Osteoarthritis year in review 2018: rehabilitation and outcomes

Effects of whole-body vibration training as an adjunct to conventional rehabilitation exercise on pain, physical function and disability in knee osteoarthritis: A systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is a prevalent degenerative joint condition that impairs mobility and quality of life. While whole-body vibration training (WBVT) shows promise as an adjunct to conventional KOA rehabilitation, its efficacy remains unclear due to inconsistent clinical evidence.

OBJECTIVE

To elucidate the combined effects of WBVT and rehabilitation exercise on pain, physical function, and disability in KOA management through a systematic review and meta-analysis.

METHODS

A comprehensive search was conducted across eight electronic databases (PubMed, Web of Science, Embase, PEDro, SPORTDiscus, Scopus, ScienceDirect, and China National Knowledge Infrastructure) up to February 2024. Inclusion criteria were (i) randomized controlled trials comparing combined WBVT and rehabilitation exercise versus rehabilitation alone in KOA (ii) reported clinical outcomes (iii) human studies, and (iv) publications in English or Chinese. Trial quality was assessed using the PEDro scale and Cochrane risk-of-bias tool. The meta-analysis employed random-effects models in Review Manager 5.3 to account for heterogeneity, supported by sensitivity analyses for robustness and subgroup analyses on WBVT frequency effects.

RESULTS

Sixteen RCTs comprising 589 participants were included. The systematic review found that WBVT combined with conventional rehabilitation significantly reduced pain and improved physical function in KOA patients. The meta-analysis quantified these effects, showing that WBVT significantly (i) reduced knee pain (MD = -0.43, 95% CI [-0.70, -0.16], p = 0.002), with greater reductions observed from high-frequency WBVT, and (ii) increased isokinetic knee peak torque compared to rehabilitation exercise alone. No significant differences were found in balance, functional mobility, and disability outcomes. Sensitivity analysis of high-quality trials supported these results. However, the heterogeneity among studies and variations in control group interventions warrant cautious interpretation.

CONCLUSION

WBVT seems to be effective in reducing pain and enhancing muscle strength in KOA patients when used in conjunction with conventional rehabilitation. Future high-quality RCTs must standardize WBVT protocols, emphasize long-term follow-up, and refine dosage for clinically meaningful outcomes. Systematic review registration: International prospective register of systematic reviews (PROSPERO CRD42024508386).

Effects of photobiomodulation combined with rehabilitation exercise on pain, physical function, and radiographic changes in mild to moderate knee osteoarthritis: A randomized controlled trial protocol

BACKGROUND

Photobiomodulation, specifically high-energy photobiomodulation therapy (H-PBMT), is gaining recognition as a promising non-invasive intervention for managing knee osteoarthritis (KOA). While H-PBMT has demonstrated effectiveness in reducing pain and improving physical function, most evidence to date focuses on short-term symptomatic relief. The potential for H-PBMT to offer sustained benefits and modify the underlying progression of KOA remains insufficiently explored, warranting further investigation.

OBJECTIVE

This study aims to assess the short-term and sustained effects of H-PBMT combined with rehabilitation exercises in patients with mild to moderate KOA, focusing on knee radiographic morphological changes over a 3-month follow-up period.

METHODS

This protocol outlines a parallel-group, randomized, double-blind, placebo-controlled trial. Fifty participants with mild to moderate KOA (based on the Kellgren-Lawrence classification) will be randomly assigned to either the active H-PBMT plus exercise group (H-PBMT+E, n = 25) or the placebo photobiomodulation plus exercise group (PL+E, n = 25). Both groups will undergo an 8-week intervention, consisting of conventional rehabilitation exercises paired with either active or placebo photobiomodulation. H-PBMT will be delivered using the BTL-6000 HIL device with a 1064 nm wavelength, providing a total energy dose of 3190 J per 15-minute session. The treatment protocol includes both pulse mode (25 Hz, 5 W, 190 J) for analgesia and continuous mode (5 W, 3000 J) for biostimulation. Participants will be blinded to their group allocation through the use of a placebo device that mimics the active treatment without emitting therapeutic energy. Additionally, the outcome assessors will be blinded to the group allocations to ensure unbiased evaluation of the trial outcomes. The primary outcome is the Knee Injury and Osteoarthritis Outcome Score. Secondary outcomes include the Timed Up-and-Go test, Numerical Pain Rating Scale, and knee X-rays. Outcomes will be evaluated at baseline, immediately post-intervention (week 8), and at 3-month follow-up (week 20). Data will be analyzed according to the intention-to-treat principle, with a two-way repeated measures ANOVA used to assess time, group, and interaction effects.

CONCLUSION

This study is expected to provide valuable insights into the sustained effects and potential disease-modifying properties of combining H-PBMT with rehabilitation exercises in managing KOA. The findings could inform more effective treatment protocols, improving rehabilitation outcomes and patient quality of life.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12624000699561p).

Retrospective analysis of the occurrence, potential risk factors and medical significance of pulmonary complications after total shoulder arthroplasty from the National Inpatient Sample database (2010-2019)

BACKGROUND

In USA, total shoulder arthroplasty (TSA) ranks amongst the top five surgeries that require hospitalization. As a result, the healthcare system in USA could face a considerable financial strain due to the emergence of subsequent pulmonary problems. This study aimed to conduct a thorough examination of the prevalence, influential factors and medical importance of pulmonary complications, with emphasis on pneumonia, respiratory failure and pulmonary embolism (PE) following total shoulder arthroplasty (TSA) procedures in USA.

METHODS

The National Inpatient Sample (NIS) was utilized to survey all patients who underwent primary elective TSA from 2010 to 2019. Pneumonia, respiratory failure and PE following TSA were considered to be pulmonary consequences. The inpatient expenses, length of hospitalization, death rates and patient characteristics of those with and without reported perioperative pulmonary problems were compared. The utilization of trend weights was necessary to obtain incidence estimates across USA, considering the stratified framework of the NIS database and the dependence on observed frequencies within the database. Two assessments were utilized to assess the projected annual rates of complications.

RESULTS

Between 2010 and 2019, a total of 189,695 patients were estimated to underwent primary elective TSA. Infections, such as pneumonia, respiratory failure or PE, complicated 1.4% (95% CI, 1.52%-1.64%) of TSA operations. The ailments at this period that were most likely to result in pulmonary problems were ulcer (adjusted odds ratio [AOR] = 9.43; 95% CI, 4.99-46.91), pulmonary circulation disorders (AOR = 9.01; 95% CI, 4.56- 31.92), weight loss (AOR = 4.84; 95% CI, 2.15-10.88), fluid and electrolyte disorders (AOR = 3.55; 95% CI, 2.55-4.95), alcohol abuse (AOR = 1.56; 95% CI, 1.08-2.26), congestive heart failure (AOR = 3.09; 95% CI, 1.83-5.24), chronic pulmonary disease (AOR = 2.45; 95% CI, 1.60-3.75), deficiency anaemia (AOR = 1.56; 95% CI, 1.08-2.26), depression (AOR = 1.47; 95% CI, 1.03-2.11) and obesity (AOR = 1.46; 95% CI, 1.01-2.11). A correlation was found between perioperative pulmonary problems and extended LOS (+ 3 days; 95% CI, 2-6) and increased hospitalization costs (= + 20,514 US dollars; 95% CI, 14,109-35,281).

CONCLUSIONS

This investigation primarily aimed to ascertain potential risk factors linked to pulmonary issues that may occur after TSA. The analysis revealed that the pneumonia rates decreased each year, whereas the PE rates remained relatively stable. A noticeable and consistent increase was found in respiratory failure from 2010 to 2019. The findings suggests that individuals who are older (primarily between the ages of 60 and 80 years) and female exhibit increased rates. These factors could help stratify patients and reduce the risk of potential complications. This claim is especially applicable in PE because it is associated with more significant improvements in resource utilization.

A Comparison Between Intensive and Conventional Therapies: A Systematic Review and Meta-Analysis Regarding the Pre-operative Outcomes After Total Knee Replacement

Joint degeneration characterized by cartilage deterioration and bone wear is the hallmark of osteoarthritis (OA), a condition that worsens over time. Total knee arthroplasty (TKA) is the most common effective treatment for OA. Conventional therapy training (CTT) is the standard intervention; we are testing whether intensive therapy training (ITT) provides different results when used preoperatively. Our study compared intensive and standard preoperative physical therapy in randomized and non-randomized controlled trials, excluding various other study types. Two independent researchers assessed the risk of bias using appropriate tools (RoB 2 for RCTs (Cochrane Methods, London, UK) and ROBINS-I for non-randomized studies (Cochrane Methods, London, UK)). The analysis, conducted using ReviewManager 5.4 (Cochrane Methods, London, UK), presented results as mean differences (MD) with 95% CIs, employing fixed or random-effects models based on heterogeneity assessments. With a total number of 490 participants, ITT showed significant improvements in the six or 10-minute walk test (MD = 45.07m, P < 0.000001), quadriceps strength (MD = 0.07 Kg, P < 0.0001), range of motion (ROM) flexion (MD = 4.29, P = 0.03), isometric knee flexion (MD =2.32, P=0.04), SF-36 physical component (MD = 1.19, P <,0.0001), stair test (MD = -2.01, P = 0.01), timed up and go test (MD = -1.12, P = 0.02), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score (MD = -8.43, P = 0.002). Conversely, CTT showed better results in isometric knee extension (MD = 3.45, P = 0.02). No significant differences were found in ROM extension or visual analog score (VAS) pain scores. Preoperative ITT demonstrates overall superior outcomes compared to CTT for total knee arthroplasty patients. ITT significantly improved various functional and patient-reported outcomes, including walking capacity, quadriceps strength, range of motion, and quality of life measures. However, CTT showed superiority in isometric knee extension. We recommend implementing preoperative ITT protocols for TKA patients while acknowledging the need for further research to optimize exercise specifics, frequency, and duration for optimal results.

