All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study

Recommendations of the French Society of Rheumatology on pharmacological treatment of knee osteoarthritis

OBJECTIVES

To establish recommendations for pharmacological treatment of knee osteoarthritis specific to France.

METHODS

On behalf of the French Society of Rheumatology (SFR), a bibliography group analyzed the literature on the efficacy and safety of each pharmacological treatment for knee osteoarthritis. This group joined a multidisciplinary working group to draw up recommendations. Strength of recommendation and quality of evidence level were assigned to each recommendation. A review committee gave its level of agreement.

RESULTS

Five general principles were established: 1) need to combine pharmacological and non-pharmacological treatments, 2) personalization of treatment, 3) symptomatic and/or functional aim of pharmacological treatments, 4) need to regularly re-assess the treatments and 5) discussion about arthroplasty if medical treatment fails. Six recommendations involved oral treatments: 1) paracetamol should not necessarily be prescribed systematically and/or continuously, 2) NSAIDs, possibly as first-line, 3) weak opioids, 4) strong opioids, 5) symptomatic slow-acting drugs of osteoarthritis, and 6) duloxetine (off-label use). Two recommendations involved topical agents (NSAIDs and capsaicin<1%). Three recommendations involved intra-articular treatments: corticosteroid or hyaluronic acid injections that can be proposed to patients. The experts did not draw a conclusion about the benefits of platelet-rich plasma injections.

CONCLUSION

These are the first recommendations of the SFR on the pharmacological treatment of knee osteoarthritis.

Five years' trajectories of functionality and pain in patients after hip or knee replacement and association with long-term patient survival

To describe the 5 years’ trajectories in functionality and pain of patients with hip or knee osteoarthritis and arthroplasty and analyze the association of these with long-term patients survival. Patients with OA receiving total hip or knee arthroplasty were recruited and completed two sets of standardized questionnaires for functionality and pain 6, 12, and 60 months postoperatively. Multivariate mixed models were conducted to assess trajectories over time and the resulting improvement per month during the last time period was included in a landmark-model to estimate adjusted hazard ratios for mortality. In total 809 patients with joint replacement were included (mean age 65.0 years, 62.2% female), 407 patients died (median follow-up 18.4 years). Both instruments of functionality and pain showed extensive improvement during the first 6 months. Baseline and change in functionality (both p < 0.001) and pain (p = 0.02) during the first 6 months were associated with mortality. Better values in functionality corresponded with improved survival whereas the association with the pain scores was inverse. In patients with hip and knee OA, an explicit improvement in function is seen within the first 6 months after arthroplasty. In addition, especially the functionality scores at baseline as well as their improvement showed an association with long-term patient survival.

Tackling the Burden of Osteoarthritis as a Health Care Opportunity in Indigenous Communities-A Call to Action

Osteoarthritis is a highly prevalent and disabling disease, causing a significant individual and socioeconomic burden worldwide. Until now, there has been a dearth of research exploring the impact of osteoarthritis in global Indigenous communities. Osteoarthritis has a similar risk factor profile to many chronic diseases that disproportionately affect Indigenous peoples. In this editorial, we argue that osteoarthritis and associated mobility restrictions play a central role in the chronic disease profile of Indigenous peoples. We present a call to action for clinicians and health care providers, researchers and policymakers to begin to recognise the interrelated nature of osteoarthritis and chronic disease. We have an opportunity to change the way we do business, to improve access to culturally secure osteoarthritis care and the health and wellbeing of Indigenous communities.

A long non-coding RNA, HOTAIR, promotes cartilage degradation in osteoarthritis by inhibiting WIF-1 expression and activating Wnt pathway

Background

Long noncoding RNAs (lncRNAs) are recently found to be critical regulators of the epigenome. However, our knowledge of their role in osteoarthritis (OA) development is limited. This study investigates the mechanism by which HOTAIR, a key lncRNA with elevated expression in OA, affects OA disease progression.

Results

HOTAIR expression was greatly elevated in osteoarthritic compared to normal chondrocytes. Silencing and over-expression of HOTAIR in SW1353 cells respectively reduced and increased the expression of genes associated with cartilage degradation in OA. Investigation of molecular pathways revealed that HOTAIR acted directly on Wnt inhibitory factor 1 (WIF-1) by increasing histone H3K27 trimethylation in the WIF-1 promoter, leading to WIF-1 repression that favours activation of the Wnt/β-catenin pathway.

Conclusions

Activation of Wnt/β-catenin signalling by HOTAIR through WIF-1 repression in osteoarthritic chondrocytes increases catabolic gene expression and promotes cartilage degradation. This is the first study to demonstrate a direct link between HOTAIR, WIF-1 and OA progression, which may be useful for future investigations into disease biomarkers or therapeutic targets.

What Is the Appropriate Price for Platelet-Rich Plasma Injections for Knee Osteoarthritis? A Cost-Effectiveness Analysis Based on Evidence From Level I Randomized Controlled Trials

PURPOSE

To identify the price of treatment at which platelet-rich plasma (PRP) is cost-effective relative to hyaluronic acid (HA) and saline solution intra-articular injections.

METHODS

A systemized review process of the PubMed, Embase, and MEDLINE databases was undertaken to identify randomized controlled trials comparing PRP with HA and saline solution with up to 1 year of follow-up. Level I trials that reported Western Ontario and McMaster Universities Arthritis Index Likert scores were included. These scores were converted into utility scores. Cost data were obtained from Centers for Medicare & Medicaid Services fee schedules. Total costs included the costs of the injectable, clinic appointments, and procedures. The change in utility scores from baseline to 6 months and 1 year for the PRP, HA, and saline solution groups was divided by total cost to determine utility gained per dollar and to identify the price needed for PRP to be cost-effective relative to these other injection options.

RESULTS

Nine randomized controlled trials met the inclusion criteria. A total of 882 patients were included: 483 in the PRP group, 338 in the HA group, and 61 in the saline solution group. Baseline mean utility scores ranged from 0.55 to 0.57 for the PRP, HA, and saline solution groups. The 6-month gains in utility were 0.12, 0.02, and -0.06, respectively. The 12-month gains in utility from before injection were 0.14, 0.03, and 0.06, respectively. The lowest total costs for HA and saline solution were $681.93 and $516.29, respectively. For PRP to be cost-effective, the total treatment cost would have to be less than $3,703.03 and $1,192.08 for 6- and 12-month outcomes, respectively.

CONCLUSIONS

For patients with symptomatic knee osteoarthritis, PRP is cost-effective, from the payer perspective, at a total price (inclusive of clinic visits, the procedure, and the injectable) of less than $1,192.08 over a 12-month period, relative to HA and saline solution.

LEVEL OF EVIDENCE

Level I, systematic review.

High self-efficacy - a predictor of reduced pain and higher levels of physical activity among patients with osteoarthritis: an observational study

BACKGROUND

Self-efficacy is considered a core component in self-management. However, there is a lack of knowledge about the association between self-efficacy and health-related outcomes in osteoarthritis. The aim of this study was to investigate whether self-efficacy at baseline was associated with change over time in pain and physical activity after a supported osteoarthritis self-management programme.

METHODS

A total of 3266 patients with hip or knee osteoarthritis attended this observational, register-based study. Self-efficacy was assessed using the Arthritis Self-Efficacy Scale. Pain was estimated on a visual analogue scale and physical activity by self-reporting number of days per week the patients were physically active ≥30 min. Data were self-reported at baseline and at follow-ups after 3 and 12 months. Analyses were performed using a mixed linear model analysis and are presented with an unadjusted and an adjusted model.

RESULTS

High vs low self-efficacy for pain management at baseline resulted in reduced pain and increased physical activity at the follow-ups; least squares means and standard error were 37.43 ± 0.40 vs 44.26 ± 0.40, for pain, and 5.05 ± 0.07 vs 4.90 ± 0.08 for physical activity. High self-efficacy for management of other symptoms resulted in lower pain and higher physical activity at follow-up: 35.78 ± 0.71 vs 41.76 ± 0.71 for pain, and 5.08 ± 0.05 vs 4.72 ± 0.05 for physical activity. Patients with obesity reported lower activity levels at the follow-ups.

CONCLUSION

Self-efficacy at baseline was associated with change over time in pain and physical activity at 3 and 12 months after the supported osteoarthritis self-management programme. High self-efficacy had a positive effect on pain and physical activity, indicating the need for exploring and strengthening patients' self-efficacy. Patients with obesity may need further interventions and support during a self-management programme to achieve an increase in physical activity.

Proportion and associated factors of meeting the 2018 Physical Activity Guidelines for Americans in adults with or at risk for knee osteoarthritis

OBJECTIVES

Evaluate the prevalence of meeting the updated 2018 Physical Activity Guidelines for Americans (150 unbouted minutes in moderate-to-vigorous intensity physical activity [MVPA]) and determine cross-sectional factors associated with Guideline attainment in a community-based cohort of adults with or at elevated risk for knee osteoarthritis (OA).

METHODS

Physical activity was monitored for 1 week in a subset of Osteoarthritis Initiative (OAI) participants with or at increased risk for knee OA. Accelerometer-measured weekly MVPA minutes were calculated; sociodemographic (age, sex, race, education, and working status) and health-related (body mass index [BMI], comorbidity, depressive symptoms, radiographic knee OA, and frequent knee symptoms) factors were assessed. We evaluated the prevalence of meeting 2018 Guidelines and used multivariate partial proportional odds model to identify factors associated with Guideline attainment, controlling for other factors in the model.

