A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative

Biomechanical-Based Protocol for in vitro Study of Cartilage Response to Cyclic Loading: A Proof-of-Concept in Knee Osteoarthritis

Osteoarthritis (OA) is an evolving disease and a major cause of pain and impaired mobility. A deeper understanding of cartilage metabolism in response to loading is critical to achieve greater insight into OA mechanisms. While physiological joint loading helps maintain cartilage integrity, reduced or excessive loading have catabolic effects. The main scope of this study is to present an original methodology potentially capable to elucidate the effect of cyclic joint loading on cartilage metabolism, to identify mechanisms involved in preventing or slowing down OA progression, and to provide preliminary data on its application. In the proposed protocol, the combination of biomechanical data and medical imaging are integrated with molecular information about chondrocyte mechanotransduction and tissue homeostasis. The protocol appears to be flexible and suitable to analyze human OA knee cartilage explants, with different degrees of degeneration, undergoing ex vivo realistic cyclic joint loading estimated via gait analysis in patients simulating mild activities of daily living. The modulation of molecules involved in cartilage homeostasis, mechanotransduction, inflammation, pain and wound healing can be analyzed in chondrocytes and culture supernatants. A thorough analysis performed with the proposed methodology, combining in vivo functional biomechanical evaluations with ex vivo molecular assessments is expected to provide new insights on the beneficial effects of physiological loading and contribute to the design and optimization of non-pharmacological treatments limiting OA progression.

Strength training in addition to neuromuscular exercise and education in individuals with knee osteoarthritis-the effects on pain and sensitization

BACKGROUND

There is a lack of evidence of the relative effects of different exercise modes on pain sensitization and pain intensity in individuals with knee osteoarthritis (KOA).

METHODS

Ninety individuals with radiographic and symptomatic KOA, ineligible for knee replacement surgery, were randomized to 12 weeks of twice-weekly strength training in addition to neuromuscular exercise and education (ST+NEMEX-EDU) or neuromuscular exercise and education alone (NEMEX-EDU). Outcomes were bilateral, lower-leg, cuff pressure pain- and tolerance thresholds (PPT, PTT), temporal summation (TS), conditioned pain modulation (CPM), self-reported knee pain intensity and number of painful body sites.

RESULTS

After 12 weeks of exercise, we found significant differences in increases in PPT (-5.01 kPa (-8.29 to -1.73, p = .0028)) and PTT (-8.02 kPa (-12.22 to -3.82, p = .0002)) in the KOA leg in favour of ST+NEMEX-EDU. We found no difference in effects between groups on TS, CPM or number of painful body sites. In contrast, there were significantly greater pain-relieving effects on VAS mean knee pain during the last week (-8.4 mm (-16.2 to -0.5, p = .0364) and during function (-16.0 mm (-24.8 to -7.3, p = .0004)) in favour of NEMEX-EDU after 12 weeks of exercise.

CONCLUSION

Additional strength training reduced pain sensitization compared to neuromuscular exercise and education alone, but also attenuated the reduction in pain intensity compared to neuromuscular exercise and education alone. The study provides the first dose- and type-specific insight into the effects of a sustained exercise period on pain sensitization in KOA. Future studies are needed to elucidate the role of different exercise modes.

SIGNIFICANCE

This study is an important step towards better understanding the effects of exercise in pain management of chronic musculoskeletal conditions. We found that strength training in addition to neuromuscular exercise and education compared with neuromuscular exercise and education only had a differential impact on pain sensitization and pain intensity, but also that regardless of the exercise mode, the positive effects on pain sensitization and pain intensity were comparable to the effects of other therapeutic interventions for individuals with knee osteoarthritis.

Targeting Nerve Growth Factor for Pain Management in Osteoarthritis-Clinical Efficacy and Safety

Nerve growth factor (NGF) is a neurotrophin that mediates pain sensitization in pathologic states, including osteoarthritis. In clinical trials, antibodies to NGF reduce pain and improve physical function due to osteoarthritis of the knee or hip and have a long duration of action. Rapidly progressive osteoarthritis is a dose-dependent adverse event with these agents, and additional joint safety signals, such as subchondral insufficiency fractures and increased rates of total joint replacement, are reported. The effects on pain and potential mechanisms behind these joint events both are of considerable importance in the consideration of future use of anti-NGF therapies for osteoarthritis.

Precision Medicine Approach to Develop and Internally Validate Optimal Exercise and Weight-Loss Treatments for Overweight and Obese Adults With Knee Osteoarthritis: Data From a Single-Center Randomized Trial

OBJECTIVE

To apply a precision medicine approach to determine the optimal treatment regime for participants in an exercise (E), dietary weight loss (D), and D + E trial for knee osteoarthritis that would maximize their expected outcomes.

METHODS

Using data from 343 participants of the Intensive Diet and Exercise for Arthritis (IDEA) trial, we applied 24 machine-learning models to develop individualized treatment rules on 7 outcomes: Short Form 36 physical component score, weight loss, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain/function/stiffness scores, compressive force, and interleukin-6 level. The optimal model was selected based on jackknife value function estimates that indicate improvement in the outcomes if future participants follow the estimated decision rule compared to the optimal single, fixed treatment model.

RESULTS

Multiple outcome random forest was the optimal model for the WOMAC outcomes. For the other outcomes, list-based models were optimal. For example, the estimated optimal decision rule for weight loss indicated assigning the D + E intervention to participants with baseline weight not exceeding 109.35 kg and waist circumference above 90.25 cm, and assigning D to all other participants except those with a history of a heart attack. If applied to future participants, the optimal rule for weight loss is estimated to increase average weight loss to 11.2 kg at 18 months, contrasted with 9.8 kg if all participants received D + E (P = 0.01).

CONCLUSION

The precision medicine models supported the overall findings from IDEA that the D + E intervention was optimal for most participants, but there was evidence that a subgroup of participants would likely benefit more from diet alone for 2 outcomes.

Effect of acupotomy in knee osteoarthritis patients: study protocol for a randomized controlled trial

Background

Symptomatic knee osteoarthritis (KOA) is common in China. Pharmacological therapy is not the first recommendation because of its safety issues. Nonpharmacological therapy, such as lifestyle adjustments, weight loss, muscle strengthening, and aerobic exercise programs, is strongly recommended for KOA. However, these approaches may fail due to poor patient compliance. There is a lack of high-quality randomized controlled trials of acupotomy, an effective treatment for KOA. This study was designed to investigate the efficacy of acupotomy in patients with KOA.

Methods

A total of 136 patients will be enrolled at the First Affiliated Hospital of Guangzhou University of Chinese Medicine and assigned to the acupotomy group or sham acupotomy group according to the block randomization scheme. Patients in the acupotomy group will receive 2 sessions of acupotomy for 2 weeks (once a week). Patients in the sham group will receive 2 sessions of sham stimulation for 2 weeks (once a week). All patients will use indomethacin cream externally. The primary outcome will be the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the secondary outcomes will be the visual analog scale (VAS) score, plantar pressure distribution test result, X-ray examination findings, musculoskeletal ultrasound findings, maximum knee circumference, joint mobility, and quality of life. Measurements will be taken at baseline, 1 week after the end of treatment, and at the 3- and 6-month follow-ups.

Discussion

To the best of our knowledge, this will be the first single-blind, sham-controlled study of acupotomy. The outcome assessors will also be blinded. The aim of this work is to demonstrate the efficacy of acupotomy in treating KOA.

Trial registration

Chinese Clinical Trial Registry ChiCTR2000033047. Registered on 18 May 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05247-z.

Knowledge, confidence and learning needs of physiotherapists treating persistent knee pain in Australia and Canada: a mixed-methods study

Aim: To determine the knowledge and confidence of physiotherapists in managing knee osteoarthritis (OA) and patellofemoral pain (PFP); and explore their learning behaviors and preferences related to the management of these knee conditions.Methods: One hundred and sixteen Australian and Canadian Physiotherapists were recruited via social media, e-mail, and an online course. Part 1: Quantitative involved an online survey evaluating knowledge of evidence and confidence in providing treatments for knee OA and PFP. Part 2: Qualitative involved semi-structured interviews with 13 participants exploring current practice and learning needs, that were analyzed using an initial framework structured on interview questions, followed by inductive approach to identify additional themes.Results: Awareness regarding evidence supporting exercise for knee OA and PFP was good (89-96%), and qualitative themes indicated physiotherapists emphasized exercise-therapy and education. Perceived value of passive treatments and surgery varied. Preference for face-to-face workshops to address learning needs, alongside describing time and cost barriers to access them, emerged from qualitative findings. Online learning formats were viewed as convenient, but not as effective as face-to-face learning.Conclusion: Knowledge and confidence related to interventions for knee OA and PFP of Australian and Canadian physiotherapist participants broadly aligns with guidelines. Knowledge translation strategies focused on face-to-face workshops, supported by online education may help to bridge evidence-to-practice gaps.

