The effects of specific medical conditions on the functional limitations of elders in the Framingham Study

Naturally occurring osteoarthritis in male mice with an extended lifespan

Aim: The purpose of this study was to evaluate whether pharmacologic treatments or genotypes shown to prolong murine lifespan ameliorate the severity of age-associated osteoarthritis.Materials and Methods: Male UM-HET3 mice were fed diets containing 17-α-estradiol, acarbose, nordihydroguaiaretic acid, or control diet per the National Institute on Aging Interventions Testing Program (ITP) protocol. Findings were compared to genetically long-lived male Ames dwarf mice. Stifles were analyzed histologically with articular cartilage structure (ACS) and safranin O scoring as well as with quantitative histomorphometry.Results: Depending on the experimental group, ITP mice were between 450 and 1150 days old at the time of necropsy and 12-15 animals were studied per group. Two age groups (450 and 750 days) with 16-20 animals per group were used for Ames dwarf studies. No differences were found in the ACS or safranin O scores between treatment and control groups in the ITP study. There was high variability in most of the histologic outcome measures. For example, the older UM-HET3 controls had ACS scores of 6.1 ± 5.8 (mean±SD) and Saf O scores of 6.8 ± 5.6. Nevertheless, 17-α-estradiol mice had larger areas and widths of subchondral bone compared to controls, and dwarf mice had less subchondral bone area and width and less articular cartilage necrosis than non-dwarf controls.Conclusions: UM-HET3 mice developed age-related OA but with a high degree of variability and without a significant effect of the tested ITP treatments. High variability was also seen in the Ames dwarf mice but differences in several measures suggested some protection from OA.

What is the Likelihood of Subsequent Arthroplasties after Primary TKA or THA? Data from the Osteoarthritis Initiative

BACKGROUND

Osteoarthritis is common and debilitating, in part because it often affects more than one large weightbearing joint. The likelihood of undergoing more than one total joint arthroplasty has not been studied in a heterogeneous, multicenter population in the United States.

QUESTIONS/PURPOSES

We used prospectively collected data of patients with osteoarthritis from the multicenter Osteoarthritis Initiative (OAI) project to ask (1) What is the likelihood of a subsequent THA or TKA after primary TKA or THA? (2) What risk factors are associated with undergoing contralateral TKA after primary TKA?

METHODS

Longitudinally maintained data from the OAI were used to identify 332 patients who underwent primary TKA and 132 patients who underwent primary THA for osteoarthritis who did not have a previous TKA or THA in this retrospective study. OAI was a longitudinal cohort study of knee osteoarthritis conducted at five centers in the United States (Columbus, OH, USA; Pittsburgh, PA, USA; Baltimore, MD, USA; Pawtucket, RI, USA; and San Francisco, CA, USA). In this study, the mean follow-up time was 4.0 ± 2.3 years, with 24% (112 of 464) followed for less than 2 years. The primary outcome was the cumulative incidence of subsequent arthroplasty calculated using the Kaplan-Meier method. Age, BMI, gender, and contralateral Kellgren-Lawrence grade, medial joint space width, and hip-knee-ankle angles were modeled as risk factors of contralateral TKA using Cox proportional hazards.

RESULTS

Using the Kaplan-Meier method, at 8 years the cumulative incidence of contralateral TKA after the index TKA was 40% (95% CI 31 to 49) and the cumulative incidence of any THA after index TKA was 13% (95% CI 5 to 21). The cumulative incidence of contralateral THA after the index THA was 8% (95% CI 2 to 14), and the cumulative incidence of any TKA after index THA was 32% (95% CI 15 to 48). Risk factors for undergoing contralateral TKA were younger age (HR 0.95 for each year of increasing age [95% CI 0.92 to 0.98]; p = 0.001) and loss of medial joint space width with a varus deformity (HR 1.26 for each 1 mm loss of joint space width at 1.6 varus [1.06 to 1.51]; p = 0.005).

CONCLUSION

Patients who underwent TKA or THA for osteoarthritis had a high rate of subsequent joint arthroplasties in this study conducted at multiple centers in the United States. The rate of subsequent joint arthroplasty determined in this study can be used to counsel patients in similar settings and institutions, and may serve as a benchmark to assess future osteoarthritis disease-modifying interventions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Effects of Otago exercise combined with action observation training on balance and gait in the old people

This study aimed to investigate the effects of Otago exercise combined with action observation (AO) training on the balance, and gait in the old people to prevent falls in the community. A total of 30 old women participated and randomly assigned into three groups: AO plus Otago (n=10), Otago (n=10), or control (n=10). The AO plus Otago and Otago groups performed 50 min of strength training and balance exercises from the Otago Exercise Program 3 times a week for 12 weeks. The AO plus Otago group received an additional 20 min of training 3 times a week. We used the electronic muscle dynamometer to changes in strength, Timed Up and Go (TUG) test to evaluate dynamic balance, and the short version of the Falls Efficacy Scale-International was used to evaluate the fear of falls, and GAITRite was used to evaluate changes in the spatiotemporal parameters of walking. The muscle strength significantly increased in the AO plus Otago and Otago groups compared to the strength before training. The TUG test showed a significant improvement in the dynamic balance in both intervention groups. A significant increase was observed in the walking speed, cadence, step length, and stride length in both intervention groups. We also noted a significant change in the efficacy measures for falls. It is expected that Otago exercise combined with AO training will be used as an intervention method in hospital treatment programs and the old people facilities for preventing falls in the old people.

The Role of Cohabitating Partner and Relationship Characteristics on Physical Activity among Individuals with Osteoarthritis

BACKGROUND

Most individuals with knee or hip osteoarthritis do not meet recommendations for physical activity. The Social Cognitive Theory suggests that the social environment (e.g., spouses/partners) may influence the physical activity of individuals with osteoarthritis. The purpose of this study was to examine whether the physical activity of insufficiently active, coupled adults with osteoarthritis was associated with received partner support for physical activity, partner's engagement in physical activity, and relationship satisfaction.

METHODS

Cross-sectional data from 169 couples were collected. Accelerometers estimated moderate-to-vigorous physical activity and daily steps for participants with osteoarthritis and their partners. Participants with osteoarthritis reported total received partner support for physical activity and relationship satisfaction.

RESULTS

Participants with osteoarthritis were on average 65 years old, 65% female, 86% non-Hispanic white, and 47% retired. Receiving total partner support more frequently was associated with more minutes of moderate-to-vigorous physical activity but not with steps. Relationship satisfaction moderated the association of partner's physical activity on the daily steps of individuals with osteoarthritis such that having a partner who accomplished more daily steps was associated with participants with osteoarthritis accomplishing more daily steps themselves when they reported greater relationship satisfaction.

CONCLUSIONS

Partners and relationship satisfaction may play an important role in the physical activity of individuals with osteoarthritis. Interventions seeking to increase physical activity in this population may be enhanced by promoting partner support. Additional research is needed to further explain these associations within the context of relationship satisfaction.

PET/computed tomography shows association between subjective pain in knee joints and fluorine-18-fluorodeoxyglucose uptake

The aim of this study was to evaluate the capability of fluorine-18-fluorodeoxyglucose (¹⁸F-FDG)-PET/computed tomography (CT) in screening for musculoskeletal inflammation and injury in the knee region.

Effects of Physical Activity in Knee and Hip Osteoarthritis: A Systematic Umbrella Review

INTRODUCTION

We conducted a systematic umbrella review to evaluate the literature relating to effects of physical activity on pain, physical function, health-related quality of life, comorbid conditions and osteoarthritis (OA) structural disease progression in individuals with lower-extremity OA.

METHODS

Our primary search encompassed 2011 to February 2018 for existing systematic reviews (SR), meta-analyses (MA) and pooled analyses dealing with physical activity including exercise (not mixed with any other intervention and compared to a no-activity control group). A supplementary search encompassed 2006 to February 2018 for original research related to physical activity (including exercise) and lower limb OA progression. Study characteristics were abstracted, and risk of bias was assessed.