RESULTS

Among 1922 participants (age 65.1 [standard deviation 9.1] years, BMI 28.4 [4.8] kg/m², 55.2% women), 44.1% men and 22.2% women met the 2018 PA Guidelines. Adjusted cross-sectional factors associated with not-meeting 2018 Guidelines were: women, older age, higher BMI, non-Whites, depressive symptoms, not working, and frequent knee symptoms.

CONCLUSION

In community-recruited adults with or at high risk for knee OA, more than 50% of men and nearly 80% of women failed to achieve the 2018 recommended level of at least 150 weekly unbouted minutes of MVPA. Study findings support gender and racial disparity in Guideline attainment and suggest addressing potentially modifiable factors (e.g., BMI, depressive symptoms, and frequent knee symptoms) to optimize benefits in PA-promoting interventions.

The Effect of Neuromuscular Electrical Stimulation During Walking on Muscle Strength and Knee Pain in Obese Women With Knee Pain: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to assess the effectiveness of a hybrid training system with walking that simultaneously applies electrical stimulation to the knee extensors/flexors during walking in obese women with knee pain.

DESIGN

This is a randomized, single-blind (assessor), controlled trial. Twenty-eight obese women with knee pain were randomized to 12 weeks of biweekly walking with either hybrid training system with walking or with transcutaneous electrical nerve stimulation (control). Primary outcomes (maximum isokinetic knee extensor torque and maximum isokinetic knee flexor torque) and secondary outcomes (20-m walk time, chair-stand time, stair-climb time, knee pain, and knee-related quality life) were evaluated. Change-point regression analyses were used to model the interaction for the primary outcomes. Two-sample t tests were used on pre-post change scores in secondary outcomes.

RESULTS

Knee extensor torque increased significantly more in the hybrid training system with walking group than the control group when baseline knee extensor torque was greater than 57.2 Nm (P = 0.0033). When baseline knee flexor torque was at 30 or 50 Nm, there was a trend toward greater increase in the hybrid training system with walking group than the control group (P = 0.0566, P = 0.0737, respectively). There were no significant differences between groups in secondary outcomes.

CONCLUSIONS

These results suggest that hybrid training system with walking is effective for improving knee extensor torque in obese women with knee pain. However, the superiority of hybrid training system with walking may vary depending on baseline knee muscle strength.

Misconceived expectations: Patient reflections on the total knee replacement journey

INTRODUCTION

Fifty per cent of patients consent for total knee replacement (TKR) with unrealistic expectations about what it involves and can achieve. A framework is needed to help surgeons identify key knowledge gaps and misconceptions that can be targeted during the informed consent process. In this qualitative study, we explored knowledge gaps and misconceptions by asking patients to reflect on their expectations along the TKR journey.

METHODS

Eligible adults were ≥18 years, 12-month post-TKR and had completed a validated expectations questionnaire pre-TKR as part of a joint replacement registry. To capture a variety of perspectives, people with a range of pre-TKR expectation scores were invited. In interviews, participants reflected on anticipated and actual experiences and unexpected experiences they had along the way. Transcripts were analysed through inductive thematic analysis. Recruitment ceased when thematic saturation was reached.

ETHICS APPROVAL

Ethical approval for this study was granted by the St Vincent's Hospital Melbourne Ethics Committee (LRR 077/18).

RESULTS

In the final sample (n = 20; 50% female; median age = 72 years; contralateral TKR = 11), all participants described instances where their anticipated and actual experiences diverged, including high expectations of improvements in pain/function (pre-surgical optimism), lacking awareness about anaesthetic procedures (perioperative misunderstandings), feeling unprepared for the length of the recovery period (post-operative misestimations) and trying to make sense of ongoing functional limitations (long-term misattributions).

DISCUSSION AND CONCLUSION

These findings are captured in a preliminary framework of therapeutic misconception. Although future research is needed to test this framework prospectively in larger, more generalisable samples, surgeons can consider these key knowledge gaps and misconceptions when consenting for TKR.

An Enhanced Approach for Economic Evaluation of Long-Term Benefits of School-Based Health Promotion Programs

Chronic diseases constitute a tremendous public health burden globally. Poor nutrition, inactive lifestyles, and obesity are established independent risk factors for chronic diseases. Public health decision-makers are in desperate need of effective and cost-effective programs that prevent chronic diseases. To date, most economic evaluations consider the effect of these programs on body weight, without considering their effects on other risk factors (nutrition and physical activity). We propose an economic evaluation approach that considers program effects on multiple risk factors rather than on a single risk factor. For demonstration, we developed an enhanced model that incorporates health promotion program effects on four risk factors (weight status, physical activity, and fruit and vegetable consumption). Relative to this enhanced model, a model that considered only the effect on weight status produced incremental cost-effectiveness ratio (ICER) estimates for quality-adjusted life years that were 1% to 43% higher, and ICER estimates for years with chronic disease prevented that were 1% to 26% higher. The corresponding estimates for return on investment were 1% to 20% lower. To avoid an underestimation of the economic benefits of chronic disease prevention programs, we recommend economic evaluations consider program effects on multiple risk factors.

Overexpression of miR-10a-5p facilitates the progression of osteoarthritis

The current study was aimed at exploring the potential roles and possible mechanisms of miR-10a-5p in osteoarthritis (OA). We performed RT-qPCR, Western blot, CCK8, EdU Assay, and flow cytometry assay to clarify the roles of miR-10a-5p in OA. Furthermore, the whole transcriptome sequencing together with integrated bioinformatics analyses were conducted to elucidate the underlying mechanisms of miR-10a-5p involving in OA. Our results demonstrated that miR-10a-5p was upregulated in OA and acted as a significant contributing factor for OA. A large number of circRNAs, lncRNAs, miRNAs, and mRNAs were identified by overexpressing miR-10a-5p. Functional enrichment analyses indicated that these differentially-expressed genes were enriched in some important terms including PPAR signaling pathway, PI3K-Akt signaling pathway, and p53 signaling pathway. A total of 42 hub genes were identified in the protein-protein interaction network including SERPINA1, TTR, APOA1, and A2M. Also, we constructed the network regulatory interactions across coding and noncoding RNAs triggered by miR-10a-5p, which revealed the powerful regulating effects of miR-10a-5p. Moreover, we found that HOXA3 acted as the targeted genes of miR-10a-5p and miR-10a-5p contributed to the progression of OA by suppressing HOXA3 expression. Our findings shed insight on regulatory mechanisms of miR-10a-5p, which might provide novel therapeutic targets for OA.

Reference Values and Correlations for Multiple Physical Performance Measures: A Cross-Sectional Study among Independently Mobile Older Men in Japan

Purpose: Japan is one of few countries with a male life expectancy over 80 years. The gap between the healthy life span and the total life expectancy is large, highlighting the importance of maintaining physical performance. The present study aims to establish reference values for multiple physical performance measures among high-functioning oldest-old Japanese men and to investigate the correlations among these measurements to understand how these variables are related. Methods: This study was conducted with 120 Japanese males aged 80 years or older who were able to walk independently. Seven measures of physical performance were assessed: handgrip strength, quadriceps strength, static balance ability (one-legged stance), dynamic balance ability (Functional Reach Test; FRT), walking ability (5-m walking time test), combined movement ability (Timed Up & Go test), and bone quality. Cognitive function was also measured (Mini-Mental State Examination; MMSE). Results: Specific reference values are reported for each physical performance measurement explored in this study. Only six participants were classified as cognitively impaired, and 16 had mild cognitive impairment. There were significant correlations of varying levels among all of the measures of physical performance. Age was significantly correlated with all performance measures except FRT, and there was no correlation between age and MMSE. MMSE was weakly correlated with FRT and unrelated to the other performance measures. Conclusions: The reference ranges can be used by older men who have not yet reached 80 years and their health care providers as physical performance targets to facilitate the maintenance of independent mobility in later life.

High Levels of Kinesiophobia at Discharge from the Hospital May Negatively Affect the Short-Term Functional Outcome of Patients Who Have Undergone Knee Replacement Surgery

Background: Kinesiophobia is a psycho-cognitive factor that hampers recovery after orthopedic surgery. No evidence exists on the influence of kinesiophobia on the short-term recovery of function in patients with knee replacement (KR). Therefore, the aim of the present study is to investigate the impact of kinesiophobia on short-term patient-reported outcomes (PROMs) and performance-based measures (PBMs). Methods: Forty-three KR patients filled in the Tampa scale for kinesiophobia (TSK) at time of discharge. Patients with TSK ≥ 37 were allocated to the kinesiophobia group (n = 24), others to the no-kinesiophobia group (n = 19). Patients were asked to complete PROMs and to execute PBMs at discharge and at 6-weeks follow-up. An independent samples t-test was used to compare group differences for PROMs and PBMs at both measurement sessions. Multiple linear regression analysis models were used to model PBM outcomes from age, pain and TSK scores. Results: Significant differences were observed between groups for PROMs and PBMs. Kinesiophobia significantly contributed to the reduced functional outcomes. Conclusion: At discharge from the hospital, 55.8% of KR patients demonstrated high levels of kinesiophobia (TSK ≥ 37). This may negatively influence short-term recovery of these patients, by putting them at higher risk for falling and reduced functionality.