Healthy Aging-Nutrition Matters: Start Early and Screen Often

The amount of time spent in poor health at the end of life is increasing. This narrative review summarizes consistent evidence indicating that healthy dietary patterns and maintenance of a healthy weight in the years leading to old age are associated with broad prevention of all the archetypal diseases and impairments associated with aging including: noncommunicable diseases, sarcopenia, cognitive decline and dementia, osteoporosis, age-related macular degeneration, diabetic retinopathy, hearing loss, obstructive sleep apnea, urinary incontinence, and constipation. In addition, randomized clinical trials show that disease-specific nutrition interventions can attenuate progression-and in some cases effectively treat-many established aging-associated conditions. However, middle-aged and older adults are vulnerable to unhealthy dietary patterns, and typically consume diets with inadequate servings of healthy food groups and essential nutrients, along with an abundance of energy-dense but nutrient-weak foods that contribute to obesity. However, based on menu examples, diets that are nutrient-dense, plant-based, and with a moderately low glycemic load are better equipped to meet the nutritional needs of many older adults than current recommendations in US Dietary Guidelines. These summary findings indicate that healthy nutrition is more important for healthy aging than generally recognized. Improved public health messaging about nutrition and aging, combined with routine screening and medical referrals for age-related conditions that can be treated with a nutrition prescription, should form core components of a national nutrition roadmap to reduce the epidemic of unhealthy aging.

Assessing the feasibility of using the short physical performance battery to measure function in the immediate postoperative period after total knee replacement

Measurements of physical function after total knee arthroplasty (TKA) are uncertain and require investments for special equipment, space, and staff. Therefore, we evaluated the Short Physical Performance Battery (SPPB) 4 to 6 weeks preoperatively and 2 weeks following TKA as this test battery addresses lower extremity strength, coordination, and balance, without additional special investments. For context, we also employed the Six-Minute Walk test (6MWT) and peak torque knee extension. Our analysis consisted of three women and one man, with average ages of 68.3±3.9 years. Patients showed a decrease in all functional measurements: SPPB (mean change: -4.8±1.9, 44% decrease), 6MWT (-0.37±.21 m/s, 34% decrease), and peak torque (-11.8±8.8°/s, 68% decrease). Our findings suggest the SPPB is feasible and can be integrated easily in daily clinical practice.

Alignment of Physical Activity in Older Couples Affected by Osteoarthritis: Investigation by Accelerometry and Questionnaire

This study examined whether an alignment of physical activity (PA) between osteoarthritis patients and their spouses, which was previously proven by accelerometry, might also be revealed by self-report. The PA of 28 cohabitating couples (58–83 years) was assessed by means of synchronous accelerometry (ActiGraph wGTX3-BT) and compared to their according self-reports in the German Physical Activity, Exercise, and Sport Questionnaire (BSA-F). Both methods were used to quantify the average weekly light PA, moderate to vigorous PA (MVPA), and total PA. Accelerometry revealed no differences in weekly light PA and total PA (p ≥ 0.187) between patients and spouses, whereas the patients’ spouses accumulated significantly more MVPA (p = 0.015). In contrast, the self-report did not reveal any differences between the two groups in terms of PA (p ≥ 0.572). Subsequent correlation analyses indicated that accelerometry data for mild PA and total PA were significantly correlated in couples (r ≥ 0.385, p ≤ 0.024), but MVPA was not (r = 0.257, p = 0.097). The self-reported PA data, on the other hand, did not indicate any significant correlation (r ≤ 0.046, p ≥ 0.409). The presented results give a first indication that an alignment of PA between osteoarthritis patients and their spouses is most likely to be detected by accelerometry, but not by self-report.

Is It Worth Delaying Total Knee Replacement as Late as Possible? A Cost-Effectiveness Analysis Using a Markov Model in the Indian Setting

BACKGROUND

Total knee replacement (TKR) is often delayed in younger patients in an attempt to prolong the longevity of the prosthesis and avoid the risk of revision. But delaying a TKR might compromise the quality of life of young patients who are otherwise active and healthy.

METHODS

We built a Markov decision model to study the simulated clinical course of a 50-year-old patient with severe unilateral knee osteoarthritis who could be either treated with conservative therapies or with a TKR at some point in time. An Indian healthcare payer perspective model was used, and lifetime costs (in Indian rupees), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated.

RESULTS

In the base case scenario, patients who did not receive a TKR had a total lifetime cost of ₹216 709 and accumulated 13.59 QALYS in their lifetime. Those who received a TKR without delay (at age 50) accumulated 16.71 QALYS in their lifetime with an ICER of ₹9789 per QALY. When TKR was delayed, the total QALYs decreased, and ICER increased with each year of delay. But the cumulative risk of revision decreased from 27.4% when TKR was performed at 50 years to 10.0% when TKR was done at 70 years.

CONCLUSION

Our analysis found that TKR is a cost-effective procedure when the healthcare payer is willing to pay at least ₹9789 ($132) per QALY. The results also suggested that an early TKR is preferred to a delayed TKR despite the higher incidence of revisions.

Marine Collagen Hydrolysates Promote Collagen Synthesis, Viability and Proliferation While Downregulating the Synthesis of Pro-Catabolic Markers in Human Articular Chondrocytes

Cartilage is a non-innervated and non-vascularized tissue. It is composed of one main cell type, the chondrocyte, which governs homeostasis within the cartilage tissue, but has low metabolic activity. Articular cartilage undergoes substantial stresses that lead to chondral defects, and inevitably osteoarthritis (OA) due to the low intrinsic repair capacity of cartilage. OA remains an incurable degenerative disease. In this context, several dietary supplements have shown promising results, notably in the relief of OA symptoms. In this study, we investigated the effects of collagen hydrolysates derived from fish skin (Promerim^®30 and Promerim^®60) and fish cartilage (Promerim^®40) on the phenotype and metabolism of human articular chondrocytes (HACs). First, we demonstrated the safety of Promerim^® hydrolysates on HACs cultured in monolayers. Then we showed that, Promerim^® hydrolysates can increase the HAC viability and proliferation, while decreasing HAC SA-β-galactosidase activity. To evaluate the effect of Promerim^® on a more relevant model of culture, HAC were cultured as organoids in the presence of Promerim^® hydrolysates with or without IL-1β to mimic an OA environment. In such conditions, Promerim^® hydrolysates led to a decrease in the transcript levels of some proteases that play a major role in the development of OA, such as Htra1 and metalloproteinase-1. Promerim^® hydrolysates downregulated HtrA1 protein expression. In contrast, the treatment of cartilage organoids with Promerim^® hydrolysates increased the neosynthesis of type I collagen (Promerim^®30, 40 and 60) and type II collagen isoforms (Promerim^®30 and 40), the latter being the major characteristic component of the cartilage extracellular matrix. Altogether, our results demonstrate that the use of Promerim^® hydrolysates hold promise as complementary dietary supplements in combination with the current classical treatments or as a preventive therapy to delay the occurrence of OA in humans.

Exercise as Medicine During the Course of Hip Osteoarthritis

Exercise is now considered medicine in numerous chronic conditions and is essentially without side effects. We hypothesize that exercise is primary, secondary, and tertiary prevention at different stages of hip osteoarthritis (preclinical, mild-moderate, and severe hip osteoarthritis) and after total hip arthroplasty.

Progress in the use of mesenchymal stromal cells for osteoarthritis treatment

LITERATURE REVIEW OF MSCS IN THE TREATMENT OF OSTEOARTHRITIS IN THE PAST FIVE YEARS: Osteoarthritis (OA) is one of the most common chronic joint diseases, with prominent symptoms caused by many factors. However, current medical interventions for OA have resulted in poor clinical outcomes, demonstrating that there are huge unmet medical needs in this area. Cell therapy has opened new avenues of OA treatment. Different sources of mesenchymal stromal cells (MSCs) may have different phenotypes and cellular functions. Pre-clinical and clinical studies have demonstrated the feasibility, safety and efficacy of MSC therapy. Mitogen-activated protein kinase, Wnt and Notch signaling pathways are involved in the chondrogenesis of MSC-mediated treatments. MSCs may also exert effective immunoregulatory and paracrine effects to stimulate tissue repair. Therapy with extracellular vesicles containing cytokines, which are secreted by MSCs, might be a potential treatment for OA.

An exploratory study to investigate the association between age, physical activity, femoral trochlear cartilage thickness and biomarkers of tissue metabolism in adult males

Purpose

To investigate the association between age, physical activity, femoral trochlear cartilage thickness and biomarkers of tissue metabolism in a cross-sectional sample of adult males. This study utilizes several emerging biomarkers that have been associated with early joint degenerative changes; serum COMP (cartilage oligomeric matrix protein), HA (hyaluronan) and lubricin.

