The increasing need for nonoperative treatment of patients with osteoarthritis

Current concepts and techniques in posttraumatic arthritis

Posttraumatic arthrosis is a commonly encountered clinical problem, but the pathoetiology of its development is not yet clarified. Many contributing mechanical biologic factors interplay with the traumatic event that necessarily precedes the posttraumatic syndrome. New biologic concepts involving the ability of the cartilage to repair and how such healing can be promoted are being realized in new modalities of treatment. The traumatic event as such and the resulting pathomechanical consequences require new ways of evaluation.

Osteoarthritis in older adults: current treatments

Although there is no cure for osteoarthritis, numerous treatments are available for symptom relief. Pharmacological treatments primarily focus on pain relief; however, in older adults there is continuing concern related to the risk of side effects and interactions with other medications. In contrast, non-pharmacological treatments, such as exercise, joint protection, and stress reduction, provide symptom relief with few side effects. In addition, alternative treatments such as nutritional supplements, herbal preparations, acupuncture, and tai chi are being investigated for their efficacy. Nurses should encourage patients to use a combination of treatments that provide optimum symptom relief with the fewest side effects.

Activity limitations and participation restrictions in women with hand osteoarthritis: patients' descriptions and associations between dimensions of functioning

OBJECTIVE

To describe the functional consequences of hand osteoarthritis, and analyse associations between personal factors, hand impairment, activity limitations, and participation restrictions within the framework of the International Classification of Functioning (ICF).

METHODS

87 women with hand osteoarthritis completed a clinical examination including recording of sociodemographic data, measures of hand impairment, and completion of self reported health status measures. The function subscale of the AUSCAN Osteoarthritis Hand Index was used as a measure of hand related activity limitations, while the Canadian Occupational Performance Measure (COPM) was used to describe and measure activity limitations and participation restrictions as perceived by the individual. The study variables were categorised using the dimensions in the ICF framework and analysed using bivariate and multivariate statistical approaches.

RESULTS

The patients described problems in many domains of activity and participation. The most frequently described hand related problems were activities requiring considerable grip strength combined with twisting of the hands. On the impairment level, the patients had reduced grip force and joint mobility in the hands, and resisted motion was painful. Regression analyses showed that hand related activity limitations were associated with measures of hand impairment, while activity and participation (as measured by the COPM) were more strongly associated with personal factors than with hand impairment.

CONCLUSIONS

Hand osteoarthritis has important functional consequences in terms of pain, reduced hand mobility and grip force, activity limitations, and participation restrictions. Rehabilitation programmes should therefore be multidisciplinary and multidimensional, focusing on hand function, occupational performance, and coping strategies.

A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (part I)

Disability and poor quality of life attributable to chronic diseases such as arthritis, diabetes, and heart disease constitute challenging public health problems for American society. In the absence of any effective cure for these conditions, the secondary prevention of complications and improving quality of life and functional capacity through better disease self-management becomes critical and are key objectives of Healthy People 2010. The organizing focus of such disease self-management should be on improving coping, communication, and control by enhancing self-efficacy. Part I of this two-part article describes the common clinical features of chronic diseases and the diverse disease management strategies used for alleviating pain and preventing disability associated with these and reviews the role of self-efficacy as a theoretical framework for successful self-management interventions. Part II identifies and synthesizes the key research evidence for educational interventions designed to enhance individual self-efficacy perceptions and presents implications for practice in patient education.

Effects of spouse-assisted coping skills training and exercise training in patients with osteoarthritic knee pain: a randomized controlled study

