The efficacy of non-surgical treatment on pain and sensitization in patients with knee osteoarthritis: a pre-defined ancillary analysis from a randomized controlled trial

Neurophysiological pain education for patients with symptomatic knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of neurophysiological pain education in patients with symptomatic knee osteoarthritis considering pain-related variables.

METHODS

A systematic review and meta-analysis was carried out according to the PRISMA guidelines. A search was conducted in PubMed, PEDro Database, Cochrane Library, Scopus, and Web of Science. Only randomized controlled trials enrolling patients ≥ 18 years of age with symptomatic knee osteoarthritis were included. The Downs and Black quality assessment tool was used to assess the quality of the articles, and the risk of bias was evaluated with the Cochrane Risk of Bias Assessment Tool.

RESULTS

A total of 7 studies were included in the study. Most of the studies were rated as "fair" on the Downs and Black quality assessment tool, and in the category of "some concerns" according to the Cochrane Risk of Bias Assessment Tool. Neurophysiological pain education was conducted alone or combined with exercise, joint mobilizations, or self-management programs. The number of sessions ranged from 1 to 10. The meta-analysis results showed significant differences in favor of the intervention group in pain (MD = -0.49; 95% CI = -0.66; -0.32; p < 0.001) and catastrophization (MD = -1.81; 95% CI = -3.31, -0.3; p = 0.02).

CONCLUSION, PRACTICE IMPLICATIONS

Neurophysiological pain education interventions in isolation or combined with exercise, joint mobilizations, or self-management programs have proven to significantly improve pain and catastrophization in patients with symptomatic knee osteoarthritis. These findings could provide clinicians with more information regarding the management of patients with symptomatic knee osteoarthritis.

The effectiveness of a combined exercise and psychological treatment programme on measures of nervous system sensitisation in adults with chronic musculoskeletal pain - a systematic review and meta-analysis

BACKGROUND

Quantitative sensory testing (QST) offers information regarding underlying mechanisms contributing to chronic pain (CP) in adults with musculoskeletal disorders. This review examined the use of QST measures in adults with CP following participation in a combined exercise and psychological intervention.

METHODS

The review was conducted in accordance with the PRISMA guidelines. Five databases were searched from inception to November 2022. All study designs which evaluated the effects of a combined exercise and psychological treatment on measures of nervous system sensitivity in adults with chronic musculoskeletal pain were included.

RESULTS

A total of 13 studies met the selection criteria, 10 of which were included in a meta-analysis. Local pressure pain thresholds were the most frequently used measure (n = 12 studies). Meta-analysis revealed statistically significantly improvements in favour of the combined exercise and psychological intervention group, compared to a control group, for local pressure pain threshold measures [SMD = 0.44, 95% CI 0.08-0.81, I2 = 84%], pain intensity scores [SMD=-0.89, 95% CI -1.66- -0.13, I2 = 94%] and the Central Sensitisation Inventory [SMD=-0.69, 95% CI -1.37- -0.02, I2 = 87%]. There were no significant differences found between groups for remote pressure pain thresholds, temporal summation or conditioned pain modulation.

CONCLUSIONS

The results suggest that a combined exercise and psychological intervention may lead to greater improvements in local pressure pain threshold, pain intensity and Central Sensitisation Inventory scores when compared to a control intervention in adults with CP, however these findings must be interpreted with caution as a large degree of heterogeneity was present in these results (I2: 84-94%). Further large, longitudinal studies are required using standardised QST measurement procedures and patient reported outcome measures to explore changes in nervous system sensitisation.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO, ID Number CRD42022380464.

Cooled radiofrequency ablation of genicular nerves for knee osteoarthritis

Knee osteoarthritis (OA) is a prevalent and debilitating musculoskeletal condition that significantly affects the quality of life of millions of individuals worldwide. In recent years, cooled radiofrequency ablation (CRFA) has become a viable treatment option for knee OA. This review thoroughly evaluated the existing literature on CRFA therapy for knee OA. It delved into the mechanisms behind CRFA, evaluated its clinical efficacy, and investigated potential avenues for future research and application. The insights gained from this review are crucial for healthcare professionals, researchers, and policymakers, offering an updated perspective on CRFA's role as a viable therapeutic option for knee OA.

