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

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.

Patient characteristics associated with a poor response to non-surgical multidisciplinary management of knee osteoarthritis: a multisite prospective longitudinal study in an advanced practice physiotherapist-led tertiary service

OBJECTIVES

To explore patient characteristics recorded at the initial consultation associated with a poor response to non-surgical multidisciplinary management of knee osteoarthritis (KOA) in tertiary care.

DESIGN

Prospective multisite longitudinal study.

SETTING

Advanced practice physiotherapist-led multidisciplinary orthopaedic service within eight tertiary hospitals.

PARTICIPANTS

238 patients with KOA.

PRIMARY AND SECONDARY OUTCOME MEASURES

Standardised measures were recorded in all patients prior to them receiving non-surgical multidisciplinary management in a tertiary hospital service across multiple sites. These measures were examined for their relationship with a poor response to management 6 months after the initial consultation using a 15-point Global Rating of Change measure (poor response (scores -7 to +1)/positive response (scores+2 to+7)). Generalised linear models with binomial family and logit link were used to examine which patient characteristics yielded the strongest relationship with a poor response to management as estimated by the OR (95% CI).

RESULTS

Overall, 114 out of 238 (47.9%) participants recorded a poor response. The odds of a poor response decreased with higher patient expectations of benefit (OR 0.74 (0.63 to 0.87) per 1/10 point score increase) and higher self-reported knee function (OR 0.67 (0.51 to 0.89) per 10/100 point score increase) (p<0.01). The odds of a poor response increased with a greater degree of varus frontal knee alignment (OR 1.35 (1.03 to 1.78) per 5° increase in varus angle) and a severe (compared with mild) radiological rating of medial compartment degenerative change (OR 3.11 (1.04 to 9.3)) (p<0.05).

CONCLUSIONS

These characteristics may need to be considered in patients presenting for non-surgical multidisciplinary management of KOA in tertiary care. Measurement of these patient characteristics may potentially better inform patient-centred management and flag the need for judicious monitoring of outcome for some patients to avoid unproductive care.

Guidelines for the diagnosis and treatment of osteoarthritis in China (2019 edition)

Osteoarthritis (OA) is a degenerative disease of middle-aged and elderly people, contributed a higher burden of disease in China and the world. In 2017, under the support of the Rheumatology and Immunology Expert Committee of the Cross-Strait Medical and Health Exchange Association. The objective was to develop an evidence-based diagnosis and treatment guideline for OA in China based on emerging new evidence. The guideline was registered at International Practice Guidelines Registry Platform (IPGRP-2018CN028). The grading of recommendations assessment, development and evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations, and the RIGHT (Reporting Items for Practice Guidelines in Healthcare) checklist was followed to report the guideline. The guideline provides recommendations for the OA diagnosis, disease risks monitoring and evaluate, treatment purpose and physical, medical and surgical interventions. This guideline is intended to serve as a tool for Chinese clinicians for the best decisions-making on diagnosis and treatment of OA.

Regional variation in hip and knee arthroplasty rates in Switzerland: A population-based small area analysis

Background

Compared to other OECD countries, Switzerland has the highest rates of hip (HA) and knee arthroplasty (KA).

Objective

We assessed the regional variation in HA/KA rates and potential determinants of variation in Switzerland.

Methods

We conducted a population-based analysis using discharge data from all Swiss hospitals during 2013–2016. We derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-/sex-standardized procedure rates and measures of variation (the extremal quotient [EQ, highest divided by lowest rate] and the systemic component of variation [SCV]). We estimated the reduction in variance of HA/KA rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, sex, language, urbanization, socioeconomic factors, burden of disease, and the number of orthopedic surgeons.

Results

Overall, 69,578 HA and 69,899 KA from 55 HSAs were analyzed. The mean age-/sex-standardized HA rate was 265 (range 179–342) and KA rate was 256 (range 186–378) per 100,000 persons and increased over time. The EQ was 1.9 for HA and 2.5 for KA. The SCV was 2.0 for HA and 2.2 for KA, indicating a low variation across HSAs. When adjusted for procedure year and demographic, cultural, and sociodemographic factors, the models explained 75% of the variance in HA and 63% in KA across Swiss HSAs.

Conclusion

Switzerland has high HA/KA rates with a modest regional variation, suggesting that the threshold to perform HA/KA may be uniformly low across regions. One third of the variation remained unexplained and may, at least in part, represent differing physician beliefs and attitudes towards joint arthroplasty.

Viscossuplementation for the treatment of osteoarthritis of the knee: A protocol for an umbrella review of systematic reviews with meta-analyses of randomized controlled trials

BACKGROUND

Knee osteoarthritis (KOA) is a common chronic disease with worldwide prevalence of 10% to 79%, with costs ranging from $560 to $635 billion for year in United States of America. The main guidelines recommend interventions with undesirable adverse events (AE) or highly dependent on the patient's persistence. Thus, intra-articular (IA) therapies appear to be attractive in patients with KOA, as well as a valid therapy by maximizing effects locally in the joint and limiting systemic AE. Presently, the main available IA therapies are corticosteroids and hyaluronic acid.As several meta-analyses about the efficacy of intra-articular hyaluronic acid (IAHA) for treatment of KOA with discordant results were published, we decided to conduct an umbrella review to summarize this efficacy METHODS:: We will search MEDLINE/PubMed, EMBASE, Cochrane Library, and Virtual Health Library (BVS) from inception to February 2020 for systematic reviews with meta-analyses of randomized clinical trials that investigate IAHA for therapy of KOA. Grey literature will be searched in Opengray platform, Research Gate, and Google Scholar. The reference lists of eligible studies will be screened. The search will be performed without language restriction.We will include any type of IAHA as experimental intervention and different types of oral or intra-articular placebo or medications as controls. The primary outcome will be measures of efficacy as the Western Ontario and McMaster Universities Osteoarthritis Index.A synthesis of the evidence will be conducted and data will be presented in tables.Two reviewers will independently appraise the quality of included meta-analyses using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) tool and will classify the included systematic reviews into high, moderate, low, or critically low levels of confidence.

RESULTS

The results of this study will be published in a peer-reviewed journal.

ETHICS AND DISSEMINATION

No ethical approval is required since this study data is based on published literature.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD42019120269 (https://www.crd.york.ac.uk/PROSPERO/#joinuppage).

A Comparison of Treatment Effects for Nonsurgical Therapies and the Minimum Clinically Important Difference in Knee Osteoarthritis: A Systematic Review

BACKGROUND

The minimum clinically important difference (MCID) was developed to ascertain the smallest change in an outcome that patients perceive as beneficial. The objectives of the present review were (1) to compare the MCIDs for pain assessments used among guidelines and meta-analyses investigating different nonsurgical therapies for knee osteoarthritis and (2) to compare the effect estimates of different nonsurgical interventions against a single commonly-utilized MCID threshold.

METHODS

Systematic and manual searches were conducted to identify guidelines and meta-analyses evaluating pain outcomes for nonsurgical knee osteoarthritis interventions. Individual treatment effects for pain were presented on a common scale (the standardized mean difference [SMD]). To evaluate the perception of the relative benefit of each nonsurgical treatment, the variation in MCIDs selected from the published MCID literature was assessed.

RESULTS

Thirty-seven guidelines and meta-analyses were included. MCIDs were often presented as an SMD or a mean difference (MD) on a validated scale and varied in magnitude across sources. This analysis demonstrated that intra-articular hyaluronic acid, intra-articular corticosteroids, and acetaminophen all had relatively larger effect sizes than topical nonsteroidal anti-inflammatory drugs (NSAIDs). Higher-molecular-weight intra-articular hyaluronic acid had a greater relative effect compared with both non-selective and cyclooxygenase-2-selective oral NSAIDs. Evaluating the treatment effect estimates against a commonly utilized MCID revealed similarities in which observations attained clinical significance among treatments; however, this observation varied across the range of reported MCIDs.