Methods

Eighty-one males (age: mean (range): 43(18–70) years; body mass index: 25.2 (21.0–30.6) kg/m²) volunteered. Resting serum COMP, HA and lubricin concentrations were determined via commercially available enzyme-linked immunosorbent assay (ELISA) and femoral trochlear cartilage thickness via supra-patellar ultrasound imaging. Physical activity levels were assessed using questionnaires. Statistical analyses were performed using correlation and regression analyses.

Results

Age was correlated with lateral trochlear cartilage thickness (r = − 0.372; p < 0.01) and serum COMP (r = 0.342; p < 0.01). 7-day physical activity was correlated with serum COMP (r = 0.357, p < 0.01), and 12-month physical activity with both lateral trochlear cartilage thickness (r = 0.340, p = 0.01) and serum HA (r = 0.296, p < 0.05). Regression analyses revealed that age significantly accounted for the variability in lateral cartilage thickness and serum COMP, following the adjustment for potential cofounders. However, the association between age and lateral trochlear cartilage thickness was not moderated by physical activity levels (all p > 0.05).

Conclusion

This study indicates that older age may be associated with thinner lateral trochlear cartilage and higher cartilage turnover. Being physically active may also be positive for lateral trochlear cartilage thickness. However, overall, both age and physical activity level only account for a small amount of the variability in cartilage thickness and serum biomarkers.

Recent Developments in Clinical Applications of Mesenchymal Stem Cells in the Treatment of Rheumatoid Arthritis and Osteoarthritis

Mesenchymal stem cell (MSC) therapies have been used as cell-based treatments for decades, owing to their anti-inflammatory, immunomodulatory, and regenerative properties. With high expectations, many ongoing clinical trials are investigating the safety and efficacy of MSC therapies to treat arthritic diseases. Studies on osteoarthritis (OA) have shown positive clinical outcomes, with improved joint function, pain level, and quality of life. In addition, few clinical MSC trials conducted on rheumatoid arthritis (RA) patients have also displayed some optimistic outlook. The largely positive outcomes in clinical trials without severe side effects establish MSCs as promising tools for arthritis treatment. However, further research is required to investigate its applicability in clinical settings. This review discusses the most recent advances in clinical studies on MSC therapies for OA and RA.

Follow-up of a Wuqinxi exercise at home programme to reduce pain and improve function for knee osteoarthritis in older people: a randomised controlled trial

BACKGROUND

Exercise therapy is a key intervention in the management of knee osteoarthritis (KOA) and recommended in international guidelines on KOA management. An effective home-exercise programme for frail older adults with KOA was successful in achieving high adherence. This randomised controlled trial was to compare the adherence to the exercise and lasting effects of follow-up 3 months.

METHODS

Sixty-eight participants in the original Wuqinxi (WQX) exercise study were community dwelling older adults (age = 70.95 ± 9.85 years) with KOA were categorised into 34 controls group, 34 WQX group adherers. The Western Ontario and Mc Master Universities Osteoarthritis Index questionnaire score (WOMAC) pain and Berg Balance Scale, Timed Up and Go Test, 6-min Walk Test, 30-s chair stand test, isokinetic muscle strength testing of knee flexion and extension measured at pre-test and post-test of the intervention period and follow-up for two groups.

RESULTS

The WQX group maintained or improved in all nine measures from post-test to follow-up, whereas the control group significantly declined in WOMAC pain, Knee extensor strength and Knee flexor strength.

CONCLUSION

The WQX programme was an effective home-exercise programme that achieves high adherence in older adults with KOA who lived in these communities.

Many physiotherapists lack preparedness to prescribe physical activity and exercise to people with musculoskeletal pain: A multi-national survey

OBJECTIVES

Determine physiotherapists' (i) awareness of physical activity, and exercise prescription guidelines; (ii) perceived role, knowledge, confidence, skills and training in prescribing and progressing aerobic exercise and resistance training to people with musculoskeletal pain; (iii) professional development preferences; and (iv) perceived influences of external factors on exercise prescription for people with musculoskeletal pain.

DESIGN

Multi-national cross-sectional survey.

METHODS

An open online survey was developed specifically for this study.

RESULTS

1,352 physiotherapists from 56 countries participated. The majority of respondents correctly stated physical activity guidelines for adults (60%) and children (53%), but only 37% correctly stated guidelines for older adults. Eleven percent and 16% could name an accepted guideline for aerobic exercise and resistance training, respectively. Most agreed their role included prescribing aerobic exercise (75%) and resistance training (89%). Fewer reported they had the confidence, training or skills to prescribe aerobic exercise (38-50%) and resistance training (49-70%). Workshops were the most preferred (44%) professional development option. Most respondents believed appointment scheduling and access to equipment and professional development (62-79%) affected their ability to prescribe effective exercise.

CONCLUSION

Many physiotherapists lack knowledge and training to provide physical activity advice, and to prescribe aerobic exercise and resistance training to people with musculoskeletal pain.

Polycaprolactone-Based Scaffolds Facilitates Osteogenic Differentiation of Human Adipose-Derived Stem Cells in a Co-Culture System

(1) Background: Stem cells in combination with scaffolds and bioactive molecules have made significant contributions to the regeneration of damaged bone tissues. A co-culture system can be effective in enhancing the proliferation rate and osteogenic differentiation of the stem cells. Hence, the aim of this study was to investigate the osteogenic differentiation of human adipose derived stem cells when co-cultured with human osteoblasts and seeded on polycaprolactone (PCL):hydroxyapatite (HA) scaffold; (2) Methods: Human adipose-derived stem cells (ASC) and human osteoblasts (HOB) were seeded in three different ratios of 1:2, 1:2 and 2:1 in the PCL-HA scaffolds. The osteogenic differentiation ability was evaluated based on cell morphology, proliferation rate, alkaline phosphatase (ALP) activity, calcium deposition and osteogenic genes expression levels using quantitative RT-PCR; (3) Results: The co-cultured of ASC/HOB in ratio 2:1 seeded on the PCL-HA scaffolds showed the most positive osteogenic differentiation as compared to other groups, which resulted in higher ALP activity, calcium deposition and osteogenic genes expression, particularly Runx, ALP and BSP. These genes indicate that the co-cultured ASC/HOB seeded on PCL-HA was at the early stage of osteogenic development; (4) Conclusions: The combination of co-culture system (ASC/HOB) and PCL-HA scaffolds promote osteogenic differentiation and early bone formation.

Assessing the Quality of Clinical Practice Guidelines in the Middle East and North Africa (MENA) Region: A Systematic Review

AIM

Clinical practice guidelines (CPGs) have progressively become a popular tool for making optimal clinical decisions. The literature shows that the poor quality of CPGs can form a barrier against adhering to them, resulting in a suboptimal level of healthcare. The objective of this systematic review is to evaluate the quality of CPGs in the Middle East and North Africa (MENA) region using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) Instrument.

METHODS

The authors searched in the MEDLINE and EMBASE databases through the Ovid interface on May 25, 2019. Keywords relating to CPGs and MENA countries were combined using Boolean search operators. The search was not limited to specific diseases. The quality of guidelines was appraised by two reviewers independently using the AGREE II Instrument. Discrepancies within a group were resolved through the involvement of a principle investigator.

RESULTS

A total of 61 CPGs were appraised. These guidelines were mainly from Saudi Arabia, and the most covered disease topic was cancer. Among the six domains of the AGREE II Instrument, CPGs scored the highest on clarity of presentation (mean 82%), while the lowest score was granted to the rigor of development domain (mean 28%). This indicates substantial deficiencies in reporting the developmental processes of CPGs and the resources used for the synthesis of evidence.

CONCLUSION

From this review, it was found that the number of retrieved guidelines published in the MENA region is limited considering the large geographical area of the MENA region. The main domains that have higher quality scores were clarity of presentation and scope and purpose, whereas domains with the lowest scores were rigor of development and applicability. The authors' findings will help policymakers identify areas for improvement in CPGs, which can lead them to implement strategies such as the training of individuals and recruitment of international experts to ultimately develop high-quality CPGs.

Impact of COVID-19 'Stay Home, Stay Healthy' Orders on Function among Older Adults Participating in a Community-Based, Behavioral Intervention Study

Background: Early mitigation orders for COVID-19 halted participation in community-based programs. We examined the early impact of “Stay Home, Stay Healthy” orders on functioning in older adults participating in a behavioral intervention study involving community-based exercise. Methods: A quasi-natural experiment, using mixed methods (n = 39). Participants completed interviews and questionnaires after 3–4 weeks of the Stay Home, Stay Healthy directive. PROMIS-29 outcomes were compared to pre-COVID-19 responses. Results: Participants had a mean age of 74.1 (6.5) years, 79.5% were women, and 20.5% were racial/ethnic minorities. Compared to pre-COVID-19, there was a significant increase in anxiety and decrease in fatigue and social participation. Thematic analysis revealed five main themes related to disruption of daily life, the emotional and physical impact of stay-at-home orders, unexpected positive outcomes, and perspectives on messaging surrounding the pandemic. Conclusions: Efforts to curb the spread of COVID-19 have substantially impacted the lives of older adults participating in community-based exercise.