Forkhead box C1 promotes the pathology of osteoarthritis in subchondral bone osteoblasts via the Piezo1/YAP axis

Subchondral bone sclerosis is a key characteristic of osteoarthritis (OA). Prior research has shown that Forkhead box C1 (FoxC1) plays a role in the synovial inflammation of OA, but its specific role in the subchondral bone of OA has not been explored. Our research revealed elevated expression levels of FoxC1 and Piezo1 in OA subchondral bone tissues. Further experiments on OA subchondral bone osteoblasts with FoxC1 or Piezo1 overexpression showed increased cell proliferation activity, expression of Yes-associated Protein 1 (YAP) and osteogenic markers, and secretion of proinflammatory factors. Mechanistically, the overexpression of FoxC1 through Piezo1 activation, in combination with downstream YAP signaling, led to increased levels of alkaline phosphatase (ALP), collagen type 1 (COL1) A1, RUNX2, Osteocalcin, matrix metalloproteinase (MMP) 3, and MMP9 expression. Notably, inhibition of Piezo1 reversed the regulatory function of FoxC1. The binding of FoxC1 to the targeted area (ATATTTATTTA, residues +612 to +622) and the activation of Piezo1 transcription were verified by the dual luciferase assays. Additionally, Reduced subchondral osteosclerosis and microangiogenesis were observed in knee joints from FoxC1-conditional knockout (CKO) and Piezo1-CKO mice, indicating reduced lesions. Collectively, our study reveals the significant involvement of FoxC1 in the pathologic process of OA subchondral bone via the Piezo1/YAP signaling pathway, potentially establishing a novel therapeutic target.

Eight weeks of a lower limb resistance training protocol and gait performance in patients with symptomatic mild to moderate knee osteoarthritis

BACKGROUND

The role of strengthening the lower limbs to optimize the biomechanics of the hip, knee and ankle during walking in patients with knee osteoarthritis, is still unclear. This study aimed to analyse the walking biomechanics of individuals with symptomatic mild to moderate knee osteoarthritis before and after a simplified lower limb resistance training protocol, focused on knee joint exercises with individualized load.

METHODS

Forty-one patients with symptomatic and radiographic mild to moderate knee osteoarthritis underwent 3D gait analysis pre-post 8 weeks lower limb resistance training protocol performed 3 times a week. Parameters investigated were spatiotemporal, sagittal range of motion, flexion and extension minimum and maximum values, power and moment of hip, knee and ankle, as well as self-reported pain and physical function by the Western Ontario MacMaster University Osteoarthritis Index. Paired t test, Wilcoxon, Spearman's correlation and a logistic model were used for statistical analysis, with p < 0.05. Pain improvement more than 2 points was considered clinically relevant. The effect size (ES) was calculated using Cohen's d.

RESULTS

Post protocol walking speed increased 6.7% (ES: 0.711), cadence 3.7% (ES: 0.655), stride length 2.6% (ES: 0.542), and double support time reduced 6.9% (ES:0.459). It was also observed a significant increase in one maximum repetition test for legpress 46%, knee extension 23% and knee flexion chair 27% (p < 0.001). Patients reported a 62.5% reduction in pain (ES:1.518) and 64.9% improvement in physical function (ES:1.376). 82% of the patients presented more than 2 points improvement in pain. No evidence of strong correlations between pain, strength gains and gait parameters were found.

CONCLUSIONS

There was a significant and clinical improvement of spatiotemporal gait parameters, pain, physical function, and strength after 8-week lower limb resistance training protocol. Patients who had a clinically relevant pain improvement presented better gait performance.

Does commonly used femoral components of total knee arthroplasty fit well in the Indian population?

Background

20 % of patients remain dissatisfied post-Total Knee Arthroplasty. We intend to find the correlation between sizes of commonly used femoral components and morphometric data of distal femur in Indian population.

Materials and methods

Prospective observational study in 178 knees (178 individuals) was conducted on Magnetic Resonance Imaging scans (Axial section). The anteroposterior dimension at intercondylar notch (AP), anteroposterior dimension on the medial (MAP) and lateral (LAP) femoral condyle, total mediolateral width (ML), width of medial condyle (MLM), lateral condyle (MLL) and intercondylar distance (ICD) and aspect ratio (AR) were measured on males and females separately. These measurements were then analyzed keeping in view the available sizes of three latest knee arthroplasty systems (Attune CR, Next Gen II, Genesis II) to look for correlation and best fitting system.

Results

On observation between values of male and female femur, a significant difference was seen in all the parameters (p-value<0.0001) except ICD (p-value 0.6591). On scatter plots, Attune was found to be nearer to the line of best fit compared to other two implant companies in both males and females. Outliers were highest in cases of NextGen II (45 % in males and 46 % in females) whereas it was lowest in the case of Attune (12.5 %in males and 41 % in females).

Conclusion

Attune CR was seen to fit best in the Indian population followed by Genesis II and NextGen II. These femoral implants are designed as per the sizes of the Western population and the Caucasians are oversized for the Indian subcontinent, especially female patients, thus needing improvement in design/sizes.

Level of evidence

III.

Comparison between Low-Level and High-Intensity Laser Therapy as an Adjunctive Treatment for Knee Osteoarthritis: A Randomized, Double-Blind Clinical Trial

BACKGROUND

Low-level (LLLT) and high-intensity laser therapy (HILT) can be beneficial additions to knee osteoarthritis (KOA) rehabilitation exercises; however, it is still being determined which electrophysical agent is more effective.

AIM

To compare the effects of LLLT and HILT as adjuncts to rehabilitation exercises (LL + EX and HL + EX) on clinical outcomes in KOA.

METHODS

Thirty-four adults with mild-to-moderate KOA were randomly allocated to either LL + EX or HL + EX (n = 17 each). Both groups underwent their respective intervention weekly for twelve weeks: LL + EX (400 mW, 830 nm, 10 to 12 J/cm², and 400 J per session) or HL + EX (5 W, 1064 nm, 19 to 150 J/cm², and 3190 J per session). The laser probe was placed vertically in contact with the knee and moved in a slow-scan manner on the antero-medial/lateral sides of the knee joint. Participants' Knee Injury and Osteoarthritis Outcome Score (KOOS), Numerical Pain Rating Scale (NPRS), active knee flexion, and Timed Up-and-Go test (TUG) were assessed.

RESULTS

Post intervention, both groups showed improvements in their KOOS, NPRS, active knee flexion, and TUG scores compared to baseline (p < 0.01). The mean difference of change in KOOS, NPRS, and active knee flexion scores for the HL + EX group surpassed the minimal clinically important difference threshold. In contrast, the LL + EX group only demonstrated clinical significance for the NPRS scores.

CONCLUSIONS

Incorporating HILT as an adjunct to usual KOA rehabilitation led to significantly higher improvements in pain, physical function, and knee-related disability compared to LLLT applied in scanning mode.

The Invasive Management of Pain: Diagnosis and New Treatment Options

Both the diagnosis and treatment of pain are evolving, especially in interventional approaches. Diagnosis of low back pain combines old and new methodologies, in particular, it involves an expanded role for ultrasound. While low back pain is a common complaint, there are many etiologies to the condition which must be explored before a final diagnosis can be made and treatment planned. Tumors and infections are rarely involved in low back pain but should be ruled out in the initial phase itself since failing to address them early can have devastating consequences. Some invasive treatments seem promising in the management of low back pain. Treating musculoskeletal pain with regenerative medicine, such as platelet-rich plasma, holds great promise. Autologous blood products are safe and may help stimulate the body's own responses for regeneration. The so-called "orthobiologics" play a role in sports medicine and the treatment of musculoskeletal pain. Neuromodulation, especially spinal cord stimulation, is undergoing a renaissance with new waveforms, devices, and a greater albeit incomplete understanding of its mechanisms of action. Spinal cord stimulation is not a first-line therapy and not all patients or all back problems respond to this treatment. Nevertheless, the therapy can be safe, effective, and cost-effective with appropriate patient selection. Radiofrequency ablation of nerves in the form of neurotomy can be effective in reducing the pain of osteoarthritis. These procedures, including the newer cooled radiofrequency neurotomy, can restore function, reduce pain, and may potentially have an opioid-sparing effect. Technical expertise in nerve and anatomy is needed for the use of this technique. This review article aims to provide updated information on some invasive intervention techniques in pain management.

Effectiveness of home-based conventional exercise and cryotherapy on daily living activities in patients with knee osteoarthritis: A randomized controlled clinical trial

BACKGROUND

Knee osteoarthritis (KOA) is a prevalent joint condition associated with aging that causes pain, disability, loss of function, and a decline in quality of life. This study aimed to evaluate the effectiveness of home-based conventional exercise and cryotherapy on daily living activities in patients with KOA.

METHODS

In this randomized controlled clinical trial, the patients who were diagnosed with KOA were assigned to 3 groups: an experimental group (n = 18), the control group 1 (n = 16), and the control group 2 (n = 15). Control and experimental groups engaged in a 2-month home-based exercise (HBE) program. The experimental group received cryotherapy along with HBE. In contrast, the patients in the second control group received regular therapeutic and physiotherapeutic services at the center. The patients were recruited from the Specialized Center for Rheumatic and Medical Rehabilitation in Duhok, Iraq.