Knee Osteoarthritis Grade does not Correlate with Quadriceps Muscle Strength or Bone Properties of the Calcaneus in Men Aged 80 Years or More who Can Walk independently

Purpose: Muscle weakness and bone deterioration in the elderly are related to falls and fractures, resulting in decreased mobility. Knee osteoarthritis also may contribute to falls and fractures and thereby affect mortality rates. The Kellgren–Lawrence (KL) classification is widely used in the radiographic evaluation of knee osteoarthritis. Aims: This study aimed to evaluate the quadriceps strength and bone properties of the calcaneus for each KL grade, and to clarify the impact of knee osteoarthritis grade on quadriceps strength and bone properties. Methods: This prospective cross-sectional study included data on 108 male patients (213 knees), aged ≥80 years, who could walk independently. A handheld dynamometer was used to measure quadriceps strength. Bone properties were evaluated using broadband ultrasound attenuation with a portable bone densitometer. Weight-bearing standing knee radiographs were evaluated using KL classification. Quadriceps strength and bone properties were evaluated for each KL grade and the correlations between the grade and quadriceps strength and bone properties were assessed simultaneously. Results: The numbers of participants in KL grades I–IV were 46, 102, 45, and 20, respectively. There were no differences among grades for either quadriceps strength or bone properties. Conclusions: Participants exhibited good quadriceps strength and bone properties regardless of their KL grade. Relatively high mechanical loading of muscle and bone incurred while walking independently, likely explaining this result. Clinically, this study demonstrated the absence of correlations between KL grade and quadriceps strength and bone properties, as was previously reported in studies showing the absence of a correlation between KL grade and pain.

Osteoarthritis and inflammation: a serious disease with overlapping phenotypic patterns

Globally, osteoarthritis (OA) is the most prevalent arthritic condition in those aged over 60 years. OA has a high impact on patient disability and is associated with a significant economic burden. Pain is the most common first sign of disease and the leading cause of disability. Data demonstrating the increasing global prevalence of OA, together with a greater understanding of the burden of the disease, have led to a reassessment of the seriousness of OA and calls for the designation of OA as a serious disease in line with the diseases impact on comorbidity, disability, and mortality. While OA was traditionally seen as a prototypical 'wear and tear' disease, it is now more accurately thought of as a disease of the whole joint involving cartilage together with subchondral bone and synovium. As more has become known of the pathophysiology of OA, it has become increasingly common for it to be described using a number of overlapping phenotypes. Patients with OA will likely experience multiple phenotypes during their disease. This review focuses on what we feel are three key phenotypes: post-trauma, metabolic, and aging. A greater understanding of OA phenotypes, particularly at the early stages of disease, may be necessary to improve treatment outcomes. In the future, non-pharmacological and pharmacological treatments could be tailored to patients based on the key features of their phenotype and disease pathway.

Comorbid conditions and the transition among states of hip osteoarthritis and symptoms in a community-based study: a multi-state time-to-event model approach

Background

We examined the association of three common chronic conditions (obesity, diabetes mellitus [DM], and cardiovascular disease [CVD]) with transitions among states of hip osteoarthritis (HOA).

Methods

This longitudinal analysis used data from the Johnston County Osteoarthritis Project (JoCo OA, n = 3857), a community-based study in North Carolina, USA, with 18.4 ± 1.5 years of follow-up. Transitions across the following states were modeled: development of radiographic HOA (rHOA; Kellgren-Lawrence grade [KLG] of< 2); development of hip symptoms (self-reported hip pain, aching, or stiffness on most days) or symptomatic HOA (sxHOA; rHOA and symptoms in the same hip), and resolution of symptoms. Obesity (body mass index ≥ 30 kg/m²) and self-reported DM and CVD were the time-dependent comorbid conditions of interest. Markov multi-state models were used to estimate adjusted hazard ratios and 95% confidence intervals to describe the associations between the conditions and HOA states.

Results

The sample included 33% African Americans, 39% men, with a mean (SD) age of 62.2 (9.8) years; the frequencies of the comorbidities increased substantially over time. When considered individually, obesity was associated with incident hip symptoms, while CVD and DM were associated with reduced symptom resolution. For those with > 1 comorbidity, the likelihood of incident sxHOA increased, while that of symptom resolution significantly decreased. When stratified by sex, the association between obesity and incident symptoms was only seen in women; among men with DM versus men without, there was a significant (~ 75%) reduction in symptom resolution in those with rHOA. When stratified by race, African Americans with DM, versus those without, were much more likely to develop sxHOA.

Conclusions

Comorbid chronic conditions are common in individuals with OA, and these conditions have a significant impact on the persistence and progression of HOA. OA management decisions, both pharmacologic and non-pharmacologic, should include considerations of the inter-relationships between OA and common comorbidities such as DM and CVD.

Behavioral Conformity of Physical Activity and Sedentary Behavior in Older Couples with One Partner Suffering from End-Stage Osteoarthritis

PURPOSE

The present study investigates behavioral conformity regarding physical activity (PA) and sedentary behavior (SB) in older couples where one partner suffers from osteoarthritis (OA). Hereby the question is addressed whether and to what extent the typical physical limitations of OA patients have negative effects on their partners.

PATIENTS AND METHODS

The habitual PA and SB of end-stage osteoarthritis patients (n = 32, 52-81 years | n = 14 gonarthrosis, n = 18 coxarthrosis), their spouses (n = 32, 50-83 years) and control couples (n = 26 subjects, 52-78 years) were assessed by accelerometry. Besides individual results of accelerometry hourly couple-specific performance ratios were calculated for four parameters of PA (number of steps, vector magnitude (VM), metabolic rate (MET), and total time in moderate-to-vigorous PA (MVPA)) and two parameters of SB (number of sedentary bouts and total time of sedentary bouts per hour). Analyses of covariance were used to explore differences in hourly couple-specific performance ratios between couples affected by osteoarthritis and control couples.

RESULTS

Significant differences in PA were observed between the three groups, whereby the patients showed the lowest PA and the subjects of the control group the highest PA. In contrast to this, SB did not differ between the three groups. The hourly analyses of couple-specific performance ratios revealed significant differences between the target couples (patients and spouses) and the control couples for all parameters of PA. Thereby, the deviance in PA between the patients and their spouses was always smaller than in control couples and also decreased with age. The investigation of SB, on the other hand, revealed larger deviations between the patients and their spouses as compared to control couples and no changes with age.

CONCLUSION

This study confirmed the known negative impact of osteoarthritis on the PA and SB of elderly patients. More important, however, was the finding that the patients' spouses adapt to this poor health behavior and show reduced PA as well. Consequentially, spouses of OA patients should be considered as a risk group for inactivity-related diseases in old age. This should be considered in interventions that aim to use the individual support of spouses to increase the PA of OA patients.

[Symptomatic slow-acting drugs in the treatment of osteoarthritis: focus on glucosamine preparations]

The article discusses the place of symptomatic slow-acting drugs in current guidelines for the treatment of osteoarthritis. Special emphasis is put ot glucosamine preparations, the attitude towards which, until recently, was ambiguous. The results of experimental and clinical studies demonstrating the advantages of crystalline glucosamine sulfate over preparations/food additives of glucosamine hydrochloride are presented. The differences in the pharmacodynamics and pharmacokinetics of glucosamine sulfate and glucosamine hydrochloride, which may be the reason for the ineffectiveness of the latter in clinical trials, are discussed.

The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery

Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.

Treat-to-target strategy for knee osteoarthritis. International technical expert panel consensus and good clinical practice statements

Background:

In this work, we aimed to establish a clinical target in the management of knee osteoarthritis (KOA) and to propose good clinical practice (GCP) statements for carrying out a treat-to-target strategy.

Methods:

A steering committee of seven experts had formulated a provisional set of recommendations that were exposed for discussion and modification to a technical expert panel (TEP) of 25 multidisciplinary experts from Europe, North America, South America and Asia. The level of evidence and strength of each recommendation was discussed. The TEP formulated overarching principles and GCP statements based on the level of agreement for each item with a vote using a 10-point numerical scale.

Results:

Two overarching principles and 10 GCP statements were formulated by the TEP. These GCP statements suggest: treatment should achieve clinical improvement bringing the patient to the Patient Acceptable Symptom State (PASS); pharmacological and nonpharmacological treatment should begin as early as possible, with an early diagnosis of symptomatic KOA; the patient should be evaluated every 3–6 months; risk factors of KOA progression should be identified and managed with patients at the beginning of the treatment and monitored regularly; treatment should be adapted according to patient phenotype and disease severity; healthy lifestyle must be promoted and monitored. The level of agreement average ranged from 8.7 to 9.6 on scale.

Conclusions:

The proposed overarching principles and GCP statements have the aim of involving patients, general practitioners and multidisciplinary specialists in sharing a therapeutic treat-to-target strategy for KOA management based on the best evidence and expert opinions.

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis

Objectives

We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation.

Data sources

PubMed, CINAHL, Scopus; inception to January 2019.

Eligibility criteria

Randomised clinical trials (RCT), cohort studies, case series.

Design

We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models.

Results

Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (−3.56 beats per minute; 95% CI −5.60 to −1.52) and DBP (−4.10 mm Hg; 95% CI −4.82 to −3.38) and no change in SBP (−0.36 mm Hg; 95% CI −3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI −0.11 to 0.85). Within-group differences were also small to moderate.

Conclusions

In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA.

PROSPERO registration number

CRD42018087859.

