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Hall BE, Mazhar K, Macdonald E, Cassidy M, Doty M, Judkins C, Terse A, Shiers S, Tadros S, Yun S, Burton MD, Price TJ, Kulkarni A. Transcriptome Analysis of Rheumatoid Arthritis Uncovers Genes Linked to Inflammation-Induced Pain. RESEARCH SQUARE 2024:rs.3.rs-4218885. [PMID: 38712195 PMCID: PMC11071542 DOI: 10.21203/rs.3.rs-4218885/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Autoimmune diseases such as rheumatoid arthritis (RA) can promote states of chronic Inflammation with accompanying tissue destruction and pain. RA can cause inflammatory synovitis in peripheral joints, particularly within the hands and feet, but can also sometimes trigger temporomandibular joint (TMJ) arthralgia. To better understand the effects of ongoing Inflammation-induced pain signaling, dorsal root ganglia (DRGs) were acquired from individuals with RA for transcriptomic study. We conducted RNA sequencing from the L5 DRGs because it contains the soma of the sensory neurons that innervate the affected joints in the foot. DRGs from 5 RA patients were compared with 9 non-arthritic controls. RNA-seq of L5 DRGs identified 128 differentially expressed genes (DEGs) that were dysregulated in the RA subjects as compared to the non-arthritic controls. The DRG resides outside the blood brain barrier and, as such, our initial transcriptome analysis detected signs of an autoimmune disorder including the upregulated expression of immunoglobulins and other immunologically related genes within the DRGs of the RA donors. Additionally, we saw the upregulation in genes implicated in neurogenesis that could promote pain hypersensitivity. overall, our DRG analysis suggests that there are upregulated inflammatory and pain signaling pathways that can contribute to chronic pain in RA.
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Affiliation(s)
- Bradford E Hall
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | | | - Emma Macdonald
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | - Margaret Cassidy
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | - Megan Doty
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | - Christian Judkins
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | - Anita Terse
- National Institute of Dental and Craniofacial Research, National Institutes of Health
| | | | - Saber Tadros
- National Cancer Institute, National Institutes of Health
| | | | | | | | - Ashok Kulkarni
- National Institute of Dental and Craniofacial Research, National Institutes of Health
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Yang J, Wang X, Zhang Y, He R, Fu Z, Wang R, Ma Y, Fu D, Meng S, Cai W, Zhou Y, Chen C, Chen G, Gong X. Intra-Articular Injection of Interleukin-8 Neutralizing Monoclonal Antibody Effectively Attenuates Osteoarthritis Progression in Rabbits. Cartilage 2024:19476035241240361. [PMID: 38525935 DOI: 10.1177/19476035241240361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE Cytokines are implicated in the pathogenesis of osteoarthritis (OA), and this study aims to assess the therapeutic potential of an IL-8 neutralizing monoclonal antibody (mAb) for OA intervention. DESIGN The study employed a rabbit model of OA induced by anterior cruciate ligament transection (ACLT) surgery to investigate the effects of an interleukin (IL)-8 neutralizing mAb, with hyaluronic acid (HA) used as a positive control. Primary outcomes assessed in the rabbits included cartilage repair, synovitis, joint effusion, changes in footprints, and lower limb loading conditions. RESULTS Compared to HA, intra-articular injection of the IL-8 neutralizing mAb demonstrated a more pronounced attenuation of OA progression and enhancement of cartilage repair. We observed a reduction in synovitis and joint effusion, indications of bone marrow edema, as well as improvements in lower limb function. In knees treated with the neutralizing IL-8 mAb, there was a significant decrease in IL-8 levels within the synovial tissues. CONCLUSIONS The IL-8 neutralizing mAb exhibits promising therapeutic potential in the management of OA by attenuating inflammation and facilitating cartilage repair. However, further investigations are warranted to comprehensively elucidate the underlying mechanisms, optimize treatment protocols, and ensure the long-term safety and efficacy of this innovative therapeutic approach.