RESULTS

The patients in the experimental group had statistically significant better daily activity functions compared to the first and second control groups in pain (2.22 vs 4.81 and 12.7; P < .0001), stiffness (0.39 vs 1.56 and 4.33; P < .0001), physical function (5.72 vs 13.31 and 38.13; P < .0001), and the total score (8.33 vs 19.69 and 55.33; P < .0001) at 2 months. The patients in the experimental and the first control groups had statistically significantly lower balance scores compared to the second control group at 2 months, 8.56 versus 9.30. At 3 months, similar patterns were observed for the daily activity function and balance.

CONCLUSIONS

This study showed that combining HBE and cryotherapy may be an effective technique to improve function among patients with KOA. Cryotherapy could be suggested as a complementary therapy for KOA patients.

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance.

METHODS

CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033.

DISCUSSION

The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN19778222. Protocol v4.1, 24th October 2022.

Nanofat lysate ameliorates pain and cartilage degradation of osteoarthritis through activation of TGF-β-Smad2/3 signaling of chondrocytes

Introduction: Nanofat is an effective cell therapy for osteoarthritis (OA). However, it has clinical limitations due to its short half-life. We developed Nanofat lysate (NFL) to overcome the defect of Nanofat and explore its anti-OA efficacy and mechanism. Methods: Monoiodoacetate (MIA) was employed to establish rat OA model. For pain assessment, paw withdrawal latency (PWL) and thermal withdrawal latency (TWL) were evaluated. Degeneration of cartilage was observed by histopathological and immunohistochemical examination. Primary chondrocytes were treated with TNF-α to establish the cellular model of OA. MTT, wound healing, and transwell assays were performed to assess effects of NFL on chondrocytes. RNA-seq, qPCR and Western blot assays were conducted to clarify the mechanism of NFL. Results and Discussion: The animal data showed that PWL and TWL values, Mankin's and OARSI scorings, and the Col2 expression in cartilage were significantly improved in the NFL-treated OA rats. The cellular data showed that NFL significantly improved the proliferation, wound healing, and migration of chondrocytes. The molecular data showed that NFL significantly restored the TNF-α-altered anabolic markers (Sox9, Col2 and ACAN) and catabolic markers (IL6 and Mmp13). The RNA-seq identified that TGF-β-Smad2/3 signaling pathway mediated the efficacy of NFL, which was verified by qPCR and Western blot that NFL significantly restored the abnormal expressions of TGFβR2, phosphorylated-Smad2, phosphorylated-Smad2/3, Col2, Mmp13 and Mmp3. After long-term storage, NFL exerted similar effects as its fresh type, indicating its advantage of storability. In sum, NFL was developed as a new therapeutic approach and its anti-OA efficacy and mechanism that mediated by TGF-β-Smad2/3 signaling was determined for the first time. Besides, the storability of NFL provided a substantial advantage than other living cell-based therapies.

Effects of Self-management Program as Adjunctive to Usual Rehabilitation Exercise on Pain and Functional Outcomes in Knee Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

Home-based exercise (HBE) and patient education (EDU) have been reported as beneficial additions to usual knee osteoarthritis (KOA) rehabilitation. However, previous trials mostly examined the effects of HBE and EDU separately. Thus, this study aimed to evaluate the effects of a structured combined HBE and EDU program in addition to usual KOA rehabilitation on pain score, functional mobility, and disability level.

STUDY DESIGN

A parallel-group, single-blinded randomized controlled trial.

METHODS

Eighty adults with KOA were randomly allocated to experimental (n=40) and control (n=40) groups. All participants underwent their usual physiotherapy care weekly for eight weeks. The experimental group received a structured HBE+EDU program to their usual care, while the control group performed home stretching exercises to equate treatment time. The Knee Injury and Osteoarthritis Outcome Score (KOOS) for the disability level, visual analogue scale (VAS) for pain, and timed up-and-go test (TUG) for mobility were measured pre-post intervention.

RESULTS

After eight weeks, the experimental group demonstrated significant improvements in the KOOS (all subscales), pain VAS, and TUG scores compared to baseline (P<0.001); meanwhile, only KOOS (activities of daily living and sports subscales) was significant in the control group. Relative to the control, the experimental group presented higher improvements (P<0.001) by 22.2%, 44.1%, and 15.7% for KOOS, pain VAS, and TUG, respectively.

CONCLUSION

Integrating the HBE+EDU program into usual KOA rehabilitation could reduce pain and disability, while it improved functional mobility. The finding of this study suggests a combination of a structured HBE and EDU program to be considered as part of mainstream KOA management.

Development of a mobile application to improve exercise accuracy and quality of life in knee osteoarthritis patients: a randomized controlled trial

INTRODUCTION

Knee Osteoarthritis (OA) is a degenerative joint disease that needs consistent exercise and an accurate understanding of the condition for long-term maintenance. While the accessibility of outpatient care is essential for disease management, many patients lack the resources to receive adequate healthcare. To address this challenge, we developed a not-for-profit interactive mobile application that provides a disease-specific educational background and a structured exercise regimen to patients.

MATERIAL AND METHODS

"Rak Kao" (English translation: Love-Your-Knee) mobile application was designed to analyze the questionnaire data to assess the stage of knee OA and generate a personalized recommendation of treatment and exercise type using rule-based and Artificial Intelligence (AI) techniques. A single-blinded study was conducted with patients (n = 82) who were randomly assigned to the mobile application group (M-group) and the handout group (H-group). Patient groups were controlled for age, gender, BMI, onset of pain, grade of disease, education level, and occupation. Accuracy in performance of three prescribed knee exercises (catch-bend-down, stretch-touch-feet, and sit-stretch-hold) was evaluated. Clinical outcomes were evaluated before and after the 4-weeks program to assess the range of motion, symptoms, pain, physical activity, and quality of life via the KOOS and KSS scores.

RESULTS

Completion of the study led to significantly more overall exercise accuracy in the M-group (76.2%) than the H-group (52.5%). Activities of daily life, quality of life, ability to do sports and recreational activities were significantly more improved in the M-group than the H-group (p < .01). No difference in the range of motion between groups. Satisfaction of patients' experience was higher in the M-group than the H-group (p = .001) after the 4-week regimen.

CONCLUSIONS

With the better accuracy and outcomes for rehabilitation in the M-group than the H-group, we strongly recommend using our mobile application as a better alternative than handouts for exercises and information for patients with knee OA.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03666585.

Effect of compression by elastic bandages on pain and function in individuals with knee osteoarthritis: protocol of a randomised controlled clinical trial

INTRODUCTION

Although compression is used to control pain in knee osteoarthritis (KOA), its clinical application is poorly supported, and there is a lack of scientific evidence to support its clinical use. As a low-cost and accessible protocol, compression using elastic bands could be a non-pharmacological intervention to reduce pain and improve physical function in individuals with KOA. This study aims to evaluate the effects of compression on pain and function in individuals with KOA.

METHODS AND ANALYSIS

A randomised controlled clinical trial will be conducted. Individuals with KOA (n=90; both sexes; between 40 and 75 years old) will be allocated to three groups (n=30/group): compression (compression by the elastic bandage on the affected knee, once a day for 20 min, on four consecutive days); sham (same protocol, but the elastic band is placed around the affected knee without compression) and control (no intervention). The individuals in the three groups will be evaluated 1 day before the first intervention, 1 day after the last intervention, and at the 12th and 24th weeks after the end of the intervention. Pain intensity by the Visual Analogue Scale and pain scale from Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) will be the primary outcomes. The secondary variables will be physical function assessed by the WOMAC questionnaire and physical tests (step test; 30 s sit and stand test; 40 m accelerated walk test). The Global Rating of Change Scale (GRC) will also be applied to quantify the volunteers' perceived change.

ETHICS AND DISSEMINATION

The project was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (3955692). The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04724902.

Disparities Exist in Physical Therapy Utilization and Time to Utilization Between Black and White Patients With Musculoskeletal Pain

OBJECTIVE

Black patients are less likely than White patients to receive physical therapy for musculoskeletal pain conditions. Current evidence, however, is limited to self-reported conditions and health services use. The purpose of this study was to use a large electronic health record database to determine whether a race disparity existed in use of physical therapy within 90 days of a new musculoskeletal diagnosis.

METHODS

Eligible patients (n = 52,384) were sampled from an Optum deidentified electronic health record database of 5 million adults distributed throughout the United States. In this database, patients were designated as "Black" and "White." Patients were eligible if they had a new diagnosis for musculoskeletal neck, shoulder, back, or knee pain between January 1, 2012, and December 31, 2017. Logistic regression and Cox proportional hazard models were computed before and after adjusting for covariates to estimate the association between race and receipt of physical therapy services within 90 days of musculoskeletal pain diagnoses.

RESULTS

Patients were on average 47.5 (SD = 14.9) years of age, 12.8% were Black, 87.2% were White, and 52.7% were female. Ten percent of Black patients and 15.5% of White patients received physical therapy services within 90 days of musculoskeletal pain diagnoses. After adjusting for covariates, White patients were 57% more likely (odds ratio = 1.57; 95% CI = 1.44-1.71) to receive physical therapy compared with Black patients and had significantly shorter time to physical therapy than Black patients (hazard ratio = 1.53; 95% CI = 1.42-1.66).

CONCLUSIONS

In a nationally distributed cohort, Black patients were less likely than White patients to utilize physical therapy and had a longer time to utilization of physical therapy for musculoskeletal pain.

IMPACT

These findings highlight the need to determine the mechanisms underlying the observed disparities and how these disparities influence health outcomes.