Review of cooled radiofrequency ablation utilization for the treatment of symptomatic advanced knee arthritis and total knee arthroplasty

Degenerative knee osteoarthritis is a progressive debilitating condition that affects millions of people worldwide. Most patients experience limited range of motion, inflammation, swelling, and pain. Management options can lead to short- and long-term pain relief. Short-term pain relief usually involves conservative medical treatments such as NSAIDs, weight loss, physical therapy, and corticosteroid injections. The ultimate long-term pain relief treatment method involves total knee arthroplasty. The treatment algorithm for knee OA also includes managing pain until a patient is eligible for arthroplasty. Furthermore, about 20% of patients experience chronic pain after TKA without complications such as hardware loosening and infection with limited treatment options. The pathophysiology of this is unknown. Cooled radiofrequency ablation has been demonstrated to be clinically effective by disrupting the integrity of deep sensory nerves and hence interfering with transmission of pain signal. The analgesic effect after c-RFA has been reported up to 24 months. Here, we present an overview of the clinical application of cooled radiofrequency ablation and a summary of its effectiveness in the treatment of pain in the setting of advanced OA and symptomatic TKA.

Training-induced hypoalgesia and its potential underlying mechanisms

It is well-established that a single bout of exercise can reduce pain sensitivity (i.e., exercise-induced hypoalgesia) in healthy individuals. However, exercise-induced hypoalgesia is often impaired in individuals with chronic pain. This might suggest that repeated bouts of exercise (i.e., exercise training) are needed in order to induce a reduction in pain sensitivity (i.e., training-induced hypoalgesia) among individuals with chronic pain, given that a single bout of exercise seems to be insufficient to alter pain. However, the effect of repeated bouts of exercise on pain sensitivity and its underlying mechanisms remain poorly understood. Therefore, the purpose of this review was to provide an overview of the existing literature on training-induced hypoalgesia, as well as discuss potential mechanisms of training-induced hypoalgesia and offer considerations for future research. Existing literature suggests that training interventions may induce hypoalgesic adaptations potentially driven by central nervous system and immune system factors. However, the limited number of randomized controlled trials available, along with the lack of understanding of underlying mechanisms, provides a rationale for future research.

Review of Extraosseous Applications of Thermal Ablation in the Treatment of Moderate to Severe Large Joint Osteoarthritis

Osteoarthritis (OA) is the most common joint disease worldwide, leading to significant pain, restricted range of motion, and disability. A gap exists between short- and long-term symptom-relieving therapies. Although arthroplasty is an effective treatment for symptomatic end-stage disease, most patients ultimately do not receive a joint replacement due to suboptimal surgical qualifications, comorbidities, or an aversion to surgery. The lack of additional treatment options in this setting makes opioid agonists a commonly used pharmacologic agent, contributing to the addiction epidemic that greatly afflicts our communities. Cooled radiofrequency ablation (CRFA) has arisen as a treatment modality in the setting of moderate to severe OA among patients refractory to conservative management, generally showing greater efficacy compared with other existing strategies. This review focuses on the benefits of CRFA and its technical feasibility as a management option among patients experiencing debilitating large joint OA with limited clinical options.

Multimodal Interventions Including Rehabilitation Exercise for Older Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-analyses of Randomized Controlled Trials

BACKGROUND AND PURPOSE

Musculoskeletal disorders (MSKDs) are the most common causes of disabilities for older adults. The aim of this systematic review and meta-analysis is to assess the effectiveness of multimodal interventions including exercise rehabilitation for older adults with chronic MSKDs.

METHODS

A literature search was conducted up to February 2019 in 5 bibliographical databases to identify randomized controlled trials (RCTs) that compared multimodal interventions including exercise rehabilitation with usual medical care or no intervention. Randomized controlled trials were assessed with the Cochrane risk-of-bias tool. Meta-analyses were performed and pooled mean differences (MDs) or standardized mean differences (SMDs) were calculated.

RESULTS

Sixteen RCTs (n = 2322 participants) were included. One RCT was considered at low risk of bias, 8 had some concerns of bias, and 7 had a high risk of bias. Participants suffered from hip or knee osteoarthritis (OA) (n = 12 RCTs), low back pain (LBP) (n = 2 RCTs) and generalized chronic pain (GCP) (n = 2 RCTs). Multimodal interventions were significantly more effective than usual care to decrease pain (visual analog scale, out of 10 points) in the short term, MD: -0.71 (95% confidence interval [CI] -1.08 to -0.34, n = 900), and in the long term: MD: -0.52 (95% CI -0.98 to -0.05, n = 575), but these differences are not considered clinically important. In terms of disabilities, multimodal interventions were also significantly more effective than usual care. The SMDs were -0.47 (95% CI -0.61 to -0.34, n = 903) and -0.29 (95% CI -0.46 to -0.13, n = 568) for OA trials in the short and long terms, respectively, and -0.47 (95% CI -0.81 to -0.12, n = 211) for LBP and GCP trials in the short term. The magnitude of these effects may be considered as small to moderate.