RESULTS

Physical activity decreased pain and improved physical function (strong evidence) and improved health-related quality of life (moderate evidence) among people with hip or knee OA relative to less active adults with OA. There was no evidence to suggest accelerated OA progression for physical activity below 10,000 steps per day. Both physical activity equivalent to the 2008 Physical Activity Guidelines for Americans (150 min·wk of moderate-intensity exercise in bouts ≥10 min) and lower levels of physical activity (at least 45 total minutes per week of moderate-intensity) were associated with improved or sustained high function. No SR/MA addressing comorbid conditions in OA were found. Measurable benefits of physical activity appeared to persist for periods of up to 6 months following cessation of a defined program.

CONCLUSIONS

People with lower-extremity OA should be encouraged to engage in achievable amounts of physical activity, of even modest intensities. They can choose to accrue minutes of physical activity throughout the entire day, irrespective of bout duration, and be confident in gaining some health and arthritis-related benefits.

The effect of extra-osseous talotarsal stabilization (EOTTS) to reduce medial knee compartment forces - An in vivo study

Background

Excessive hindfoot pronation, talotarsal joint (TTJ) instability, has been attributed to an increase in medial knee compartment pathology. Advocacy for hindfoot realignment has been the subject of research. An internal solution for TTJ instability, extra-osseous talotarsal stabilization (EOTTS), exists but its effect on knee forces is unknown. This is the first study to measure the in vivo forces acting within the medial knee compartment before and after EOTTS. We hypothesized that following EOTTS there should be a reduction of force acting on the medial knee compartment.

Methods

10 fresh frozen cadaver lower extremities exhibiting clinical and radiographic evidence of TTJ instability were evaluated. The proximal femur segment was mounted to a mechanical testing unit. Pressure sensors were placed within the medial knee compartment. A force of 1000 newtons was then applied, and the femur was internally rotated 10 degrees. Measurements were recorded before and after the insertion of a type II EOTTS stent.

Results

Pre-EOTTS resulted in an average of 842 ± 247N acting within the medial knee joint compartment. These forces then decreased to an average of 565 ± 260N (<0.05) following EOTTS, representing an average reduction of force by 32.8%.

Conclusion

EOTTS has been shown to decrease the in vivo forces action within the medial knee compartment. This helps to further illustrate the importance of realigning and stabilizing the hindfoot for the prevention and treatment of chronic knee pain.

Static Low-Angle Squatting Reduces the Intra-Articular Inflammatory Cytokines and Improves the Performance of Patients with Knee Osteoarthritis

Osteoarthritis (OA) is one of the major diseases leading to disability, and inflammation plays an important role in the pathogenesis of OA. However, inflammation of OA is multifactorial, chronic, and in low intensity, which makes drug-based immunotherapy difficult. Here, we have designed a novel method of exercise—static low angle squat (SLAS), which reduces the intra-articular inflammation of OA knee as well as strengthens the vastus medialis of quadriceps. A two-year follow-up trial of current exercise methods demonstrated long-term, significant improvement in pain relief, range of motion, muscle strength, and knee stability.

Differentiating knee pain phenotypes in older adults: a prospective cohort study

Objective

To identify and validate knee pain phenotypes in an older population across different pain-related domains over 10.7 years.

Methods

A total of 963 participants (mean age 63 years) from a population-based older adult cohort study were studied at baseline and followed up at 2.6 (n = 875), 5.1 (n = 768) and 10.7 years (n = 563). Baseline demographic, psychological, lifestyle and comorbidities data were obtained and MRI was performed to measure knee structural pathology. WOMAC pain and pain at multiple sites were assessed by questionnaires at each time-point. Latent class analysis was used to identify knee pain phenotypes, considering sex, BMI, emotional problems, education level, comorbidities, number of painful sites and knee structural pathology.

Results

Three pain phenotypes were identified: Class 1: high prevalence of emotional problems and low prevalence of structural damage (25%); Class 2: high prevalence of structural damage and low prevalence of emotional problems (20%); Class 3: low prevalence of emotional problems and low prevalence of structural damage (55%). Participants within Class 1 and 2 had greater BMI, more comorbidities, a higher prevalence of radiographic knee OA and knee structural pathology compared with Class 3. Furthermore, compared with Class 2 and 3, WOMAC pain and number of painful sites were consistently greater at each time-point over 10.7 years in Class 1. Results were similar when the analyses were restricted to participants with radiographic knee OA.

Conclusion

Psychological and structural factors interact with each other to exacerbate pain perception, suggesting that tailored treatment approaches for older people with knee pain in clinical practice are needed.

Is Intra-Articular Injection of Synvisc Associated with a Delay to Knee Arthroplasty in Patients with Knee Osteoarthritis?

OBJECTIVE

There is debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We asked the following questions: (1) What is the epidemiology of IA HA use in knee arthroplasty (KA) patients? (2) Is Synvisc associated with a delay to KA? (3) Is there a difference in the delay to KA with the number of HA courses?

DESIGN

The Optum Clinformatics data set (2006-June 2016) was used to identify patients with knee osteoarthritis (OA). Patients who did not receive IA HA were identified, along with those who received Synvisc or non-Synvisc HA. The median duration from knee OA to KA was compared using quantile regression modeling with propensity score weighting. The trend in time to KA with each HA course was evaluated.

RESULTS

Of 4,027,848 knee OA patients, 141,305 patients underwent KA. Overall median time from knee OA diagnosis to KA was 1.2 years (average: 1.9 ± 1.9 years; interquartile range of 0.4-2.8 years). HA patients had significantly longer adjusted median time to KA by at least 7 months (P < 0.001). After adjusting for the time to HA and number of injections, Synvisc patients had 1.7 months longer time to KA than non-Synvisc HA patients (P < 0.001). There was a trend toward longer time to KA with more HA courses.

CONCLUSIONS

Most KA patients did not use HA (73.7%) and when received, it was associated with a longer median time to KA by at least 7 months, though the cause and effect could not be examined. The delay to KA increased with more HA courses.

Improving Patient Reported Outcomes and Preventing Depression and Anxiety in Older Adults With Knee Osteoarthritis: Results of a Sequenced Multiple Assignment Randomized Trial (SMART) Study

OBJECTIVE

Older adults with knee osteoarthritis (OA) and comorbid subsyndromal depressive symptoms are at elevated risk for incidental major depression or anxiety disorders. Using an indicated prevention paradigm, the authors conducted a sequenced multiple assignment randomized trial (SMART) to: 1) evaluate the effect of cognitive behavioral therapy (CBT) and physical therapy (PT), together with the temporal ordering of these interventions, on patient-reported global impression of change (P-GIC), mood, anxiety, and pain; and 2) compare the strategies' impact on incidence of common psychiatric disorders over 12-months.

METHODS

This intervention development trial compared four adaptive strategies delivered in two stages (each up to 8 weeks), contrasted with enhanced usual care (EUC). The strategies were CBT followed by an increased dose of CBT (CBT-CBT), CBT followed by PT (CBT-PT), PT followed by an increased dose of PT (PT-PT), and PT followed by CBT (PT-CBT). Participants (n = 99) were aged 60 years and older and met clinical criteria for knee OA and subthreshold depression. Response was defined as at least "much better" on the P-GIC. Participants were assessed quarterly for 12 months for incidence of psychiatric disorders.

RESULTS

Stage 1 response was higher for PT (47.5%) compared to CBT (20.5%). Non-responders receiving an additional dose of the same intervention experienced a response rate of 73%, higher than for switching to a different intervention. All strategies were superior to EUC (5%). Although not powered to detect effects on disorders, neither intervention strategy nor response status affected 12-month incidence of depression and anxiety disorders.

CONCLUSION

As response rates were similar for PT-PT and CBT-CBT, it may be dose and not type of these interventions that are necessary for clinical benefit. For non-responders, this finding may guide providers to stay the clinical course for up to 12 weeks before switching. These results support future trials of SMART designs in late-life depression prevention.