Unbiased comparison and modularization identify time-related transcriptomic reprogramming in exercised rat cartilage: Integrated data mining and experimental validation

Exercise is indispensable for maintaining cartilage integrity in healthy joints and remains a recommendation for knee osteoarthritis. Although the effects of exercise on cartilage have been implied, the detailed mechanisms, such as the effect of exercise time which is important for exercise prescription, remain elusive. In this study, bioinformatic analyses, including unbiased comparisons and modularization, were performed on the transcriptomic data of rat cartilage to identify the time-related genes and signaling pathways. We found that exercise had a notable effect on cartilage transcriptome. Exercise prominently suppressed the genes related to cell division, hypertrophy, catabolism, inflammation, and immune response. The downregulated genes were more prominent and stable over time than the upregulated genes. Although exercise time did not prominently contribute to the effects of exercise, it was a factor related to a batch of cellular functions and signaling pathways, such as extracellular matrix (ECM) homeostasis and cellular response to growth factors and stress. Two clusters of genes, including early and late response genes, were identified according to the expression pattern over time. ECM organization, BMP signaling, and PI3K-Akt signaling were early responsive in the exercise duration. Moreover, time-related signaling pathways, such as inositol phosphate metabolism, nicotinate/nicotinamide metabolism, cell cycle, and Fc epsilon RI signaling pathway, were identified by unbiased mapping and polarization of the highly time-correlated genes. Immunohistochemistry staining showed that Egfr was a late response gene that increased on day 15 of exercise. This study elucidated time-related transcriptomic reprogramming induced by exercise in cartilage, advancing the understanding of cartilage homeostasis.

PCB153 suppressed autophagy via PI3K/Akt/mTOR and RICTOR/Akt/mTOR signaling by the upregulation of microRNA-155 in rat primary chondrocytes

Polychlorinated biphenyls (PCBs) are a typical type of persistent organic pollutant. PCB exposure is associated to the occurrence and development of osteoarthritis (OA); however, the involved mechanisms have yet to be elucidated. Here, we investigated the pro-osteoarthritic effect of 2, 2', 4, 4', 5, 5'-hexachlorobiphenyl (PCB153), and the involvement of the phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt)/ mammalian target of rapamycin (mTOR) and the RICTOR/Akt/mTOR signaling pathways. PCB153 of 20 and 30 μM increased the expression of MMP13 and decreased the expression of type II collagen, in a concentration-dependent manner. PCB153 treatment reduced the expression of Beclin 1 and LC3B, but increased the expression of p62 by upregulating miR-155 levels. PCB153 treatment activated the PI3K/Akt/mTOR signaling pathway by upregulating miR-155 levels. RICTOR was involved in activating the Akt/mTOR signaling pathway, and was also regulated by miR-155. In conclusion, PCB153 could promote the degradation of the extracellular matrix of chondrocytes by upregulating miR-155 via a mechanism related to the activation of the PI3K/Akt/mTOR and RICTOR/Akt/mTOR signaling pathway, which suppressed autophagy and facilitated the development of OA. MiR-155 may represent potential therapeutic targets to alleviate the development of OA.

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

Short- and Long-Term Effectiveness of Low-Level Laser Therapy Combined with Strength Training in Knee Osteoarthritis: A Randomized Placebo-Controlled Trial

Background: Both physical activity and low-level laser therapy (LLLT) can reduce knee osteoarthritis (KOA) inflammation. We conducted a randomized clinical trial to investigate the short- and long-term effectiveness of LLLT combined with strength training in persons with KOA. Methods: Fifty participants were randomly divided in two groups, one with LLLT plus strength training (n = 26) and one with placebo LLLT plus strength training (n = 24). LLLT and strength training were performed triweekly for 3 and 8 weeks, respectively. In the laser group, 3 joules 904 nm wavelength laser was applied to fifteen points (45 joules) per knee per session. Patient-reported outcomes, physical tests, and ultrasonography assessments were performed at baseline and 3, 8, 26, and 52 weeks after initial LLLT or placebo therapy. The primary outcomes were pain on movement, at rest, at night (Visual Analogue Scale), and globally (Knee injury and Osteoarthritis Outcome Score (KOOS) subscale). Parametric data were assessed with analysis of variance using Šidák’s correction. Results: There were no significant between-group differences in the primary outcomes. However, in the laser group there was a significantly reduced number of participants using analgesic and non-steroidal anti-inflammatory drugs and increased performance in the sit-to-stand test versus placebo-control at week 52. The joint line pain pressure threshold (PPT) improved more in the placebo group than in the laser group, but only significantly at week 8. No other significant treatment effects were present. However, pain on movement and joint line PPT were worse in the placebo group at baseline, and therefore, it had more room for improvement. The short-term percentage of improvement in the placebo group was much higher than in similar trials. Conclusions: Pain was reduced substantially in both groups. LLLT seemed to provide a positive add-on effect in the follow-up period in terms of reduced pain medication usage and increased performance in the sit-to-stand test.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

N6-methyladenosine (m6A) methyltransferase METTL3-mediated LINC00680 accelerates osteoarthritis through m6A/SIRT1 manner

Increasing evidence suggest the biological roles of N⁶-methyladenosine (m⁶A) and long noncoding RNAs (lncRNAs) in the bone disease, especially osteoarthritis (OA). However, the interaction of m⁶A and lncRNA in osteoarthritis is still unclear. Here, we found that a m⁶A-related lncRNA LINC00680 upregulated in the OA tissue and IL-1β-induced isolated primary chondrocytes. Functionally, in IL-1β-induced chondrocytes, silencing of LINC00680 recovered the proliferation and repressed the extracellular matrix (ECM) degradation. Mechanistically, m⁶A methyltransferase METTL3 combined tithe the m⁶A site of LINC00680 to up-regulate its expression. Moreover, LINC00680 interacted with SIRT1 mRNA through binding at m⁶A site on SIRT1 mRNA 3'-UTR, thereby enhancing the stability of SIRT1 mRNA. Overall, these findings exhibited a role of LINC00680/m⁶A/SIRT1 mRNA complex in chondrocytes. Taken together, the present study intends to uncover the mechanism by which METTL3-mediated LINC00680 accelerates OA progression, which may provide novel insight for OA.

CEMIP (KIAA1199) regulates inflammation, hyperplasia and fibrosis in osteoarthritis synovial membrane

Osteoarthritis (OA) synovial membrane is mainly characterized by low-grade inflammation, hyperplasia with increased cell proliferation and fibrosis. We previously underscored a critical role for CEMIP in fibrosis of OA cartilage. However, its role in OA synovial membrane remains unknown. An in vitro model with fibroblast-like synoviocytes from OA patients and an in vivo model with collagenase-induced OA mice were used to evaluate CEMIP-silencing effects on inflammation, hyperplasia and fibrosis. Our results showed that i. CEMIP expression was increased in human and mouse inflamed synovial membrane; ii. CEMIP regulated the inflammatory response pathway and inflammatory cytokines production in vitro and in vivo; iii. CEMIP induced epithelial to mesenchymal transition pathway and fibrotic markers in vitro and in vivo; iv. CEMIP increased cell proliferation and synovial hyperplasia; v. CEMIP expression was increased by inflammatory cytokines and by TGF-β signaling; vi. anti-fibrotic drugs decreased CEMIP expression. All these findings highlighted the central role of CEMIP in OA synovial membrane development and underscored that targeting CEMIP could be a new therapeutic approach.

Factors Influencing Pain Management of Patients with Osteoarthritis: A Cross-Sectional Study

BACKGROUND

Osteoarthritis (OA) is a complex disease associated with chronic pain. Many patients treat their joint pain at a symptomatic level with over-the-counter (OTC) pain medications, often without the knowledge of their physicians. The aim of this study was to provide physicians with data about osteoarthritic patients' habits of pain management and to examine the explanatory factors of various ways of self-treatment.

METHODS

A cross-sectional study involving 189 patients with hip or knee OA and scheduled for joint replacement surgery was carried out. Participants filled out a self-administered questionnaire consisting of the Western Ontario and McMaster Universities Osteoarthritis Index and questions about their methods of alleviating pain.

RESULTS

2.6% of patients did not use anything to alleviate their pain, while 63% practiced a non-pharmacological method. Diclofenac was the most frequently used drug, followed by ibuprofen. Profession had the greatest impact on medication habits; patients doing manual work were significantly more likely to take OTC non-steroidal anti-inflammatory drugs and use topical analgesics.

CONCLUSIONS

Patients utilized a wide variety of pain management techniques. They seemed to use well-known painkillers, even if their side effects were less desirable. Such patients require comprehensive pain management, including educational and behavioural interventions, complemented by topical and oral medication.

Efficacy and safety of radiofrequency treatment for improving knee pain and function in knee osteoarthritis: a meta-analysis of randomized controlled trials

Background

The clinical utility of radiofrequency (RF) in patients with knee osteoarthritis (OA) remains unclear. We conducted a meta-analysis to systematically evaluate the efficacy and safety of RF treatment in patients with knee OA.

Methods

Searches of the PubMed, Web of Science, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data databases were performed through August 30, 2021. The major outcomes from published randomized controlled trials (RCTs) involving patients with knee OA were compared between RF and control groups, including Visual Analogue Scale (VAS) or Numerical Rating Scale (NRS) scores, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Global Perceived Effect (GPE) scale, and adverse effects at available follow-up times.

Results

Fifteen RCTs involving 1009 patients were included in this meta-analysis, and the results demonstrated that RF treatment correlated with improvements in pain relief (VAS/NRS score, all P < 0.001) and knee function (WOMAC, all P < 0.001) at 1–2, 4, 12, and 24 weeks after treatment as well as patients’ degree of satisfaction with treatment effectiveness (GPE scale, 12 weeks, P < 0.001). OKSs did not differ significantly between the two groups. Moreover, treatment with RF did not significantly increase adverse effects. Subgroup analysis of knee pain indicated that the efficacy of RF treatment targeting the genicular nerve was significantly better than intra-articular RF at 12 weeks after treatment (P = 0.03).