CONCLUSION

Multimodal intervention including exercise rehabilitation combined with usual medical care is an efficacious therapeutic option to reduce disabilities in older adults with chronic MSKDs. A significant but not clinically important effect was observed for pain. The most beneficial component of the multimodal interventions in terms of education, exercises, or medication remains to be determined.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

Main types of insoles described in the literature and their applicability for musculoskeletal disorders of the lower limbs: A systematic review of clinical studies

The objective of this review was to identify the main types of insoles described in the literature that are used to treat musculoskeletal alterations of lower limbs and to analyze the existence of previous evaluation for the prescription of these insoles. To this end, two researchers, independently and blindly, searched the PubMed, SciELO, Bireme, MEDLINE, Lilacs, PEDro, Cochrane Library and Web of Science databases between June and July of 2018, from the free combination of the following descriptors: insoles, foot orthoses, foot, orthoses, musculoskeletal diseases and clinical trial. We included randomized or non-randomized clinical trials in which at least one intervention group used insoles and individuals with some type of musculoskeletal disorder had been sampled. Of the 227 documents identified in date bases, 20 were included in this review. In general, it is suggested to carry out more studies with more precise methods and that include evaluation before the prescription. This is a systematic review of clinical trials registered in PROSPERO (International Prospective Register of Systematic Reviews) under the protocol no. CRD42018099534e.

Pressure pain sensitivity in patients with traumatic first-time and recurrent anterior shoulder dislocation: a cross-sectional analysis

Background and aims Traumatic anterior shoulder dislocation (ASD) is frequent in active populations and associated with a 39% higher risk of recurrent dislocation, which may cause persistent shoulder problems, pain, and impaired shoulder-related quality of life. While local and distant pressure pain sensitivity has been demonstrated in other shoulder conditions, little is known about the link between pressure pain sensitivity and ASD. The interesting aspect is whether recurrent dislocation - resulting in symptoms of longer duration - is associated with more pronounced pressure pain sensitivity, or if presence of pressure pain sensitivity may be part of the reasons why patients develop recurrent dislocation. Therefore, this study aimed at evaluating whether patients with recurrent ASD display greater pressure pain sensitivity and more painful body sites than patients with first-time ASD. Methods This was a cross-sectional analysis of baseline data from a randomized controlled trial including 34 patients with first-time ASD [82% male, mean (SD) age 26 (7) years] and 22 patients with recurrent ASD [96% male, mean (SD) age 25 (5) years]. Patients were assessed as follows: (1) assessment of local and distant pressure pain sensitivity evaluated by pressure pain thresholds (PPTs) using a handheld algometer on mm. trapezius superior, levator scapula, pectorales major, deltoideus, and tibialis anterior, (2) pain intensity at rest during the previous 24 h, (3) number of ASD, and (4) number of painful body sites on a region-divided body chart. Results The PPTs were not significantly different between first-time and recurrent ASD [mean (SD) kPa for m. trapezius superior 264 (110) vs. 261 (88), m. levator scapula 301 (157) vs. 325 (163), m. pectorales major 234 (163) vs. 269 (130), m. deltoideus 290 (166) vs. 352 (173), m. tibialis anterior 420 (202) vs. 449 (184)], two-way ANCOVA, adjusted for sex and age, F (4,263) = 0.29, p = 0.88. For both groups, the PPTs were lower at the shoulder sites than at m. tibialis anterior (difference 117-184 kPa, 95% CI range 33-267). Females had lower PPTs than males (difference 124 kPa, 95% CI 64-183). The number (SD) of painful body sites were 2.2 (1.9) for first-time ASD and 2.6 (5.4) for recurrent ASD, with no between-group differences, one-way ANCOVA, adjusted for sex and age, F (1, 52) = 0.24, p = 0.63. There was a strong correlation between PPTs at the shoulder and lower leg, r = 0.84, p < 0.01. Conclusions This study demonstrated no differences in local and distant pressure pain sensitivity or number of painful body sites between patients with first-time and recurrent ASD. Females had lower PPTs than males, and a strong correlation was found between PPTs at the shoulder and lower leg. Implications Patients with first-time and recurrent ASD seem to have similar pressure pain sensitivity, but lower PPTs compared to existing normative data, suggesting that it is relevant to evaluate the status of the pain system in these patients to prevent triggering or worsening of their symptoms. However, it remains unanswered how these changes affect the patients' ability to undergo rehabilitation, symptom response and long-term shoulder function.