Chondroprotective Properties of Human-Enriched Serum Following Polyphenol Extract Absorption: Results from an Exploratory Clinical Trial

Polyphenols are widely acknowledged for their health benefits, especially for the prevention of inflammatory and age-related diseases. We previously demonstrated that hydroxytyrosol (HT) and procyanidins (PCy), alone or in combination, drive preventive anti-osteoathritic effects in vivo. However, the lack of sufficient clinical evidences on the relationship between dietary phytochemicals and osteoarthritis remains. In this light, we investigated in humans the potential osteoarticular benefit of a grapeseed and olive extract (OPCO) characterized for its hydroxytyrosol (HT) and procyanidins (PCy) content. We first validated, in vitro, the anti-inflammatory and chondroprotective properties of the extract on primary cultured human articular chondrocytes stimulated by interleukin-1 beta (IL-1 β). The sparing effect involved a molecular mechanism dependent on the nuclear transcription factor-kappa B (NF-κB) pathway. To confirm the clinical relevance of such a nutritional strategy, we designed an innovative clinical approach taking into account the metabolites that are formed during the digestion process and that appear in circulation after the ingestion of the OPCO extract. Blood samples from volunteers were collected following ingestion, absorption, and metabolization of the extract and then were processed and applied on human primary chondrocyte cultures. This original ex vivo methodology confirmed at a clinical level the chondroprotective properties previously observed in vitro and in vivo.

A single intra-articular injection of 2.0% non-chemically modified sodium hyaluronate vs 0.8% hylan G-F 20 in the treatment of symptomatic knee osteoarthritis: A 6-month, multicenter, randomized, controlled non-inferiority trial

OBJECTIVES

The aim of the study was to demonstrate the non-inferiority of a single intra-articular injection of 2.0% non-chemically modified sodium hyaluronate (SH) vs 0.8% hylan G-F 20 (control) in symptomatic knee osteoarthritis.

DESIGN

This was a double-blind, randomized, controlled trial conducted in patients with painful tibiofemoral osteoarthritis (American College of Rheumatology criteria) with insufficient response or intolerance to first-line analgesics and regular non-steroidal anti-inflammatory drugs. Subjects received a single intra-articular injection of either SH or hylan G-F 20. The primary outcome was the 6-month change from baseline in the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale (WOMAC A), with a pre-specified lower margin for non-inferiority of 8 mm.

RESULTS

Of the 292 patients randomized (SH: 144), 288 received an injection (SH: 142), 266 completed the study (SH: 134). In the Per Protocol dataset (SH: 113, control: 112), the WOMAC A change at 6 months was -34.3 mm (95% confidence interval (CI): -37.8, -30.8) and -36.2 mm (95% CI: -40.3, -32.1) for the SH and hylan G-F 20 patients, respectively (P = 0.5). The intergroup difference was -1.9 mm (95% CI: -7.3, 3.5). Results were similar in the Full Analysis Set (SH: 139, control: 141) with a difference between the groups of -2.9 mm (95% CI: -7.9, 2.2). A total of 31.3% of the injected patients reported a treatment-emergent adverse event, including injection site reactions (pain, inflammation or effusion) which occurred in 8.5% of the SH patients vs 13.0% of the hylan G-F 20 patients. No serious reactions were reported.

CONCLUSIONS

This clinical trial demonstrated the non-inferiority of a single intra-articular injection of SH vs hylan G-F 20 on the WOMAC A change from baseline at 6 months.

Biomaterial-engineered intra-articular drug delivery systems for osteoarthritis therapy

Osteoarthritis (OA) is a progressive and degenerative disease, which is no longer confined to the elderly. So far, current treatments are limited to symptom relief, and no valid OA disease-modifying drugs are available. Additionally, OA relative joint is challenging for drug delivery, since the drugs experience rapid clearance in joint, showing a poor bioavailability. Existing therapeutic drugs, like non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, are not conducive for long-term use due to adverse effects. Though supplementations, including chondroitin sulfate and glucosamine, have shown beneficial effects on joint tissues in OA, their therapeutic use is still debatable. New emerging agents, like Kartogenin (KGN) and Interleukin-1 receptor antagonist (IL-1 ra), without a proper formulation, still will not work. Therefore, it is urgent to establish a suitable and efficient drug delivery system for OA therapy. In this review, we pay attention to various types of drug delivery systems and potential therapeutic drugs that may escalate OA treatments.

An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

OBJECTIVES

The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) sought to revisit the 2014 algorithm recommendations for knee osteoarthritis (OA), in light of recent efficacy and safety evidence, in order to develop an updated stepwise algorithm that provides practical guidance for the prescribing physician that is applicable in Europe and internationally.

METHODS

Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, a summary of evidence document for each intervention in OA was provided to all members of an ESCEO working group, who were required to evaluate and vote on the strength of recommendation for each intervention. Based on the evidence collected, and on the strength of recommendations afforded by consensus of the working group, the final algorithm was constructed.

RESULTS

An algorithm for management of knee OA comprising a stepwise approach and incorporating consensus on 15 treatment recommendations was prepared by the ESCEO working group. Both "strong" and "weak" recommendations were afforded to different interventions. The algorithm highlights the continued importance of non-pharmacological interventions throughout the management of OA. Benefits and limitations of different pharmacological treatments are explored in this article, with particular emphasis on safety issues highlighted by recent literature analyses.

CONCLUSIONS

The updated ESCEO stepwise algorithm, developed by consensus from clinical experts in OA and informed by available evidence for the benefits and harms of various treatments, provides practical, current guidance that will enable clinicians to deliver patient-centric care in OA practice.

Reasons why osteoarthritis predicts mortality: path analysis within a Cox proportional hazards model

Objectives

To identify potentially modifiable factors that mediate the association between symptomatic osteoarthritis (OA) and premature mortality.

Methods

A population-based prospective cohort study; primary care medical record data were linked to self-report information collected by questionnaire in adults aged 50 years and over (n=10 415). OA was defined by primary care consultation and moderate-to-severe pain interference in daily life. A Cox proportional hazards analysis determined the total effect (TE) of OA on mortality after adjustment for potential confounders. Within the Cox model, path analysis was used to decompose the TE to assess the indirect and direct effects for selected potential mediators (anxiety, depression, unrefreshed sleep and walking frequency). Results are expressed as HRs with 95% CIs derived from bootstrap resampling.

Results

OA was significantly associated with mortality (TE-adjusted HR 1.14; 95% CI 1.00 to 1.29). The indirect effects for walking frequency were 1.05 (95% CI 1.04 to 1.06), depression 1.02 (95% CI 1.02 to 1.03), anxiety 1.01 (95% CI 1.00 to 1.02) and unrefreshed sleep 1.01 (95% CI 1.00 to 1.01).

Conclusions

The analysis indicates that encouraging people to walk and ‘get out and about’ in addition to targeting OA could be protective against excessive mortality. The findings also suggest that depression, anxiety and unrefreshed sleep have a role in premature mortality for people with OA; however, this has low clinical significance.

Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With Osteoarthritis: The FORWARD Randomized Clinical Trial

IMPORTANCE

Sprifermin is under investigation as a disease-modifying osteoarthritis drug.

OBJECTIVE

To evaluate the effects of sprifermin on changes in total femorotibial joint cartilage thickness in the more symptomatic knee of patients with osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) was a 5-year, dose-finding, multicenter randomized clinical trial conducted at 10 sites. Eligible participants were aged 40 to 85 years with symptomatic, radiographic knee osteoarthritis and Kellgren-Lawrence grade 2 or 3. Enrollment began in July 2013 and ended in May 2014; the last participant visit occurred on May 8, 2017. The primary outcome at 2 years and a follow-up analysis at 3 years are reported.

INTERVENTIONS

Participants were randomized to 1 of 5 groups: intra-articular injections of 100 μg of sprifermin administered every 6 months (n = 110) or every 12 months (n = 110), 30 μg of sprifermin every 6 months (n = 111) or every 12 months (n = 110), or placebo every 6 months (n = 108). Each treatment consisted of weekly injections over 3 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was change in total femorotibial joint cartilage thickness measured by quantitative magnetic resonance imaging at 2 years. The secondary end points (of 15 total) included 2-year change from baseline in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The minimal clinically important difference (MCID) is unknown for the primary outcome; for total WOMAC score in patients with hip and knee osteoarthritis, the absolute MCID is 7 U (95% CI, 4 to 10 U) and the percentage MCID is 14% (95% CI, 9% to 18%).

RESULTS

Among 549 participants (median age, 65.0 years; 379 female [69.0%]), 474 (86.3%) completed 2-year follow-up. Compared with placebo, the changes from baseline to 2 years in total femorotibial joint cartilage thickness were 0.05 mm (95% CI, 0.03 to 0.07 mm) for 100 μg of sprifermin administered every 6 months; 0.04 mm (95% CI, 0.02 to 0.06 mm) for 100 μg of sprifermin every 12 months; 0.02 mm (95% CI, -0.01 to 0.04 mm) for 30 μg of sprifermin every 6 months; and 0.01 mm (95% CI, -0.01 to 0.03 mm) for 30 μg of sprifermin every 12 months. Compared with placebo, there were no statistically significant differences in mean absolute change from baseline in total WOMAC scores for 100 μg of sprifermin administered every 6 months or every 12 months, or for 30 μg of sprifermin every 6 months or every 12 months. The most frequently reported treatment-emergent adverse event was arthralgia (placebo: n = 46 [43.0%]; 100 μg of sprifermin administered every 6 months: n = 45 [41.3%]; 100 μg of sprifermin every 12 months: n = 50 [45.0%]; 30 μg of sprifermin every 6 months: n = 40 [36.0%]; and 30 μg of sprifermin every 12 months: n = 48 [44.0%]).