Conclusions

This meta-analysis showed that RF is an efficacious and safe treatment for relieving knee pain and improving knee function in patients with knee OA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02906-4.

The Use of Scoring Hip Osteoarthritis with MRI as an Assessment Tool for Physiotherapeutic Treatment in Patients with Osteoarthritis of the Hip

Rehabilitation programs are considered effective at reducing the impact of osteoarthritis (OA) of the hip; however, studies using reliable measures related to OA biomarkers to assess the effects of rehabilitation are lacking. The objective of this study was to investigate whether an MRI-based (Magnetic Resonance Imaging-based), semi-quantitative system for an OA severity assessment is feasible for the evaluation of the structural changes in the joint observed during a long-term physiotherapy program in patients with hip OA. The study group consisted of 37 adult OA patients who participated in a 12-month physiotherapy program. The Scoring hip osteoarthritis with MRI (SHOMRI) system was used to evaluate the severity of structural changes related to hip OA. Hip disability and the osteoarthritis outcome score (HOOS) and the core set of performance-based tests recommended by Osteoarthritis Research Society International were used for functional assessment. SHOMRI showed excellent inter- and intra-rater agreement, proving to be a reliable method for the evaluation of hip abnormalities. At the 12-month follow-up no statistically significant changes were observed within the hip joint; however, a trend of structural progression was detected. There was a negative correlation between most of the SHOMRI and HOOS subscales at baseline and the 12-month follow-up. Although SHOMRI provides a reliable assessment of the hip joint in patients with OA it showed a limited value in detecting significant changes over time in the patients receiving physiotherapy over a 12-month period.

Ankle Osteoarthritis

Osteoarthritis (OA) is characterized by a chronic, progressive and irreversible degradation of the joint surface associated with joint inflammation. The main etiology of ankle OA is post-traumatic and its prevalence is higher among young and obese people. Despite advances in the treatment of fractures around the ankle, the overall risk of developing post-traumatic ankle OA after 20 years is almost 40%, especially in Weber type B and C bimalleolar fractures and in fractures involving the posterior tibial border. In talus fractures, this prevalence approaches 100%, depending on the severity of the lesion and the time of follow-up. In this context, the current understanding of the molecular signaling pathways involved in senescence and chondrocyte apoptosis is fundamental. The treatment of ankle OA is staged and guided by the classification systems and local and patient conditions. The main problems are the limited ability to regenerate articular cartilage, low blood supply, and a shortage of progenitor stem cells. The present update summarizes recent scientific evidence of post-traumatic ankle OA with a major focus on changes of the synovia, cartilage and synovial fluid; as well as the epidemiology, pathophysiology, clinical implications, treatment options and potential targets for therapeutic agents.

Effects of an Exercise Therapy Targeting Knee Kinetics on Pain, Function, and Gait Kinetics in Patients With Knee Osteoarthritis: A Randomized Clinical Trial

In this study, the effects of an exercise therapy comprising yoga exercises and medial-thrust gait (YogaMT) on lower-extremity kinetics, pain, and function in patients with medial knee osteoarthritis were investigated. Fifty-nine patients were randomly allocated to three treatment groups: (a) the YogaMT group practiced yoga exercises and medial thrust gait, (b) the knee-strengthening group performed quadriceps- and hamstring-strengthening exercises, and (c) the treadmill walking group practiced normal treadmill walking in 12 supervised sessions. The adduction and flexion moments of the hip, knee, and ankle; pain intensity; and 2-min walking test were assessed before and after treatment and at 1-month follow-up. The YogaMT group experienced a significant reduction in knee adduction moment. All groups showed significant improvement in pain and function. The YogaMT may reduce medial knee load in patients with knee osteoarthritis in the short term. A larger clinical trial is required to investigate the long-term outcomes of this intervention.

Osteoarthritis-Related Knee Pain Treated With Genicular Artery Embolization: A Systematic Review and Meta-analysis

BACKGROUND

Genicular artery embolization (GAE) is an innovative technique that has been investigated as a supplementary treatment method for chronic pain secondary to knee osteoarthritis (OA).

PURPOSE

To evaluate the current evidence on the effectiveness and safety of GAE for OA-related knee pain.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic literature search was conducted in the PubMed, Web of Science, EMBASE, and Scopus databases to identify studies related to knee OA treated with GAE. Treatment agents were categorized as Embozene, imipenem/cilastatin, resorbable microspheres, and polyvinyl alcohol. The main outcomes were the mean difference (MD) in pre- and postembolization pain based on the visual analog scale (VAS) or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores as well as changes in the need for pain medication. Random- and fixed-effects models were applied for data analysis.

RESULTS

Of 379 initially inspected publications, 11 (N = 225 patients; 268 knees) were included in the final review. The quality of the studies was fair in 8 and poor in 3-categorized according to the National Institutes of Health quality assessment tool. Overall, 119, 72, 13, and 21 patients were treated with imipenem/cilastatin, Embozene, resorbable microspheres, and polyvinyl alcohol, respectively. Symptomatic improvement was reported in all studies. The pooled effect size, characterized by MD, showed a significant improvement in the VAS and WOMAC pain scores, with better functional status after GAE. Pre- versus postembolization MDs in VAS scores ranged from 32 within the first week to 58 after a 2-year follow-up (equivalent to 54% and 80% improvement, respectively). There was a similar trend in the overall WOMAC scores, with MDs ranging from 28.4 to 36.8 (about 58% and 85% improvement, respectively). GAE resulted in a decreased need for pain medication for knee OA, with a 27%, 65%, and 73% decline in the number of patients who used opioids, nonsteroidal anti-inflammatory drugs, and intra-articular hyaluronic acid injection, respectively (P < .00001 for all). No significant difference between embolic agents was seen with regard to post-GAE pain reduction. No severe or life-threatening complications were reported.

CONCLUSION

OA treated by GAE using different embolic particles can be considered generally safe, with good efficacy and no reported serious complications.

New Viscoelastic Hydrogel Hymovis MO.RE. Single Intra-articular Injection for the Treatment of Knee Osteoarthritis in Sportsmen: Safety and Efficacy Study Results

Viscosupplementation by hyaluronic acid (HA) is recommended for non-surgical management of knee osteoarthritis (OA). This study investigated the efficacy and safety of a single i.a. (32 mg/4 ml) Hymovis MO.RE. injection, a new HA derivative hydrogel, for the treatment of adult regular sports players affected by knee OA arising from overuse injuries. Patients were prospectively enrolled if regularly practicing sports and diagnosed with Kellgren-Lawrence grade I-III OA. They received a single Hymovis MO.RE. intra-articular (i.a.) injection and were evaluated 30, 90, 180, and 360 days thereafter. The assessment involved measuring changes in knee function, pain, the activity of daily living (ADL), and quality of life (QOL) by using the Knee injury and Osteoarthritis Outcome Score (KOOS), GAIT analysis, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores for knee pain (WOMAC A) and function (WOMAC C), and a visual analogue scale (VAS) pain score. The study involved thirty-one patients, 23 women and eight men, whose median age was 49. KOOS function subscore, as well as GAIT cadence and velocity, showed a statistically significant increase at each time-point after injection (p < 0.0001). WOMAC, KOOS pain, symptoms, ADL, and QOL scores also significantly improved at all control visits. No severe adverse events or treatment-related events were detected. A single Hymovis MO.RE. (32 mg/4 ml) intra-articular injection provides a rapid, lasting, and safe response in regular sports players affected by knee OA, possibly representing a viable therapeutic option for this demanding patient subgroup. Further investigations are necessary to confirm these findings.

Association of urinary phthalate metabolites with osteoarthritis in American adults: Results from the national health and nutrition examination survey 2003-2014

Phthalates have extensive existence in the living environment of human, probably tightly associated with multiple human diseases. The present study aimed to exploratorily investigate the association of urinary phthalate metabolites with osteoarthritis (OA) in American adults by exploiting the data extracted from National Health and Nutrition Examination Survey (NHANES) 2003-2014 with levels of eleven urinary phthalate metabolites as exposure. The multivariable logistic regression models were performed after controlling for urinary creatinine, age, gender, race/ethnicity, education level, marital status, smoking, body mass index, physical activity in recreational time, family poverty income ratio, diabetes, hypertension, as well as survey cycle. Compared with those in the lowest quantile, we observed higher prevalence of OA in the maximal quantile of MCOP (OR = 1.55, 95% CI = 1.06-2.27) in adjusted model. A one-unit increase in log-transformed phthalate metabolites was significantly associated with higher OA prevalence, including MCOP (OR = 1.13, 95% CI = 1.02-1.26) and MBzP (OR = 1.12, 95% CI = 1.00-1.26) in adjusted model. In subgroup analysis, the positive associations between phthalate metabolites and OA prevalence remained robust both in males and females. In brief, this study first presented positive evidence for the association of urinary level of phthalate metabolites with OA prevalence in American adults. Additional causal research is required to confirm the finding from our analysis and elucidate the potential underlying mechanisms of phthalates exposure on OA.

Effects of low-level and high-intensity laser therapy as adjunctive to rehabilitation exercise on pain, stiffness and function in knee osteoarthritis: a systematic review and meta-analysis

BACKGROUND

When treating knee osteoarthritis (KOA), rehabilitation exercise is often combined with low-level (LLLT) or high-intensity laser therapy (HILT). However, the effectiveness of these combinations is still uncertain.