CONCLUSIONS

The present review confirmed the variability in the MCIDs for pain assessments that are used across guidelines and meta-analyses evaluating nonsurgical interventions for knee osteoarthritis. This variability may yield conflicting treatment recommendations, ranging from rejecting treatments that are indeed efficacious to accepting treatments that may not be beneficial. Additional research is required to determine why some nonsurgical therapies are more consistently recommended in knee osteoarthritis guidelines than others as these findings suggest similarities in their effect estimates for pain. Relevant stakeholders need to reach a consensus on a standard approach to determining the MCIDs for these therapies to ensure that appropriate and effective treatment options are available to patients prior to invasive surgical intervention.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Characteristics of Non-Spine Musculoskeletal Ambulatory Care Visits in the United States, 2009-2016

BACKGROUND

Despite the enormous economic and societal impact of musculoskeletal disorders, detailed data on the patient demographics and visit characteristics of nonspine musculoskeletal ambulatory care are sparse. Such data are essential to inform policymakers on population health needs and to justify health care resource allocation.

OBJECTIVE

To determine the demographic, patient, and visit characteristics of adult musculoskeletal ambulatory clinic visits, with the exception of spine visits, in the United States.

DESIGN

Survey/registry.

SETTING

National Ambulatory Medical Care Survey (NAMCS), Centers for Disease Control and Prevention (CDC) 2009 to 2016.

PATIENTS

The NAMCS was designed to capture information regarding the provision and use of ambulatory medical care services in the United States. Nonfederally employed office-based physicians reported data for this survey from 2009 to 2016.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Average annual estimated number (in 100 000s), Average annual estimated rate of ambulatory care musculoskeletal visits per 100 U.S. adults.

RESULTS

During 2009 to 2016, the leading cause of musculoskeletal visits was knee symptoms (15.3 million annually from 2009 to 2010, 14.0 million annually from 2011 to 2012, 12.5 million annually from 2013 to 2014, and 12.4 million annually from 2015 to 2016). Musculoskeletal visits were most frequent in patients that were 45 to 64 years of age (40.4% to 43.6% of visits were for patients 45 to 64 years of age depending on body region). Orthopedic surgeons conducted more musculoskeletal visits than any other physician specialty for all body regions. Among body regions, magnetic resonance imaging (MRI) studies were ordered most commonly for patients with shoulder (total visits in 100 000 ± standard error [SE] 47.00 ± 0.21; 12.5% of total visits for shoulders) and knee symptoms (61.85 ± 0.15; 11.4% of total visits for knees). Opioid and opioid analgesic combinations (9.2% to 14.8% of visits) were most commonly prescribed in visits related to hip complaints.

CONCLUSIONS

Visits were most frequent for knee symptoms and in patients of working age groups, which likely affects work productivity. Orthopedic surgeons were the most common provider specialty. Opioid medications were prescribed most commonly for patients with hip symptoms, which may highlight an area for potential intervention given the ongoing opioid crisis.

Choosing interventions for hip or knee osteoarthritis - What matters to stakeholders? A mixed-methods study

Objective

To identify what factors drive choices among interventions for hip or knee osteoarthritis (OA), and to rank the characteristics of interventions.

Methods

In this phased, mixed-methods design involving cross-sectoral and multi-disciplinary stakeholders - healthcare consumers, providers, policy-makers, Māori health advocates and OA experts - we used the Nominal Group Technique in focus groups to generate data. We conducted thematic analysis of the focus group data to inform a framework of categories and sub-categories describing factors and characteristics influencing the choice of OA interventions. We then used a dual-panel, two-round e- Delphi survey to verify the framework and rank the characteristics of interventions.

Results

From six focus groups (n = 38 participants), 364 factors were identified and clustered into 56 themes (mean 9 themes per focus group; range 5-15). Thematic analysis revealed a framework of 3 core categories: characteristics of interventions (10 sub-categories), characteristics of consumers (10 sub-categories) and characteristics of the health system (7 sub-categories). In Delphi round 1, the framework was verified by each of two panels (n = 65, ≥80% acceptability). In round 2, two characteristics of interventions were combined, resulting in 9 characteristics (in decreasing order of importance): effectiveness, appropriateness, quality of the evidence, accessibility, harm, cost, duration, passivity, and immediacy of intervention effect.

Conclusion

Stakeholders make choices among interventions for hip or knee OA within a framework of characteristics of interventions, of consumers, and of the health system. We identified and ranked 9 key characteristics of interventions that stakeholders consider when choosing or recommending interventions for hip or knee OA.

Intra-articular Injection of Culture-Expanded Mesenchymal Stem Cells Without Adjuvant Surgery in Knee Osteoarthritis: A Systematic Review and Meta-analysis

BACKGROUND

Although many clinical studies have assessed the efficacy of mesenchymal stem cells (MSCs) in knee osteoarthritis, evidence on their efficacy remains unclear owing to heterogeneity of cell entity and concomitant procedures.

PURPOSE

To determine the efficacy of culture-expanded MSCs in knee osteoarthritis in terms of clinical outcome and cartilage repair via meta-analysis of randomized controlled trials (RCTs) without adjuvant surgery.

STUDY DESIGN

Meta-analysis.

METHODS

PubMed, Embase, the Cochrane Library, CINAHL, and Scopus were searched from inception to December 31, 2018. RCTs with culture-expanded MSCs for treating knee osteoarthritis were included. Studies with adjuvant surgery or cell concentrate were excluded. Quality was assessed by the Cochrane Collaboration risk-of-bias tool. For meta-analysis, data on clinical outcomes were measured using a visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and data on cartilage repair were measured using the Whole-Organ Magnetic Resonance Imaging Score (WORMS); categorization related to improvement was extracted.

RESULTS

Six RCTs (203 patients) were included. Two studies were deemed to have a low risk of bias. In pooled analysis, the only significant difference was in the VAS score (mean difference, -13.55; 95% CI, -22.19 to -4.9). In cumulative pain analysis with VAS and WOMAC pain scores, there was significant improvement after treatment (standardized mean difference, -0.54; 95% CI, -0.85 to -0.23). There was no significant difference in cartilage repair assessed by magnetic resonance imaging (standardized mean difference, 0.11; 95% CI, -0.51 to 0.73), WORMS (standardized mean difference, 1.68; 95% CI -14.84 to 18.21), or categorical results (odds ratio, 1.56; 95% CI, 0.32-7.59).

CONCLUSION

Intra-articular injection of culture-expanded MSCs without adjuvant surgery can improve pain for patients experiencing knee osteoarthritis at short-term follow-up (6-12 months). However, evidence regarding function and cartilage repair remains limited.

Patterns and Perceptions of Self-Management for Osteoarthritis Pain in African American Older Adults

OBJECTIVE

To explore and describe older African Americans' patterns and perceptions of managing chronic osteoarthritis pain.

METHODS

A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews.

SETTING

One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled.

RESULTS

Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins.

CONCLUSIONS

This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

Nano wet milled celecoxib extended release microparticles for local management of chronic inflammation

Osteoarthritis (OA), the most common form of arthritis, is characterized by chronic inflammation, degeneration of articular cartilage and whole joints. Local delivery by intra-articular (IA) injection of small molecules is an established treatment to relieve pain and improve joint motion, requiring month-lasting release of therapeutic drug doses. We incorporated anti-inflammatory drug celecoxib in poly (D, L-lactic acid) microparticles using two spray-drying approaches - either as a solid drug solution or embedded as milled nano drug. Differential scanning calorimetry, X-ray powder diffraction, electron microscopy and in vitro drug release allowed comparison of the microparticles. Both types resulted in spherical particles ranging from 20 to 40 μm mean size, with high drug loadings (10% to 50% w/w) and entrapment efficiencies > 80%. However, after 90 days, in vitro celecoxib release from nano drug embedded microparticles presented a significantly slower release in comparison to drug in solution microparticles, attributed to the presence of stabilized amorphous drug. No cytotoxicity was observed in human articular synoviocytes and PGE₂ release was fully suppressed at low doses of both microparticulate systems. This study provides techniques to release high drug loads over months in a tunable manner, providing valuable options for the IA management of osteoarthritis.

Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach.

OBJECTIVE

This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA.

METHODS

A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence.

RESULTS

A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.18 and SMD -0.26, 95% CI -0.35 to -0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD -0.10, 95% CI -0.17 to 0.03 and SMD -0.17, 95% CI -0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach.

CONCLUSIONS

Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes.

Short-Term Effect of a New Oral Sodium Hyaluronate Formulation on Knee Osteoarthritis: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial

Objective: the aim of this pilot study was to test the short-term effect of oral supplementation with a sodium hyaluronate with a large spectrum of molecular weights (FS-HA^®) on the symptoms and functionality of knee osteoarthritis (OA). Methods: 60 subjects affected by clinical and/or radiological diagnosis of symptomatic knee OA were consecutively enrolled in a randomized, double blind, placebo-controlled, clinical trial. At randomization visit, at day 28 (visit 2), and day 56 (visit 3), the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC), the Lequesne Functional Index (LFI) and the Visual Analogue Scale (VAS) for pain (VAS-p) were administered to the enrolled patients. Then, patients were asked how many times they used rescue medications (non-steroidal antinflammatory drugs–NSAIDs and/or anti-pain drugs) during the previous 4 weeks. Finally, the range of knee joint motion (ROM) was also instrumentally measured. Results: In FS-HA^® treated subjects, VAS-p, pain and total WOMAC score, LFI and ROM significantly improved compared to the baseline values (p < 0.05). At 60 days, the VAS-p and the pain WOMAC score were significantly lower after FS-HA^® treatment when compared with placebo as well (p < 0.05). The FS-HA^® treated subjects significantly reduced the weekly use of NSAIDs and/or antipain drugs when compared to the placebo-treated ones (p < 0.05). Conclusion: the oral supplementation with a FS-HA^® characterized by a large spectrum of molecular weight was associated with a short-term improvement in symptomatology and functionality of osteoarthritis-affected knees, and associated with a reduction in the use of NSAIDS and anti-pain drugs.

Longitudinal Assessment of Pain Management Among the Employed Japanese Population with Knee Osteoarthritis

Purpose

To assess comorbidity burden and pain-management patterns among working-aged patients with knee osteoarthritis only (KOA/O) and patients with knee osteoarthritis plus osteoarthritis at another site (KOA/+) in Japan.

Patients and Methods

Retrospective claims data analysis was conducted using the Japan Medical Data Center database. Working-aged adults (aged 40 to 71 years) with 5 years of follow-up and diagnosed with knee osteoarthritis (KOA) between January 1, 2011, and December 31, 2012, were evaluated. The first claim with a KOA diagnosis defined the index date. Patients were divided into two mutually exclusive cohorts: KOA/O and KOA/+. Longitudinal pain-management patterns during each year of follow-up were analyzed.

Results

A total of 2542 patients met study criteria: 1575 KOA/O and 967 KOA/+. Mean age and number of comorbidities were higher among the KOA/+ versus KOA/O cohort. Pharmaceutical treatment was received by 91.5% of patients in the KOA/+ compared with 85.1% of patients in the KOA/O cohort during the first year of follow-up. The most common pharmacological treatment received during the first year of follow-up was either topical or oral nonsteroidal anti-inflammatory drugs for both cohorts. During each year of follow-up, the KOA/+ cohort had greater proportion of patients with at least one health-care encounter (ie, hospital admissions, outpatient and pharmacy visits) and higher direct medical costs compared with the KOA/O cohort.

Conclusion

This study demonstrates that a greater proportion of the working population with KOA/+ received pain-related treatment compared with patients with KOA/O. Further studies are necessary to evaluate appropriate pain management for both KOA only and KOA with other sites.

Use of Physical Therapy in Patients With Osteoarthritis in Germany: An Analysis of a Linkage of Claims and Survey Data

OBJECTIVE

To examine the utilization of physical therapy (PT) and predictors for its use in individuals with osteoarthritis (OA) while focusing on sociodemographic and disease-related factors.

METHODS

For this cross-sectional study, 657,807 patients (age 30-79 years) diagnosed with hip, knee, or polyarticular OA were identified in claims data. In 2016, a questionnaire including information on disease status, demography, and socioeconomics was sent to a random sample of 8,995 patients stratified by sex, age, and type of diagnosis. Claims data from 2016 included the utilization and type of PT, as well as the prescribing medical specialist, and were linked to questionnaire data. Multivariable logistic regression was conducted to determine variables associated with the use of PT.

RESULTS

In total, 3,564 (40%) patients completed the questionnaire and agreed to linking questionnaire and claims data (69% female, mean age 66.5 years). In 2016, 50% of the study population received PT at least once, and women received it more frequently than men (53% versus 43%). Most PT was prescribed by orthopedists (45%) and general practitioners (32%). Multivariable logistic regression showed that women, higher household income, having both hip and knee OA, lower functional status, higher disease activity, and individuals living in the eastern, southern, and western states of Germany were associated with an increased utilization of PT.

CONCLUSION

Considering current guideline recommendations and that more than one-third of OA patients with high functional impairment and/or pain did not receive PT in the last 12 months, there is considerable potential for improvement. This is especially true for men and individuals with a low income.

Cost-effectiveness of 12 weeks of supervised treatment compared to written advice in patients with knee osteoarthritis: a secondary analysis of the 2-year outcome from a randomized trial

OBJECTIVE

To assess the 24-month cost-effectiveness of supervised treatment compared to written advice in knee osteoarthritis (OA).

DESIGN

100 adults with moderate-severe OA not eligible for total knee replacement (TKR) randomized to a 12-week individualized, supervised treatment (exercise, education, diet, insoles and pain medication) or written advice. Effectiveness was measured as change in quality-adjusted life years (QALYs) from baseline to 24 months, including data from baseline, 3, 6, 12 and 24 months, while healthcare costs and transfer payments were derived from national registries after final follow-up. Incremental costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated. A sensitivity analysis resampling existing data was conducted and the probability of cost-effectiveness was estimated using a 22,665 Euros/QALY threshold. In a sensitivity analysis, cost-effectiveness was calculated for different costs of the supervised treatment (actual cost in study; cost in private practice; and in-between cost).

RESULTS

Average costs were similar between groups (6,758 Euros vs 6,880 Euros), while the supervised treatment were close to being more effective (incremental effect (95% CI) of 0.075 (-0.005 to 0.156). In the primary analysis excluding deaths, this led the supervised treatment to be cost-effective, compared to written advice. The sensitivity analysis demonstrated that the results were sensitive to changes in the cost of treatment, but in all scenarios the supervised treatment was cost-effective (ICERs of 6,229 to 20,688 Euros/QALY).

CONCLUSIONS

From a 24-month perspective, a 12-week individualized, supervised treatment program is cost-effective compared to written advice in patients with moderate-severe knee OA not eligible for TKR.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT01535001.