CONCLUSIONS AND RELEVANCE

Among participants with symptomatic radiographic knee osteoarthritis, the intra-articular administration of 100 μg of sprifermin every 6 or 12 months vs placebo resulted in an improvement in total femorotibial joint cartilage thickness after 2 years that was statistically significant, but of uncertain clinical importance; there was no significant difference for 30 μg of sprifermin every 6 or 12 months vs placebo. Durability of response also was uncertain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01919164.

Association of osteoarthritis and pain with Alzheimer's Diseases and Related Dementias among older adults in the United States

BACKGROUND

Emerging evidence suggests that Pain Interference (PI) and certain chronic pain conditions, including Osteoarthritis (OA) may be associated with risk for Alzheimer's disease and Related Dementias (ADRD). However, research exploring the relation of OA and PI to ADRD remains sparse.

OBJECTIVE

To assess the association of OA and PI to ADRD using cross-sectional data from a representative sample of USA adults aged ≥65 years.

DESIGN

Retrospective cross-sectional.

STUDY SAMPLE

Older adults (age ≥ 65 years) drawn from the Medical Expenditure Panel Survey (MEPS, 2009-2015).

METHODS

OA was identified using both medical conditions files and participant responses to arthritis-specific queries. ADRD was ascertained using the medical conditions files. PI was defined as reported frequent PI with normal activities (PIA). OA and PIA were categorized as a composite variable: 1) OA with PIA; 2) OA without PIA; 3) No OA with PIA; and 4) No OA and no PIA (reference group). Adjusted associations of OA and PIA to ADRD were assessed using logistic regression and adjusted for biological, demographic, socio-economic, lifestyle, and health conditions.

RESULTS

Overall, 27.1% had OA, of whom 47.6 % reported PIA vs 31.1% of those without OA; 2.8% had diagnosed ADRD. Adults with PIA either with or without OA had significantly higher odds of ADRD relative to those without OA or PIA (Adjusted odd ratios (AOR's) = 1.37, 95%CI - 1.01, 1.86 (p = 0.04) and 1.44, 95%CI - 1.13, 1.82 (p = 0.003), respectively).

CONCLUSION

PIA in both the presence and absence of OA remained significantly and positively associated with ADRD after adjustment for multiple confounders.

Exploring Cerebrovascular Function in Osteoarthritis: "Heads-up"

Individuals with osteoarthritis (OA) are at greater risk of cardiovascular and cerebrovascular incidents; yet, cerebrovascular control remains uncharacterized. Our primary outcome was to acquire cerebrovascular control metrics in patients with OA and compare measures to healthy control adults (CTL) without OA or cardiovascular complications. Our primary covariate was a 10-year risk factor for cardiovascular and stroke incidents, and secondary covariates were other cardiovascular disease risk factors (i.e., body mass index, carotid intima media thickness, and brachial flow-mediated dilation). Our secondary outcomes were to assess anatomical and functional changes that may be related to cerebrovascular reactivity were also acquired such as white matter lesion volume and brief cognitive assessments. In 25 adults (n = 13 CTL, n = 12 OA), under hypercapnia, magnetic resonance imaging (3T) was used to acquire a "Global Cerebrovascular Reactivity" index across the larger intracranial cerebral arteries and white matter lesions, and transcranial Doppler was used for both middle cerebral artery hemodynamic responses to hypercapnia and to assess autoregulation via a sit-to-stand task. Compared to CTL, OA had lower "Global Cerebrovascular Reactivity" index responses to hypercapnia, autoregulatory responses, and greater white matter lesions (P < 0.05). These differences persisted after covarying for the outlined primary and secondary covariates. Patients with OA, in the absence of known cardiovascular disease, can exhibit pre-clinical and impaired (compared to CTL) peripheral and cerebrovascular control metrics.

Geographical and ethnic differences of osteoarthritis-associated hip and knee replacement surgeries in New Zealand: a population-based cross-sectional study

OBJECTIVES

To (1) explore the regional and ethnic differences in rates of publicly funded osteoarthritis-associated hip and knee replacement surgeries and (2) investigate the mortality after surgery.

DESIGN

Population-based, retrospective, cross-sectional study.

SETTING

General population in New Zealand.

PARTICIPANTS

Patients with osteoarthritis who underwent publicly funded primary hip and knee replacement surgeries in 2005-2017. Patients aged 14-99 years were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Age-standardised rate, standardised mortality ratio (SMR) and 30 days, 90 days and 1 year mortality.

RESULTS

We identified 53 439 primary hip replacements and 50 072 primary knee replacements with a diagnosis of osteoarthritis. The number and age-standardised rates of hip and knee replacements increased over time. Māori had the highest age-standardised rate of hip replacements, followed by European/others and Pacific, and Asian had the lowest rate. Pacific had the highest age-standardised rate of knee replacements, followed by Māori and European/others, and Asian had the lowest rate. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. The SMRs of patients undergoing hip and knee replacements were lower than the general population: 0.92 (95% CI 0.89 to 0.95) for hip and 0.79 (95% CI 0.76 to 0.82) for knee. The SMRs were decreasing over time. The patterns of 30 days, 90 days and 1 year mortality were similar to the SMR.

CONCLUSIONS

The numbers of publicly funded osteoarthritis-associated primary hip and knee replacements are steadily increasing. Māori people had the highest age-standardised rate of hip replacements and Pacific people had the highest rate of knee replacements. The Northern Health Network had the lowest rate of hip surgeries, and the Southern Health Network had the lowest rate of knee surgeries. Compared with the general population, patients who had hip and knee replacements have a better life expectancy.

Knee and hip osteoarthritis as predictors of premature death: a review of the evidence

Rheumatic and musculoskeletal diseases (RMDs) are common, with osteoarthritis (OA) being the most prevalent. RMDs, including OA, are associated with significant pain and functional limitations, as well as mortality rates up to 1.6-fold higher than in the general population. Most studies of OA and mortality have focused on knee and hip OA. Some, but not all, of these studies suggest an increased risk of death, however risks may differ by region. Reasons for discordant findings may be due to methodological considerations including definition of OA, study design, length of follow-up, and whether variables that can change and develop over time, such as measures of OA, body mass index (BMI) and comorbidities, were re-assessed during the follow-up period. Research has shown that the prognosis of OA is similar to that seen in rheumatoid arthritis (RA) patients, in many respects. In RA, disability and comorbidities are the most important predictors of mortality, although pain may be more prominent in the prognosis of OA mortality. The data suggest that addressing functional limitations and pain seen with OA could potentially reduce the increased mortality that has been observed in these individuals. Further study is needed concerning the potential excess mortality attributable to lower body OA, as well as associated disability, pain and comorbidities.

Causal Factors for Knee, Hip, and Hand Osteoarthritis: A Mendelian Randomization Study in the UK Biobank

OBJECTIVE

There is no curative treatment for osteoarthritis (OA), which is the most common form of arthritis. This study was undertaken to identify causal risk factors of knee, hip, and hand OA.

METHODS

Individual-level data from 384,838 unrelated participants in the UK Biobank study were analyzed. Mendelian randomization (MR) analyses were performed to test for causality for body mass index (BMI), bone mineral density (BMD), serum high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride levels, type 2 diabetes, systolic blood pressure (BP), and C-reactive protein (CRP) levels. The primary outcome measure was OA determined using hospital diagnoses (all sites, n = 48,431; knee, n = 19,727; hip, n = 11,875; hand, n = 2,330). Odds ratios (ORs) with 95% confidence intervals (95% CIs) were calculated.

RESULTS

MR analyses demonstrated a robust causal association of genetically determined BMI with all OA (OR per SD increase 1.57 [95% CI 1.44-1.71]), and with knee OA and hip OA, but not with hand OA. Increased genetically determined femoral neck BMD was causally associated with all OA (OR per SD increase 1.14 [95% CI 1.06-1.22]), knee OA, and hip OA. Low systolic BP was causally associated with all OA (OR per SD decrease 1.55 [95% CI 1.29-1.87]), knee OA, and hip OA. There was no evidence of causality for the other tested metabolic factors or CRP level.

CONCLUSION

Our findings indicate that BMI exerts a major causal effect on the risk of OA at weight-bearing joints, but not at the hand. Evidence of causality of all OA, knee OA, and hip OA was also observed for high femoral neck BMD and low systolic BP. However, we found no evidence of causality for other metabolic factors or CRP level.

Vitamin K as a Powerful Micronutrient in Aging and Age-Related Diseases: Pros and Cons from Clinical Studies

Vitamin K is a multifunctional micronutrient implicated in age-related diseases such as cardiovascular diseases, osteoarthritis and osteoporosis. Although vitamin K-dependent proteins (VKDPs) are described to have a crucial role in the pathogenesis of these diseases, novel roles have emerged for vitamin K, independently of its role in VKDPs carboxylation. Vitamin K has been shown to act as an anti-inflammatory by suppressing nuclear factor κB (NF-κB) signal transduction and to exert a protective effect against oxidative stress by blocking the generation of reactive oxygen species. Available clinical evidences indicate that a high vitamin K status can exert a protective role in the inflammatory and mineralization processes associated with the onset and progression of age-related diseases. Also, vitamin K involvement as a protective super-micronutrient in aging and ‘inflammaging’ is arising, highlighting its future use in clinical practice. In this review we summarize current knowledge regarding clinical data on vitamin K in skeletal and cardiovascular health, and discuss the potential of vitamin K supplementation as a health benefit. We describe the clinical evidence and explore molecular aspects of vitamin K protective role in aging and age-related diseases, and its involvement as a modulator in the interplay between pathological calcification and inflammation processes.