Promoting mobility and healthy aging in men: a narrative review

Maintaining mobility is an important aspect of health and well-being in older men. This literature review describes several modifiable and nonmodifiable risk factors impacting bone, muscle, and joint health. Exercise and nutritional interventions may help to prevent the progressive deterioration in bones, muscles, and joints impacting mobility in later life. Limitations in mobility are increasingly recognized as a major public health problem due to an aging population and growing number of older individuals affected by disabling comorbidities. Despite increasing numbers and debilitating consequences, there are no guidelines providing recommendations on strategies to maintain mobility for healthy aging among older men. This narrative review aims to fill this literature gap. PubMed, Scopus, and Google Scholar databases were searched using predefined search terms. Primary studies, exploratory analyses, cross-sectional surveys, meta-analyses, evidence-based clinical reviews, and guidelines from nationally recognized societies focusing on mobility in older men and key elements including bone, muscle and joint health, and balance were selected. Several modifiable and nonmodifiable risk factors have been reported in the literature that impact bone, muscle, and joint health and predispose older men to falls and fractures. The most common conditions impacting bones, muscles, and joints are osteoporosis, sarcopenia, and osteoarthritis, respectively. In addition to being key contributors to disability in the elderly, these conditions are all associated with a higher mortality risk. Although more studies are required, current evidence supports the use of various nonpharmacological (mainly exercise and nutrition) and/or pharmacological treatment modalities to help prevent and/or reverse these conditions. Incorporating lifestyle interventions involving exercise and nutrition at a younger age can help prevent the age-related, progressive deterioration in bones, muscles, and joints that can reduce mobility in later life. Established barriers to physical activities (e.g., poor health, social isolation) in men are important to consider for optimizing outcomes.

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.

mHealth technologies for osteoarthritis self-management and treatment: A systematic review

Osteoarthritis is a common chronic disease that can be better treated with the help of self-management interventions. Mobile health (mHealth) technologies are becoming a popular means to deliver such interventions. We reviewed the current state of research and development of mHealth technologies for osteoarthritis self-management to determine gaps future research could address. We conducted a systematic review of English articles and a survey of apps available in the marketplace as of 2016. Among 117 unique articles identified, 25 articles that met our inclusion criteria were reviewed in-depth. The app search identified 23 relevant apps for osteoarthritis self-management. Through the synthesis of three research themes (osteoarthritis assessment tools, osteoarthritis measurement tools, and osteoarthritis motion monitoring tools) that emerged from the current knowledge base, we provide a design framework to guide the development of more comprehensive osteoarthritis mHealth apps that facilitate self-management, decision support, and shared decision-making.

Thresholds in the Relationship of Quadriceps Strength With Functional Limitations in Women With Knee Osteoarthritis

OBJECTIVE

To investigate thresholds of strength below which individuals with knee osteoarthritis (OA) may have more difficulty carrying out physical functions of daily life. Individuals below such thresholds might benefit more from strengthening interventions than those with greater strength.

METHODS

We studied individuals with symptomatic OA at baseline in the Multicenter Osteoarthritis Study who had knee extensor strength measured isokinetically at 60º/second. Participants underwent a 20-meter walk test and a sit-to-stand test and answered questions from the Western Ontario and McMaster Universities Osteoarthritis Index. Physical function results were plotted against measures of quadriceps strength (Nm) (and as strength:body weight) for the worst knee. Loess technique was used to examine inflection points. Nonlinear relationships were examined in piecewise linear regression models. Differences were tested using linear and logistic regression models.

RESULTS

The study had 834 participants (65.8% women). The mean ± SD age of the participants was 62.9 ± 7.9 years. In women, there were thresholds of strength below which the slope of strength versus function was steeper: walking speed (<58 Nm), chair stand time (<32 Nm), and the McMaster Universities Osteoarthritis Index functions of rising from a chair and getting on/off the toilet (<38 Nm). We found no thresholds in men. Loess analyses using strength:weight showed similar results.

CONCLUSION

In individuals with symptomatic knee OA, thresholds in the strength function relationship may help identify individuals, especially women, at the brink of disability insofar as strength and capacity for daily tasks. In those with low strength, small increments in strength may be associated with improvement in function and greater ease with common daily life, emphasizing the importance of preventing loss of strength.

Kellgren-Lawrence scoring system underestimates cartilage damage when indicating TKA: preoperative radiograph versus intraoperative photograph

INTRODUCTION

The Kellgren-Lawrence score helps the orthopedic surgeon to classify the severity of knee osteoarthritis (OA) before total knee arthroplasty (TKA). There might be a discrepancy between subjective complaints of the patients and radiologically visible changes of the knee joint in many cases. In this context, we performed a prospective clinical study to compare the preoperative degree of knee OA using the Kellgren-Lawrence score with the intraoperative extent of cartilage damage during primary TKA.

MATERIALS AND METHODS

A total of 251 primary TKA surgeries due to a primary knee OA were prospectively included. Preoperative Kellgren-Lawrence score was determined using standardized preoperative plain radiographs of three views; anteroposterior, lateral and skyline of the patella by a senior radiologist. Intraoperatively, in all cases, photographs of the medial, lateral, and patellofemoral joint compartments were taken. Using the International Cartilage Repair Society (ICRS) score, the degree of chondromalacia was assessed. Subsequently, correlation analysis was performed using the Pearson-Clopper 95% confidence interval (CI).

RESULTS

There were higher intraoperative scores compared to the preoperative scores in 160 of all cases (63.7% of 251, 95% CI 57.5-69.7%). A mismatch of two score grade points was found in 8.4% (95% CI 5.3-12.5%). The most common mismatch was noted in patients with preoperative Kellgren-Lawrence score of 3 and an intraoperative score of 4 in 48.2% (95% CI 41.9-54.6%).

CONCLUSIONS

The preoperative radiographs using Kellgren-Lawrence underestimate the severity of knee osteoarthritis. The true extent of articular cartilage damage can be better appreciated intraoperatively. In patients undergoing primary TKA, the correlation of clinical symptoms with radiological findings is crucial in deciding when to perform the surgery. Besides, other imaging modalities may be used as an adjunct when the clinical findings and plain radiographs do not correlate.

Association Between Cardiovascular Risk and Perceived Fatigability in Mid-to-Late Life

Background

Cardiovascular disease (CVD) and fatigue commonly co‐occur in older adults, yet the subjective nature of fatigue and its situational dependence leave the true magnitude of this association undefined.

Methods and Results

Six‐hundred and twenty‐five participants with no history of CVD (aged 68.1+12.0 years), from the Baltimore Longitudinal Study of Aging who underwent ≥2 clinic visits between 2007 and 2015 were classified according to sex‐specific predicted 10‐year CVD risk scores using the Framingham CVD risk score (Framingham) and the Pooled Cohort Equation at baseline. Perceived fatigability was assessed using the Borg rating of perceived exertion scale after a 5‐minute treadmill walk (0.67 m/s, 0% grade). Linear models were used to assess the association between baseline CVD risk and perceived fatigability an average of 4.5 years later, adjusted for demographics, behaviors, and medical history. In final models, a 5% higher baseline Pooled Cohort Equation score was associated with greater perceived fatigability at follow‐up (β=0.13 rating of perceived exertion, P=0.008). Stratified analyses suggested this association was stronger among those aged ≤70 years and those with obesity. Of the individual CVD risk score components, older age was most strongly associated with perceived fatigability (β=0.48, P<0.001), followed by women (β=0.11, P=0.002), and treated hypertension (β=0.11, P=0.003). There was no association with the Framingham risk score.

Conclusions

Perceived fatigability was higher among participants with greater CVD risk measured using the Pooled Cohort Equation risk score. The strong associations with hypertension and obesity suggest prevention and promotion of cardiovascular health may also lower perceived fatigability, particularly among those aged ≤70 years or living with obesity.

[Inflammation and osteoarthritis-related pain]

Osteoarthritis (OA) is one of the major causes of chronic pain. Although OA has long been considered a non-inflammatory "wear and tear" disease leading to loss of articular cartilage, recent findings provide convincing evidence that inflammatory mechanisms play a pivotal role in the pathophysiology of OA. In OA mononuclear cells (e. g. T‑cells and macrophages) infiltrate the synovial membrane and the levels of pro-inflammatory cytokines in peripheral blood and synovial fluid samples are elevated. Increased release of inflammatory mediators including interleukin (IL) IL-1β, IL-6, IL-8, IL-15 und tumor necrosis factor alpha (TNF‑α) induces the expression of proteolytic enzymes such as matrix metalloproteinases resulting in cartilage breakdown. Molecular and cellular interactions between the immune and nervous system are also involved in the development of OA-related pain. Inflammatory mediators including IL-6 und TNF‑α lead to peripheral sensitization of joint nociceptors and growth factors (e. g. NGF) trigger the expression of TRPV1 channels in primary afferents. Moreover, neuropeptides reduce the threshold of nociceptors of OA joints. The current review highlights the role of inflammatory mechanisms in OA-induced joint pain considering clinical signs of inflammation and major inflammatory pathways.