Effectiveness of platelet-rich plasma in the management of hip osteoarthritis: a systematic review and meta-analysis

The effectiveness of platelet-rich plasma (PRP) injections for osteoarthritis (OA) is still controversial. Previous research supports the use of intra-articular PRP injections to promote a favorable environment for joint tissue healing and to delay the progression of OA. The purpose of this review is to investigate the effectiveness of PRP in the management of hip osteoarthritis (HOA). Five electronic databases were searched from inception to May 2019: Medline (via PubMed), SportDiscus via EBSCO, ProQuest Health & Medical Complete, CINAHL, and Cochrane. Risk of bias was assessed with the Cochrane risk of bias tool. The GRADE method was used to assess the level of evidence for the studies included in this review. Clinical trials evaluate PRP injections among adult patients diagnosed with HOA according to the American College of Rheumatology criteria. At least one outcome measure for pain or function must have been reported. A total of 4 trials (334 participants, 340 hips) were included, all marked as "moderate risk of bias". Pain and function were assessed throughout the studies with visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Harris Hip Score (HHS) tools. Intra-articular PRP injections were more effective at stages earlier than 3 months for both treatment groups with the exception of WOMAC score in one study. The superiority of PRP against comparative treatments was only reported in one study; longer-term evaluations from 4 to 12 months showed diverse results, with only one study reporting significantly better results for PRP. PRP may be beneficial and safe for patients with HOA at mid-term follow-up. However, its superiority over other procedures such as hyaluronic acid remains unclear. Further researches with high-quality designs and larger samples become imperative.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review

PURPOSE OF REVIEW

Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation.

RECENT FINDINGS

Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

Low-dose strength training in addition to neuromuscular exercise and education in patients with knee osteoarthritis in secondary care - a randomized controlled trial

OBJECTIVES

To investigate the effects of lower limb strength training in addition to neuromuscular exercise and education (ST + NEMEX-EDU) compared to neuromuscular exercise and education alone (NEMEX-EDU) on self-reported physical function in patients with knee osteoarthritis (KOA).

DESIGN

Patient-blinded, parallel-group randomized controlled trial (RCT).

METHODS

The trial included 90 patients in secondary care with radiographic and symptomatic KOA, ineligible for knee replacement. Both groups exercised twice weekly for 12 weeks. Additional strength training consisted of a single, fatiguing knee extension set (30-60RM) before four sets of leg-press (8-12RM). Primary outcome was the between-group difference on the subscale activities of daily living from the Knee Injury and Osteoarthritis Outcome Score (KOOS_ADL) at 12 weeks. Secondary outcomes included KOOS symptoms, pain, function in sport and recreation, and quality of life, 40 m walk, stair climb, leg extension power, EuroQol-5D-5L, pain medication usage, and adverse events.

RESULTS

There was no statistically significant between-group difference in KOOS_ADL at 12-weeks; adjusted mean difference -1.15 (-6.78 to 4.48). Except for the stair climb test, which demonstrated an adjusted mean difference of 1.15 (0.09-2.21) in favor of ST + NEMEX-EDU, all other outcomes showed no statistically significant between-group differences. Neither group improved leg extension power.

CONCLUSION

The addition of lower-limb strength training, using a low-dose approach, to neuromuscular exercise and education carried no additional benefits on self-reported physical function or on most secondary outcomes. Both groups displayed similar improvements at 12-week follow-up. Hence, the current low-dose strength training approach provided no additional clinical value in this group of KOA patients. Trial identifier (ClinicalTrials.gov): NCT03215602.

Insulin Resistance in Osteoarthritis: Similar Mechanisms to Type 2 Diabetes Mellitus

Osteoarthritis (OA) and type 2 diabetes mellitus (T2D) are two of the most widespread chronic diseases. OA and T2D have common epidemiologic traits, are considered heterogenic multifactorial pathologies that develop through the interaction of genetic and environmental factors, and have common risk factors. In addition, both of these diseases often manifest in a single patient. Despite differences in clinical manifestations, both diseases are characterized by disturbances in cellular metabolism and by an insulin-resistant state primarily associated with the production and utilization of energy. However, currently, the primary cause of OA development and progression is not clear. In addition, although OA is manifested as a joint disease, evidence has accumulated that it affects the whole body. As pathological insulin resistance is viewed as a driving force of T2D development, now, we present evidence that the molecular and cellular metabolic disturbances associated with OA are linked to an insulin-resistant state similar to T2D. Moreover, the alterations in cellular energy requirements associated with insulin resistance could affect many metabolic changes in the body that eventually result in pathology and could serve as a unified mechanism that also functions in many metabolic diseases. However, these issues have not been comprehensively described. Therefore, here, we discuss the basic molecular mechanisms underlying the pathological processes associated with the development of insulin resistance; the major inducers, regulators, and metabolic consequences of insulin resistance; and instruments for controlling insulin resistance as a new approach to therapy.

Impact of Jiggling Exercise as Conservative Treatment for Hip Osteoarthritis: A Report of Two Cases

Total hip arthroplasty has been recognized as a feasible treatment for hip osteoarthritis, especially in advanced and terminal stages, but whether it is the best treatment for patients who are younger, have comorbidities, and/or are likely to have low compliance to medical treatment is unknown. Jiggling exercise, which involves the continuous shaking of the foot and leg in small steps, has been reported to be the easiest and a less invasive exercise for patients with hip osteoarthritis. We herein report two patients who performed jiggling exercise as conservative treatment and had successful outcomes. The first case was a 28-year-old woman with advanced-stage hip osteoarthritis that could not be treated with hip preservation surgery; furthermore, the patient refused to undergo total hip arthroplasty because of her young age. The second case was a 74-year-old woman with terminal-stage hip osteoarthritis in whom total hip arthroplasty was deemed not feasible because of possible low compliance due to mental disorder. One year after the initiation of the jiggling exercise, both patients had remarkable clinical improvement. Three years later, remarkable joint remodelling was also revealed in plain radiographs. Jiggling exercise might be a feasible conservative treatment option for joint preservation.

The association between psychological characteristics and physical activity levels in people with knee osteoarthritis: a cross-sectional analysis

Background

The aim of this study was to examine the relationship between psychological characteristics and physical activity levels, measured as the average number of steps per day, in people with knee osteoarthritis (OA).

Methods

This study analysed baseline data from a randomized controlled trial (Australian New Zealand Clinical Trials Registry reference: ACTRN12612000308897). A total of 167 adults aged over 50 years, with knee pain rated as four or more on an 11-point numeric rating scale, and knee OA diagnosed using American College of Rheumatology clinical criteria, were recruited from the community (62 men and 105 women, mean age, 62.2 ± 7.5 years). The average number of steps per day over seven consecutive days was measured using an accelerometer-based device. Psychological characteristics evaluated were: depressive symptoms (Depression Anxiety Stress Scale), self-efficacy (Arthritis Self-Efficacy Scale for pain and other symptoms), fear of movement (Brief Fear of Movement Scale for Osteoarthritis), and pain catastrophizing (Pain Catastrophizing Scale). The association between the average number of steps per day and psychological characteristics was analyzed using a multiple linear regression analysis, with the average number of steps per day as the dependent variable, adjusting for each psychological characteristic separately, and age, sex, body mass index, and pain entered as covariates.

Results

There was evidence that the amount of physical activity was associated with fear of movement (coefficient [B]: − 117, 95% confidence interval [95%CI]: − 227 to − 8) and with pain catastrophizing (B: -44, 95%CI: − 86 to − 1). The association with self-efficacy was similar (B:117, 95%CI: − 12 to 246). However, the direction of the association with depressive symptoms was less clear (B: -59, 95%CI: − 138 to 19).

Conclusions

The results of this study revealed that the relationship was such that lower fear of movement and lower pain catastrophizing may be associated with more steps per day. It may be hypothesized that fear of moving and pain catastrophizing lead to activity avoidance and that strategies to improve these disease-related psychological aspects may be useful in enhancing physical activity participation, although this hypothesis is highly speculative and needs further testing given the cross-sectional design of this study.