OBJECTIVE

To examine the effects of LLLT or HILT combined with rehabilitation exercise (LLLT+E or HILT+E) on pain, stiffness and function in KOA.

DATA SOURCES

Five databases (PubMed, Web of Science, CINAHL, PEDro and SPORTDiscus) were searched for relevant studies published up to 31 December 2019.

STUDY SELECTION

KOA randomised controlled trials, LLLT+E or HILT+E against exercise alone with or without placebo laser, reported clinical outcomes, human studies and English language.

DATA SYNTHESIS

Methodological quality was assessed by the PEDro and Cochrane risk-of-bias scales, and the meta-analysis was undertaken using RevMan 5.3.

RESULTS

Of the 10 retrieved studies, six investigated LLLT+E, three on HILT+E, and one evaluated both. All the studies had high PEDro scores. However, as most of the studies employed a single type of laser therapy, only indirect comparison of LLLT+E and HILT+E was possible. This study found all treatment modalities were effective in reducing KOA symptoms. Interestingly, relative to control, the meta-analysis showed significant improvements in knee pain, stiffness and function for the HILT+E.

CONCLUSION

Both LLLT and HILT are beneficial as adjuncts to rehabilitation exercise in the management of KOA. Based on an indirect comparison, the HILT+E seems to have higher efficacy in reducing knee pain and stiffness, and in increasing function. To confirm this finding, a direct comparative investigation of the two types of laser therapy may be necessary. Systematic review registration PROSPERO ID CRD42020206228.

Psychometric properties of the Polish version of the 36-item WHODAS 2.0 in patients with hip and knee osteoarthritis

Purpose

To examine psychometric properties of the Polish version of the 36-item WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) in the population with hip and knee osteoarthritis (OA).

Methods

This was a longitudinal study with repeated measures during retest examinations. Subjects from a Polish Specialist Hospital (age = 68.3 ± 9.2years, 71% female, 44.2% knee OA, 55.8% hip OA) were tested three times. They completed the Polish version of the 36-item WHODAS 2.0, the SF-36 Health Survey 2.0, the Western Ontario and Macmaster Universities Osteoarthritis Index 3.1, the Hospital Anxiety and Depression Scale, and the Numerical Rating Scale.

Results

The 36-item WHODAS 2.0—Polish version demonstrated high internal consistency (Cronbach’s alpha for total = 0.94), and test–retest reliability (Total ICC_2,1 = 0.98). High construct validity was found as 12 out of 15 a priori hypotheses (80%) were confirmed. Most domains and Total Scores in the 36-item WHODAS 2.0 (Total ES = − 0.62, SMR = − 1.09) showed a moderate degree of responsiveness. Minimal clinically important difference (MCID) for the Total WHODAS 2.0 was 3.29 in patients undergoing rehabilitation for knee or hip OA.

Conclusions

The Polish version of the 36-item WHODAS 2.0 assesses disability according to ICF in a reliable, valid and responsive way. Therefore, it provides considerable support in clinical practice and national and international scientific research of patients with hip or knee OA.

A novel cell-free formulation for the treatment of knee osteoarthritis generates better patient-reported health outcomes in more severe cases

BACKGROUND

The bioactive cell-free formulation (BIOF2) for cartilage regeneration has shown a major therapeutic response in severe knee osteoarthritis. However, its effect on patients with mild or moderate stages of the disease has not been studied.

OBJECTIVE

To evaluate the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, minimal clinically important improvement (MCII) and sleep disturbances in mild, moderate, and severe stages of knee osteoarthritis (OA) with the novel cell-free formulation treatment (BIOF2).

METHODS

An open-label, nonrandomized, baseline-controlled, parallel group study on patients with mild, moderate, and severe knee OA was conducted to evaluate the effect of intra-articular administration of BIOF2. Clinical improvement was determined through the WOMAC score and MCII, whereas sleep disturbances were measured through a Likert scale questionnaire.

RESULTS

At 6 months post-treatment, the mean decrease in the total WOMAC score was 16.4 +/- 4.7%, 49.9 +/- 6.4%, and 62.7 +/- 4.5% in the patients with mild, moderate, and severe disease, respectively (p < 0.001, analysis of variance test). MCII at 6 months was 18%, 78%, and 100% for mild, moderate, and severe disease, respectively (p < 0.001, likelihood-ratio χ² test). Concerning sleep disturbances, 60% of the patients with severe OA had important sleep problems before beginning treatment, and those difficulties were overcome 6 months after treatment. Only 18% of the patients with mild disease and 16% with moderate disease had serious sleep disturbances at the beginning of the study, and there was slight improvement after treatment. No adverse events were recorded during follow-up.

CONCLUSION

BIOF2 generates better patient-reported health outcomes (on pain, stiffness, function, and sleep) in the more severe cases of knee OA.

Effectiveness of Low-Level Laser Therapy Associated with Strength Training in Knee Osteoarthritis: Protocol for a Randomized Placebo-Controlled Trial

Physical activity and low-level laser therapy (LLLT) can reduce knee osteoarthritis (KOA) inflammation. We are conducting a randomized placebo-controlled trial to investigate the long-term effectiveness of LLLT combined with strength training (ST) in persons with KOA, since it, to our knowledge, has not been investigated before. Fifty participants were enrolled. LLLT and ST was performed 3 times per week over 3 and 8 weeks, respectively. In the LLLT group, 3 Joules of 904 nm wavelength laser was applied to 15 spots per knee (45 Joules/knee/session). The primary outcomes are pain during movement, at night and at rest (Visual Analogue Scale) and global pain (Knee injury and Osteoarthritis Outcome Score, KOOS) pain subscale. The secondary outcomes are KOOS disability and quality-of-life, analgesic usage, global health change, knee active range of motion, 30 s chair stand, maximum painless isometric knee extension strength, knee pain pressure threshold and real-time ultrasonography-assessed suprapatellar effusion, meniscal neovascularization and femur cartilage thickness. All the outcomes are assessed 0, 3, 8, 26 and 52 weeks post-randomization, except for global health change, which is only evaluated at completed ST. This study features the blinding of participants, assessors and therapists, and will improve our understanding of what occurs with the local pathophysiology, tissue morphology and clinical status of persons with KOA up to a year after the initiation of ST and a higher 904 nm LLLT dose than in any published trial on this topic.

Osteoarthritis year in review 2020: rehabilitation and outcomes

OBJECTIVE

Systematically review and synthesize guidelines, systematic reviews, or randomized controlled trials (RCTs) published between April 1, 2019 and April 30, 2020 which evaluated or made recommendations for rehabilitation of persons with osteoarthritis.

DESIGN

Five electronic databases (Medline, EMBASE, Cochrane CENTRAL, CINHAL, Web of Science) were searched with a comprehensive search strategy. Guidelines for rehabilitation of persons with osteoarthritis, and systematic reviews and RCTs evaluating osteoarthritis rehabilitation that included at least one patient-reported outcome measure and/or clinical test of function were included. Two authors independently screened records and assessed methodological quality using the AGREE-II (guidelines), AMSTAR-2 (systematic reviews) or PEDro scale (RCTs). Data were extracted to summarize included records and a narrative synthesis of findings related to core recommended osteoarthritis rehabilitation treatments performed.

RESULTS

Of 2,479 potential records, 253 records were reviewed. Two guidelines, 18 systematic reviews and 38 RCTs were included. 84% (n = 49) of included records related to knee osteoarthritis, 13% (n = 8) to hip, 10% (n = 6) to hand, 3% (n = 2) to mixed, and 1% (n = 1) to foot osteoarthritis. Exercise-therapy, methods to deliver exercise-therapy remotely, and approaches to facilitate exercise-therapy behaviour change were the most commonly evaluated interventions (n = 27). 94% of systematic reviews and 63% of RCTs rated high-quality.

CONCLUSIONS

Osteoarthritis rehabilitation research continues to focus on knee osteoarthritis and exercise-based interventions. Emerging topics include rehabilitation of comorbid populations, exercise behaviour change and technology supports. A better understanding of rehabilitation of osteoarthritis in joints other than the knee, and methods to determine and promote ideal exercise-therapy prescription are needed.

Effect of Internet-Based Rehabilitation Programs on Improvement of Pain and Physical Function in Patients with Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Osteoarthritis (OA) is a chronic, debilitating, and degenerative joint disease. However, it is difficult for patients with knee OA to access conventional rehabilitation when discharging from the hospital. Internet-based rehabilitation is one of the promising telemedicine strategies to provide a means combining monitoring, guidance, and treatment for patients with knee OA.

Objective

The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based rehabilitation programs on pain and physical function in patients with knee OA.

Methods

Keywords related to knee OA and internet-based rehabilitation were systematically searched in the Web of Science, MEDLINE, EMBASE, CENTRAL, Scopus, PEDro (Physiotherapy Evidence Database), CNKI, SinoMed, and WANFANG databases from January 2000 to April 2020. Only randomized controlled trials were included. The authors independently screened the literature. The main outcome measures were focused on pain and physical function. A meta-analysis was performed on the collected data. Review Manager (RevMan, version 5.3) was used for all analyses.

Results

The systematic review identified 6 randomized controlled trials, 4 of which were included in the meta-analysis, comprising a total of 791 patients with knee OA. The meta-analysis with the fixed-effects model showed that the internet-based rehabilitation programs could significantly alleviate the osteoarthritic pain for patients compared with conventional rehabilitation (standardized mean difference [SMD] –0.21, 95% CI  −0.4 to –0.01, P=.04). No significant difference was found in the improvement of physical function in patients with knee OA compared with conventional rehabilitation within 2 to 12 months (SMD –0.08, 95% CI −0.27 to 0.12, P=.43).