Development of a Robotic Unloader Brace for Investigation of Conservative Treatment of Medial Knee Osteoarthritis

Knee osteoarthritis (KOA) is a painful and debilitating condition that is associated with mechanical loading of the knee joint. Numerous conservative treatment strategies have been developed to delay time to total joint replacement. Unloader braces are commonly prescribed for medial uni-compartmental KOA, however their evidence of efficacy is inconclusive and limited by user compliance. Typical commercial braces transfer load from the medial knee compartment to the lateral knee compartment by applying a continuous brace abduction moment (BAM). We propose that brace utilization and effectiveness could be improved with a robotic device that intelligently modulates BAM in real time over the course of a step, day, and year to better protect the knee joint, improve pain relief, and increase comfort. To this end, we developed a robotic unloader knee brace ABLE (active brace for laboratory exploration) to flexibly emulate and explore different active and passive brace behaviors that may be more efficacious than traditional braces. The system is capable of modulating BAM within each step per researcher defined unloading profiles. ABLE was realized as a lightweight orthosis driven by an off-board system containing a servo motor, drive, real-time controller, and host PC. Frequency response and intra-step trajectory tracking during level-ground walking were evaluated in a single healthy human subject test to verify system performance. The system tracked BAM vs percent gait cycle trajectories with a root mean square error of 0.18 to 0.58 Nm for conditions varying in walking speed, 85-115% nominal, and trajectory peak BAM, 2.7 to 8.1 Nm. Biomechanical and subjective outcomes will be evaluated next for KOA patients to investigate how novel robotic brace operation affects pain relief, comfort, and KOA progression.

Effects of electromagnetic fields on osteoarthritis

Osteoarthritis (OA), characterized by joint malfunction and chronic disability, is the most common form of arthritis. The pathogenesis of OA is unclear, yet studies have shown that it is due to an imbalance between the synthesis and decomposition of chondrocytes, cell matrices and subchondral bone, which leads to the degeneration of articular cartilage. Currently, there are many therapies that can be used to treat OA, including the use of pulsed electromagnetic fields (PEMFs). PEMFs stimulate proliferation of chondrocytes and exert a protective effect on the catabolic environment. Furthermore, this technique is beneficial for subchondral trabecular bone microarchitecture and the prevention of subchondral bone loss, ultimately blocking the progression of OA. However, it is still unknown whether PEMFs could be used to treat OA in the clinic. Furthermore, the deeper signaling pathways underlying the mechanism by which PEMFs influence OA remain unclear.

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.

Concurrent Change in Quadriceps Strength and Physical Function Over Five Years in the Multicenter Osteoarthritis Study

OBJECTIVE

Quadriceps weakness, associated with functional limitations, is a target of treatment of knee osteoarthritis (OA). Limited data exist on the relationship between modest strength increases and improvements in function. The aim of this study was to evaluate concurrent change in strength and physical function over 5 years.

METHODS

Among subjects from the Multicenter Osteoarthritis (MOST) study, we excluded those with knee replacement after baseline. A 3-category variable defined whether, at 5 years, knee extensor strength increased, decreased, or remained within 15% of baseline, a clinically important cut-off. The outcomes were the 5-times sit-to-stand test, 20-meter walk test, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) physical function score, and 3 individual physical functions from WOMAC: arising from a chair, going up stairs, and getting on/off toilet. Linear and logistic models, stratified by sex, evaluated associations between change in strength and change in physical function over 5 years. To compare weaker versus stronger women, we stratified analyses at 56 Nm baseline strength.

RESULTS

Among 1,534 participants (60.6% women), 22% of men and 30% of women increased strength by at least 15% at 5 years. Compared with women whose strength did not change, women whose strength increased had improved chair stand performance (odds ratio 2.27 [95% confidence interval 1.56, 3.30]) but no improvement in other functions. In men, an increase in strength was not associated with significant improvement in physical function. Similar results were observed for a 20% or 30% increase.

CONCLUSION

Modest improvement in quadriceps strength was associated with improved chair stand performance in women but not in men. Most functions did not improve with an increase in strength, and targeted interventions may be required to improve functional status.

CDH2 gene rs11564299 polymorphism is a risk factor for knee osteoarthritis in a Chinese population: a case-control study

Background

Cadherin-2 (CDH2) gene polymorphisms were reported to be associated with the induction and development of knee osteoarthritis (OA).

Methods

This case–control study was designed to explore the association between CDH2 gene rs11564299 polymorphism and the risk of knee OA in Chinese subjects. The polymorphism was genotyped by polymerase chain reaction and Sanger sequencing.

Results

G allele or GG genotype of CDH2 gene rs11564299 polymorphism was related to increased risk for knee OA in the Chinese Han population. Additionally, subgroup analyses indicated that the female, smoker, drinker, and BMI ≥ 25 kg/m² groups showed increased risk for knee OA. Additionally, this polymorphism was associated with CRP and Kellgren–Lawrence grade.

Conclusion

In summary, this current study reveals that CDH2 gene rs11564299 polymorphism is a risk factor for knee OA development in this Chinese population. The genotypes distribution differed significantly among OA patients and healthy controls and may be a useful tool in the evaluation of OA susceptibility in Chinese Han population.

Stair climbing ability in patients with early knee osteoarthritis: Defining the clinical hallmarks of early disease

BACKGROUND

A growing clinical interest has been shown towards identifying knee osteoarthritis (OA) patients at earlier stages. The early detection of knee OA may allow for more effective interventions.

RESEARCH QUESTION

The aim of this study was to determine the discriminative ability of a stair-climb test (SCT) in identifying patients with early knee OA, and to determine if descending stair time during the SCT is better than ascending stair time for the identification of these patients.

METHODS

This study was a secondary, cross-sectional analysis of baseline data from a randomized controlled trial. Adults with moderate to severe knee pain were enrolled (n = 57; mean age 58.9 years; 71.9% women). Each participant performed an 11-step SCT (11-SCT) while wearing shoes with a pressure sensor insole. A receiver operating characteristic analysis was used to examine the discriminative power of 11-SCT for identifying early knee OA (Kellgren and Lawrence grade 1). The discriminative power was also compared between the ascending and descending 11-SCT time as evaluated by the pressure sensor.

RESULTS

The 11-SCT time in patients with early knee OA was 0.55 s longer than that in those with symptomatic non-radiographic OA. A one-second increase in the 11-SCT time was significantly associated with 1.9-fold increased odds of early knee OA being present. The 11-SCT value with the best balance of sensitivity and specificity for identifying early knee OA was 8.33 s (area under the curve: 0.711). The descending time was not significantly better than the ascending time for identifying early knee OA.

SIGNIFICANCE

This study determined the time values of an 11-SCT that may be useful for identifying early knee OA patients. These preliminary findings may serve as the foundation for future studies investigating the clinical hallmarks associated with early knee OA.

The use of patient-specific equipoise to support shared decision-making for clinical care and enrollment into clinical trials

Background:

To enhance enrollment into randomized clinical trials (RCTs), we proposed electronic health record-based clinical decision support for patient–clinician shared decision-making about care and RCT enrollment, based on “mathematical equipoise.”

Objectives:

As an example, we created the Knee Osteoarthritis Mathematical Equipoise Tool (KOMET) to determine the presence of patient-specific equipoise between treatments for the choice between total knee replacement (TKR) and nonsurgical treatment of advanced knee osteoarthritis.

Methods:

With input from patients and clinicians about important pain and physical function treatment outcomes, we created a database from non-RCT sources of knee osteoarthritis outcomes. We then developed multivariable linear regression models that predict 1-year individual-patient knee pain and physical function outcomes for TKR and for nonsurgical treatment. These predictions allowed detecting mathematical equipoise between these two options for patients eligible for TKR. Decision support software was developed to graphically illustrate, for a given patient, the degree of overlap of pain and functional outcomes between the treatments and was pilot tested for usability, responsiveness, and as support for shared decision-making.