Knee Osteoarthritis: An Investigation into the Clinical Practice of Physiotherapists in Canada

Purpose: The purpose of this study was to establish the clinical practice of physiotherapists who treat people with knee osteoarthritis (OA) in Canada and examine their knowledge, awareness, use of, and attitudes toward clinical practice guidelines (CPGs). Method: We conducted a cross-sectional survey of physiotherapists who are licensed to practise in Canada and who treat people with knee OA. Results: A total of 388 physiotherapists completed our survey. Approximately two-thirds of them (271) were aware of CPGs. Out of all CPG recommendations, most respondents provided leg strengthening exercises (380) and education (364). More than 80% believed that CPGs improved patient care and enhanced decision making and were confident in their ability to interpret CPGs. More physiotherapists (204) identified barriers to the use of CPGs than facilitators of their use (117). Physiotherapists who were employed in private practice were substantially more likely to use interventions such as acupuncture (odds ratio [OR] 5.98; 95% CI: 2.92, 12.23; p < 0.01) and joint mobilization and manipulation (OR 6.58; 95% CI: 3.45, 12.55; p < 0.01) than were physiotherapists employed in hospital settings. Conclusions: Two-thirds of respondents were aware of CPGs. Physiotherapists provided education and leg strengthening exercises more often than aerobic exercise and weight management advice. Physiotherapists employed in private practice were more likely to use adjunct interventions.

Clinical Efficacy of Platelet-Rich Plasma Injection and Its Association With Growth Factors in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized Double-Blind Controlled Clinical Trial As Compared With Hyaluronic Acid

BACKGROUND

Although platelet-rich plasma (PRP) has potential as a regenerative treatment for knee osteoarthritis, its efficacy varies. Compositional differences among types of PRP could affect clinical outcomes, but the biological characterization of PRP is lacking.

PURPOSE

To assess the efficacy of intra-articular PRP injection in knee osteoarthritis as compared with hyaluronic acid (HA) injection and to determine whether the clinical efficacy of PRP is associated with its biological characteristics.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 110 patients with symptomatic knee osteoarthritis received a single injection of leukocyte-rich PRP (1 commercial kit) or HA. Clinical data were assessed at baseline and at 6 weeks and 3 and 6 months after injection. The primary endpoint was an improvement in the International Knee Documentation Committee (IKDC) subjective score at 6 months, and the secondary endpoints were improvements in scores based on the Patient Global Assessment, the visual analog scale (VAS) for pain, the Western Ontario and McMaster Universities Osteoarthritis Index, and the Samsung Medical Center patellofemoral score. Cell counts and concentrations of growth factors and cytokines in the injected PRP were assessed to determine their association with clinical outcomes.

RESULTS

PRP showed significantly improvement in IKDC subjective scores at 6 months (11.5 in the PRP group vs 6.3 in the HA group; P = .029). There were no significant differences between groups in other clinical outcomes. The Patient Global Assessment score at 6 months was better in the PRP group (P = .035). The proportion of patients who scored above the minimal clinically important difference (MCID) for VAS at 6 months was significantly higher in the PRP group (P = .044). Within the PRP group, the concentrations of platelet-derived growth factors were high in patients with a score above the MCID for VAS at 6 months. The incidence of adverse events did not differ between the groups (P > .05).

CONCLUSION

PRP had better clinical efficacy than HA. High concentrations of growth factors were observed in patients who scored above the MCID for clinical outcomes in the PRP group. These findings indicate that concentration of growth factors needs to be taken into consideration for future investigations of PRP in knee osteoarthritis.

REGISTRATION

NCT02211521 (ClinicalTrials.gov identifier).

Quality and content analysis of clinical practice guidelines which include nonpharmacological interventions for knee osteoarthritis

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines (CPGs) for knee osteoarthritis (OA) guide the provision of high-quality healthcare for people with knee OA, which may improve outcomes. Our aim was to evaluate the quality of and content within recently published CPGs for people with knee OA.

METHODS

CPGs (2014-2019) that described recommendations for nonpharmacological interventions for knee OA were included in the analysis. Two pairs of evaluators used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the quality of guideline development. CPG content was reviewed and summarized for comparison.

RESULTS

Ten CPGs were identified for inclusion in the quality and content analysis (seven newly developed and three recently updated). Overall CPG scores ranged between 42% and 100%. Six CPGs were found to be high-quality. Exercise was the only intervention recommended by all CPGs that we appraised. Weight-management and education were the next most frequently recommended interventions. Inter-rater reliability scores were high in domain 1: scope and purpose, (P-value = .001, intraclass correlation coefficient [ICC] = 0.90, 95% confidence interval [CI] = 0.62-0.98), domain 3: rigor of development (P-value = .000, ICC = 0.95, 95% CI = 0.80-0.99) and domain 5: applicability (P-value = .001, ICC = 0.91, 95% CI = 0.64-0.98).

CONCLUSION

Several CPGs have been developed or recently updated since 2014. Over half of the ten CPGs we appraised were deemed to be high-quality. Exercise, education, and weight-management advice are interventions that were most commonly recommended by CPGs.

Non-viral Gene Therapy for Osteoarthritis

Strategies for delivering nucleic acids into damaged and diseased tissues have been divided into two major areas: viral and non-viral gene therapy. In this mini-review article we discuss the application of gene therapy for the treatment of osteoarthritis (OA), one of the most common forms of arthritis. We focus primarily on non-viral gene therapy and cell therapy. We briefly discuss the advantages and disadvantages of viral and non-viral gene therapy and review the nucleic acid transfer systems that have been used for gene delivery into articular chondrocytes in cartilage from the synovial joint. Although viral gene delivery has been more popular due to its reported efficiency, significant effort has gone into enhancing the transfection efficiency of non-viral delivery, making non-viral approaches promising tools for further application in basic, translational and clinical studies on OA. Non-viral gene delivery technologies have the potential to transform the future development of disease-modifying therapeutics for OA and related osteoarticular disorders. However, further research is needed to optimize transfection efficiency, longevity and duration of gene expression.

Approaches to osteoarthritis - A qualitative study among patients in a rural setting in Central Western India

BACKGROUND

Osteoarthritis (OA) represents a major cause of disability in India. For implementation of best practice management, it is important to consider the views of people in India since they might deviate from those expressed in previous studies by people with OA in the Western world.

OBJECTIVE

The purpose of this study was to explore and describe approaches toward OA and its management among patients in a rural setting in Central Western India.

DESIGN AND METHOD

Conventional content analysis was used to analyze semi-structured interviews with 24 patients diagnosed with OA from the target area of Pravara University Hospital and ten adjacent primary health care centers in Maharashtra, India.

RESULTS

Four categories; lack of power, active ambivalence, taking control and a constant struggle were identified as patients' approaches to OA. The categories were further elaborated on in seven subcategories.

CONCLUSION

Daily challenges and efforts, of which some may be unique to patients in a rural setting in India, underlie passive and active approaches to OA and its management. Understanding these may enhance Indian physiotherapists' implementation of evidence-based self-management programs adapted to Indian conditions and reduce the distress of their patients.

Marine Collagen Hydrolysates Downregulate the Synthesis of Pro-Catabolic and Pro-Inflammatory Markers of Osteoarthritis and Favor Collagen Production and Metabolic Activity in Equine Articular Chondrocyte Organoids

Articular cartilage experiences mechanical constraints leading to chondral defects that inevitably evolve into osteoarthritis (OA), because cartilage has poor intrinsic repair capacity. Although OA is an incurable degenerative disease, several dietary supplements may help improve OA outcomes. In this study, we investigated the effects of Dielen^® hydrolyzed fish collagens from skin (Promerim^®30 and Promerim^®60) and cartilage (Promerim^®40) to analyze the phenotype and metabolism of equine articular chondrocytes (eACs) cultured as organoids. Here, our findings demonstrated the absence of cytotoxicity and the beneficial effect of Promerim^® hydrolysates on eAC metabolic activity under physioxia; further, Promerim^®30 also delayed eAC senescence. To assess the effect of Promerim^® in a cartilage-like tissue, eACs were cultured as organoids under hypoxia with or without BMP-2 and/or IL-1β. In some instances, alone or in the presence of IL-1β, Promerim^®30 and Promerim^®40 increased protein synthesis of collagen types I and II, while decreasing transcript levels of proteases involved in OA pathogenesis, namely Htra1, and the metalloproteinases Mmp1-3, Adamts5, and Cox2. Both Promerim^® hydrolysates also decreased Htra1 protein amounts, particularly in inflammatory conditions. The effect of Promerim^® was enhanced under inflammatory conditions, possibly due to a decrease in the synthesis of inflammation-associated molecules. Finally, Promerim^® favored in vitro repair in a scratch wound assay through an increase in cell proliferation or migration. Altogether, these data show that Promerim^®30 and 40 hold promise as dietary supplements to relieve OA symptoms in patients and to delay OA progression.

