A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative

Implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia: A mixed-methods program evaluation

INTRODUCTION

We aimed to evaluate the implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program via telehealth in Australia using Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation framework.

METHODS

Using a convergent mixed-methods design, semi-structured one-on-one interviews with physiotherapist adopters and nonadopters of GLA:D® via telehealth were analyzed thematically alongside the examination of registry data (1 March 2020-10 February 2022) from patients with hip or knee osteoarthritis completing GLA:D® via telehealth (telehealth-only) or combined with in-person care (hybrid). Effectiveness was determined as changes from baseline to 3-month follow-up (mean differences, 95% confidence intervals, effect size) for Knee injury and Osteoarthritis Outcome Score (KOOS-12)/Hip disability and Osteoarthritis Outcome Score-12 (HOOS-12), and chair stand test. Group- and individual-level changes were compared to published minimally clinically important change scores.

RESULTS

Twenty-three interviews (12 adopters, 11 nonadopters) found key barriers/facilitators to reach and adoption, high perceived effectiveness, and strategies to support sustainability. Of 2612 registered patients, 85 (3%) and 115 (4%) completed GLA:D® via telehealth-only or hybrid model, respectively. Most effectiveness outcomes were associated with moderate-large improvements. Group-level changes exceeded minimally clinically important change values for KOOS/HOOS-quality of life and chair stand test. Nearly two out of three patients reached a minimally clinically important change for KOOS/HOOS-quality of life. With telehealth-only and hybrid delivery, 99% (n = 82) and 85% (n = 97) were satisfied/very satisfied. Physiotherapist adoption was limited (n = 128, 6%).

DISCUSSION

GLA:D® delivered via telehealth is effective, had high patient satisfaction, and was perceived positively by physiotherapist adopters. Addressing low reach and adoption requires further implementation strategies to facilitate greater telehealth opportunities for patients and physiotherapists.

The effectiveness of peer support interventions for community-dwelling adults with chronic musculoskeletal pain: a systematic review and meta-analysis of randomised trials

ABSTRACT

This systematic review and meta-analysis critically examined the evidence for peer support interventions to reduce pain and improve health outcomes in community-dwelling adults with chronic musculoskeletal pain (PROSPERO CRD42022356850). A systematic search (inception-January 2023) of electronic databases and grey literature was undertaken to identify relevant randomised controlled trials, with risk of bias and GRADE assessments performed on included studies. Meta-analyses used a generic, inverse-variance, random-effects model, calculating mean difference (MD) or standardised mean difference (SMD). Of 16,445 records identified, 29 records reporting on 24 studies (n = 6202 participants) were included. All evidence had unclear/high risk of bias and low-very low certainty. Peer support interventions resulted in small improvements in pain (medium-term: MD -3.48, 95% CI -6.61, -0.35; long-term: MD -1.97, 95% CI -3.53, -0.42), self-efficacy (medium-term: SMD 0.26, 95% CI 0.16, 0.36; long-term: SMD 0.21, 95% CI 0.07, 0.36), and function (long-term: SMD -0.10, 95% CI -0.19, -0.00) relative to usual care and greater self-efficacy (medium-term: SMD 0.36, 95% CI 0.20, 0.51) relative to waitlist control. Peer support interventions resulted in similar improvement as active (health professional led) interventions bar long-term self-efficacy (MD -0.41, 95% CI -0.77, -0.05), which favoured active interventions. No point estimates reached minimal clinically important difference thresholds. Pooled health service utilisation outcomes showed unclear estimates. Self-management, quality of life, and social support outcomes had mixed evidence. Despite low-very low evidence certainty, peer support interventions demonstrated small improvements over usual care and waitlist controls for some clinical outcomes, suggesting that peer support may be useful as an adjunct to other treatments for musculoskeletal pain.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis

OBJECTIVES

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity.

BACKGROUND

An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR.

METHODS

Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity.

RESULTS

Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR.

CONCLUSIONS

Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Barriers, facilitators and referral patterns of general practitioners, physiotherapists, and people with osteoarthritis to exercise

BACKGROUND

Barriers and facilitators of general practitioners (GPs), physiotherapists (PTs), and people with hip and knee osteoarthritis (PwOA) may influence uptake of and referral to guideline-based exercise treatments for OA.

OBJECTIVE

To identify barriers and facilitators of GPs, PTs and PwOA to uptake of and referral to exercise treatments for OA.

METHODS

An online survey was circulated to GPs, PTs, and PwOA in Ireland from March to September 2021. Data were collected on demographics, barriers and facilitators, and referral patterns to exercise treatments for OA. Frequency distributions were used to illustrate demographics, barriers and facilitators, and referral patterns to exercise treatments for OA.

RESULTS

388 stakeholders responded (GPs = 148; PTs = 154; PwOA = 86). Barriers and facilitators were related to (1) stakeholder (e.g., patient tiredness and fatigue), (2) healthcare setting (e.g., appropriate referrals from GP or other sources), and (3) treatment (e.g., low-cost community-based exercise programmes) factors. While 91% of GPs would refer PwOA to physiotherapy if no barriers existed, only 60% would in their current practice. Only 33% of PwOA reported receiving a GP referral to physiotherapy.