The Validity of All-Cause 30-Day Readmission Rate as a Hospital Performance Metric After Primary Total Hip and Knee Arthroplasty: A Systematic Review

BACKGROUND

Risk-adjusted all-cause 30-day readmission rate (ACRR) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is currently used as a metric of hospital performance as part of the Hospital Readmissions Reduction Program. However, the extent to which it is determined by hospital-related factors and is therefore a fair method of determining reimbursement remains unclear.

METHODS

Our aim was to systematically review the available literature pertaining to whether ACRR is a valid metric of hospital performance after elective primary THA or TKA as determined by (1) its association with other performance metrics, (2) the extent to which variation in ACRR can be explained by between-hospital variation, and (3) the relative importance of hospital-related versus surgeon- or patient-related factors in determining ACRR. The MEDLINE, EMBASE, and Health Management Information Consortium databases were searched from inception to November 2018 and reference lists of selected articles scanned. The final list of articles was determined by consensus.

RESULTS

Eight articles were included. Correlation of ACRR with established composite metrics of both outcome and process measures was poor. There was a weak positive correlation between ACRR and mortality. Only 1.5% of the variation in readmission rates for THA and TKA was found to be attributable to hospital-level factors, with patient-related factors such as age and comorbidities having much greater influence. Use of composite outcome metrics, for example, combining readmission and mortality, or considering the "surgical" readmission rate, improved the sensitivity to detect important between-hospital variation.

CONCLUSION

There is insufficient evidence in the current literature to justify the use of ACRR following elective THA and TKA for financially penalizing hospitals. Further work is needed to define what is acceptable variation. The use of a composite metric or surgical readmission rate may improve the ability to detect between-hospital variation.

When You Can't Walk a Mile: Walking Limitation Prevalence and Associations Among Middle-Aged and Older US Adults with Arthritis: A Cross-Sectional, Population-Based Study

OBJECTIVE

We examined walking limitations and associated characteristics among middle-aged and older US adults with arthritis, overall, and by sex.

METHODS

Using 2005-2006 Arthritis Conditions and Health Effects Survey (ACHES) data (n = 1793), we estimated "a lot" and "any" ("a lot" or "a little" combined) walking limitation for more than 1 mile (1.6 km) among US adults 45 years or older with arthritis and examined associations (sociodemographics, arthritis symptoms and effects, psychosocial measures, and physical health) with walking limitations in unadjusted and multivariable (MV) adjusted logistic regression models using prevalence ratios (PRs) and 95% confidence intervals, accounting for the complex survey design.

RESULTS

Respondents frequently reported "a lot" (48%) and "any" (72%) limitation for more than 1 mile. Women reported higher prevalence of all levels of walking limitation versus men (eg, 51% vs 42% for "a lot" overall); additionally, the gap for walking limitations between women and men widened with age. Limitation was high for both sexes at all ages, affecting 1-in-3 to 4-in-5, depending on level of walking limitation. The strongest MV associations for "a lot" of walking limitation among all respondents included substantial and modest arthritis-attributable life interference (PR = 2.5 and 1.6, respectively), age 75 years or older (PR = 1.5), and physical inactivity and fair/poor self-rated health (PR = 1.4 for both).

CONCLUSION

Walking limitations among middle-aged and older adults are substantial. Existing proven interventions that improve walking ability and physical function may help this population to reduce and delay disability.

The protective role of microRNA-140-5p in synovial injury of rats with knee osteoarthritis via inactivating the TLR4/Myd88/NF-κB signaling pathway

Objective: Recently, many studies have revealed the effect of microRNAs (miRNAs) in knee osteoarthritis (KOA). This study aims to explore the role of miR-140-5p in protective effects and mechanisms of synovial injury of rats with KOA via regulating the TLR4/Myd88/NF-κB signaling pathway.

Methods: The models of KOA Wistar rats were established by operation of anterior cruciate ligament transection. Rats were injected with agomir NC or miR-140-5p agomir. MiR-140-5p expression in KOA synovial tissues and synoviocytes was evaluated by reverse transcription quantitative polymerase chain reaction (RT-qPCR). The synoviocytes were transfected with mimics NC sequence and miR-140-5p mimics sequence. The expression of TLR4/Myd88/NF-κB signaling pathway-related proteins was measured by RT-qPCR and western blot analysis. The proliferation and apoptosis of synoviocytes in rats with KOA were evaluated by a string of experiments. The expression levels of inflammatory factors in KOA synovial tissues and synoviocytes were detected.

Results: MiR-140-5p was down-regulated in KOA synovial tissues and synoviocytes. Upregulation of miR-140-5p could inhibit the inflammation reaction and the apoptosis of synoviocytes as well as promote proliferation of synoviocytes of rats with KOA. Furthermore, upregulated miR-140-5p could inactivate the TLR4/Myd88/NF-κB signaling pathway in rats with KOA.

Conclusion: This study suggests that upregulated miR-140-5p could protect synovial injury by restraining inflammation reaction and apoptosis of synoviocytes in KOA rats via TLR4/Myd88/NF-κB signaling pathway inactivation.

Cost-effectiveness and budget impact analysis of viscosupplementation with hylan G-F 20 for knee and hip osteoarthritis

Purpose

To estimate the cost-effectiveness and budget impact of viscosupplementation with one intra-articular (IA) injection of 6 mL hylan G-F 20 (Synvisc-One^®) and with three injections of 2 mL hylan G-F 20 (Synvisc^®3×2) in knee osteoarthritis (OA) patients compared with conventional support therapy (CST - eg, NSAIDs and acetaminophen) and the cost-effectiveness of one IA injection of 2 mL hylan G-F 20 (Synvisc^®1×2) in hip OA patients compared with CST from an Italian Health System perspective.

Methods

The model used was a Markov model with states for stages II-IV on the Kellgren-Lawrence scale and runs on 6-month cycles over a 5-year time horizon. A 3.5% discount was applied to both costs and utilities. Direct costs were determined from the perspective of the Italian National Health Service. A one-way and probabilistic sensitivity analysis was conducted for both comparisons.

Results

Hylan G-F 20 1×6 mL and hylan G-F 20 3×2 mL for knee OA were very likely to be cost-effective when compared to acetaminophen (ICER = €3,160.61 and €3,845.81 per QALY, respectively) and NSAIDs as both ICERs are below €25,000. The hip OA treatment by hylan G-F 20 1×2 mL was dominant compared to NSAIDs and very likely compared to acetaminophen. The results of the cost-effectiveness analysis were confirmed by one-way sensitivity analysis. The budget impact analysis for knee and hip OA showed a small increase in expenditure during 5 years.

Conclusions

Hylan G-F 20 1×6 mL/hylan G-F 20 is a cost-effectiveness treatment compared to NSAIDs and acetaminophen in the treatment of knee/hip OA in Italy. The treatment of hip and knee OA resulted in cost-saving with hylan G-F 20 1×2 mL and economically sustainable with hylan G-F 20 1×6 mL. However, Real Word Evidence studies should be conducted in order to estimate costs associated with both prosthetics and to understand the reduction of physiotherapy and medication due to hylan G-F 20.

Physiotherapist as primary assessor for patients with suspected knee osteoarthritis in primary care-a randomised controlled pragmatic study

Background

In Swedish primary care, the healthcare process for patients with knee osteoarthritis (KOA) can be initiated by a physician or physiotherapist assessment. However, it is unclear how the different assessments affect the healthcare processes and patient reported outcomes over time. The purpose of this study was to examine the differences in health-related quality of life (HrQoL), adjusted for pain and physical function, for patients with KOA when the healthcare process is initiated by a physiotherapist assessment compared to a physician assessment in primary care.

Methods

An assessor-blinded randomised controlled pragmatic trial. Using a computer-generated list of random numbers, patients seeking primary care during 2013–2017 with suspected KOA were randomised to either a physiotherapist or physician for primary assessment and treatment. Data was collected before randomisation and at 3, 6, and 12-month follow-ups. Primary outcome was HrQoL using EuroQol 5 dimensions 3 levels questionnaire, index (EQ-5D-3L index) and a visual analogue scale (VAS) (EQ-5D-3L VAS); pain intensity was measured with VAS (0–100) and physical function measured with the 30-s chair stand test. Mixed effect model analyses compared repeated measures of HrQoL between groups. The significance level was p < 0.05 and data was applied with intention-to-treat.

Results

Patients were randomised to either a physiotherapist (n = 35) or physician (n = 34) for primary assessment. All 69 patients were included in the analyses. There were no significant differences in HrQoL for patients assessed by a physiotherapist or a physician as primary assessor (EQ-5D-3L index, p = 0.18; EQ-5D-3L VAS, p = 0.49). We found that HrQoL changed significantly 12 months after baseline assessment for all patients regardless of assessor (EQ-5D-3L index, p < 0.001; EQ-5D-3 L VAS, p = 0.0049). No adverse events or side effects were reported.

Conclusions

There were no differences in HrQoL, when adjusted for pain and physical function, for patients with KOA when the healthcare process was initiated with physiotherapist assessment compared to physician assessment in primary care. Both assessments resulted in significantly higher HrQoL at the 12-month follow-up. The results imply that physiotherapists and physicians in primary care are equally qualified as primary assessors.