Interventional radiology techniques for pain reduction and mobility improvement in patients with knee osteoarthritis

Osteoarthritis of the knee is the most common cause of chronic knee pain being more prevalent in middle-aged and elderly patients. Symptomatic patients complain of pain and mobility impairment. Therapeutic armamentarium includes physical therapy, oral pharmacologic therapy, intra-articular injections, nerve ablation or modulation, trans-catheter arterial embolization, minimally invasive arthroscopic treatment and partial or total knee arthroplasty. Interventional radiology therapies for knee osteoarthritis include intra-articular injections, neurotomy and neuromodulation techniques as well as transcatheter intra-arterial therapies. These therapies aim to control pain and inflammation, improve mobility and function whilst the novel cell-based therapies have the potential for bone and cartilage regenerative repair facilitating the delay to surgery. The purpose of this review is to illustrate the technical aspects, the indications and the methodology of local therapies for knee osteoarthritis performed by interventional radiologists and provide current evidence.

Upregulation of microRNA‑590 in rheumatoid arthritis promotes apoptosis of bone cells through transforming growth factor‑β1/phosphoinositide 3‑kinase/Akt signaling

The aim of the present study was to further define the role of microRNA (miR)‑590 in osteoarthritis (OA) and to investigate the underlying mechanism. In brief, reverse transcription‑quantitative polymerase chain reaction was used to analyze miR‑590 expression in bone tissue samples from rats with OA. Results indicated the expression of miR‑590 was increased. miR‑590 upregulation induced apoptosis in bone cells, whereas miR‑590 downregulation reduced apoptosis of bone cells. Furthermore, miR‑590 upregulation suppressed the protein expression levels of transforming growth factor (TGF)‑β1, phosphoinositide 3‑kinase (PI3K) and phosphorylated (p)‑Akt in bone cells. However, downregulation of miR‑590 induced the protein expression levels of TGF‑β1, PI3K and p‑Akt in bone cells. In addition, TGF‑β1 attenuated the effects of miR‑590 upregulation on bone cell apoptosis and the inactivation of PI3K inhibited the effects of miR‑590 downregulation on bone cell apoptosis. Taken together, the present data suggested that miR‑590 promoted apoptosis in bone cells from rats with OA by regulating the TGF‑β1/PI3K signaling pathway.

Preoperative Pain Neuroscience Education Combined With Knee Joint Mobilization for Knee Osteoarthritis: A Randomized Controlled Trial

OBJECTIVES

This study aimed to first compare the effects of a preoperative treatment combining pain neuroscience education (PNE) with knee joint mobilization versus biomedical education with knee joint mobilization on central sensitization (CS) in patients with knee osteoarthritis, both before and after surgery. Second, we wanted to compare the effects of both interventions on knee pain, disability, and psychosocial variables.

MATERIALS AND METHODS

Forty-four patients with knee osteoarthritis were allocated to receive 4 sessions of either PNE combined with knee joint mobilization or biomedical education with knee joint mobilization before surgery. All participants completed self-administered questionnaires and quantitative sensory testing was performed at baseline, after treatment and at a 1 month follow-up (all before surgery), and at 3 months after surgery.

RESULTS

Significant and clinically relevant differences before and after surgery were found after treatments for both knee pain and disability, and some measures of CS (ie, widespread hyperalgesia, CS inventory), with no significant between-group differences. Other indicators of CS (ie, conditioned pain modulation, temporal summation) did not change over time following either treatment, and in some occasions the observed changes were not in the expected direction. Patients receiving PNE with knee joint mobilization achieved greater improvements in psychosocial variables (pain catastrophizing, kinesiophobia) both before and after surgery.

DISCUSSION

Preoperative PNE combined with knee joint mobilization did not produce any additional benefits over time for knee pain and disability, and CS measures compared with biomedical education with knee joint mobilization. Superior effects in the PNE with knee joint mobilization group were only observed for psychosocial variables related to pain catastrophizing and kinesiophobia.