Results:

The KOMET predictive regression model for knee pain had four patient-specific variables, and an r² value of 0.32, and the model for physical functioning included six patient-specific variables, and an r² of 0.34. These models were incorporated into prototype KOMET decision support software and pilot tested in clinics, and were generally well received.

Conclusions:

Use of predictive models and mathematical equipoise may help discern patient-specific equipoise to support shared decision-making for selecting between alternative treatments and considering enrollment into an RCT.

Racial Differences in Change in Physical Functioning in Older Male Veterans with HIV

Little is known about longitudinal change in physical functioning of older African American/Black and White HIV-infected persons. We examined up to 10 years of data on African American (N = 1,157) and White (N = 400) men with HIV infection and comparable HIV-negative men (n = 1,137 and 530, respectively), age 50-91 years from the Veterans Aging Cohort Study Survey sample. Physical functioning was assessed using the SF-12 (12-Item Short Form Health Survey) physical component summary (PCS) score. Mixed-effects models examined association of demographics, health conditions, health behaviors, and selected interactions with PCS score; HIV biomarkers were evaluated for HIV-infected persons. PCS scores were approximately one standard deviation below that of the general U.S. population of similar age. Across the four HIV/race groups, over time and through ages 65-75 years, PCS scores were maintained; differences were not clinically significant. PCS score was not associated with race or with interactions among age, race, and HIV status. CD4 and viral load counts of African American and White HIV-infected men were similar. Older age, low socioeconomic status, chronic health conditions and depression, lower body mass index, and smoking were associated with poorer PCS score in both groups. Exercising and, counterintuitively, being HIV infected were associated with better PCS score. Among these older African American and White male veterans, neither race nor HIV status was associated with PCS score, which remained relatively stable over time. Chronic disease, depression, and lack of exercise were associated with lower PCS score. To maintain independence in this population, attention should be paid to controlling chronic conditions, and emphasizing good health behaviors.

Single-staged Bilateral Revision Knee Prosthesis Results

Total knee arthroplasty (TKA) can become impaired in the functionality of the bone-prosthetic unit for various reasons, thereby leading to prosthetic loosening. For patients with bilateral aseptic loosening, revision knee arthroplasty surgery is usually performed in different sessions. Today, with developing anesthetic techniques, the patients' intraoperative and postoperative additional medical treatment needs are reduced; there is a reduction in complication rates too. Complications such as laryngospasm, bronchospasm, malignant hyperthermia, respiratory depression, postoperative delirium, or cognitive dysfunction can be seen. In the postoperative period, patient satisfaction, with adequate pain control, makes the rehabilitation of the knee is easier and shortens the duration of hospital stay. In addition, the risks of complications such as deep venous thrombosis, pulmonary embolism, pneumonia, and urinary retention are decreased with early rehabilitation, preventing the development of arthrofibrosis. Maximum recovery in the early postoperative period may be possible with the early recovery of movement. Between the years 2017 and 2018, patients admitted to our hospital for bilateral TKA application due to bilateral aseptic loosening and the early results of the application of bilateral revision TKA in one session with four selected patients are compared according to the requirements for blood transfusion and overall costs. Patient selection was shared with the anesthesiologist and the decision to continue bilaterally was made in the intraoperative assessment. In patients who did not develop any pathologies in the initial operation, the second operation was performed, where the risks of the second operation were not taken into account. As a result, we conclude that bilateral revision TKA application on correct patient selection is a surgical procedure that can be performed safely by an experienced team.

Comorbidities in Patients With End-Stage Knee OA: Prevalence and Effect on Physical Function

OBJECTIVE

To investigate the prevalence of comorbidities and their effect on physical function, quality of life (QOL), and pain, in patients with end-stage knee osteoarthritis (OA).

DESIGN

A cross-sectional study.

SETTING

A rehabilitation facility at university hospital.

PARTICIPANTS

Patients (N=577; 503 women and 74 men) diagnosed with end-stage knee OA between October 2013 and June 2018.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Comorbidities were as follows: osteoporosis, presarcopenia, degenerative spine disease, diabetes, and hypertension. All patients completed the following performance-based physical function tests: stair-climbing test (SCT), 6-minute walk test (6MWT), timed Up and Go (TUG) test, and gait analysis. Self-reported physical function and pain were measured using Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and a visual analog scale (VAS), respectively, and self-reported QOL was measured using EuroQoL 5 dimensions (EQ-5D) questionnaire.

RESULTS

Univariate analyses revealed that patients with osteoporosis had significantly higher scores in SCT ascent, SCT descent, TUG, WOMAC pain tests, and lower scores in 6MWT, gait speed, and cadence tests than those without osteoporosis. Patients with presarcopenia recorded higher scores in SCT ascent, TUG, EQ-5D, and lower scores in 6MWT and gait speed tests than those without presarcopenia. Patients with degenerative spine disease showed higher scores in WOMAC pain and lower scores in gait speeds than those without degenerative spine disease. Patients with diabetes showed higher scores in SCT ascent than those without diabetes, and patients with hypertension showed lower scores in 6MWT than those without hypertension. After adjusting age, sex, and body mass index, SCT descent retained significant association with osteoporosis, SCT ascent showed independent association with presarcopenia and diabetes, and WOMAC pain revealed significant association with degenerative spine disease.

CONCLUSION

The results confirm associations between comorbidities, performance-based and self-reported physical functions, and QOL in patients with end-stage knee OA.

Predicting knee osteoarthritis severity: comparative modeling based on patient's data and plain X-ray images

Knee osteoarthritis (KOA) is a disease that impairs knee function and causes pain. A radiologist reviews knee X-ray images and grades the severity level of the impairments according to the Kellgren and Lawrence grading scheme; a five-point ordinal scale (0-4). In this study, we used Elastic Net (EN) and Random Forests (RF) to build predictive models using patient assessment data (i.e. signs and symptoms of both knees and medication use) and a convolution neural network (CNN) trained using X-ray images only. Linear mixed effect models (LMM) were used to model the within subject correlation between the two knees. The root mean squared error for the CNN, EN, and RF models was 0.77, 0.97 and 0.94 respectively. The LMM shows similar overall prediction accuracy as the EN regression but correctly accounted for the hierarchical structure of the data resulting in more reliable inference. Useful explanatory variables were identified that could be used for patient monitoring before X-ray imaging. Our analyses suggest that the models trained for predicting the KOA severity levels achieve comparable results when modeling X-ray images and patient data. The subjectivity in the KL grade is still a primary concern.

Preoperative high-intensity strength training improves postural control after TKA: randomized-controlled trial

PURPOSE

This study investigates the effectiveness of preoperative high-intensity strength training (with a special emphasis on lower limb muscle strength and secondarily on balance training) on postural control after TKA.

METHODS

Forty-four subjects (7 men, 37 women, and mean age 66.7 ± 3.9 years) scheduled for unilateral TKA for osteoarthritis (OA) participated in this randomized-controlled trial. Each patient performed two postural control tests: Romberg test with eyes open and closed. These tests were assessed at 8 weeks before surgery (T1), after 8 weeks of training (T2), 1 month after TKA (T3), and finally 3 months after TKA (T4). The intervention group completed an 8-week training program 3 days per week prior to surgery, while the control group received no intervention.

RESULTS

The Center of Pressure area (COP) was lower (i.e., better score) for the intervention group at T2, T3, and T4. The anteroposterior range of COP with eyes open was lower in the intervention group at T2, T3, and T4 and with eyes closed at T2. The medial-lateral standard deviation of COP with eyes open was lower in the intervention group at T2 and T4 and with eyes closed at T2 and T3. The anteroposterior standard deviation of COP with eyes open did not change, while that with eyes closed the intervention group showed lower score at T2.

CONCLUSION

Preoperative high-intensity strength training is effective for improving postural control before and early after TKA. Recommendations should include preoperative strength training, and not only balance training, to speed-up recovery of postural control after TKA.

LEVEL OF EVIDENCE

1.

Validation of a new symptom outcome for knee osteoarthritis: the Ambulation Adjusted Score for Knee pain

OBJECTIVE

Validation of a symptom measure for early knee OA may help identify new treatments and modifiable risk factors. Symptom measures that consider pain in the context of activity level may provide better discrimination than pain alone. Therefore, we aimed to compare sensitivity to change for radiographic progression between Ambulation Adjusted Score for Knee pain (AASK), which accounts for self-reported ambulation, and Western Ontario McMaster Osteoarthritis (WOMAC) knee pain score.