Angiogenesis stimulated by elevated PDGF-BB in subchondral bone contributes to osteoarthritis development

Increased subchondral bone angiogenesis with blood vessels breaching the tidemark into the avascular cartilage is a diagnostic feature of human osteoarthritis. However, the mechanisms that initiate subchondral bone angiogenesis remain unclear. We show that abnormally increased platelet-derived growth factor-BB (PDGF-BB) secretion by mononuclear preosteoclasts induces subchondral bone angiogenesis, contributing to osteoarthritis development. In mice after destabilization of the medial meniscus (DMM), aberrant joint subchondral bone angiogenesis developed during an early stage of osteoarthritis, before articular cartilage damage occurred. Mononuclear preosteoclasts in subchondral bone secrete excessive amounts of PDGF-BB, which activates platelet-derived growth factor receptor-β (PDGFR-β) signaling in pericytes for neo-vessel formation. Selective knockout of PDGF-BB in preosteoclasts attenuates subchondral bone angiogenesis and abrogates joint degeneration and subchondral innervation induced by DMM. Transgenic mice that express PDGF-BB in preosteoclasts recapitulate pathological subchondral bone angiogenesis and develop joint degeneration and subchondral innervation spontaneously. Our study provides the first evidence to our knowledge that PDGF-BB derived from preosteoclasts is a key driver of pathological subchondral bone angiogenesis during osteoarthritis development and offers a new avenue for developing early treatments for this disease.

Common Musculoskeletal Disorders in the Elderly: The Star Triad

Musculoskeletal disorders are debilitating conditions that significantly impair the state of health, especially in elderly subjects. A pathological triad of inter-related disorders that are highly prevalent in the elderly consists of the following main “components”: sarcopenia, tendinopathies, and arthritis. The aim of this review is to critically appraise the literature relative to the different disorders of this triad, in order to highlight the pathophysiological common denominator and propose strategies for personalized clinical management of patients presenting with this combination of musculoskeletal disorders. Their pathophysiological common denominator is represented by progressive loss of (focal or generalized) neuromuscular performance with a risk of adverse outcomes such as pain, mobility disorders, increased risk of falls and fractures, and impaired ability or disability to perform activities of daily living. The precise management of these disorders requires not only the use of available tools and recently proposed operational definitions, but also the development of new tools and approaches for prediction, diagnosis, monitoring, and prognosis of the three disorders and their combination.

Using TENS to Enhance Therapeutic Exercise in Individuals with Knee Osteoarthritis

Transcutaneous electrical nerve stimulation (TENS) facilitates quadriceps voluntary activation in experimental settings. Augmenting therapeutic exercise (TE) with TENS may enhance the benefits of TE in individuals with knee osteoarthritis (KOA) and quadriceps voluntary activation failure (QVAF).

PURPOSE

This study aimed to determine the effect of TENS + TE on patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance compared with sham TENS + TE (Sham) and TE alone in individuals with symptomatic KOA and QVAF.

METHODS

Ninety individuals participated in a double-blinded randomized controlled trial. Everyone received 10 standardized TE sessions of physical therapy. TENS + TE and Sham groups applied the respective devices during all TE sessions and throughout activities of daily living over 4 wk. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC), quadriceps strength, and voluntary activation, as well as a 20-m walk test, chair-stand test, and stair-climb test were performed at baseline, after the 4-wk intervention (post 1) and at 8 wk after the start of the intervention (post 2). Mixed-effects models were used to determine between-group differences between baseline and post 1, as well as baseline and post 2.

RESULTS

Improvements in WOMAC subscales, quadriceps strength, and voluntary activation, 20-m walk times, chair-stand repetitions, and stair-climb time were found at post 1 and post 2 compared with baseline for all groups (P < 0.05). WOMAC Pain and Stiffness improved in the TENS + TE group compared with TE alone at post 1 (P < 0.05); yet, no other between-group differences were found.

CONCLUSIONS

TE effectively improved patient-reported function, quadriceps strength, and voluntary activation, as well as physical performance in individuals with symptomatic KOA and QVAF, but augmenting TE with TENS did not improve the benefits of TE.

The PI3K/AKT/mTOR signaling pathway in osteoarthritis: a narrative review

Osteoarthritis (OA) is a complicated degenerative disease that affects whole joint tissue. Currently, apart from surgical approaches to treat late stage OA, effective treatments to reverse OA are not available. Thus, the mechanisms leading to OA, and more effective approaches to treat OA should be investigated. According to available evidence, the PI3K/AKT/mTOR signaling pathway is essential for normal metabolism of joint tissues, but is also involved in development of OA. To provide a wide viewpoint to roles of PI3K/AKT/mTOR signaling pathway in osteoarthritis, a comprehensive literature search was performed using PubMed terms 'PI3K OR AKT OR mTOR' and 'osteoarthritis'. This review highlights the role of PI3K/AKT/mTOR signaling in cartilage degradation, subchondral bone dysfunction, and synovial inflammation, and discusses how this signaling pathway affects development of the disease. We also summarize recent evidences of therapeutic approaches to treat OA by targeting the PI3K/AKT/mTOR pathway, and discuss potential challenges in developing these strategies for clinical treatment of OA.

Association between platelet count and osteoarthritis in women older than 50 years

Background:

Osteoarthritis (OA) is a multifactorial disease involving inflammatory processes. Platelets play important roles in both hemostasis and the inflammatory response; however, the relationship between platelet count and OA is unclear. Our aim was to evaluate the association between platelet count and knee and hip OA in Korean women.

Methods:

In this cross-sectional designed study, we included a total of 6011 women aged ⩾50 years from the 2010–2013 Korea National Health and Nutrition Examination Survey. Knee and hip OA were defined as Kellgren–Lawrence grade ⩾2 and presence of knee or hip pain, respectively. Platelet counts were divided into quartiles as follows: Q1, 150–212 (10³/µl); Q2, 213–246 (10³/µl); Q3, 247–283 (10³/µl); and Q4, 284–450 (10³/µl). Multiple logistic-regression analysis was conducted to calculate odds ratios and 95% confidence intervals. Receiver operating characteristic analysis was performed to determine the optimal platelet count cut-off with which to discriminate participants with knee and/hip OA versus those without OA.

Results:

Of the 6011 participants, 1141 (18.1%) had knee or hip OA. The mean age of participants without OA was 60.6 years, and that of participants with OA was 68.0 years. Compared with the lowest quartile, odds ratios (95% confidence intervals) for OA were 1.08 (0.84–1.39) for Q2, 0.94 (0.73–1.23) for Q3, and 1.35 (1.08–1.69) for Q4 after adjusting for confounders. The prevalence of OA was significantly higher with platelet counts ⩾288 × 10³/µl, compared with platelet counts <288 × 10³/µl.

Conclusion:

High platelet counts within the normal range are significantly associated with knee and hip OA.

The knowledge and self-management educational needs of older adults with knee osteoarthritis: A qualitative study

Knee osteoarthritis (KOA) is closely related with ageing, physical disability and functional dependency. The course of KOA is considered progressive and irreversible. Engagement with self-management may, however, minimize the impact of KOA. To be fully engaged with self-management activities, knowledge about KOA is a prerequisite. There is limited empirical data on older adults’ understanding on KOA and their information needs about KOA. Therefore, the aims of this study were to explore older adults’ knowledge about KOA and their perspectives on the information required to enable self-management. Three focus groups were conducted with 16 older adults with KOA. The sample consisted of three men and thirteen women with the mean age 73.2 years (range from 61 to 89). Thematic content analysis revealed two themes which were understanding about KOA and information needed about KOA. Participants’ knowledge about KOA varied between individuals with many expressing that they needed more information about KOA. A targeted strategy is needed to educate older adults about KOA in order to support and prepare them for self-management.