Osteoarthritis In Vitro Models: Applications and Implications in Development of Intra-Articular Drug Delivery Systems

Osteoarthritis (OA) is a complex multi-target disease with an unmet medical need for the development of therapies that slow and potentially revert disease progression. Intra-articular (IA) delivery has seen a surge in osteoarthritis research in recent years. As local administration of molecules, this represents a way to circumvent systemic drug delivery struggles. When developing intra-articular formulations, the main goals are a sustained and controlled release of therapeutic drug doses, taking into account carrier choice, drug molecule, and articular joint tissue target. Therefore, the selection of models is critical when developing local administration formulation in terms of accurate outcome assessment, target and off-target effects and relevant translation to in vivo. The current review highlights the applications of OA in vitro models in the development of IA formulation by means of exploring their advantages and disadvantages. In vitro models are essential in studies of OA molecular pathways, understanding drug and target interactions, assessing cytotoxicity of carriers and drug molecules, and predicting in vivo behaviors. However, further understanding of molecular and tissue-specific intricacies of cellular models for 2D and 3D needs improvement to accurately portray in vivo conditions.

EHealth to empower patients with musculoskeletal pain in rural Australia (EMPoweR) a randomised clinical trial: study protocol

BACKGROUND

Low back pain (LBP) and knee osteoarthritis (OA) are major contributors to disability worldwide. These conditions result in a significant burden at both individual and societal levels. Engagement in regular physical activity and exercise programs are known to improve physical function in both chronic LBP and knee OA populations. For people residing in rural areas, musculoskeletal conditions are often more frequent and disabling compared to urban populations, which could be the result of reduced access to appropriate health services and resources in rural settings. EHealth is an innovative solution to help provide equitable access to treatment for people with musculoskeletal pain living in rural settings.

METHODS/DESIGN

We will conduct a randomised clinical trial investigating the effects of an eHealth intervention compared to usual care, for people with chronic non-specific LBP or knee OA in rural Australia. We will recruit 156 participants with non-specific chronic LBP or knee OA. Following the completion of baseline questionnaires, participants will be randomly allocated to either the eHealth intervention group, involving a tailored physical activity and progressive resistance exercise program remotely delivered by a physiotherapist (n = 78), or usual care (n = 78) involving referral to a range of care practices in the community. Outcomes will be measured at baseline, 3 and 6 months post-randomisation. The primary outcome will be physical function assessed by the Patient-Specific Functional Scale (PSFS). Secondary outcomes include pain intensity, physical activity levels, activity limitations, quality of life, pain coping. We will also collect process evaluation data such as recruitment rate, attendance and adherence, follow-up rate, participants' opinions and any barriers encountered throughout the trial.

DISCUSSION

The findings from this trial will establish the effectiveness of eHealth-delivered interventions that are known to be beneficial for people with LBP and knee OA when delivered in person. As a result, this trial will help to inform health care policy and clinical practice in Australia and beyond for those living in non-urban areas.

TRIAL REGISTRATION

This study was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12618001494224 ) registered 09.05.2018.

Protocol for systematic review: patient decision aids for total hip and knee arthroplasty decision-making

BACKGROUND

Total hip and knee arthroplasty are a highly performed surgery; however, patient satisfaction with surgery results and patient involvement in the decision-making process remains low. Patient decision aids (PtDAs) are tools used in clinical practices to facilitate active patient involvement in healthcare decision-making. Nonetheless, PtDA effects have not been systematically evaluated for hip and knee total joint arthroplasty (TJA) decision-making. The aim of this systematic review is to determine the effect of patient decision aids compared to alternative of care on quality and process of decision-making when provided to adults with hip and knee osteoarthritis considering primary elective TJA.

METHODS

This systematic review will follow the Cochrane Handbook for Systematic Reviews. This protocol was reported based on the PRISMA-P checklist guidelines. Studies will be searched in CINAHL, MEDLINE, Embase, PsycINFO, and Web of Science. Eligible studies will be randomized control trial (RCT) evaluating the effect of PtDA on TJA decision-making. Descriptive and meta-analysis of outcomes will include decision quality (knowledge and values-based choice), decisional conflict, patient involvement, decision-making process satisfaction, actual decision made, health outcomes, and harm(s). Risk of bias will be evaluated with Cochrane's risk of bias tool for RCTs. Quality and strength of recommendations will be appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

DISCUSSION

This review will provide a summary of RCT findings on PtDA effect on decision-making quality and process of adults with knee and hip osteoarthritis considering primary elective TJA. Further, it will provide evidence comparing different types of PtDA used for TJA decision-making. This review is expected to inform further research on joint replacement decision-making quality and processes and on ways PtDAs facilitate shared decision-making for orthopedic surgery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020171334.

Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Knee Osteoarthritis: A Meta-analysis of 26 Randomized Controlled Trials

PURPOSE

To compare the effectiveness and safety of platelet-rich plasma (PRP) and hyaluronic acid (HA) in patients with adult knee osteoarthritis (KOA) and to explore the most effective and safe protocol by using a meta-analysis method.

METHODS

This study was based on Cochrane methodology for conducting a meta-analysis. Only randomized controlled trials with an experimental group that used PRP and a control group that received HA were eligible for this study. The participants were adults who had KOA. The outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the visual analog scale (VAS), the EuroQol VAS, the International Knee Documentation Committee, the Tegner score, the Lequesne Scale, the Knee injury Osteoarthritis Outcome Score, satisfaction rate, and adverse events. Subgroup analyses was performed for patients with different doses, types, and times of PRP interventions and grades of OA. The Review Manager Database was used to analyze the included studies.

RESULTS

Twenty-six randomized controlled trials involving 2430 patients were included. The WOMAC total scores, WOMAC physical function scores, and VAS scores of the PRP group were better than the those of the HA group at 3, 6, and 12 months. The PRP group had better WOMAC pain, WOMAC stiffness, EuroQol VAS, and International Knee Documentation Committee scores than the HA group at 6 and 12 months. There was no significant difference in adverse events between the 2 groups (relative risk 1.21, 95% confidence interval 0.95-1.54; P = .13).

CONCLUSIONS

For the nonsurgical treatment of KOA, compared with HA, intra-articular injection of PRP could significantly reduce patients' early pain and improve function. There was no significant difference in adverse events between the 2 groups. PRP was more effective than HA in the treatment of KOA, and the safety of these 2 treatment options was comparable.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I RCTs.

Systematic Review of Studies Using Conjoint Analysis Techniques to Investigate Patients' Preferences Regarding Osteoarthritis Treatment

BACKGROUND

The use of conjoint analysis (CA) to elicit patients' preferences for osteoarthritis (OA) treatment has the potential to contribute to tailoring treatments and enhancing patients' compliance and adherence. This review's main aim was to identify and summarise the evidence that used conjoint analysis techniques to quantify patient preferences for OA treatments.

METHODS

A comprehensive search strategy was conducted using electronic databases and hand reference checks. Databases were searched from their inception until 10th June 2019. All OA and CA related terms were used to conduct the search. The authors reviewed the papers and used the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) checklist to assess the quality of the included studies.

RESULTS

The search identified 534 records. Sixteen records were selected for full-text review and quality assessment and all were included in the narrative data synthesis. All included studies suggested that the severity of symptoms influenced the patients' preference for OA treatment. All included studies recognised CA as a useful method to investigate patients' preferences concerning OA treatment.

CONCLUSION

Patients preference for OA treatment is driven by the severity of patients' symptoms and the desire to avoid treatment side effects and CA is a useful tool to investigate patients' preferences for OA treatment.

Rejuvenated ageing mesenchymal stem cells by stepwise preconditioning ameliorates surgery-induced osteoarthritis in rabbits

Aims

Ageing-related incompetence becomes a major hurdle for the clinical translation of adult stem cells in the treatment of osteoarthritis (OA). This study aims to investigate the effect of stepwise preconditioning on cellular behaviours in human mesenchymal stem cells (hMSCs) from ageing patients, and to verify their therapeutic effect in an OA animal model.