DESIGN

Participants were assessed annually up to 48 months using WOMAC, Physical Activity Scale for the Elderly (PASE) ambulation, and knee radiographs. AASK was defined as ((WOMAC pain) + 1)/((average daily hours of walking) + 1). Radiographs were scored for Kellgren-Lawrence (KL) grade. Linear regression, stratified by OA status, evaluated relationships between changes in AASK and WOMAC pain and KL grade over time.

RESULTS

For 4191 people (8030 knees), the mean age was 61.2 (+ 9.2) years old and BMI was 28.6 (+ 4.8) kg/m2; 58% female. Over 40% of knees had WOMAC pain scores of 0; by design, no knees had AASK scores of 0. Annual changes in AASK were more sensitive to changes in KL than changes in WOMAC in those without baseline OA (0.20 and 0.16 change per unit KL change, p = 0.005 and 0.070 respectively), but performed similarly in knees with OA.

CONCLUSION

AASK is simple to assess using existing validated questionnaires. AASK performs well in individuals with and without OA and should be considered in clinical trials and observational studies of early knee OA.

Developing strategic priorities in osteoarthritis research: Proceedings and recommendations arising from the 2017 Australian Osteoarthritis Summit

Background

There is a pressing need to enhance osteoarthritis (OA) research to find ways of alleviating its enormous individual and societal impact due to the high prevalence, associated disability, and extensive costs.

Methods

Potential research priorities and initial rankings were pre-identified via surveys and the 1000Minds process by OA consumers and the research community. The OA Summit was held to decide key research priorities that match the strengths and expertise of the Australian OA research community and align with the needs of consumers. Facilitated breakout sessions were conducted to identify initiatives and strategies to advance OA research into agreed priority areas, and foster collaboration in OA research by forming research networks.

Results

From the pre-Summit activities, the three research priority areas identified were: treatment adherence and behaviour change, disease modification, and prevention of OA. Eighty-five Australian and international leading OA experts participated in the Summit, including specialists, allied health practitioners, researchers from all states of Australia representing both universities and medical research institutes; representatives from Arthritis Australia, health insurers; and persons living with OA. Through the presentations and discussions during the Summit, there was a broad consensus on the OA research priorities across stakeholders and how these can be supported across government, industry, service providers and consumers.

Conclusion

The Australian OA Summit brought consumers, experts and opinion leaders together to identify OA research priorities, to enhance current research efforts by fostering collaboration that offer the greatest potential for alleviating the disease burden.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2455-x) contains supplementary material, which is available to authorized users.

Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States

Background

Community characteristics such as poverty affect total knee arthroplasty (TKA) outcomes. However, it is unknown whether other community factors such as immigrant proportion (IP) also affect outcomes. Our objective was to determine the association of neighborhood IP on preoperative (pre-op) and 2-year postoperative (post-op) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function after elective TKA.

Methods

Patients in a high volume institutional TKA registry between May 2007 and February 2011 were retrospectively analyzed. Demographics, pre-op and 2-year post-op WOMAC pain and function scores, and geocodable addresses were obtained. Patient-level variables were linked to US Census Bureau census tract data. The effect of patient and neighborhood-level factors on WOMAC scores were analyzed using linear mixed effects models.

Results

3898 TKA patients were analyzed. Pre-op and 2-year post-op WOMAC pain and function scores were between 2.75–4.88 WOMAC points worse in neighborhoods with a high IP (≥ 40%) compared to low IP (< 10%). In multivariable analyses, these differences were not statistically significant. Women had worse pre-op and 2-year post-op WOMAC scores (all p ≤ 0.04), but this difference was not influenced by neighborhood IP (all p_interaction NS).

Conclusions

Patients living in high (≥40%) IP neighborhoods do not have worse pre-op or 2-year post-op pain and function outcomes after TKA compared to those living in low (< 10%) IP neighborhoods. Although sex differences favoring males are notable, these differences are not associated with IP. High neighborhood IP do not appear to affect outcomes after TKA.

Concurrent validity and measurement error of stair climb test in people with pre-radiographic to mild knee osteoarthritis

BACKGROUND

Stair climbing is the task first affected in patients with knee osteoarthritis (OA); therefore, the precise measurement of time required to climb stairs is important to identify mobility limitations, particularly in the early phase of knee OA.

RESEARCH QUESTION

This study aimed to examine the test-retest reliability, measurement error, and concurrent validity of the stopwatch-based stair-climb test (SCT) in adults with pre-radiographic to mild knee OA.

METHODS

Fifty-nine participants (mean age, 59.1 [range, 50-69] years; 72.9% female) with Kellgren and Lawrence grade ≤2 disease underwent an 11-step SCT (11-SCT) in accordance with the Osteoarthritis Research Society International recommended method while wearing pressure sensor-mounted standard shoes that is used as a gold standard procedure. Test-retest reliability, measurement errors, and the concurrent validity of the stopwatch-based 11-SCT were evaluated.

RESULTS

The test-retest reliability of the stopwatch-based 11-SCT was excellent (intra-class correlation coefficient_1,1 [ICC_1,1], 0.952; 95% confidence interval [CI], 0.560 to 0.985; p <  0.001) and the minimal detectable change₉₅ was 0.102 s. Concurrent validity was excellent (ICC_2,1: 0.957; 95% CI: 0.661 to 0.986; p <  0.001).

SIGNIFICANCE

The stopwatch-based 11-SCT had high test-retest reliability and high concurrent validity, which justify its clinical use for identifying mobility limitations in individuals with pre-radiographic to mild knee OA. A difference of 0.2 s in the stopwatch-based 11-SCT time would be considered a true difference beyond a 95% measurement error.

Validation of the Fitbit Charge 2 compared to the ActiGraph GT3X+ in older adults with knee osteoarthritis in free-living conditions

Objective

To evaluate physical activity (PA) and sedentary time in subjects with knee osteoarthritis (OA) measured by the Fitbit Charge 2 (Fitbit) and a wrist-worn ActiGraph GT3X+ (AGW) compared to the hip-worn ActiGraph (AGH).

Design

We recruited a cohort of subjects with knee OA from rheumatology clinics. Subjects wore the AGH for four weeks, AGW for two weeks, and Fitbit for two weeks over a four-week study period. We collected accelerometer counts (ActiGraphs) and steps (ActiGraphs, Fitbit) and calculated time spent in sedentary, light, and moderate-to-vigorous activity. We used triaxial PA intensity count cut-points from the literature for ActiGraph and a stride length-based cadence algorithm to categorize Fitbit PA. We compared Fitbit wear times calculated from a step-based algorithm and a novel algorithm that incorporates steps and heart rate (HR).

Results

We enrolled 15 subjects (67% female, mean age 68 years). Relative to AGH, Fitbit, on average, overestimated steps by 39% and sedentary time by 37% and underestimated MVPA by 5 minutes. Relative to AGH, AGW overestimated steps 116%, underestimated sedentary time by 66%, and captured 281 additional MVPA minutes. The step-based wear time Fitbit algorithm captured 14% less wear time than the HR-based algorithm.

Conclusions

Fitbit overestimates steps and underestimates MVPA in knee OA subjects. Cut-offs validated for AGW should be developed to support the use of AGW for PA assessment. The HR-based Fitbit algorithm captured more wear time than the step-based algorithm. These data provide critical insight for researchers planning to use commercially-available accelerometers in pragmatic studies.