Conclusions

This systematic review shows that internet-based rehabilitation programs could improve the pain but not physical function for patients with knee OA. However, there was a very small number of studies that could be included in the review and meta-analysis. Thus, further studies with large sample sizes are warranted to promote the effectiveness of internet-based rehabilitation and to develop its personalized design.

A cycling and education intervention for the treatment of hip osteoarthritis: A quality improvement replication programme

Objectives:

The Cycling against Hip Pain programme is a 6-week exercise and education treatment pathway for people with hip osteoarthritis. Preliminary results of the Cycling against Hip Pain programme found significant improvements in clinical and patient-reported outcome measures for patients referred from primary care. This article evaluates the effectiveness of the changes made to the pathway in a quality improvement replication programme.

Methods:

The replicated Cycling against Hip Pain programme was delivered between February 2018 and September 2019 in a region of England with a high percentage of adults aged over 65 years. All participants were referred from the orthopaedic outpatient department of the funding hospital (secondary care). The programme was delivered at a local leisure centre and combined 30 min of education on osteoarthritis with 30 min of progressive static cycling, once a week for 6 weeks.

Results:

The participants on the replicated Cycling against Hip Pain programme did not differ from the original cohort in terms of age or pre-programme weight, however, presented with worse hip symptoms at baseline. Consistent with the findings from the original cohort, participants demonstrated significant improvements to their Oxford Hip Score, 30-s chair stand performance, Timed Up and Go score, Hip Osteoarthritis Outcome Score function and pain, EQ5D health rating, EQ5D-5L score and pain at rest and on weight bearing. In addition, participants reported an increase in knowledge, confidence and motivation to exercise.

Conclusion:

A 6-week cycling and education intervention for the treatment of hip osteoarthritis provided benefits to function, pain and quality of life for patients referred from secondary care. These results are consistent with findings from patients who were referred from primary care and further support the potential of the pathway in the conservative management of hip osteoarthritis.

Cryotherapy associated with tailored land-based exercises for knee osteoarthritis: a protocol for a double-blind sham-controlled randomised trial

INTRODUCTION

There is an unmet need to develop tailored therapeutic exercise protocols applying different treatment parameters and modalities for individuals with knee osteoarthritis (KOA). Cryotherapy is widely used in rehabilitation as an adjunct treatment due to its effects on pain and the inflammatory process. However, disagreement between KOA guidelines remains with respect to its recommendation status. The aim of this study is to verify the complementary effects of cryotherapy when associated with a tailored therapeutic exercise protocol for patients with KOA.

METHODS AND ANALYSIS

This study is a sham-controlled randomised trial with concealed allocation and intention-to-treat analysis. Assessments will be performed at baseline and immediately following the intervention period. To check for residual effects of the applied interventions, 3-month and 6-month follow-up assessments will be performed. Participants will be community members living with KOA divided into three groups: (1) the experimental group that will receive a tailored therapeutic exercise protocol followed by a cryotherapy session of 20 min; (2) the sham control group that will receive the same regimen as the first group, but with sham packs filled with dry sand and (3) the active treatment control group that will receive only the therapeutic exercise protocol. The primary outcome will be pain intensity according to a Visual Analogue Scale. Secondary outcomes will be the Western Ontario & McMaster Universities Osteoarthritis Index; the Short-Form Health Survey 36; the 30-s Chair Stand Test; the Stair Climb test; and the 40-m fast-paced walk test.

ETHICS AND DISSEMINATION

The trial was approved by the Institutional Ethics Committee of Federal University of São Carlos, São Paulo, Brazil. Registration approval number: CAAE: 65966617.9.0000.5504. The results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03360500.

The impact of a significant weight loss on inflammation assessed on DCE-MRI and static MRI in knee osteoarthritis: a prospective cohort study

OBJECTIVE

To study the impact of weight loss on inflammation in individuals with overweight and knee osteoarthritis (OA) using both static- and dynamic contrast-enhanced (DCE)-MRI and assess the association of these changes to pain.

DESIGN

Individuals with overweight (BMI > 27) and knee OA were examined before and after a >5% weight loss over 8 weeks (ClinicalTrials.gov NCT02905864). Using 3-T MRI, inflammation was quantified from non-contrast enhanced static-MRI according to MOAKS and contrast enhanced static MRI according to BLOKS and 11-point whole-knee synovitis score. DCE-MRI was used to assess the inflammation in the infra patellar fat pad (IPFP). Pain was assessed using KOOS.

RESULTS

Complete data were available in 117 participants with a mean age of 60 years, BMI of 35 kg/m² and KOOS pain score of 64. Mean weight loss was 12 kg and KOOS pain was improved by 13 points at follow-up. Change in inflammation was not associated with weight loss in static MRI. None of the MRI variables correlated with the change in KOOS pain.

CONCLUSION

Weight loss did not induce a significant change in inflammation in individuals with overweight and OA. The significant clinical beneficial effect of weight loss on knee pain in individuals with overweight and knee OA seems uncoupled to changes in imaging markers of synovitis.

Photobiomodulation therapy associated with supervised therapeutic exercises for people with knee osteoarthritis: a randomised controlled trial protocol

BACKGROUND

Physical exercise, a cornerstone of the conservative management of knee osteoarthritis (KOA), is exhaustively recommended by important clinical guidelines. A strength therapeutic exercise program (STEP) relieves pain, improves physical function and ultimately ameliorates quality of life (QoL). Furthermore, photobiomodulation (PBM) has been used as an adjunct treatment for people with KOA; however, there are still controversial recommendations regarding its use on this population. Thus, we hypothesised that PBM, when associated with a STEP protocol on patients with KOA, could induce better clinical outcomes than a STEP protocol alone.

METHODS AND ANALYSIS

The study is a 6-month triple-blind placebo-controlled randomised clinical trial with intention-to-treat analysis. The trial will include 120 people with clinic and radiographic signs of KOA. The intervention consists of a supervised STEP and PBM protocols conducted over an 8-week intervention period. Assessments are performed at baseline, right after treatment, and 3-month and 6-month follow-up periods. The primary clinical outcome is pain intensity according to a 10 cm Visual Analogue Scale. Secondary outcomes are the global Western Ontario & McMaster Universities Osteoarthritis Index; QoL assessed by the 36-item Short-Form health survey questionnaire; and performance-based physical parameters assessed by the 30 s chair stand test; the stair climb test; and the 40 m fast-paced walk test.

ETHICS AND DISSEMINATION

The trial was approved by the Human Research Ethics Committee of the Federal University of São Carlos, São Paulo, Brazil (REC no 2.016.122). Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Brazilian Clinical Trials Registry (U1111-1215-6510).

Defactinib attenuates osteoarthritis by inhibiting positive feedback loop between H-type vessels and MSCs in subchondral bone

Background

Abnormal bone formation in subchondral bone resulting from uncoupled bone remodeling is considered a central feature in osteoarthritis (OA) pathogenesis. H-type vessels can couple angiogenesis and osteogenesis. We previously revealed that elevated H-type vessels in subchondral bone were correlated with OA and focal adhesion kinase (FAK) in MSCs is critical for H-type vessel formation in osteoporosis. The aim of this study was to explore the correlation between H-type vessels and MSCs in OA pathogenesis through regulation of H-type vessel formation using defactinib (an FAK inhibitor).

Methods

In vivo: 3-month-old male C57BL/6J (WT) mice were randomly divided into three groups: sham controls, vehicle-treated ACLT mice, and defactinib-treated ACLT mice (25 mg/kg, intraperitoneally weekly). In vitro: we explored the role of conditioned medium (CM) of MSCs from subchondral bone of different groups on the angiogenesis of endothelial cells (ECs). Flow cytometry, Western blotting, ELISA, real time (RT)-PCR, immunostaining, CT-based microangiography, and bone micro-CT (μCT) were used to detect changes in relative cells and tissues.

Results

This study demonstrated that inhibition of H-type vessels with defactinib alleviated OA by inhibiting H-type vessel-linked MSCs in subchondral bone. During OA pathogenesis, H-type vessels and MSCs formed a positive feedback loop contributing to abnormal bone formation in subchondral bone. Elevated H-type vessels provided indispensable MSCs for abnormal bone formation in subchondral bone. Flow cytometry and immunostaining results confirmed that the amount of MSCs in subchondral bone was obviously higher in vehicle-treated ACLT mice than that in sham controls and defactinib-treated ACLT mice. In vitro, p-FAK in MSCs from subchondral bone of vehicle-treated ALCT mice increased significantly relative to other groups. Further, the CM from MSCs of vehicle-treated ACLT mice enhanced angiogenesis of ECs through FAK-Grb2-MAPK-linked VEGF expression.

Conclusions

Our results demonstrate that defactinib inhibits OA by suppressing the positive feedback loop between H-type vessels and MSCs in subchondral bone.

The translational potential of this article

Our results provide a mechanistic rationale for the use of defactinib as an effective candidate for OA treatment.

Osteoarthritis year in review 2019: rehabilitation and outcomes

OBJECTIVE

Inactivity and obesity are risk factors for osteoarthritis (OA) progression. The purpose of this review was to highlight intervention parameters of exercise and lifestyle diet interventions on clinical outcomes in OA that were published over 15 months, starting January 1, 2018.

DESIGN

Systematic literature searches were performed in Medline (Pubmed, OVID), Scopus, CINAHL, CENTRAL and Embase from January 1, 2018 to April 1, 2019. Key words included osteoarthritis, exercise, physical activity, diet and nutrition. Randomized controlled designs and data synthesis papers (systematic reviews, meta-analyses, clinical guidelines) written in English, that included humans with OA of any joint were included. Trials were evaluated using the Physiotherapy Evidence Database (PEDro) critical appraisal tool and the Template for Intervention Description and Replication (TIDieR). Systematic reviews and meta-analyses were evaluated using A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2). Intervention details (RCTs) and key finding from papers were summarized.