Methods

Mesenchymal stem cells (MSCs) were isolated from ageing patients and preconditioned with chondrogenic differentiation medium, followed by normal growth medium. Cellular assays including Bromodeoxyuridine / 5-bromo-2'-deoxyuridine (BrdU), quantitative polymerase chain reaction (q-PCR), β-Gal, Rosette forming, and histological staining were compared in the manipulated human mesenchymal stem cells (hM-MSCs) and their controls. The anterior cruciate ligament transection (ACLT) rabbit models were locally injected with two millions, four millions, or eight millions of hM-MSCs or phosphate-buffered saline (PBS). Osteoarthritis Research Society International (OARSI) scoring was performed to measure the pathological changes in the affected joints after staining. Micro-CT analysis was conducted to determine the microstructural changes in subchondral bone.

Results

Stepwise preconditioning approach significantly enhanced the proliferation and chondrogenic potential of ageing hMSCs at early passage. Interestingly, remarkably lower immunogenicity and senescence was also found in hM-MSCs. Data from animal studies showed cartilage damage was retarded and subchondral bone remodelling was prevented by the treatment of preconditioned MSCs. The therapeutic effect depended on the number of cells applied to animals, with the best effect observed when treated with eight millions of hM-MSCs.

Conclusion

This study demonstrated a reliable and feasible stepwise preconditioning strategy to improve the safety and efficacy of ageing MSCs for the prevention of OA development.

Cite this article: Bone Joint Res 2021;10(1):10–21.

Multimodal Treatment Patterns for Osteoarthritis and Their Relationship to Patient-Reported Pain Severity: A Cross-Sectional Survey in the United States

Purpose

The purpose of this study was to assess how patient-reported pain is related to osteoarthritis (OA) treatment patterns in routine clinical practice.

Patients and Methods

Data were collected between February and May 2017 from 153 United States (US) primary care physicians, rheumatologists, and orthopedic surgeons. Each invited up to nine consecutive patients to rate their OA pain in the last week. Physicians provided demographic, clinical, and treatment information for patients, including nonpharmacologic therapies ever recommended, currently recommended over-the-counter (OTC) medications, and currently and ever prescribed medications for the management of OA. Findings for patients with mild (0─3), moderate (4─6), and severe current pain (7─10) were compared using appropriate statistics.

Results

Among the 841 patients (61% female; mean 65 years; 57% knee OA), 45% reported mild, 36% moderate, and 19% severe current OA pain. Current treatment modalities differed by pain severity (P<0.05). Most patients (70%) had been recommended nonpharmacologic therapy and 40% were currently recommended OTC medications. More patients with moderate (81%) or severe pain (78%) currently received prescription medications, with or without nonpharmacologic therapy, versus those with mild pain (67%). Overall, 47% of patients currently received just one prescription drug, while 49% had received one prescription drug ever. Nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common current (58%) and ever received (88%) prescriptions. Current NSAID prescriptions were not associated with pain severity. Acetaminophen recommendations, opioid prescriptions (current and ever), and multiple prescription medications tried were numerically highest in the severe pain group (all P<0.05 by pain severity). In all groups, >80% of treatment switches were due to lack of efficacy.

Conclusion

Real-life treatment patterns for OA in the US are significantly associated with current patient-reported pain. Combining nonpharmacologic and pharmacologic treatments is common but higher pain ratings are associated with multiple failed prescription treatments. Current use of acetaminophen and opioids, but not NSAIDs, increases alongside pain severity.

Stakeholders' preferences for osteoarthritis interventions in health services: A cross-sectional study using multi-criteria decision analysis

Objectives

To combine cross-sectoral stakeholders' preferences over interventions for knee osteoarthritis (OA) with guideline recommendations and evidence about interventions, and to investigate if these preferences differ by stakeholder group.

Design

A survey based on multi-criteria decision analysis was implemented whereby the stakeholders revealed the relative importance, represented as weights, of eight criteria for choosing or recommending knee OA interventions. Using data from an OA clinical guideline, 15 recommended interventions were rated on the criteria and ranked by their total scores, calculated by summing the corresponding weights. Associations between the weights and stakeholder groups were explored using regression analysis.

Results

Participants comprised 58 consumers with OA, 5 Māori health advocates, 79 healthcare providers, 24 policy-informants and 12 OA-researchers (N = 178; 63% female, [mean age±SD] 54 ± 13 years). Mean weights on the eight criteria, in decreasing order of importance, are: recommendation: 19.0%; quality of evidence: 17.7%; effectiveness: 15.0%; duration of effect: 13.2%; risk of serious harm: 12.8%; risk of mild/moderate side-effects: 9.4%; cost: 6.6%; and accessibility: 6.3%. For first-, second- and third-line OA interventions respectively, all land-based exercise (total score = 71.7%), NSAIDs (topical) (74.2%) and total joint replacement (74.3%) were ranked first. At all care phases, the recommended core interventions of weight management and self-management education ranked between 11th and 15th (48.0%-56.0%). Regression analysis identified only small differences in weights (≤5.7%; p < 0.01) between stakeholder groups.

Conclusions

Not all recommended core interventions are preferred by cross-sectoral stakeholders, which may represent a barrier to their uptake. Stakeholders' preferences do not appreciably differ by stakeholder group.

Intra-articular Corticosteroid Injections for the Treatment of Hip and Knee Osteoarthritis-related Pain: Considerations and Controversies with a Focus on Imaging-Radiology Scientific Expert Panel

Current management of osteoarthritis (OA) is primarily focused on symptom control. Intra-articular corticosteroid (IACS) injections are often used for pain management of hip and knee OA in patients who have not responded to oral or topical analgesics. Recent case series suggested that negative structural outcomes including accelerated OA progression, subchondral insufficiency fracture, complications of pre-existing osteonecrosis, and rapid joint destruction (including bone loss) may be observed in patients who received IACS injections. This expert panel report reviews the current understanding of pain in OA, summarizes current international guidelines regarding indications for IACS injection, and considers preinterventional safety measures, including imaging. Potential profiles of those who would likely benefit from IACS injection and a suggestion for an updated patient consent form are presented. As of today, there is no established recommendation or consensus regarding imaging, clinical, or laboratory markers before an IACS injection to screen for OA-related imaging abnormalities. Repeating radiographs before each subsequent IACS injection remains controversial. The true cause and natural history of these complications are unclear and require further study. To determine the cause and natural history, large prospective studies evaluating the risk of accelerated OA or joint destruction after IACS injections are needed. However, given the relatively rare incidence of these adverse outcomes, any clinical trial would be challenging in design and a large number of patients would need to be included.

A comparison of the effects of acupoint injection combined with hyaluronic acid versus isolated hyaluronic acid for knee osteoarthritis: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Knee osteoarthritis (KOA) is a kind of degenerative osteoarthropathy, which causes joint pain and limited mobility, seriously affects the quality of life of the patient. Traditional Chinese Medicine acupuncture and moxibustion has been widely used to treat KOA, and acupoint injection is 1 of the acupuncture treatment methods. The purpose of this work is to evaluate the effectiveness of Acupoint injection combined with Hyaluronic Acid injection compared with isolated Hyaluronic Acid injection for KOA.

METHODS

We will search articles in 7 electronic databases including Chinese National Knowledge Infrastructure, Wanfang Data, Chinese Scientific Journals Database, Chinese databases SinoMed, PubMed, Embase, and Cochrane Library databases. All the publications, with no time restrictions, will be searched without any restriction of language and status, the time from the establishment of the database to October 2020. Two reviewers will independently assess the quality of the selected studies, NoteExpress and Excel software will be used to extract data, and the content will be stored in an electronic chart. Different researchers will separately screen the titles and abstracts of records acquired potential eligibility which comes from the electronic databases. Full-text screening and data extraction will be conducted afterward independently. Statistical analysis will be conducted using RevMan 5.4 software.

RESULTS

This study will evaluate the efficacy and safety of Acupoint injection combined with Hyaluronic Acid injection compared with isolated Hyaluronic Acid injection in the treatment of KOA, to provide high-quality, evidence-based clinical recommendations.

TRIAL REGISTRATION NUMBER

INPLASY2020100058 CONCLUSION:: This study will provide reliable evidence on whether Acupoint injection combined with Hyaluronic Acid injection compared with isolated Hyaluronic Acid injection is more effective in treating KOA.