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Affiliation(s)
- Junjun Yang
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
- Key Laboratory of Biorheological Science and Technology, College of Bioengineering, Chongqing University, Ministry of Education, Chongqing, China
| | - Xin Wang
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | | | - Rui He
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhenlan Fu
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Rong Wang
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yanming Ma
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Dejie Fu
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Shuo Meng
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Wang Cai
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yizhao Zhou
- Department of Orthopedics, Hunan Provincial People's Hospital, The First-Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Cheng Chen
- College of Medical Informatics, Chongqing Medical University, Chongqing, China
| | - Guangxing Chen
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiaoyuan Gong
- Center for Joint Surgery, Southwest Hospital, Army Medical University, Chongqing, China
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Pacifico P, Coy-Dibley JS, Miller RJ, Menichella DM. Peripheral mechanisms of peripheral neuropathic pain. Front Mol Neurosci 2023; 16:1252442. [PMID: 37781093 PMCID: PMC10537945 DOI: 10.3389/fnmol.2023.1252442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 10/03/2023] Open
Abstract
Peripheral neuropathic pain (PNP), neuropathic pain that arises from a damage or disease affecting the peripheral nervous system, is associated with an extremely large disease burden, and there is an increasing and urgent need for new therapies for treating this disorder. In this review we have highlighted therapeutic targets that may be translated into disease modifying therapies for PNP associated with peripheral neuropathy. We have also discussed how genetic studies and novel technologies, such as optogenetics, chemogenetics and single-cell RNA-sequencing, have been increasingly successful in revealing novel mechanisms underlying PNP. Additionally, consideration of the role of non-neuronal cells and communication between the skin and sensory afferents is presented to highlight the potential use of drug treatment that could be applied topically, bypassing drug side effects. We conclude by discussing the current difficulties to the development of effective new therapies and, most importantly, how we might improve the translation of targets for peripheral neuropathic pain identified from studies in animal models to the clinic.
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Affiliation(s)
- Paola Pacifico
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - James S. Coy-Dibley
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Richard J. Miller
- Department of Pharmacology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Daniela M. Menichella
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Hwang CD, Pagani CA, Nunez JH, Cherief M, Qin Q, Gomez-Salazar M, Kadaikal B, Kang H, Chowdary AR, Patel N, James AW, Levi B. Contemporary perspectives on heterotopic ossification. JCI Insight 2022; 7:158996. [PMID: 35866484 PMCID: PMC9431693 DOI: 10.1172/jci.insight.158996] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Heterotopic ossification (HO) is the formation of ectopic bone that is primarily genetically driven (fibrodysplasia ossificans progressiva [FOP]) or acquired in the setting of trauma (tHO). HO has undergone intense investigation, especially over the last 50 years, as awareness has increased around improving clinical technologies and incidence, such as with ongoing wartime conflicts. Current treatments for tHO and FOP remain prophylactic and include NSAIDs and glucocorticoids, respectively, whereas other proposed therapeutic modalities exhibit prohibitive risk profiles. Contemporary studies have elucidated mechanisms behind tHO and FOP and have described new distinct niches independent of inflammation that regulate ectopic bone formation. These investigations have propagated a paradigm shift in the approach to treatment and management of a historically difficult surgical problem, with ongoing clinical trials and promising new targets.