Proprietary Milk Protein Concentrate Reduces Joint Discomfort While Improving Exercise Performance in Non-Osteoarthritic Individuals

Milk and dairy products are known to contain various bioactives with potential anti-inflammatory and immune modulating effects. Previous research has indicated that milk produced from hyperimmunized cows provided meaningful health benefits to individuals suffering from varying degrees of osteoarthritis and rheumatoid arthritis. PURPOSE: To examine the impact of a proprietary milk protein concentrate on joint discomfort and physical function, exercise performance, quality of life and various measures of affect. METHODS: Non-osteoarthritic men (42.5 ± 8.9 years, 176.7 ± 6.7 cm, 89.9 ± 11.5 kg, 28.8 ± 3.5 kg/m², n = 30) and women (46.4 ± 9.6 years, 163.1 ± 8.2 cm, 72.2 ± 13.1 kg, 27.2 ± 5.3 kg/m², n = 28) with mild to moderate knee pain during physical activity were randomized in a double-blind, placebo-controlled fashion to consume daily either a placebo (PLA) or proprietary milk protein concentrate (MP) for a period of 8 weeks. Participants completed a functional capacity test pre and post-supplementation and completed visual analog scales (VAS), a 6-min walking test, WOMAC and profile of mood states (POMS) to assess changes in joint health, discomfort, physical function, exercise performance and affect. Mixed factorial ANOVA was used for all statistical analysis and significance was set a priori at p ≤ 0.05. RESULTS: Distance covered in the 6-min walking significantly improved 9% in MP versus 2% in PLA (mean difference: 110 ± 43 m, p = 0.012) in addition to 11 WOMAC components and 5 VAS reflective of MP improving joint health, discomfort and joint stability (all p < 0.05 vs. PLA). Additionally, MP also improved overall perceptions of neck and back health compared to PLA. Serum and whole blood indicators of clinical safety remained within normal ranges throughout the study. CONCLUSIONS: In comparison to placebo, daily doses of proprietary milk protein concentrate yielded improvements in several components of the WOMAC, multiple visual analog scales indicative of joint health and stability, discomfort and pain, as well as significant improvements in distance covered during a 6-min walking test. Supplementation was well tolerated with no significant changes in whole-blood or serum markers of clinical safety.

Optimizing Clinical Use of Biologics in Orthopaedic Surgery: Consensus Recommendations From the 2018 AAOS/NIH U-13 Conference

Concern that misinformation from direct-to-consumer marketing of largely unproven "biologic" treatments such as platelet-rich plasma and cell-based therapies may erode the public trust and the responsible investment needed to bring legitimate biological therapies to patients have resulted in calls to action from professional organizations and governing bodies. In response to substantial patient demand for biologic treatment of orthopaedic conditions, the American Academy of Orthopaedic Surgeons convened a collaborative symposium and established a consensus framework for improving and accelerating the clinical evaluation, use, and optimization of biologic therapies for musculoskeletal diseases. The economic and disease burden of musculoskeletal conditions is high. Of the various conditions discussed, knee osteoarthritis was identified as a "serious condition" associated with substantial and progressive morbidity and emerged as the condition with the most urgent need for clinical trial development. It was also recognized that stem cells have unique characteristics that are not met by minimally manipulated mixed cell preparations. The work group recommended that minimally manipulated cell products be referred to as cell therapy and that the untested and uncharacterized nature of these treatments be clearly communicated within the profession, to patients, and to the public. Minimum standards for product characterization and clinical research should also be followed. A framework for developing clinical trials related to knee OA was agreed upon. In addition to recommendations for development of high-quality multicenter clinical trials, another important recommendation was that physicians and institutions offering biologic therapies commit to establishing high-quality patient registries and biorepository-linked registries that can be used for postmarket surveillance and quality assessments.

Kinesio Taping Improves Perceptions of Pain and Function of Patients With Knee Osteoarthritis: A Randomized, Controlled Trial

Context: Although increasingly used for therapeutic treatment, only limited evidence exists regarding the effects of kinesio taping on patients with knee osteoarthritis (OA). Objective: To determine the effects of kinesio taping on pain, function, gait, and neuromuscular control concerning patients with knee OA. Design: Randomized sham-controlled trial. Setting: University laboratory. Participants: A total of 141 patients (65.1 [7.0] y) with a clinical and radiographic diagnosis of knee OA. Intervention: Kinesio tape, sham tape, or no tape for 3 consecutive days. Main Outcome Measures: Self-reported pain, stiffness, and function were measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Further tests included the Balance Error Scoring System, 10-m walk test, the maximum voluntary isometric contraction force of the quadriceps femoris, and knee active range of motion. Results: At baseline, there were no differences in all outcomes between groups except for knee flexion. Significant effects were found for WOMAC pain (tape vs sham, P = .05; tape vs control, P = .047), stiffness (tape vs sham, P = .01; tape vs control, P ≤ .001), and physical function (tape vs sham, P = .03; tape vs control P = .004). No interactions were found for balance, muscle strength, walking speed, or active range of motion. Conclusion: Wearing kinesio tape for 3 consecutive days had beneficial effects regarding self-reported clinical outcomes of pain, joint stiffness, and function. This emphasizes that kinesio taping might be an adequate conservative treatment for the symptoms of knee OA.

Effects of isokinetic muscle strengthening on balance, proprioception, and physical function in bilateral knee osteoarthritis patients with moderate fall risk

OBJECTIVES

This study aims to assess the effects of isokinetic quadriceps and hamstring strengthening exercises on balance, proprioception, and physical function in patients with moderate-to-severe knee osteoarthritis and moderate fall risk.

PATIENTS AND METHODS

Between November 2011 and December 2012, a total of 39 participants (30 females, 9 males; mean age 61.7±8.6 years; range, 18 to 79 years) with Grade 2 or 3 knee osteoarthritis according to the Kellgren-Lawrence radiographic grading system and moderate risk of fall with active knee pain were included in this study. All participants received isokinetic quadriceps and hamstring strengthening exercises for six weeks. Pre-treatment quadriceps and hamstring muscle strength (peak torque and total work value) and quadriceps to hamstring muscle strength ratio at angular velocities of 60°/sec and 180°/sec, range of motion (ROM), average proprioceptive errors at 15-45° and 30-60°, the Berg Balance Scale (BBS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscale scores, the Visual Analog Scale (VAS) scores, and physical function tests results were compared with the post-treatment results. The correlations of pre- and post-treatment BBS and average proprioceptive error at 15-45° and 30-60° changes to other pre- and post-treatment clinical measurements changes were calculated.

RESULTS

Post-treatment quadriceps and hamstring muscle strength at angular velocities of 60°/sec and 180°/sec and quadriceps to hamstring muscle strength ratios at angular velocity of 60°/sec, ROM, average proprioceptive errors at 15-45° and 30-60°, BBS scores, WOMAC subscale scores, VAS scores, and physical function tests significantly improved compared to the pre-treatment results (p<0.001). Statistically significant correlations were found between the pre- and post-treatment BBS score changes and pre- and post-treatment VAS (p=0.015), WOMAC-Pain (p=0.017), WOMAC-Physical Function (p=0.005) scores and Timed Up and Go Test (p=0.036) scores.

CONCLUSION

Inclusion of isokinetic quadriceps and hamstring strengthening exercises into the rehabilitation programs for the patients with knee osteoarthritis may improve the quality of life and contribute to the decreased risk of fall.

The Predictive Validity of Physical Performance Measures in Determining Markers of Preclinical Disability in Community-Dwelling Middle-Aged and Older Adults: A Systematic Review

BACKGROUND

Identification of preclinical disability in middle-aged and older adults might allow early identification of and treatment for functional mobility deficits.

PURPOSE

This study aimed to determine which physical performance measures (PPMs) were effective in identifying preclinical disability in individuals at risk for future disability.

DATA SOURCES

CINHAL, PubMed, Scopus, and Web of Science databases were searched until September 2017 using key words.

STUDY SELECTION

Two individuals screened peer-reviewed prospective longitudinal studies that assessed healthy individuals > 45 years old using PPMs at baseline. Eight studies met inclusion criteria.

DATA EXTRACTION

Two individuals extracted data on participant demographics, PPMs, predictive validity effect size, and disability outcomes. Risk of bias was assessed using the Quality Assessment Tool for Cohort Studies II (Q-Coh II).

DATA SYNTHESIS

Four constructs were used to guide data synthesis: functional mobility, activities of daily living disability, fall(s), and hospitalization. Multiple sit-to-stands from a chair, standing balance, and gait speed were found to have some merit in identifying preclinical disability across all 4 disability constructs. All studies were scored as good-quality studies using the Q-Coh II.

LIMITATIONS

The heterogeneity in follow-up times and reporting of risk prediction statistics made it difficult to compare results across studies, PPMs, and constructs. The 4 constructs used as markers of preclinical disability potentially do not fully capture the progression of disability.

CONCLUSIONS

Physical therapists should consider using PPMs on healthy adult populations to gather baseline data during annual health screens for use in identifying preclinical disability.