Exosome-mediated delivery of kartogenin for chondrogenesis of synovial fluid-derived mesenchymal stem cells and cartilage regeneration

Transplantation of synovial fluid-derived mesenchymal stem cells (SF-MSCs) is a viable therapy for cartilage degeneration of osteoarthritis (OA). But controlling chondrogenic differentiation of the transplanted SF-MSCs in the joints remains a challenge. Kartogenin (KGN) is a small molecule that has been discovered to induce differentiation of SF-MSCs to chondrocytes both in vitro and in vivo. The clinical application of KGN however is limited by its low water solubility. KGN forms precipitates in the cell, resulting in low effective concentration and thus limiting its chondrogesis-promoting activity. Here we report that targeted delivery of KGN to SF-MSCs by engineered exosomes leads to even dispersion of KGN in the cytosol, increases its effective concentration in the cell, and strongly promotes the chondrogenesis of SF-MSCs in vitro and in vivo. Fusing an MSC-binding peptide E7 with the exosomal membrane protein Lamp 2b yields exosomes with E7 peptide displayed on the surface (E7-Exo) that has SF-MSC targeting capability. KGN delivered by E7-Exo efficiently enters SF-MSCs and induces higher degree of cartilage differentiation than KGN alone or KGN delivered by exosomes without E7. Co-administration of SF-MSCs with E7-Exo/KGN in the knee joints via intra-articular injection also shows more pronounced therapeutic effects in a rat OA model than KGN alone or KGN delivered by exosomes without E7. Altogether, transplantation of SF-MSCs with in situ chondrogenesis enabled by E7-Exo delivered KGN holds promise towards as an advanced stem cell therapy for OA.

Fight fire with fire: Neurobiology of capsaicin-induced analgesia for chronic pain

Capsaicin, the pungent ingredient in chili peppers, produces intense burning pain in humans. Capsaicin selectively activates the transient receptor potential vanilloid 1 (TRPV1), which is enriched in nociceptive primary afferents, and underpins the mechanism for capsaicin-induced burning pain. Paradoxically, capsaicin has long been used as an analgesic. The development of topical patches and injectable formulations containing capsaicin has led to application in clinical settings to treat chronic pain conditions, such as neuropathic pain and the potential to treat osteoarthritis. More detailed determination of the neurobiological mechanisms of capsaicin-induced analgesia should provide the logical rationale for capsaicin therapy and help to overcome the treatment's limitations, which include individual differences in treatment outcome and procedural discomfort. Low concentrations of capsaicin induce short-term defunctionalization of nociceptor terminals. This phenomenon is reversible within hours and, hence, likely does not account for the clinical benefit. By contrast, high concentrations of capsaicin lead to long-term defunctionalization mediated by the ablation of TRPV1-expressing afferent terminals, resulting in long-lasting analgesia persisting for several months. Recent studies have shown that capsaicin-induced Ca²⁺/calpain-mediated ablation of axonal terminals is necessary to produce long-lasting analgesia in a mouse model of neuropathic pain. In combination with calpain, axonal mitochondrial dysfunction and microtubule disorganization may also contribute to the longer-term effects of capsaicin. The analgesic effects subside over time in association with the regeneration of the ablated afferent terminals. Further determination of the neurobiological mechanisms of capsaicin-induced analgesia should lead to more efficacious non-opioidergic analgesic options with fewer adverse side effects.

Comparing the efficacy of hyaluronic acid products with various molecular weights as mono and combined with chondroitin sulfate regimens in treatment of patients with stage I–III knee osteoarthritis

Aim: to evaluate the effectiveness of hyaluronic acid (HA) preparations with different molecular weights and in combination with chondroitin sulfate (HS) for intra-articular (IA) injections in the treatment of patients with stage I–III knee OA.

Subjects and methods. IA HA injections were performed 160 patients with primary and post-traumatic knee OA of the I–III stages at the department of traumatology-orthopedics, V.A. Nasonova Research Institute of Rheumatology for the period from September 2017 to June 2019. Patients were divided into 4 groups. Group 1 consisted of 80 patients treated with low molecular weight (LMW) HA, group 2–20 patients treated with medium molecular weight (MMW) HA, group 3–30 patients treated with high molecular weight (HMW) HA, and group 4–30 patients who were intraarticular introduced HA with HS. The course of IA injections was 2 for LMW, HMW, and HA with HS, and 3 for MMW HA. Injections were performed with an interval of 1 week. To evaluate the results of treatment, we studied the intensity of pain according to VAS and the total score of KOOS before treatment and on follow-up examinations 1, 3 and 6 months after the course of IA HA injections.

Results. The maximum reduction in pain with IA HA injections at stage I of knee OA occurred by 3 months after the course of treatment. Moreover, improvement was detected by 1 month in 84.3% of cases, and remained until the end of the study in 71.1% of patients. All HA preparations used in stage I of knee OA were effective. At stage II of the knee OA after 3 months after the course of IA HA, different efficiencies of HA preparations were revealed. So, in the groups of LMW, MMW and HA with HS, the improvement persisted up to 3 months, and in the group of HMW HA – up to 1 month. After 3 months, the best results were shown by HA with HS, by 6 months the results were comparable. IA HA injections at the II stage of knee OA led to good and excellent results 1 month after the course of treatment in 53.9% of cases, but by the end of the study, improvement remained in only 30.8% of patients. In the case of the use of HA in stage III of the knee OA, the effectiveness of the studied drugs was comparable, and the maximum improvement was achieved by 1 month. The positive effect of IA HA injections in patients with stage III of the knee OA one month after the course of treatment was obtained in 40.6% of cases, by 3 months it decreased to 18.8%, and by 6 months – to 15.7% of patients.

Conclusions. IA injections of HA at stage I of the knee OA is a highly effective method of conservative treatment, which allows to relieve pain and improve the condition of the knee joint for a period of 6 months or more. The use of HA preparations at stage II of the knee OA allows reducing pain up to 3 months with IA injections of LMW and MMW HA, as well as HA with HS. HMW HA helps reduce pain intensity for a period of 1 month. The use of HA preparations in stage III of the knee OA leads to a short-term relief of symptoms of OA.

In Vitro Anti-Inflammatory Activity in Arthritic Synoviocytes of A. brachypoda Root Extracts and Its Unusual Dimeric Flavonoids

Arrabidaea brachypoda is a plant commonly used for the treatment of kidney stones, arthritis and pain in traditional Brazilian medicine. Different in vitro and in vivo activities, ranging from antinociceptive to anti-Trypanosoma cruzi, have been reported for the dichloromethane root extract of Arrabidaea brachypoda (DCMAB) and isolated compounds. This work aimed to assess the in vitro anti-inflammatory activity in arthritic synoviocytes of the DCMAB, the hydroethanolic extract (HEAB) and three dimeric flavonoids isolated from the DCMAB. These compounds, brachydin A (1), B (2) and C (3), were isolated both by medium pressure liquid and high-speed counter current chromatography. Their quantification was performed by mass spectrometry on both DCMAB and HEAB. IL-1β activated human fibroblast-like synoviocytes were incubated with both extracts and isolated compounds to determine the levels of pro-inflammatory cytokine IL-6 by enzyme-linked immunosorbent assay (ELISA). DCMAB inhibited 30% of IL-6 release at 25 µg/mL, when compared with controls while HEAB was inactive. IC₅₀ values determined for 2 and 3 were 3-fold higher than 1. The DCMAB activity seems to be linked to higher proportions of compounds 2 and 3 in this extract. These observations could thus explain the traditional use of A. brachypoda roots in the treatment of osteoarthritis.

Integrated Network and Experimental Pharmacology for Deciphering the Medicinal Substances and Multiple Mechanisms of Duhuo Jisheng Decoction in Osteoarthritis Therapy

Osteoarthritis (OA) is currently the most common joint disorder worldwide. In last decades, herbal remedies have achieved a significant advancement in the treatment of OA. Duhuo Jisheng Decoction (DHJS), an herbal formula consisting of 15 medicinal herbs, has a long-time practice in OA therapy in China. However, its therapeutic mechanisms have not been comprehensively elucidated. In the present work, integrated network and experimental pharmacology were performed for investigating the therapeutic substances and mechanisms of DHJS. Based on network analysis, the contribution of each herb to OA therapy was evaluated. Furthermore, a series of potential targets and signaling pathways were enriched, which could be involved in the therapeutic effects and mechanisms of DHJS. Further experimental results indicated that DHJS attenuated TNFα, IL-6, MMP-1, MMP-9, MMP-13, and ADAMTs-5 expression, inhibited NF-κB and p38 MAPK signaling pathway, activated AMPK-SIRT1 signaling pathway, and suppressed chondrocyte apoptosis, which synergistically contributed to OA therapy. Our work demonstrated that DHJS could be very promising for OA therapy through synergistically acting on multitargets and multipathways.

Do Quebec Physiotherapists Follow Evidence-Based Guidelines for Treating Knee Osteoarthritis?