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Affiliation(s)
- Charles D Hwang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Chase A Pagani
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Johanna H Nunez
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Masnsen Cherief
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qizhi Qin
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Balram Kadaikal
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Heeseog Kang
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ashish R Chowdary
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aaron W James
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benjamin Levi
- Department of Surgery, Center for Organogenesis Research and Trauma, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Dravid AA, M. Dhanabalan K, Agarwal S, Agarwal R. Resolvin D1-loaded nanoliposomes promote M2 macrophage polarization and are effective in the treatment of osteoarthritis. Bioeng Transl Med 2022; 7:e10281. [PMID: 35600665 PMCID: PMC9115708 DOI: 10.1002/btm2.10281] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/19/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022] Open
Abstract
Current treatments for osteoarthritis (OA) offer symptomatic relief but do not prevent or halt the disease progression. Chronic low-grade inflammation is considered a significant driver of OA. Specialized proresolution mediators are powerful agents of resolution but have a short in vivo half-life. In this study, we have engineered a Resolvin D1 (RvD1)-loaded nanoliposomal formulation (Lipo-RvD1) that targets and resolves the OA-associated inflammation. This formulation creates a depot of the RvD1 molecules that allows the controlled release of the molecule for up to 11 days in vitro. In surgically induced mice model of OA, only controlled-release formulation of Lipo-RvD1 was able to treat the progressing cartilage damage when administered a month after the surgery, while the free drug was unable to prevent cartilage damage. We found that Lipo-RvD1 functions by damping the proinflammatory activity of synovial macrophages and recruiting a higher number of M2 macrophages at the site of inflammation. Our Lipo-RvD1 formulation was able to target and suppress the formation of the osteophytes and showed analgesic effect, thus emphasizing its ability to treat clinical symptoms of OA. Such controlled-release formulation of RvD1 could represent a patient-compliant treatment for OA.
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Affiliation(s)
- Ameya A. Dravid
- BioSystems Science and EngineeringIndian Institute of ScienceBangaloreKarnatakaIndia
| | - Kaamini M. Dhanabalan
- BioSystems Science and EngineeringIndian Institute of ScienceBangaloreKarnatakaIndia
| | - Smriti Agarwal
- BioSystems Science and EngineeringIndian Institute of ScienceBangaloreKarnatakaIndia
| | - Rachit Agarwal
- BioSystems Science and EngineeringIndian Institute of ScienceBangaloreKarnatakaIndia
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Dong X, Li H, Pei M, Tan J, Chen G, Li S, Xie Z, Wang Q, Wang G, Chen Y, Wang C. Analgesic effects of nerve growth factor-directed monoclonal antibody on diabetic neuralgia in an animal model. FEBS Open Bio 2022; 12:1325-1335. [PMID: 35417079 PMCID: PMC9249326 DOI: 10.1002/2211-5463.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022] Open
Abstract
Current treatment options for diabetic neuralgia are limited and unsatisfactory. Tanezumab, a monoclonal antibody that blocks nerve growth factor (NGF) signaling, has been shown to be effective in relieving the clinical symptoms of osteoarthritis pain, chronic low back pain, cancer pain induced by bone metastasis, and diabetic neuralgia. However, the clinical development of tanezumab has been terminated due to the risk of induction of rapidly progressive osteoarthritis (RPOA), and no other NGF antibodies have been examined for their ability to treat diabetic neuralgia in either animal models or clinical trials. In this study, a humanized high‐affinity NGF monoclonal antibody (mAb), huAb45 that could neutralize the interaction between NGF and its high‐affinity receptor TrkA. In a mouse diabetic neuralgia model, it effectively relieved neuropathic pain. This study may serve as the necessary foundation for future studies of huAb45 to potentially treat diabetic neuralgia.