Preservation of Knee Articular Cartilage

Hyaline articular cartilage is critical for the normal functioning of the knee joint. Untreated focal cartilage defects have the potential to rapidly progress to diffuse osteoarthritis. Over the last several decades, a variety of interventions aiming at preserving articular cartilage and preventing osteoarthritis have been investigated. Reparative cartilage procedures, such as microfracture, penetrate the subchondral bone plate in effort to fill focal cartilage defects with marrow elements and stimulate fibrocartilaginous repair. In contrast, restorative cartilage procedures aim to replace the defective articular surface with autologous or allogeneic hyaline cartilage. This review focuses on the preservation of articular cartilage, and discusses the current reparative and restorative surgical techniques available for treating focal cartilage defects.

The efficacy of electromyographic biofeedback on pain, function, and maximal thickness of vastus medialis oblique muscle in patients with knee osteoarthritis: a randomized clinical trial

INTRODUCTION

The aim of this survey was to examine the effect of adding electromyographic biofeedback (EMGBF) to isometric exercise, on pain, function, thickness, and maximal electrical activity in isometric contraction of the vastus medialis oblique (VMO) muscle in patients with knee osteoarthritis (OA).

METHODS

In this clinical trial, 46 patients with a diagnosis of knee OA were recruited and assigned to two groups. The case group consisted of 23 patients with EMGBF-associated exercise, and the control group was made up of 23 patients with only isometric exercise. Data were gathered via visual analog scale (VAS) score, the Persian version of the Western Ontario and McMaster Universities Osteoarthritis Index and Lequesne questionnaires, ultrasonography of the VMO, and surface electromyography of this muscle at baseline and at the end of the study. Variables were compared before and after the exercise program in each group and between the two groups.

RESULTS

At the end of the study, there were no significant differences between the two groups regarding measured variables. Only the VAS score was significantly less in the case group. Although all assessed parameters, except for VMO muscle thickness, were found to be improved significantly in each group, the degree of change was not significantly different between the two groups, except for VAS score. VMO muscle thickness did not change significantly after exercise therapy in either of the groups.

CONCLUSION

Isometric exercises accompanied by EMGBF and the same exercises without biofeedback for 2 months both led to significant improvements in pain and function of patients with knee OA. Real EMGBF was not superior to exercise without biofeedback in any of the measured variables, except for VAS score.

Total Hip Arthroplasty Improves the Quality-Adjusted Life Years in Patients Who Exceeded the Estimated Life Expectancy

BACKGROUND

Hip osteoarthritis is a leading cause of functional decline and disability in the elderly. Although patients older than 80 years could significantly benefit from an elective total hip arthroplasty (THA), they pose a significant challenge to both anesthesiologist and arthroplasty surgeon. The purpose of this study was to report the clinical outcomes, complication rate, mortality, and quality-adjusted life year (QALY) of THA in patients who already exceeded the average life expectancy.

METHODS

Patients treated with elective THA for debilitating hip osteoarthritis and already exceeded the average life expectancy in Switzerland (n = 100) were included. The complication rate, QALY, and 30-day, 1-year, and midterm mortality were assessed retrospectively.

RESULTS

The overall complication rate was 12%. The 30-day and 1-year mortality was 3% and 6%, respectively. The Harris hip score increased significantly from an average of 50 preoperative to 93 points postoperative. Most of the patients (98%) had an improvement in the Harris hip score that was above the threshold for minimally significant change, whereas 75% reported an increase that exceeded the moderate improvement threshold. The average QALY was 4 years.

CONCLUSION

THA might be a safe and cost-effective procedure for improving pain, function, and quality of life with low mortality in selected elderly patients who already exceeded the average life expectancy. Hence, the arthroplasty surgeons should not hesitate to operate relatively active, independent, and cognitively intact elderly patients having debilitating hip osteoarthritis based only on the patient's age. Nevertheless, careful patient selection, surgical indications, and aggressive perioperative optimization might be necessary to minimize the risk of preoperative complications.

A phase I-II controlled randomized trial using a promising novel cell-free formulation for articular cartilage regeneration as treatment of severe osteoarthritis of the knee

BACKGROUND

A promising novel cell-free bioactive formulation for articular cartilage regeneration, called BIOF2, has recently been tested in pre-clinical trials. The aim of the present study was to evaluate the efficacy and safety of BIOF2 for intra-articular application in patients with severe osteoarthritis of the knee.

METHODS

A prospective, randomized, 3-arm, parallel group clinical trial was conducted. It included 24 patients with severe osteoarthritis of the knee (WOMAC score 65.9 ± 17). Before they entered the study, all the patients were under osteoarthritis control through the standard treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), prescribed by their family physician. Patients were distributed into three groups of 8 patients each (intra-articular BIOF2, total joint arthroplasty, or conservative treatment with NSAIDs alone). The WOMAC score, RAPID3 score, and Rasmussen clinical score were evaluated before treatment and at months 3, 6, and 12. BIOF2 was applied at months 0, 3, and 6. Complete blood count and blood chemistry parameters were determined in the BIOF2 group before treatment, at 72 h, and at months 1, 3, 6, and 12. In addition, articular cartilage volume was evaluated (according to MRI) at the beginning of the study and at month 12.

RESULTS

The NSAID group showed no improvement at follow-up. Arthroplasty and BIOF2 treatments showed significant improvement in all the scoring scales starting at month 3. There were no statistically significant differences between the BIOF2 group and the arthroplasty group at month 6 (WOMAC score: 19.3 ± 18 vs 4.3 ± 5; P = 0.24) or month 12 (WOMAC score: 15.6 ± 15 vs 15.7 ± 17; P = 1.0). Arthroplasty and BIOF2 were successful at month 12 (according to a WOMAC score: ≤ 16) in 75% of the patients and the daily use of NSAIDs was reduced, compared with the group treated exclusively with NSAIDs (RR = 0.33, 95% CI 0.12-0.87, P = 0.02. This result was the same for BIOF2 vs NSAIDs and arthroplasty vs NSAIDs). BIOF2 significantly increased the articular cartilage by 22% (26.1 ± 10 vs 31.9 ± 10 cm2, P < 0.001) and produced a significant reduction in serum lipids. BIOF2 was well tolerated, causing slight-to-moderate pain only upon application.

CONCLUSIONS

The intra-articular application of the new bioactive cell-free formulation (BIOF2) was well tolerated and showed no significative differences with arthroplasty for the treatment of severe osteoarthritis of the knee. BIOF2 can regenerate articular cartilage and is an easily implemented alternative therapy for the treatment of osteoarthritis. Trial registration Cuban Public Registry of Clinical Trials (RPCEC) Database RPCEC00000250. Registered 08/15/2017-Retrospectively registered, http://rpcec.sld.cu/en/trials/RPCEC00000250-En .

Effectiveness of a single intra-articular bone marrow aspirate concentrate (BMAC) injection in patients with grade 3 and 4 knee osteoarthritis

Aim

To evaluate the clinical efficacy and safety of an intra-articular injection of bone marrow aspirate concentrate (BMAC) as a treatment option for osteoarthritis (OA) of the knee.

Materials and methods

Between June 2014 and February 2017, data from 233 patients with knee osteoarthritis treated with BMAC injection at a single center, were retrospectively evaluated. Only patients with idiopathic osteoarthritis were included. Exclusion criteria were post-traumatic osteoarthritis, previous knee surgery, age less than 50 years old or more than 85 years old, active infection, uncontrolled diabetes mellitus, rheumatological or other systemic disease, malignancy, or treatment with immunosuppressive drugs. Bone marrow from the iliac crest was aspirated/concentrated with a standardized technique using a single-spin manual method. Patients were evaluated before and after the procedure, using the numeric pain scale (NPS) and Oxford knee score (OKS). Mean follow-up period was 11 months, range (6–30 months).

Results

A total of 121 of 233 patients had completed data as previously defined and were included in the statistical analysis. There were 85 females and 36 males, with mean age 70 years (range 50–85). Compared to baseline, the mean NPS decreased from 8.33 to 4.49 (p < 0.001) and the mean OKS increased from 20.20 to 32.29 (P < 0.001) at final follow-up. There were no complications.

Conclusion

A single intra-articular injection of BMAC is a safe and reliable procedure that results in clinical improvement of knee OA.