Trial registration

Retrospectively registered at http://clinicaltrial.gov, ID: NCT03715764.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2690-1) contains supplementary material, which is available to authorized users.

Disease Burden in Osteoarthritis Is Similar to That of Rheumatoid Arthritis at Initial Rheumatology Visit and Significantly Greater Six Months Later

OBJECTIVE

To analyze disease burden in osteoarthritis (OA) according to Multidimensional Health Assessment Questionnaire (MDHAQ)/Routine Assessment of Patient Index Data 3 (RAPID3) scores at the initial visit and the 6-month follow-up visit, compared with rheumatoid arthritis (RA) as a benchmark for high disease burden.

METHODS

All patients with all diagnoses at the Rush University Medical Center Division of Rheumatology complete a paper MDHAQ at all visits, saved as a PDF in the electronic health record. MDHAQ 0-10 scores for physical function, pain, and patient global assessment (compiled into RAPID3 0-30 scores) and additional scales at the initial and 6-month follow-up visits, for new OA and RA patients seen from 2011 to 2017, were compared. OA and RA patients were classified as self-referred or physician-referred, and RA patients were classified as disease-modifying antirheumatic drug (DMARD)-naive or having prior-DMARD treatment. Patient groups were compared using t-tests and analysis of variance, adjusted for age, disease duration, body mass index (BMI), education, and ethnicity.

RESULTS

Compared with RA patients, OA patients had higher age, BMI, and disease duration. At initial visit, the mean RAPID3 did not differ significantly in OA versus DMARD-naive RA patients, whether self- or physician-referred (range 14.8-16.4 [P = 0.38]), or in all OA patients versus DMARD-naive RA patients versus prior-DMARD RA patients (15.0, 15.7, and 15.8, respectively [P = 0.49]). After 6 months, RAPID3 was improved to 13.3, 10.3, and 10.8, respectively, which represented substantially greater improvement in RA patients than OA patients (P < 0.001). Similar results were seen for most self-reported measures and in adjusted analyses.

CONCLUSION

MDHAQ/RAPID3 scores are similar in OA and RA patients at the initial visit, but higher in OA patients than in RA patients 6 months later, reflecting superior RA treatments. The same MDHAQ/RAPID3 allows comparisons of disease burdens in different diseases.

Gait- and postural-alignment-related prognostic factors for hip and knee osteoarthritis: Toward the prevention of osteoarthritis progression

Osteoarthritis (OA) is a chronic progressive disease, and thus, prevention of this progression is an important issue. Currently, there is little evidence of the effect of exercise therapy for the prevention of hip and knee OA progression. An understanding of prognostic factors is the basis for the prevention of progression. Previous research indicates that in case of knee OA, abnormalities in knee alignment (varus or valgus) while standing, varus thrust during walking, increased knee flexion in the early stance phase, abnormal displacement of the femur in relation to the tibia, and an increase in knee adduction and flexion moment are risk factors for disease progression. At the same time, the prognostic factors in hip OA are anterior spinal inclination while standing, decreased mobility of the thoracolumbar spine, and increased cumulative hip loading during daily walking. Further research is required to investigate these prognostic factors, particularly the modifiable factors, to analyze the relationships between these factors, and to verify the structural and clinical efficacy of modifying these factors through interventions.

Osteoarthritis and risk of mortality in the USA: a population-based cohort study

Background

Osteoarthritis (OA) is the most common joint disease, but its association with mortality is unclear.

Methods

We analysed data on adult participants in the 1988–94 and 1999–2010 National Health and Nutrition Examination Surveys, followed for mortality through 2011. OA was defined by self-report, and in a subset of participants 60 years or older with knee X-rays, radiographic knee OA (RKOA) was defined as Kellgren–Lawrence score ≥2. Cox proportional hazards were used to determine the mortality hazard ratio (HR) associated with self-reported OA and RKOA, adjusting for covariates.

Results

The sample included 51 938 participants followed for a median 8.9 years; 2589 of them had knee X-rays and were followed for a median of 13.6 years. Self-reported OA and RKOA prevalences were 6.6% and 40.6%, respectively. Self-reported OA was not associated with mortality. RKOA was associated with an increased risk of mortality from cardiovascular diseases (CVD) {HR 1.43 [95% confidence interval (CI): 1.32, 1.64]}, diabetes [HR 2.04 (1.87, 2.23)] and renal diseases [HR 1.14 (1.04, 1.25)], but with a reduced risk of cancer mortality [HR 0.88 (0.80, 0.96)]. Participants with early RKOA onset (diagnosed before age 40) had a higher risk of mortality from all causes [HR 1.53 (1.43, 1.65)] and from diabetes [HR 7.18 (5.45, 9.45)]. Obese participants with RKOA were at increased risk of mortality from CVD [HR 1.89 (1.56, 2.29)] and from diabetes [HR: 3.42 (3.01, 3.88)].

Conclusions

Self-reported OA was not associated with mortality. RKOA was associated with higher CVD, diabetes and renal mortality, especially in people with early onset of the disease or with obesity.

The Validity, Reliability, Measurement Error, and Minimum Detectable Change of the 30-Second Fast-Paced Walk Test in Persons with Knee Osteoarthritis: A Novel Test of Short-Distance Walking Ability

Objective

To develop and establish the reliability, validity, measurement error, and minimum detectable change of a novel 30‐second fast‐paced walk test (30SFW) in persons with knee osteoarthritis (OA) that is easy to administer and can quantify walking performance in persons of all abilities.

Methods

Twenty females with symptomatic knee OA (mean age [SD] 58.30 [8.05] years) and 20 age‐ and sex‐matched asymptomatic controls (57.25 [8.71] years) participated in the study. Participants completed questionnaires of demographic and clinical data, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and the 36‐item Short Form Health Survey (SF‐36) followed by 30SFW performance. Participants returned 2‐7 days later and performed the 30SFW again.

Results

The knee OA group reported function that was worse than controls (all KOOS subscales; P < 0.0001). The 30SFW intrarater and interrater reliability were excellent [ICC_(2,1) = 0.95‐0.99]. Knee OA participants walked a shorter distance in the 30SFW than controls (mean [SD]: OA 44.4 m [9.5 m]; control 58.1 m [7.8 m]; P < 0.0001). Positive strong correlations were found between the 30SFW and the KOOS–Activity of Daily Living, SF‐36‐Physical Functioning, and SF‐36‐Physical Health Composite scores (P < 0.0001). A nonsignificant, weak correlation between 30SFW and SF‐36‐Mental Health scores was present (r = 0.32, P = 0.05).

Conclusion

The 30SFW has excellent intrarater and interrater reliability. The 30SFW demonstrated excellent known groups, convergent, and discriminant validity as a measure of short‐distance walking ability in persons with knee OA. Clinicians and researchers should consider using the 30SFW to quantify walking ability in persons with knee OA and assess walking ability change.

How Does Mortality Risk Change Over Time After Hip and Knee Arthroplasty?

BACKGROUND

Mortality after THA and TKA is lower than expected for several years after surgery when compared with age- and sex-adjusted population data. With long-term followup (beyond approximately 10 years), some evidence has suggested that this trend reverses, such that postsurgical mortality is higher than expected as more time passes. However, the degree to which this may be the case has not been clearly established.

QUESTIONS/PURPOSES

In this large-registry study, we asked: What is the long-term mortality after THA and TKA compared with the expected mortality, adjusted for age, sex, and calendar year.

METHODS

Using data on 243,057 THAs and 363,355 TKAs performed for osteoarthritis from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 2003 to 2016, and life tables from the Australian Bureau of Statistics the Standardised Mortality Ratio (SMR), relative mortality and excess mortality (relative to the expected mortality for people of the same sex and age in the same country) was calculated separately for hips and knees. The AOANJRR contains near-complete (98%-100%) data from all hospitals in Australia performing arthroplasty but does not include followup data on people who have left the country. Followup was from the date of surgery to 13 years, mean 5.8 years.

RESULTS

We found a lower-than-expected mortality for THA and TKA in the early years after surgery. This association diminished over time and the mortality became higher than expected after 12 years for both THA and TKA. For THA, the excess mortality (per thousand people) increased from 11 fewer deaths (95% CI, 10-11 fewer) after 1 year to four more deaths (95% CI, 0-9 more) in the 13th year, and the SMR increased from 0.50 (95% CI, 0.48-0.52) after 1 year to 1.07 (95% CI, 0.99-1.14) in the 13th year. For TKA, the excess mortality (per thousand people) increased from 12 fewer deaths (95% CI, 12-13 fewer) after 1 year to five more deaths (95% CI 2-9 more) in the 13th year, and the SMR increased from 0.39 (95% CI, 0.37-0.40) after 1 year to 1.09 (95% CI, 1.03-1.15) in the 13th year.

CONCLUSIONS

Mortality after hip and knee arthroplasty is lower than expected (based on population norms) in the first 8 years to 9 years but gradually increases over time, becoming higher than expected after 12 years. The lower-than-expected mortality in the early years after surgery is likely the result of patient selection with patients undergoing primary arthroplasty having better health at the time of surgery than that of the age- and sex-matched population. The increasing mortality over time cannot be regression to the mean, as late mortality is higher than expected, moving beyond the mean. It is important to understand if there are modifiable factors associated with this increased mortality. The reasons for the change are uncertain. Factors to consider in future research include determining the effect of different patient factors on late mortality. Some of these included higher obesity rates for joint replacement patients and the association or causal impact of osteoarthritis and/or its treatment to increase late mortality in a similar manner to other forms of arthritis. There is also a possibility that the arthroplasty device itself may affect late mortality.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Cause-specific mortality in osteoarthritis of peripheral joints

PURPOSE

To estimate cause-specific mortality in osteoarthritis patients compared to the general population.