Time Effect of Intra-articular Injection With Triamcinolone Hexacetonide and Its Correlations: A Case-Control Prospective 12-Month Study

OBJECTIVE

The aim of the study was to assess the time effect of intra-articular injection with triamcinolone hexacetonide in rheumatic patients.

DESIGN

A prospective case-control study with patients submitted to one intra-articular injection with triamcinolone hexacetonide. Patients were followed monthly (12 mos) for pain and swelling.

RESULTS

Two hundred sixty-two joints were assessed in 158 patients with mean ± SD age of 60 ± 13.7 yrs. Remission was observed at 3, 6, and 12 mos in 142 (54.19%), 111 (42.36%), and 105 (40.07%) joints, respectively. The mean ± SD time effect were 8 ± 4.0 mos; 8.4 ± 3.9 for rheumatoid arthritis patients and 6.9 ± 4.0 for osteoarthritis patients (P = 0.012) and 10.4 ± 2.7 mos for small, 7.7 ± 4.1 for medium, and 6.8 ± 4.0 for large joints. The joints were divided into two groups: long-term group (time effect of intra-articular injection longer than 6 mos) and short-term group. The following are the variables associated (P < 0.05) with long-term group: rheumatoid arthritis, small and medium-sized joints, female sex, lower pain and swelling visual analog scale scores, and use of leflunomide. The following are the variables associated with short-term group: receiving only one intra-articular injection, hypertension, diabetes mellitus, and biological therapy.

CONCLUSIONS

The mean ± SD time effect of intra-articular injection with triamcinolone hexacetonide was 8.0 ± 4.0 mos. The associated predictors were rheumatoid arthritis, small and medium joints, lower pain/swelling visual analog scale scores, and use of leflunomide.

Disparity of health services in patients with knee osteoarthritis before total knee arthroplasty

Background

Recent evidence describes which interventions are driving insurance payments in the management of osteoarthritis (OA) before total knee arthroplasty (TKA); however, relatively little is known about how these costs are distributed among patients.

Methods

We reviewed the Humana claims database for patients who underwent primary TKA from 2009 to 2016. Insurance payments for treatment, imaging, and evaluation and management were calculated from OA diagnosis to TKA, the distribution of payments was determined, and a high-payment group was identified by determining the point at which patients began to account for a disproportionate percentage of payments. This group of high-payment patients was compared with remaining patients (low-payment patients) based on demographic factors and nonarthroplasty payments and utilization.

Results

The top 30% of patients accounted for more than 70% of nonarthroplasty payments. High-payment patients were more likely to be younger, female, and more comorbid. Median time from diagnosis to TKA for high-payment patients was 3 times longer than that for low-payment patients (654 days [320-1191] vs 204 days [68-582], P < .001), and median payment per patient was more than 5 times higher ($1891 [1405-2782] vs $362 [198-613], P < .001).

Conclusions

Identification of high-payment patients in the management of knee OA may allow for targeted care pathways and cost-reduction strategies in the nonarthroplasty period, although additional studies are necessary to further characterize this population and efficiently recognize appropriate TKA candidates and timing.

Relative Efficacy of Different Exercises for Pain, Function, Performance and Quality of Life in Knee and Hip Osteoarthritis: Systematic Review and Network Meta-Analysis

Background

Guidelines recommend exercise as a core treatment for osteoarthritis (OA). However, it is unclear which type of exercise is most effective, leading to inconsistency between different recommendations.

Objectives

The aim of this systematic review and network meta-analysis was to investigate the relative efficacy of different exercises (aerobic, mind–body, strengthening, flexibility/skill, or mixed) for improving pain, function, performance and quality of life (QoL) for knee and hip OA at, or nearest to, 8 weeks.

Methods

We searched nine electronic databases up until December 2017 for randomised controlled trials that compared exercise with usual care or with another exercise type. Bayesian network meta-analysis was used to estimate the relative effect size (ES) and corresponding 95% credibility interval (CrI) (PROSPERO registration: CRD42016033865).

Findings

We identified and analysed 103 trials (9134 participants). Aerobic exercise was most beneficial for pain (ES 1.11; 95% CrI 0.69, 1.54) and performance (1.05; 0.63, 1.48). Mind–body exercise, which had pain benefit equivalent to that of aerobic exercise (1.11; 0.63, 1.59), was the best for function (0.81; 0.27, 1.36). Strengthening and flexibility/skill exercises improved multiple outcomes at a moderate level. Mixed exercise was the least effective for all outcomes and had significantly less pain relief than aerobic and mind–body exercises. The trend was significant for pain (p = 0.01), but not for function (p = 0.07), performance (p = 0.06) or QoL (p = 0.65).

Conclusion

The effect of exercise varies according to the type of exercise and target outcome. Aerobic or mind–body exercise may be the best for pain and function improvements. Strengthening and flexibility/skill exercises may be used for multiple outcomes. Mixed exercise is the least effective and the reason for this merits further investigation.

Electronic supplementary material

The online version of this article (10.1007/s40279-019-01082-0) contains supplementary material, which is available to authorized users.

Autologous conditioned serum: clinical and functional results using a novel disease modifying agent for the management of knee osteoarthritis

Objective: The purpose of this study was to investigate the potential ability of autologous conditioned serum (ACS) to decrease pain and improve joint functionality in patients affected by knee osteoarthritis (OA). Methods: Fifteen patients with clinical and radiological signs of OA of the knee were recruited for this study. Each patient received 4 injections of ACS (Orthokine; orthogen, Dusseldorf, Germany) at the site of OA once per week for 4 weeks. Clinical and functional evaluation was performed using the VAS scale for pain, WOMAC scale and KSS functional and clinical scores before the first injection, at one week, at two weeks, at three weeks, at one month and at six months. Statistical analysis was done with the Wilcoxon Signed-Rank Test. Results: Our results show an improvement of all the evaluation scales at 6 months follow-up. Particularly, VAS scales among all patients decreased by 35.8% (p = .00148), KSS functional scores improved by 38.2% (p = .00148), KSS clinical scores improved by 28.9% (p = .00236) and WOMAC scores were reduced by 19.8% (p = .00188). Few adverse effects were observed in our sample. The most common complaint was pain and swelling in the subsequent days after performing the intra-articular injection. Only one patient reported rigidity following the injection of the ACS. Conclusion: Our results, in conjunction with preexisting studies in the medical literature regarding ACS, demonstrate the viability of this therapy for the treatment of knee OA, showing positive influence on pain and joint function without significant adverse effects.

Rehabilitation needs in individuals with knee OA in rural Western Cape, South Africa: an exploratory qualitative study

BACKGROUND

Current clinical practice guidelines have suggested that each individual with knee osteoarthritis (OA) should receive three core treatments from their health care provider. These core treatments comprise of exercise, education and weight loss. Identification of the health care and rehabilitation needs of individuals with knee OA in rural areas are imperative for focusing service delivery in a specific context in order to empower the individual. The aim of this study was to explore the rehabilitation needs of individuals with knee OA living in rural Western Cape in order to identify the gaps in services offered and inform rehabilitation programmes in these settings.

METHODS

Semi-structured in-depth individual interviews were performed on 16 individuals with knee OA living in rural settings of the Western Cape, South Africa. A deductive data analysis approach was used and the needs of the individuals were identified and categorised for interpretation and comparison with the reported services received.

FINDINGS

The three major themes identified were 'I would like to know more', 'There's not much support from the clinic' and 'I don't feel myself anymore'. These themes relate to the lack of disease-specific education, barriers in the health systems and service delivery resulting in individuals lack of self-worth and poor mental wellbeing. The results revealed the integral relationship between health care systems, service delivery and the effect on patient wellbeing.