RESULTS

Of 540 titles and abstracts retrieved, 147 full articles were reviewed and 53 met the inclusion criteria, comprised of 39 RCTs and 14 synthesis papers. By addressing inactivity, exercise effectively improves clinical outcomes and, based on low-moderate quality evidence, without further damage to cartilage or synovial tissue. By comparison, much less work focused on minimizing obesity. Diet must be combined with exercise to improve pain, but alone, can improve physical function.

CONCLUSIONS

Future work is necessary to identify the ideal exercise frequency and intensity and lifestyle diet intervention parameters. Improved adherence to reporting guidelines in future work will greatly enhance the OA rehabilitation field.

The effects of weight loss on imaging outcomes in osteoarthritis of the hip or knee in people who are overweight or obese: a systematic review

OBJECTIVE

To evaluate the structural effects of weight loss on hip or knee osteoarthritis (OA) and to summarize which structural joint pathologies have been examined and the evidence for the outcome measurement instruments applied.

DESIGN

Based on a pre-specified protocol (available: PROSPERO CRD42017065263), we conducted a systematic search of the bibliographic databases, Medline, Embase and Web of Science identifying longitudinal articles reporting the effects of weight loss on structural imaging outcomes in OA of the hip or knee in people who are overweight or obese.

RESULTS

From 1625 potentially eligible records, 14 articles (from 6 cohorts) were included. 2 cohorts were derived from RCTs. Evaluated pathologies were: articular cartilage (n = 7), joint space width (n = 3), bone marrow lesions (n = 5), synovitis (n = 2), effusion (n = 1), meniscus (n = 3), bone marrow density (n = 1) and infrapatellar fat pad (IPFP; n = 2). Cartilage showed conflicting results when evaluating cartilage thickness by direct thickness measurements. Compositional dGEMRIC and T2 mapping measures in early knee OA showed trends towards reduced cartilage degeneration. Joint space width on conventional radiographs showed no change. Weight loss reduced the size of the IPFP. Synovitis and effusion were not affected. Following weight loss DXA showed bone loss at the hip.

CONCLUSION

We did not find consistent evidence of the effects of weight loss on OA structural pathology in people who are overweight or obese. There is a need to achieve consensus on which structural pathologies and measurements to apply in weight loss and OA research.

Are we missing the target? Are we aiming too low? What are the aerobic exercise prescriptions and their effects on markers of cardiovascular health and systemic inflammation in patients with knee osteoarthritis? A systematic review and meta-analysis

Objectives

We systemically reviewed published studies that evaluated aerobic exercise interventions in patients with knee osteoarthritis (OA) to: (1) report the frequency, intensity, type and time (FITT) of exercise prescriptions and (2) quantify the changes in markers of cardiovascular health and systemic inflammation.

Data sources

PubMed, CINAHL, Scopus; inception to January 2019.

Eligibility criteria

Randomised clinical trials (RCT), cohort studies, case series.

Design

We summarised exercise prescriptions for all studies and calculated effect sizes with 95% CIs for between-group (RCTs that compared exercise and control groups) and within-group (pre-post exercise) differences in aerobic capacity (VO2), heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and inflammatory markers (interleukin-6 (IL-6), tumour necrosis factor-alpha). We pooled results where possible using random effects models.

Results

Interventions from 49 studies were summarised; 8% (4/49) met all FITT guidelines; 16% (8/49) met all or most FITT guidelines. Fourteen studies (10 RCTs) reported at least one marker of cardiovascular health or systemic inflammation. Mean differences (95% CI) indicated a small to moderate increase in VO2 (0.84 mL/min/kg; 95% CI 0.37 to 1.31), decrease in HR (−3.56 beats per minute; 95% CI −5.60 to −1.52) and DBP (−4.10 mm Hg; 95% CI −4.82 to −3.38) and no change in SBP (−0.36 mm Hg; 95% CI −3.88 to 3.16) and IL-6 (0.37 pg/mL; 95% CI −0.11 to 0.85). Within-group differences were also small to moderate.

Conclusions

In studies of aerobic exercise in patients with knee OA, very few interventions met guideline-recommended dose; there were small to moderate changes in markers of cardiovascular health and no decrease in markers of systemic inflammation. These findings question whether aerobic exercise is being used to its full potential in patients with knee OA.

PROSPERO registration number

CRD42018087859.

Laser Acupuncture for Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

Objectives

To provide updated evidence from randomized controlled trials (RCTs) on the effectiveness of laser acupuncture for patients with knee osteoarthritis (KOA).

Methods

A literature search in 9 databases was conducted from their inception through February 2019. Randomized controlled trials (RCTs) written in English that compared active laser acupuncture with placebo in KOA patients were included. Two authors independently extracted data from these trials. Meta-analysis software was used to analyze the data. Included studies were assessed in terms of the follow-up period, the methodological quality, and appropriateness of their technical features.

Results

Of 357 studies, seven RCTs (totaling 395 patients) met the inclusion criteria. The short-term outcomes showed that laser acupuncture offered significant pain relief over placebo when assessed by the 100 mm visual analog scale (VAS) pain score (p = 0.02), while there was no significant difference between laser acupuncture and placebo based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score (p = 0.25). For subgroup analysis, laser acupuncture had superiority over placebo in terms of both VAS and WOMAC pain scores in the appropriate technical features subgroup and the excellent methodological quality subgroup. But the effect of laser acupuncture on pain relief was not maintained in terms of either VAS (p = 0.19) or WOMAC pain score (p = 0.60). The pooled effect showed no significant difference between laser acupuncture and placebo at either time point according to WOMAC function scale, WOMAC stiffness scale, and quality of life outcome.

Conclusions

Our findings indicate that laser acupuncture can effectively reduce knee pain for patients with KOA at short term when appropriate technical features are applied, but the effect likely fades away during the subsequent follow-up period.

Does occupational therapy delay or reduce the proportion of patients that receives thumb carpometacarpal joint surgery? A multicentre randomised controlled trial

Objectives

To evaluate whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need of surgery in thumb carpometacarpal joint (CMCJ) osteoarthritis and to explore predictors for CMCJ surgery.

Methods

This multicentre randomised controlled trial included patients referred for surgical consultation due to CMCJ osteoarthritis. An occupational therapy group received hand osteoarthritis education, assistive devices, CMCJ orthoses and exercises. A control group received only hand osteoarthritis information. Primary outcome was the proportion of patients that had received CMCJ surgery after 2 years. We examined the primary outcome and predictors for surgery with regression models, and time to surgery with the log-rank test and cox regression analyses.

Results

Of 221 patients screened for eligibility, 180 were randomised. Information on the primary outcome was collected from medical records for all included patients. Surgery was performed on 22 patients (24%) that had received occupational therapy and 29 (32%) control patients (OR 0.56, 95% CI 0.26 to 1.21; p=0.14). Median time to surgery was 350 days (IQR 210-540) in the occupational therapy group and 296 days (IQR 188-428) in the control group (p=0.13). Previous non-pharmacological treatment (OR 2.72, 95% CI 1.14 to 6.50) and higher motivation for surgery (OR 1.25, 95% CI 1.09 to 1.43) were significant predictors for CMCJ surgery.

Conclusions

Occupational therapy showed a small non-significant tendency to delay and reduce the need for surgery in CMCJ osteoarthritis. Previous non-pharmacological treatment and higher motivation for surgery were significant predictors for surgery.

Efficacy of low-level laser therapy on pain and disability in knee osteoarthritis: systematic review and meta-analysis of randomised placebo-controlled trials

OBJECTIVES

Low-level laser therapy (LLLT) is not recommended in major knee osteoarthritis (KOA) treatment guidelines. We investigated whether a LLLT dose-response relationship exists in KOA.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eligible articles were identified through PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database and Cochrane Central Register of Controlled Trials on 18 February 2019, reference lists, a book, citations and experts in the field.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We solely included randomised placebo-controlled trials involving participants with KOA according to the American College of Rheumatology and/or Kellgren/Lawrence criteria, in which LLLT was applied to participants' knee(s). There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

The included trials were synthesised with random effects meta-analyses and subgrouped by dose using the World Association for Laser Therapy treatment recommendations. Cochrane's risk-of-bias tool was used.

RESULTS

22 trials (n=1063) were meta-analysed. Risk of bias was insignificant. Overall, pain was significantly reduced by LLLT compared with placebo at the end of therapy (14.23 mm Visual Analogue Scale (VAS; 95% CI 7.31 to 21.14)) and during follow-ups 1-12 weeks later (15.92 mm VAS (95% CI 6.47 to 25.37)). The subgroup analysis revealed that pain was significantly reduced by the recommended LLLT doses compared with placebo at the end of therapy (18.71 mm (95% CI 9.42 to 27.99)) and during follow-ups 2-12 weeks after the end of therapy (23.23 mm VAS (95% CI 10.60 to 35.86)). The pain reduction from the recommended LLLT doses peaked during follow-ups 2-4 weeks after the end of therapy (31.87 mm VAS significantly beyond placebo (95% CI 18.18 to 45.56)). Disability was also statistically significantly reduced by LLLT. No adverse events were reported.

CONCLUSION

LLLT reduces pain and disability in KOA at 4-8 J with 785-860 nm wavelength and at 1-3 J with 904 nm wavelength per treatment spot.

PROSPERO REGISTRATION NUMBER

CRD42016035587.