This study tested the separate and combined effects of spouse-assisted pain coping skills training (SA-CST) and exercise training (ET) in a sample of patients having persistent osteoarthritic knee pain. Seventy-two married osteoarthritis (OA) patients with persistent knee pain and their spouses were randomly assigned to: SA-CST alone, SA-CST plus ET, ET alone, or standard care (SC). Patients in SA-CST alone, together with their spouses, attended 12 weekly, 2-h group sessions for training in pain coping and couples skills. Patients in SA-CST + ET received spouse-assisted coping skills training and attended 12-weeks supervised ET. Patients in the ET alone condition received just an exercise program. Data analyses revealed: (1) physical fitness and strength: the SA-CST + ET and ET alone groups had significant improvements in physical fitness compared to SA-CST alone and patients in SA-CST + ET and ET alone had significant improvements in leg flexion and extension compared to SA-CST alone and SC, (2) pain coping: patients in SA-CST + ET and SA-CST alone groups had significant improvements in coping attempts compared to ET alone or SC and spouses in SA-CST + ET rated their partners as showing significant improvements in coping attempts compared to ET alone or SC, and (3) self-efficacy: patients in SA-CST + ET reported significant improvements in self-efficacy and their spouses rated them as showing significant improvements in self-efficacy compared to ET alone or SC. Patients receiving SA-CST + ET who showed increased self-efficacy were more likely to have improvements in psychological disability. An intervention that combines spouse-assisted coping skills training and exercise training can improve physical fitness, strength, pain coping, and self-efficacy in patients suffering from pain due to osteoarthritis.

Corresponding articular cartilage thickness measurements in the knee joint by modelling the underlying bone (commercial in confidence)

We present a method for corresponding and combining cartilage thickness readings from a population of patients using the underlying bone structure as a reference. Knee joint femoral bone and cartilage surfaces are constructed from a set of parallel slice segmentations of MR scans. Correspondence points across a population of bone surfaces are defined and refined by minimising an objective function based on the Minimum Description Length of the resulting statistical shape model. The optimised bone model defines a set of corresponding locations from which 3D measurements of the cartilage thickness can be taken and combined for a population of patients. Results are presented for a small group of patients demonstrating the feasibility and potential of the approach as a means of detecting sub-millimetre cartilage thickness changes due to disease progression.

Neuromuscular quadriceps dysfunction prior to osteoarthritis of the knee

Decreased maximal quadriceps strength and voluntary activation has been observed in patients with osteoarthritis in previous studies, but those results do not allow any conclusions to be drawn as to whether quadriceps dysfunction precedes or follows osteoarthritis. Thirty-two patients (group a) who underwent partial meniscectomy 48+/-9 month prior to the study were matched according to their weight and body mass index with a control group (group b). The twitch interpolation technique was used to determine maximal voluntary contraction (MVC) and voluntary activation (VA) of the quadriceps muscle of both legs. Subjective assessment of the knee was performed using the Lysholm-Score. AP and lateral X-rays of the operated knee were obtained. None of the participants showed any evidence of characteristic radiological or clinical signs for osteoarthritis. A significantly lower MVC was noticed in both the affected and the contralateral knee of group a in comparison to group b (p < 0.01). The VA in group a yielded 80.9+/-15.4% for the injured side and 83.1+/-11.5% for the contralateral side, with no statistical difference (p = 0.18). The VA in group b was 89.4+/-5.8% for the right side and 88+/-6.8% for the left side both being significantly higher in comparison to group a. This study has shown, that patients following meniscus resection present with bilateral quadriceps weakness as already described in patients with manifest osteoarthritis. The authors hypothesise that muscle dysfunction may be an etiologic factor underlying the pathologic changes of osteoarthritis. Whether muscle dysfunction occurs also at other sites, e.g. in the upper extremity, remains unclear but would be of interest in order to detect a generalized neuromuscular dysfunction.

Pseudoseptic reactions to hylan viscosupplementation: diagnosis and treatment

Hyaluronans are used widely in the treatment of osteoarthritis of the knee. Three commercial hyaluronan preparations currently are available in the United States: sodium hyaluronate (Hyalgan), sodium hyaluronate (Supartz), and hylan G-F 20 (Synvisc). Although the sodium hyaluronates are derived naturally, hylan is chemically modified to increase its molecular weight. All three products have been shown to be well tolerated in clinical trials, however, there have been reports in the literature of pseudoseptic reactions, or severe acute inflammatory reactions, after injections with hylan. Our study reviewed the reported incidence of pseudosepsis. The pathogenic mechanisms and clinical treatment of this reaction are presented.

