, ultrasound, electrotherapy, electromagnetic field, Low Level Laser Therapy, preoperative physiotherapy and education could not be recommended. For the evaluation of treatment goals the following measurement instruments were recommended: Lequesne index, Western Ontario and McMaster Universities osteoarthritis index, Hip disability and Osteoarthritis Outcome Score and Knee injury and Osteoarthritis Outcome Score, 6-minute walktest, Timed Up and Go test, Patient Specific Complaint list, Visual Analoge Scale for pain, Intermittent and Constant OsteoArthritis Pain Questionnaire, goniometry, Medical Research Council for strength, handheld dynamometer.

CONCLUSIONS

This update of a Dutch physiotherapy practice guideline on HKOA included 11 recommendations on the initial assessment, treatment and evaluation. The implementation of the guideline in clinical practice needs further evaluation.

Instruments to assess physical activity in patients with osteoarthritis of the hip or knee: a systematic review of measurement properties

OBJECTIVE

There is no consensus on the best approach for measuring physical activity in patients with osteoarthritis (OA) of the hip or knee. The aims of this study were (1) to identify all physical activity measures that have been validated in patients with OA of the hip or knee and to systematically review their measurement properties, and (2) to give recommendations on which instrument is most suitable for what purpose.

DESIGN

A search was performed in PubMed, Embase, and Sportdiscus (complete databases until November 10, 2010). Three reviewers independently evaluated the quality of the included studies, using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. Subsequently, the reviewers independently evaluated the quality of the included physical activity instruments, using the recently developed QAPAQ checklist for appraising the qualitative attributes and measurement properties of physical activity questionnaires.

RESULTS

Nine studies were included, in which 12 measurement instruments were evaluated: five single-item rating scales, six multi-item questionnaires, and one pedometer. In general, the methodological quality of the studies was poor to moderate. Only the Lower-Extremity Activity Scale (LEAS) and the pedometer received positive ratings for content validity. The LEAS and Baecke questionnaire received positive ratings for reliability. The University of California at Los Angeles (UCLA), the Tegner score, and the LEAS received positive ratings for construct validity. The Daily Activity Questionnaire (DAQ) received a positive rating for criterion validity. Responsiveness was not evaluated for any of the included instruments.

CONCLUSION

For monitoring physical activity levels of populations the UCLA or LEAS seem most useful. For studies measuring physical activity as a risk factor for developing OA or as a protective factor against functional decline there is not enough evidence for any instrument to conclude that it has adequate measurement properties. For follow-up studies on wear in joint replacement patients we recommend to use accelerometers. However, more validation studies of adequate quality are needed for all included instruments.