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Affiliation(s)
- Xingchen Dong
- School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210000, China.,Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China.,Biotherapeutics Discovery Research Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Huanhuan Li
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China
| | - Min Pei
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China
| | - Jie Tan
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China
| | - Ganjun Chen
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China
| | - Santai Li
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China
| | - Zuobin Xie
- Dartsbio Pharmaceuticals Ltd, Zhongshan, Guangdong, 528400, China
| | - Qi Wang
- Biotherapeutics Discovery Research Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Guifeng Wang
- Biotherapeutics Discovery Research Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Yili Chen
- Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China.,Dartsbio Pharmaceuticals Ltd, Zhongshan, Guangdong, 528400, China
| | - Chunhe Wang
- School of Chinese Materia Medica, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, 210000, China.,Shanghai Mabstone Biotechnology Ltd, Shanghai, 201203, China.,Dartsbio Pharmaceuticals Ltd, Zhongshan, Guangdong, 528400, China.,Biotherapeutics Discovery Research Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
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Perineural Local Anesthetic Treatments for Osteoarthritic Pain. REGENERATIVE ENGINEERING AND TRANSLATIONAL MEDICINE 2021; 7:262-282. [DOI: 10.1007/s40883-021-00223-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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8
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Yu Y, Lu ST, Sun JP, Zhou W. Safety of Low-Dose Tanezumab in the Treatment of Hip or Knee Osteoarthritis: A Systemic Review and Meta-analysis of Randomized Phase III Clinical Trials. PAIN MEDICINE 2021; 22:585-595. [PMID: 33141224 DOI: 10.1093/pm/pnaa260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To evaluate the safety of low-dose tanezumab in the treatment of knee or hip osteoarthritis (OA). METHODS Databases were searched up to September 2019 for phase III randomized controlled trials (RCTs). Eleven phase III RCTs comprising 11,455 patients were eligible. The pooled estimates of safety outcomes were assessed and expressed using relative risks (RRs) and 95% confidence intervals with a random-effects model. RESULTS Tanezumab significantly increased the incidence of rapidly progressive OA (RPOA; RR = 9.07, 95% CI = 1.21-67.90, P = 0.03) and abnormal peripheral sensation (APS; RR = 2.68, 95% CI = 1.64-4.37, P < 0.00001) compared with placebo. No significant difference was found in terms of incidence of total joint replacement (TJR; RR = 1.13, 95% CI = 0.76-1.68, P = 0.55) or withdrawal due to adverse effects (AEs; RR = 1.26, 95% CI = 0.79-2.00, P = 0.33). The tanezumab group showed a statistically higher incidence of RPOA (RR = 3.96, 95% CI = 2.23-7.04, P < 0.00001) and APS (RR = 1.2, 95% CI = 1.44-2.56, P < 0.00001) compared with the nonsteroidal anti-inflammatory drugs and opioids group. No significant difference was found in terms of TJR (RR = 1.51, 95% CI = 0.65-3.47, P = 0.33) and withdrawal (RR = 0.54, 95% CI = 0.20-1.40, P = 0.20). Subgroup analysis revealed that 2.5 mg of tanezumab did not show an advantage over 5 mg of tanezumab in reducing AEs. CONCLUSIONS These results demonstrate that RPOA and APS should be the most concerning AEs when using tanezumab in OA patients. Additional data are needed to define the optimal dose to minimize risk and to determine the optimal subjects to receive this treatment.
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Affiliation(s)
- Yang Yu
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shi-Tao Lu
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jin-Peng Sun
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wei Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, Henan Province, China
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Lories RJ, Monteagudo S. Review Article: Is Wnt Signaling an Attractive Target for the Treatment of Osteoarthritis? Rheumatol Ther 2020; 7:259-270. [PMID: 32277404 PMCID: PMC7211213 DOI: 10.1007/s40744-020-00205-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Indexed: 12/11/2022] Open
Abstract
Osteoarthritis is the most common chronic joint disease affecting millions of people worldwide and a leading cause of pain and disability. Increasing incidence of obesity and aging of the population are two factors that suggest that the impact of osteoarthritis will further increase at the society level. Currently, there are no drugs available that can manage both structural damage to the joint or the associated pain. Increasing evidence supports the view that the Wnt signaling pathway plays an important role in this disease. The current concept, based on genetic and functional studies, indicates that tight regulation of Wnt signaling in cartilage is essential to keep the joint healthy. In this review, we discuss how this concept has evolved, provide insights into the regulation of Wnt signaling, in particular by Wnt modulators such as frizzled-related protein and DOT1-like histone lysine methyltransferase, and summarize preclinical evidence and molecular mechanisms of lorecivivint, the first Wnt antagonist in clinical development for osteoarthritis.
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Affiliation(s)
- Rik J Lories
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium. .,Division of Rheumatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | - Silvia Monteagudo
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, KU Leuven, Leuven, Belgium
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Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1907821. [PMID: 32309424 PMCID: PMC7104126 DOI: 10.1155/2020/1907821] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/22/2020] [Indexed: 02/05/2023]
Abstract
Background Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine). Method PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy. Results Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies. Conclusions Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.
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