CONCLUSION

The rehabilitation needs of individuals with knee OA in rural areas advocates for addressing barriers in rural primary health care system such as adequate human resources, referral systems and continuity of care. This will allow for a comprehensive, person-centred and context-specific multidisciplinary approach focused on empowering individuals with knee OA through disease-specific education, improving functional participation and symptom management strategies. This could improve the social inclusion and mental wellbeing of individuals living with knee OA.

Effect of Tai Chi Training on Plantar Loads during Walking in Individuals with Knee Osteoarthritis

Tai Chi is an available method for the treatment of knee osteoarthritis (KOA). The impacts of Tai Chi on plantar loads of individuals with KOA are not fully understood. 46 participants with knee osteoarthritis were randomly assigned into the Tai Chi group (n = 23) or the control group (n = 23). The Tai Chi group attended a 6-month Tai Chi program, and the control group participated in a wellness education program. Novel Pedar-X system was used to collect the peak pressure (PP) and maximum force (MF) during walking before and 6 months after the intervention. Significant higher peak pressure and maximum force were observed in the 4th and 5th metatarsophalangeal joints in the Tai Chi group. However, there were significant declines in the peak pressure of the whole foot and the 2nd and 3rd metatarsophalangeal joints and maximum force of the heel in the control group. These results suggested that individuals with KOA might change the pattern of plantar loads during walking through Tai Chi, and plantar loads would be useful as a parameter to assess the effect of Tai Chi on knee osteoarthritis. This trial is registered with Clinical Trials: CHiCTR-TRC-13003264.

Osteoarthritis year in review 2019: epidemiology and therapy

Over the past year many studies and clinical trials have been published in the osteoarthritis (OA) field. This review is based on systematic literature review covering the period May 1^st, 2018 to April 19^th, 2019; the final selection of articles was subjective. Specifically those articles considered to be presenting novel insights and of potential importance for clinical practice, are discussed. Further evidence has emerged that OA is a serious disease with increasing impact worldwide. Our understanding of development of pain in OA has increased. Detailed studies investigating widely used pharmacological treatments have shown the benefits to be limited, whereas the risks seem higher than expected, suggesting further studies and reconsideration of currently used guidelines. Promising new pharmacological treatments have been developed and published, however subsequent studies are warranted. While waiting for new treatment modalities to appear joint replacement is an effective alternative; new data have become available on how long they might last.

Secreted Factors and EV-miRNAs Orchestrate the Healing Capacity of Adipose Mesenchymal Stem Cells for the Treatment of Knee Osteoarthritis

Mesenchymal stem cells (MSCs) derived from adipose tissue and used either as expanded cells or minimally manipulated cell preparations showed positive clinical outcomes in regenerative medicine approaches based on tissue restoration and inflammation control, like in osteoarthritis (OA). Recently, MSCs’ healing capacity has been ascribed to the large array of soluble factors, including soluble cytokines/chemokines and miRNAs conveyed within extracellular vesicles (EVs). Therefore, in this study, 200 secreted cytokines, chemokines and growth factors via ELISA, together with EV-embedded miRNAs via high-throughput techniques, were scored in adipose-derived MSCs (ASCs) cultivated under inflammatory conditions, mimicking OA synovial fluid. Both factors (through most abundantly expressed TIMP1, TIMP2, PLG and CTSS) and miRNAs (miR-24-3p, miR-222-3p and miR-193b-3p) suggested a strong capacity for ASCs to reduce matrix degradation activities, as those activated in OA cartilage, and switch synovial macrophages, often characterized by an M1 inflammatory polarization, towards an M2 phenotype. Moreover, the crucial importance of selecting the target tissue is discussed, showing how a focused search may greatly improve potency prediction and explain clinical outcomes. In conclusion, herein presented data shed light about the way ASCs regulate cell homeostasis and regenerative pathways in an OA-resembling environment, therefore suggesting a rationale for the use of MSC-enriched clinical products, such as stromal vascular fraction and microfragmented adipose tissue, in joint pathologies.

Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55

Introduction. Osteoarthritis, which is a cause of chronic pain and disability with manifestation in any joint, with greater frequency in the joints of the lower limbs, upper limbs, but also at the spine level , affects around 250 million people in the entire world. This condition affects around 10% of the global population (18) and has an impressive impact on people, as it is one of the first 5 causes of disability. Material and method. The objectives of the treatment made by the patients diagnosed with knee osteoarthritis were: pain reduction, increased joint amplitude, increased muscle strength, increased muscle tone, increased quality of life and reintegration into the family and social environment. In the study, there were discussed demographic data regarding the patients. In order to assess the pain parameter, the VAS scale was used, as well as WOMAC subscales. To assess the quality of life of patients with knee osteoarthritis, the QOL scale (Quality of Life) was used. Anxiety was assessed with the help of a test that comprises the evaluation of symptoms at the cognitive, behavioral and physical level. Results and discussions. The pain was evaluated on the VAS scale, having a statistically significant evolution for the evaluation moments. Also with the help of the WOMAC index, two other parameters were evaluated, namely joint rigidity and functional capacity, the results being statistically significant in the 3 evaluation moments. The patients’ anxiety was evaluated with the help of the anxiety test; the results obtained were statistically significant at the 3 evaluation moments. Conclusions. It is vital that the recovery treatment in osteoarthritis be individualized and adapted to the age group. In our group, it enabled the reduction of pain and anxiety, the increase of the functional capacity and the quality of the patients’ lives.Taking into account the fact that the most affected group in the study group was the active professional one, we can evaluate the size of the recovery and the social, family and professional integration for these patients.

The quality of life - an indicator for assessing the recovery program in patients diagnosed with degenerative disorders

Introduction. Osteoarthritis is a chronic joint disease, a progressive non-inflammatory arthropathy-type. Globally, around 1.7 billion people are affected by musculoskeletal and rheumatic diseases, which indicates an increase in the last 20 years of around 45%. Material and method. The objectives of the treatment of patients diagnosed with osteoarthritis were: decreasing the pain, increasing joint mobility, muscle strength, trophic and muscle tone, increasing the quality of life and reintegration into the social and family environment. Demographic data and the functional status were assessed using the VAS scale, the WOMAC scale, the QOL scale. Results and discussions. The pain, the most important symptom in osteoarthritis, was diminished in the patients from the group, the evaluation on the VAS scale, but also on the WOMAC scale has showed the value reduction and the statistical significance of this decrease. The quality of life in the group patients after the application of the complex recovery treatment, especially of the kinetotherapy program. Conclusions. The application of the individualized recovery treatment and adapted to the age group has allowed the improvement of the values of the parameters of pain, rigidity, functional capacity. The recovery of patients aged 55-65 is important to ensure the percentage of professionally active persons, to reduce medical costs, as well as those generated by absenteeism, and the socio-professional reintegration of these patients.

Overcoming Barriers to Physical Activity in People with Osteoarthritis: the Role of Empathic Accuracy in Couples' Planning Discussions

BACKGROUND

Osteoarthritis (OA) is a common chronic joint disease with significant individual and public health consequences. Physical activity can reduce OA symptoms, but patients often fall below recommended levels. Social support from an intimate partner can help them become more active; however, some couples are better than others at enacting effective support. We examined the role of empathic accuracy (EA)-the ability to understand another person's thoughts and feelings-in couples' ability to identify strategies for overcoming barriers to increasing activity. We also examined whether EA was associated with changes in affect and with emotion regulation and communication skills.

METHOD

Forty-two insufficiently physically active participants with OA identified a barrier to becoming more active in a recorded discussion with their partner. Next, both rated self and partner thoughts and feelings during the discussion. Raters coded EA and whether discussions reached a solution. Affect and skills were assessed with validated questionnaires.