Effectiveness of Foot Biomechanical Orthoses to Relieve Patients' Knee Pain: Changes in Neural Strategy After 9 Weeks of Treatment

Knee pain is one of the most common lower leg complaints. It is often treated with plantar orthoses to provide cushioning and correct locomotion, imbalances of the foot, and postural deficits. However, the published scientific data are poor concerning the mechanisms involved in pain reduction after wearing foot orthoses, and, to the best of our knowledge, no trial has investigated the mid-term effectiveness. The aim of the present study was to evaluate the effectiveness of foot orthoses according to sound biomechanical principles in the treatment of knee pain. Attention was mainly focused on changes in the central control strategies. Fifteen subjects were included in the protocol. The patients with knee pain were compared with healthy participants (control group) exhibiting no knee pain. In the patients with knee pain, pain perception, dynamic analysis of the gait, stabilometry, the soleus Hoffmann reflex at rest and during voluntary contraction, and V-wave were measured before and 3, 6, and 9 weeks after wearing orthoses. In the control group (n = 5), the same parameters were recorded at 0, 3, 6, and 9 weeks, but the subjects had not worn orthoses. In the patient group (n = 10), the results indicated that pain had significantly decreased from the third week onward, although the parameters of gait and stabilometry remained unchanged. From the sixth week, the soleus Hoffmann reflex during voluntary contraction wave was significantly reduced, suggesting an increase in motoneuronal presynaptic inhibition by non-nociceptive afferents. The V-wave amplitude increased throughout the 9 weeks of the experiment, suggesting a progressive increase in corticospinal and/or extrapyramidal descending pathway inputs, probably due to pain reduction. In the control group, no change was observed throughout the experimental sessions. Our data indicated that foot orthoses relieved patients' knee pain and reduced the descending motor inhibition. Changes in spinal modulation could contribute to a better quality of life. However, this treatment failed to change the altered gait, despite changes in spinal and supraspinal modulation.

Osteoarthritis: Models for appropriate care across the disease continuum

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition.

New Therapeutic Targets for Osteoarthritis Pain

Osteoarthritis (OA), the most common form of arthritis, causes pain and disability, as well as emotional distress. While total joint replacement is one of the most effective treatments available for improving the quality of life in people with severe OA, it is not suitable for all patients and all joints. Current pharmacological analgesics have limited efficacy, and their use is often restricted by adverse events. Medications that might reduce pain by slowing or preventing structural disease remain elusive. Our increasing understanding of the complex mechanisms that underlie OA pain offers a wide range of potential new treatment targets. New drugs for OA pain might come from repurposing those developed for other conditions, as well as novel compounds targeting pain mechanisms specific to the joint. Here we discuss the mechanisms of OA pain and its therapeutic implications. We explore evolving treatment modalities, including combination treatment. We review recent research and patents pointing to future OA therapies. We discuss the potential for biomarkers to facilitate drug development and targeting.

Expanded Distribution of Pain as a Sign of Central Sensitization in Individuals With Symptomatic Knee Osteoarthritis

BACKGROUND

Expanded distribution of pain is considered a sign of central sensitization (CS). The relationship between recording of symptoms and CS in people with knee osteoarthritis (OA) has been poorly investigated.

OBJECTIVE

The aim of this study was to examine whether the area of pain assessed using pain drawings relates to CS and clinical symptoms in people with knee OA.

DESIGN

This was a cross-sectional study.

METHODS

Fifty-three people with knee OA scheduled to undergo primary total knee arthroplasty were studied. All participants completed pain drawings using a novel digital device, completed self-administration questionnaires, and were assessed by quantitative sensory testing. Pain frequency maps were generated separately for women and men. Spearman correlation coefficients were computed to reveal possible correlations between the area of pain and quantitative sensory testing and clinical symptoms.

RESULTS

Pain frequency maps revealed enlarged areas of pain, especially in women. Enlarged areas of pain were associated with higher knee pain severity (rs=.325, P<.05) and stiffness (rs=.341, P<.05), lower pressure pain thresholds at the knee (rs=-.306, P<.05) and epicondyle (rs=-.308, P<.05), and higher scores with the Central Sensitization Inventory (rs=.456, P<.01). No significant associations were observed between the area of pain and the remaining clinical symptoms and measures of CS.

LIMITATIONS

Firm conclusions about the predictive role of pain drawings cannot be drawn. Further evaluation of the reliability and validity of pain area extracted from pain drawings in people with knee OA is needed.

CONCLUSION

Expanded distribution of pain was correlated with some measures of CS in individuals with knee OA. Pain drawings may constitute an easy way for the early identification of CS in people with knee OA, but further research is needed.