Are foot orthotics efficacious for treating painful medial compartment knee osteoarthritis? A review of the literature

This work examined the evidence base concerning the efficacy of laterally wedged foot orthotics for improving the symptomatology associated with painful disabling osteoarthritis of the knee medial compartment. To this end, all relevant peer-reviewed publications on this topic published in the English language were retrieved and analysed. In addition, related biomechanical publications were analysed. These data indicate a strong scientific basis for applying wedged insoles in attempts to reduce osteoarthritic pain of biomechanical origin. Further research to substantiate their efficacy in well-designed clinical trials seems warranted.

Physical modalities in chronic pain management

The following conclusions can be made based on review of the evidence: There is limited but positive evidence that select physical modalities are effective in managing chronic pain associated with specific conditions experienced by adults and older individuals. Overall, studies have provided the most support for the modality of therapeutic exercise. Different physical modalities have similar magnitudes of effects on chronic pain. Therefore, selection of the most appropriate physical modality may depend on the desired functional outcome for the patient, the underlying impairment, and the patient's preference or prior experience with the modality. Certain patient characteristics may decrease the effectiveness of physical modalities, as has been seen with TENS. These characteristics include depression, high trait anxiety, a powerful others locus of control, obesity, narcotic use, and neuroticism. The effect on pain by various modalities is generally strongest in the short-term period immediately after the intervention series, but effects can last as long as 1 year after treatment (e.g., with massage). Most research has tested the effect of physical modalities on chronic low back pain and knee OA. The effectiveness of physical modalities for other chronic pain conditions needs to be evaluated more completely. Older and younger adults often experience similar effects on their perception of pain from treatment with physical modalities. Therefore, use of these modalities for chronic pain in older adults is appropriate, but special precautions need to be taken. Practitioners applying physical modalities need formal training that includes the risks and precautions for these modalities. If practitioners lack formal training in the use of physical modalities, or if modality use is not within their scope of practice, it is important to consult with and refer patients to members of the team who have this specialized training. Use of a multidisciplinary approach to chronic pain management is of value for all adults and older individuals in particular [79-81]. Historically, physical therapists have been trained to evaluate and treat patients with the range of physical modalities discussed in this article. Although members of the nursing staff traditionally have used some of these modalities (e.g. some forms of heat or cold and massage), increasing numbers of nurses now are being trained to apply more specialized procedures (e.g., TENS). Healthcare professionals must be knowledgeable about the strength of evidence underlying the use of physical modalities for the management of chronic pain. Based on the limited research evidence available (especially related to assistive devices, orthotics, and thermal modalities), it often is difficult to accept or exclude select modalities as having a potential role in chronic pain management for adults and older individuals. Improved research methodologies are needed to address physical modality effectiveness better.

Clinical benefit of joint distraction in the treatment of ankle osteoarthritis

Irrespective of underlying mechanisms, the structural changes after joint distraction and the efficacy during several years validate the concept of joint distraction in the treatment of osteoarthritis. Therefore, joint distraction in the case of severe ankle osteoarthritis at relatively young age may be a treatment of choice. In the light of increased aging, and the limited life span of an endoprosthesis, evaluation of joint distraction in the case of knee and hip osteoarthritis is justified.

Joint distraction as an alternative for the treatment of osteoarthritis

Irrespective of underlying mechanisms, the long-term efficacy of joint distraction in the treatment of severe ankle osteoarthritis at young age validates the concept of joint distraction in the treatment of osteoarthritis. Therefore, joint distraction in the case of severe ankle osteoarthritis may be a treatment of choice. This opens the possibility to study joint distraction as a treatment for other joints. Because knee osteoarthritis is much more common, it is a much greater social and economic problem. Beneficial effects of joint distraction in the case of ankle osteoarthritis, and specifically in the treatment of more common forms of osteoarthritis such as severe knee and hip osteoarthritis, may therefore have a great impact, especially in view of the increasing age of our population.