METHODS

We identified all residents in southern Sweden aged 45-84 years in 2003. Through the Skåne Healthcare Register (SHR) we identified those diagnosed with osteoarthritis in peripheral joints between 1998 and 2003. We followed all residents from 2004 until relocation outside of the region, death, or end of 2014. We classified the underlying cause of death from death certificates into: cardiovascular and neoplasms, diabetes, infections, dementia, diseases of digestive system, or other causes. For estimation, we used multi-state adjusted Cox proportional hazards models.

RESULTS

We identified 15,901 patients (mean age [SD] 67 years [10], 41% men) with prevalent doctor-diagnosed osteoarthritis in knee, 9347 in hip, 4004 in hand and 5447 in other peripheral joints among 469,177 residents. For most causes of death in osteoarthritis patients, we found no increased mortality, with hazard ratios (HRs) close to 1, similar for men and women. However, for knee and hip osteoarthritis and cardiovascular death, HRs were non proportional and increased to 1.19 (95%CI 1.10, 1.28) and 1.13 (1.03, 1.24) during 9-11 years of follow-up, mostly due to excess mortality from chronic ischemic heart diseases and heart failure.

CONCLUSIONS

The risk of cardiovascular excess deaths increases with duration of knee and hip osteoarthritis. The major contributors are chronic ischemic heart diseases and heart failure. Our results call for improved implementation of osteoarthritis treatment guidelines, with major focus on interventions to address mobility limitations and maintaining or increase physical activity level.

Clinical characteristics and disability in patients with knee osteoarthritis: real world experience from Bulgaria

Objectives

Although knee osteoarthritis (KOA) is a leading cause of impaired functioning among older adults globally, little is still known about the complex mechanisms of disability accumulation in these patients. The aim of the study was to analyze the clinical parameters of patients with KOA in a Bulgarian population and to determine which of these clinical characteristics define disability to the greatest extent.

Material and methods

Patients aged 40–80 years with symptomatic KOA were included. The assessment tools for pain, clinical disease severity, and disability were the pain visual analogue scale (VAS) and disease-specific questionnaires: Algofunctional Index of Lequesne, Western Ontario and McMaster Universities OA Index (WOMAC), and the Health Assessment Questionnaire-Disability Index (HAQ-DI), respectively. Radiographs of the knees were obtained and graded according to the Kellgren-Lawrence (KL) system.

Results

One hundred and thirty-two patients (81% women) participated in the study. The median values of VAS (mm), WOMAC, Lequesne, and HAQ-DI scores were 52, 37.5, 11, 0.88, respectively. Men had milder disease, resulting in lower VAS, WOMAC, Lequesne, and HAQ-DI scores and less structural damage compared to women (p < 0.05). WOMAC index correlated positively with age of the patients but not with duration of the complaints. Patients with severe and very severe pain did not differ in their HAQ-DI, disease severity and KL grading. WOMAC physical function score and Lequesne index were independent predictors for the HAQ-DI in patients with KOA.

Conclusions

Bulgarian patients with KOA had moderate disability which showed a strong relationship with physical function of WOMAC and disease severity. Multiple layers of causality coexist to determine the knee pain in Bulgarian patients with KOA.

Effectiveness of behavioural interventions on physical activity levels after hip or knee joint replacement: a systematic review

Purpose: To evaluate the effect of behavioural interventions on levels of physical activity after hip or knee joint replacement.Materials and methods: A systematic review with meta-analysis of randomised controlled trials to determine the effectiveness of behavioural interventions to increase physical activity levels after hip or knee joint replacement. Six databases were searched. Standardised mean differences (SMD) were calculated. The GRADE approach was used to evaluate the level of evidence of each meta-analysis.Results: From a yield of five trials, physical activity was quantified as active minutes per day, daily energy expenditure and daily steps. There was low to moderate-quality evidence from three meta-analyses with observed positive effects that could not conclude whether behavioural interventions increased physical activity in active minutes per day (SMD = 0.18, 95% CI -0.14, 0.51), daily energy expenditure (SMD = 0.31, 95% CI -0.24, 0.87) or daily steps (MD = 844.7, 95% CI -178.6, 1,868.0).Conclusions: The effectiveness of behavioural interventions to address the low levels of physical activity levels observed after hip or knee joint replacement remains uncertain.Implications for rehabilitationPhysical activity levels after hip or knee joint replacements fail to meet recommended daily activity guidelines, increasing the associated risk of cardiovascular disease and early mortality.Rehabilitation interventions that target behaviour change may have an impact in increasing physical activity levels after hip or knee joint replacement surgery.The optimal type and timing of behavioural interventions to effectively increase physical activity levels in this cohort remains unclear.Rehabilitation professionals are advised to highlight the benefits of meeting physical activity recommendations (150 min of moderate-intensity aerobic physical activity or 75 min of vigorous-intensity aerobic physical activity per week) to people who have undergone hip or knee joint replacement, and that behavioural intervention may support patients to meet these recommendations.

Evaluation of a health trainer–led service for people with knee, hip and back pain

Aims:

Chronic knee, hip and back pain is extremely prevalent. Management guidelines emphasise maintaining physical activity and healthy weight to reduce pain and improve physical and mental wellbeing. Unfortunately, few people receive support to make lifestyle changes. We evaluated whether a health trainer—led ‘joint pain advice’ (JPA) service delivering person-centred lifestyle coaching was feasible, acceptable and effective for people with knee, hip and back pain.

Methods:

Feasibility of delivering a JPA service was assessed by documenting whether the health trainers could deliver JPA and its uptake. Nine health trainers delivered JPA. Participants were offered up to four appointments. At each appointment, health trainers gave people information about their condition, co-developed care plans, suggested self-management strategies and used behavioural change techniques (motivational interviewing, goal-setting and action planning) to increase physical activity and reduce body weight. Pain, function, physical activity and body mass index (BMI) were collected at baseline, 3 weeks, 6 weeks and 6 months. Focus groups captured people’s opinions of the service’s effectiveness, acceptability and usefulness.

Results:

Of the 105 people who enquired about JPA, 85 (81%) used the service, after which their physical activity and function improved, and pain, use of analgesia and BMI decreased. They felt more knowledgeable and better motivated to adopt and maintain healthier behaviours. They attributed these improvements to the JPA service, because of its better consultations and collaborative holistic approach. Only a minority attended all four appointments because they felt they received sufficient advice from the initial appointments. The health trainers gained knowledge and skills to support clients with musculoskeletal conditions.

Conclusions:

Using a holistic, patient-centred approach, health trainers can deliver lifestyle advice to people with chronic knee, hip or back pain safely, effectively and efficiently. The service was popular with recipients and health trainers, and helped people adopt healthier lifestyles that lead to reduced pain and other clinical improvements.

Cardiometabolic Polygenic Risk Scores and Osteoarthritis Outcomes: A Mendelian Randomization Study Using Data From the Malmö Diet and Cancer Study and the UK Biobank

Objective

To investigate the causal role of cardiometabolic risk factors in osteoarthritis (OA) using associated genetic variants.

Methods

We studied 27,691 adults from the Malmö Diet and Cancer Study (MDCS) and replicated novel findings among 376,435 adults from the UK Biobank. Trait‐specific polygenic risk scores for low‐density lipoprotein (LDL) and high‐density lipoprotein (HDL) cholesterol levels, triglyceride levels, body mass index (BMI), fasting plasma glucose (FPG) levels, and systolic blood pressure (BP) were used to test the associations of genetically predicted elevations in each trait with incident OA diagnosis (n = 3,559), OA joint replacement (n = 2,780), or both (total OA; n = 4,226) in Mendelian randomization (MR) analyses in the MDCS, and with self‐reported and/or hospital‐diagnosed OA (n = 65,213) in the UK Biobank. Multivariable MR, MR‐Egger, and weighted median MR were used to adjust for potential pleiotropic biases.

Results

In the MDCS, genetically predicted elevation in LDL cholesterol level was associated with a lower risk of OA diagnosis (odds ratio [OR] 0.83 [95% confidence interval (95% CI) 0.73–0.95] per 1SD increase) and total OA (OR 0.87 [95% CI 0.78–0.98]), which was supported by multivariable MR for OA diagnosis (OR 0.84 [95% CI 0.75–0.95]) and total OA (0.87 [95% CI 0.78–0.97]), and by conventional 2‐sample MR for OA diagnosis (OR 0.86 [95% CI 0.75–0.98]). MR‐Egger indicated no pleiotropic bias. Genetically predicted elevation in BMI was associated with an increased risk of OA diagnosis (OR 1.65 [95% CI 1.14–2.41]), while MR‐Egger indicated pleiotropic bias and a larger association with OA diagnosis (OR 3.25 [1.26–8.39]), OA joint replacement (OR 3.81 [95% CI 1.39–10.4]), and total OA (OR 3.41 [95% CI 1.43–8.15]). No associations were observed between genetically predicted HDL cholesterol level, triglyceride level, FPG level, or systolic BP and OA outcomes. The associations with LDL cholesterol levels were replicated in the UK Biobank (OR 0.95 [95% CI 0.93–0.98]).

Conclusion

Our MR study provides evidence of a causal role of lower LDL cholesterol level and higher BMI in OA.