Purpose: The aim of this study was to document the types of treatment that Quebec physiotherapists use for knee osteoarthritis (OA), to assess whether treatment choices are consistent with current practice guidelines, and to explore the factors associated with using certain treatments. Method: Physiotherapists in Quebec answered a cross-sectional survey that was sent through licensing bodies and social media contacts. The respondents were asked which treatments they would use for a typical case of knee OA. We used descriptive statistics to determine the proportions of physiotherapists who chose each treatment and explored the associations between the use of treatments and demographic factors. Results: A total of 195 Quebec physiotherapists participated in this study, 74.9% of whom were women. The most common treatment choices were mobility exercises (96.4%), followed by education (93.8%), strengthening exercises (85.1%), thermotherapy and cryotherapy (72.3%), manual therapy (53.3%), and electrotherapy (42.1%). Selecting either manual or electrotherapy was significantly associated with working in private practice. Conclusions: The great majority of physiotherapists included mobility and strengthening exercises, both of which are the recommended approaches for treating knee OA. Physiotherapists in private practice were more likely to select manual therapy and electrotherapy.

Non-surgical management of knee osteoarthritis: comparison of ESCEO and OARSI 2019 guidelines

Knee osteoarthritis (OA) is a heterogeneous disease associated with substantial effects on quality of life, and its clinical management is difficult. Among the several available guidelines for the management of knee OA, those from OARSI and ESCEO were updated in 2019. Here, we examine the similarities and differences between these two guidelines and provide a narrative to help guide health-care providers through the complexities of non-surgical management of knee OA. OARSI and ESCEO both recommend education, structured exercise and weight loss as core treatments, topical NSAIDs as first-line treatments and oral NSAIDs and intra-articular injections for persistent pain. Low-dose, short-term acetaminophen, pharmaceutical grade glucosamine and chondroitin sulfate are recommended by ESCEO whereas OARSI strongly recommends against their use (including all glucosamine and chondroitin formulations). Despite this difference, the two guidelines are consistent in the majority of their recommendations and provide useful treatment recommendations for individuals with OA and health-care providers.

One-year efficacy and safety of single or one to three weekly injections of hylan G-F 20 for knee osteoarthritis: a systematic literature review and meta-analysis

The aim of this study was to evaluate the long-term efficacy and safety of single or 1–3 weekly injections of hylan G-F 20 at 1 year following the first injection for knee osteoarthritis (OA). Searches were conducted in PubMed/MEDLINE, Embase, and CENTRAL and included relevant conference proceedings (January 1, 1995–August 17, 2020). Randomized controlled trials (RCTs), non-randomized trials, and observational studies investigating 1-year efficacy and safety of 1–3 weekly injections or single hylan G-F 20 injection for knee OA were included. Primary outcomes were WOMAC pain, physical function, and stiffness. Meta-analyses of RCTs and non-randomized studies were conducted separately. Our search identified 24 eligible studies. Hylan G-F 20, in the meta-analyses of RCTs, showed statistically significant improvement in WOMAC pain (SMCC − 0.98, 95% CI − 1.50, − 0.46), physical function (SMCC − 1.05, 95% CI − 1.28, − 0.83), and stiffness (SMCC − 1.07, 95% CI −1.28, −0.86). Improvement was also seen for VAS pain, SF-36 MCS (mental component summary), and SF-36 PCS (physical component summary). Analyses of non-randomized studies showed similar efficacy estimates. There were no significant differences in efficacy based on injection schedule, nor between RCT and non-randomized studies. Rates of adverse events (AEs) were low for most types of AEs. Hylan G-F 20 (either as single or 1–3 weekly injections) showed improvement in 1-year efficacy outcomes in comparison to baseline and was generally well tolerated. While further research will inform the medical field regarding viscosupplementation treatment options for knee OA, these findings show that hylan G-F 20 at both frequencies/dosages are efficacious and generally well tolerated for long-term use.

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial

AIM

Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.

METHODS

This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis.

RESULTS

From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care.

CONCLUSION

We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02931058.

Chinese herbal medicine Wutou decoction for knee osteoarthritis: A protocol for systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) causes joint pain and limited mobility, which affects the quality of life. The use of Chinese herbal medicine to treat KOA has achieved certain effects, and Wutou decoction (WTD) is one of them. But there is no high-level evidence to support this result. The purpose of this work is to evaluate WTD's efficacy and safety in the management of KOA.

METHODS

We will search articles in 7 electronic databases including Chinese National Knowledge Infrastructure (CNKI), Wanfang Data (WF), Chinese Scientific Journals Database (VIP), Chinese databases SinoMed (CBM), PubMed, Embase, and Cochrane Library databases. All the publications, with no time restrictions, will be searched without any restriction of language and status, the time from the establishment of the database to September 2020. Two reviewers will independently assess the quality of the selected studies, NoteExpress and Excel software will be used to extract data, and the content will be stored in an electronic chart. Different researchers will separately screen the titles and abstracts of records acquired potential eligibility which comes from the electronic databases. Full-text screening and data extraction will be conducted afterward independently. Statistical analysis will be conducted using RevMan 5.4 software.

RESULTS

This study will evaluate the current efficacy and safety of WTD in the treatment of KOA, to provide high-quality, evidence-based clinical recommendations.

CONCLUSION

This study will provide reliable evidence on whether WTD is safe and effective in treating KOA.

TRIAL REGISTRATION NUMBER

INPLASY202090022.

Association Between Acupuncture and Knee Surgery for Osteoarthritis: A Korean, Nationwide, Matched, Retrospective Cohort Study

Objectives: The present study was undertaken to investigate the relationship between acupuncture therapy and surgery rate. Design: Matched, retrospective cohort study. Materials and Methods: From nationwide health insurance data (2002-2013 cohort data published by the National Health Insurance Service of Korea), patients with new cases of knee osteoarthritis that occurred between January 1, 2004 and December 31, 2010 were analyzed. Patients were divided into an acupuncture group (AG) and a control group (CG), based on records of acupuncture therapy. Propensity scores were calculated by using gender, age, income level, and Charlson comorbidity index (CCI), with the groups matched at a ratio of 1:3 (AG:CG). The final analysis period was 2 years after the first acupuncture therapy for AG and 2 years after initial diagnosis for CG; surgery rates were compared between the two groups. Stratified analyses were performed based on age, gender, and income level; sensitivity analyses were performed based on the frequency and duration of acupuncture therapy. Results: Propensity score-matched AG and CG included 8,605 and 25,815 subjects, respectively. Post-matching surgery rates were 0.26 and 0.93% in AG and CG, respectively. For all age groups, AG showed a lower surgery rate than CG. In the analysis based on gender, the female group showed a significantly lower hazard ratio of 0.225. In analysis based on income level, the results of the entire group were significant, with the lower income group showing the lowest hazard ratio. In sensitivity analyses, AG tended to show a lower surgery rate than CG. Conclusions: The present study demonstrated that acupuncture therapy is associated with a low rate of surgery for knee osteoarthritis. Additional studies are needed to support this conclusion.

PARTNER: a service delivery model to implement optimal primary care management of people with knee osteoarthritis: description of development

OBJECTIVE

Implementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service delivery to implement recommended care for people with knee osteoarthritis (OA) in a primary care setting.

METHODS

Three development stages occurred concurrently and iteratively. Each stage considered the healthcare context and was informed by stakeholder input. Stage 1 involved the design of a new model of service delivery (PARTNER). Stage 2 developed a behavioural change intervention targeting general practitioners (GPs) using the behavioural change wheel framework. In stage 3, the 'Care Support Team' component of the service delivery model was operationalised.

RESULTS

The focus of PARTNER is to provide patients with education, exercise and/or weight loss advice, and facilitate effective self-management through behavioural change support. Stage 1 model design: based on clinical practice guidelines, known evidence practice gaps in current care, chronic disease management frameworks, input from stakeholders and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER service-delivery model. The key components are: (1) an effective GP consultation and (2) follow-up and ongoing care provided remotely (telephone/email/online resources) by a 'Care Support Team'. Stage 2 GP behavioural change intervention: a multimodal behavioural change intervention was developed comprising a self-audit/feedback activity, online professional development and desktop software to provide decision support, patient information resources and a referral mechanism to the 'Care Support Team'. Stage 3 operationalising the 'care support team'-staff recruited and trained in evidence-based knee OA management and behavioural change methodology.

CONCLUSION

The PARTNER model is the result of a comprehensive implementation strategy development process using evidence, behavioural change theory and intervention development guidelines. Technologies for scalable delivery were harnessed and new primary evidence was generated as part of the process.Trial registration number ACTRN12617001595303 (UTN U1111-1197-4809).

A Review of Non-Surgical Pain Management in Osteoarthritis

Osteoarthritis is a prominent cause of disability in older adults, especially with an increasingly obese and aging population. Clinical management of pain secondary to osteoarthritis should focus on education and self-management with exercise and weight management as a priority. Surgical intervention should only be considered once conservative measures have failed. This review provides a clinical update on the pathogenesis, diagnosis, and management of osteoarthritis.