RESULTS

An actor-partner interdependence model found higher EA for participants in couples who reached a solution compared to those who did not reach a solution in the allotted time. Both partners' EA was associated with reduced negative affect in the other member of the couple. Unexpectedly, EA in people with OA was associated with reduced positive affect for their partners. EA was positively associated with one skill: emotional clarity.

CONCLUSION

Findings from this early-stage study suggest that EA can help couples manage health-related issues together. Emotional clarity emerged as a skill related to EA, suggesting avenues for additional research.

How Do Physical Therapists Approach Management of People With Early Knee Osteoarthritis? A Qualitative Study

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of disability. There is increasing emphasis on initiating treatment earlier in the disease. Physical therapists are central to the management of OA through the delivery of exercise programs. There is a paucity of research on physical therapists' perceptions and clinical behaviors related to early knee OA management.

OBJECTIVE

The study aimed to explore how physical therapists approached management of early knee OA, with a focus on evidence-based strategies. This is an important first step to begin to optimize care by physical therapists for this population.

DESIGN

We used a qualitative, descriptive research design.

METHODS

Semistructured interviews were conducted with 33 physical therapists working with people with knee symptoms and/or diagnosed knee OA in community or outpatient settings in Canada. Data were analyzed using thematic analysis.

RESULTS

Five main themes were constructed: (1) Physical therapists' experience and training: clinical experiences and continuing professional development informed clinical decision-making. (2) Tailoring treatment from the physical therapist "toolbox:" participants described their toolbox of therapeutic interventions, highlighting the importance of tailoring treatments to people. (3) The central role of exercise and physical activity in management: exercise was consistently recommended by participants. (4) Variability in support for weight management: there was variation related to how participants addressed weight management. (5) Facilitating "buy-in" to management: physical therapists used a range of strategies to gain "buy-in."

LIMITATIONS

Participants were recruited through a professional association specializing in orthopedic physical therapy and worked an average of 21 years.

CONCLUSIONS

Participants' accounts emphasized tailoring of interventions, particularly exercises, which is an evidence-based strategy for OA. Findings illuminated variations in management that warrant further exploration to optimize early intervention (eg, weight management, behavior change techniques).

Association Between Self-Reported Spinal Morning Stiffness and Radiographic Evidence of Lumbar Disk Degeneration in Participants of the Cohort Hip and Cohort Knee (CHECK) Study

BACKGROUND

Low back pain (LBP) is very common and is a main cause of limited activity and work absence. Patients with LBP may also report spinal morning stiffness; this symptom could be useful for identifying subgroups with signs and symptoms related to spinal osteoarthritis.

OBJECTIVE

This study investigated whether an association exists between reported spinal morning stiffness and radiographic evidence of lumbar disk degeneration (LDD) in people with LBP and a history of pain of the hip and/or knee.

DESIGN

This cross-sectional study used 8-year follow-up data from the Cohort Hip and Cohort Knee study.

METHODS

The association between spinal morning stiffness and radiographic LDD features was assessed with multivariable logistic regression models.

RESULTS

The presence of osteophytes was significantly associated with spinal morning stiffness (odds ratio [OR] = 2.1 [95% confidence interval [CI] = 1.3-3.2]) as was the presence of grade 2 or 3 disk space narrowing (OR = 2.0 [95% CI = 1.1-3.5]). There was also a significant association between morning stiffness persisting for > 30 minutes and grade 2 osteophytes (OR = 2.6 [95% CI = 1.1-6.2]) and grade 1 disk space narrowing (OR = 2.0 [95% CI = 1.1-3.6]). Furthermore, there was a significant association between moderate spinal morning stiffness and the presence of osteophytes (OR = 2.0 [95% CI = 1.2-3.2]). Both the presence of osteophytes and disk space narrowing were significantly associated with severe spinal morning stiffness (for osteophytes: OR = 2.0 [95% CI = 1.2-3.7]; for narrowing at L1-S1: OR = 1.8 [95% CI = 1.1-3.1]).

LIMITATIONS

Only lumbar lateral radiographs were available for each participant, implying that the LDD features could have been underestimated. The quality of the radiographs was not consistent.

CONCLUSIONS

This study showed an association between self-reported spinal morning stiffness and symptomatic LDD. When morning stiffness lasted > 30 minutes, there was a significant association with the features of LDD. The association was stronger when the severity of spinal morning stiffness increased.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Implementation of a group physical therapy program for Veterans with knee osteoarthritis

Background

A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program.

Methods

This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0–96)) and a 30-s chair rise test.

Results

During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0).

Conclusions

Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.

Development of a core capability framework for qualified health professionals to optimise care for people with osteoarthritis: an OARSI initiative

OBJECTIVE

Develop a generic trans-disciplinary, skills-based capability framework for health professionals providing care for people with OA.

DESIGN

e-Delphi survey. An international inter-professional Delphi Panel (researchers; clinicians; consumer representatives) considered a draft framework (adapted from elsewhere) of 131 specific capabilities mapped to 14 broader capability areas across four domains (A: person-centred approaches; B: assessment, investigation and diagnosis; C: management, interventions and prevention; D: service and professional development). Over three rounds, the Panel rated their agreement (Likert or numerical rating scales) on whether each specific capability in Domains B and C was essential (core) for all health professionals when providing care for all people with OA. Those achieving consensus (≥80% of Panel) rating of ≥ seven out of ten (Round 3) were retained. Generic domains (A and D) were included in the final framework and amended based on Panel comments.

RESULTS

173 people from 31 countries, spanning 18 disciplines and including 26 consumer representatives, participated. The final framework comprised 70 specific capabilities across 13 broad areas i) communication; ii) person-centred care; iii) history-taking; iv) physical assessment; v) investigations and diagnosis; vi) interventions and care planning; vii) prevention and lifestyle interventions; viii) self-management and behaviour change; ix) rehabilitative interventions; x) pharmacotherapy; xi) surgical interventions; xii) referrals and collaborative working; and xiii) evidence-based practice and service development).

CONCLUSION

Experts agree that health professionals require an array of skills in person-centred approaches; assessment, investigation and diagnosis; management, interventions and prevention; and service and professional development to provide optimal care for people with OA.

Shoulder Rotator Cuff Disorders: A Systematic Review of Clinical Practice Guidelines and Semantic Analyses of Recommendations

OBJECTIVES

To perform a systematic review of clinical practice guidelines (CPGs) and semantic analysis of specific clinical recommendations for the management of rotator cuff disorders in adults.

DATA SOURCES

A systematic bibliographic search was conducted up until May 2018 in Medline, Embase, and Physiotherapy Evidence Database, or PEDro, databases, in addition to 12 clinical guidelines search engines listed on the Appraisal of Guidelines for Research and Evaluation (AGREE) website.

STUDY SELECTION

Nine CPGs on the management of rotator cuff disorders in adults or workers, available in English or French, and published from January 2008 onward, were included and screened by 2 independent reviewers.

DATA EXTRACTION

CPG methodology was assessed with the AGREE II checklist. A semantic analysis was performed to compare the strength of similar recommendations based on their formulation. The recommendations were categorized in a standardized manner considering the following 4 levels: "essential," "recommended," "may be recommended," and "not recommended."

DATA SYNTHESIS

Methodological quality was considered high for 3 CPGs and low for 6. All CPGs recommended active treatment modalities, such as an exercise program in the management of rotator cuff disorders. Acetaminophen or nonsteroidal anti-inflammatory drug prescriptions and corticosteroid injections were presented as modalities that may be recommended to decrease pain. Recommendations related to medical imagery and surgical opinion varied among the guidelines. The most commonly recommended return-to-work strategies included intervening early, use of a multidisciplinary approach, and adaptation of work organization.

CONCLUSIONS

Only 3 CPGs were of high quality. The development of more rigorous CPGs is warranted.