CONCLUSION

Stakeholder, healthcare setting and treatment barriers and facilitators of GPs, PTs, and PwOA influence uptake of and referral to exercise treatments for OA. Future strategies Future strategies addressing these factors may improve implementation of guideline-based management for OA. CONTRIBUTION OF THE PAPER.

Exploring Congruence Between Patient and Clinician Expectations of Benefit in the Non-Surgical Management of Common Musculoskeletal Conditions in Tertiary Care

BACKGROUND

Patient and clinician expectations of benefit from recommended management approaches may potentially impact the success of managing musculoskeletal conditions.

METHODS

This was a multisite study in an advanced practice musculoskeletal service across Queensland, Australia. Relationships between patient and clinician (advanced physiotherapy practitioner) expectations of benefit, patient characteristics, and clinical outcome recorded 6 months later were explored with regression analysis in 619 patients undergoing non-surgical multidisciplinary care for either knee osteoarthritis (n = 286), low back pain (n = 249) or shoulder impingement syndrome (n = 84).

RESULTS

Patient and clinician expectation ratings had a weak positive association (standardized coefficient (β) 0.28, adjusted R2 0.09). Higher patient expectation ratings were associated with higher readiness for change scores (β 0.31, model adjusted R2 = 0.18), while higher clinician expectation ratings were associated with the condition managed, higher patient education level, lower potential presence of neuropathic pain or yellow flags, and more favourable radiological findings (model adjusted R2 0.4). Patient expectations and self-reported engagement with care were poorly correlated. Higher patient (β 0.33, adjusted R2 0.12) and clinician (β 0.32, adjusted R2 0.14) expectations were associated with better clinical outcomes. This positive association was stronger when patient and clinician expectation ratings were congruent.

CONCLUSIONS

Findings suggest that expected benefits from recommended care may impact outcomes and should be considered in the initial phases of management. In particular, congruence between patient and clinician expectations appears to have relevance to outcomes.

Association of inflammation and nutrition status with all-cause and cardiovascular mortality in individuals with osteoarthritis: NHANES, 1999-2018

Background

Osteoarthritis (OA) is the most prevalent form of arthritis worldwide. Inflammation and nutrition status play crucial roles in the development and progression of OA. The advanced lung cancer inflammation index (ALI) serves as a composite indicator for evaluating inflammation and nutritional status, while the systemic immune inflammation index (SII) is a novel marker for assessing immune-related inflammation. The study aimed to investigate the associations of the ALI and SII with all-cause and cardiovascular mortality among US adults with OA.

Methods

A total of 2,602 individuals aged 20 years and above with OA were included in the study from the National Health and Nutrition Examination Survey (NHANES) spanning from 1999 to 2018. Participants were categorized into higher or lower ALI and SII groups using cut-off values determined by the maximally selected rank statistics method. The Kaplan-Meier analysis, Cox proportional hazards models, and Fine Gray competing risk regression models were employed to assess the associations between the ALI/SII and mortality in OA patients. Additionally, stratified and subgroup analyses were conducted to enhance the robustness of the findings. Furthermore, time-dependent receiver operating characteristic (ROC) analysis was used to evaluate the predictive capacity of ALI and SII for mortality.

Results

Higher SII levels were associated with a 2-fold increase in the risk of all-cause mortality (HR: 2.00, 95% CI: 1.59-2.52, p < 0.001), whereas individuals with higher ALI in the OA group exhibited a significantly reduced risk of all-cause mortality (HR: 0.49, 95% CI: 0.39-0.60, p < 0.001). Notably, in Model 3, individuals with higher ALI demonstrated a substantially lower risk of cardiovascular mortality (HR: 0.60, 95% CI: 0.44-0.82, p < 0.001). Conversely, in fully adjusted models, those with higher SII experienced a significantly higher risk (HR: 1.83, 95% CI: 1.29-2.60, p < 0.001). The RCS analysis revealed a J-shaped non-linear relationship between SII levels and all-cause mortality (p overall < 0.001; p non-linear < 0.001), and an L-shaped non-linear association between ALI levels and all-cause mortality (p overall < 0.001; p non-linear = 0.002). The time-dependent ROC curves illustrated that ALI and SII displayed a reasonably good and consistent predictive performance for both short- and long-term mortality in OA patients.

Conclusions

Lower ALI and higher SII values were correlated with increased risks of all-cause and cardiovascular mortality among US adults with OA.

The effectiveness of massage on pain, external knee adduction moment, and muscle Co-contraction in individuals with medial compartment knee osteoarthritis

BACKGROUND

The pain, external knee adduction moment (EKAM), and muscle co-contraction are increased in knee osteoarthritis (KOA). Massage therapy decreases pain in KOA, yet KOA is a mechanical disease and biomechanical changes need to be investigated as well. Therefore, the current study aims to investigate the effectiveness of massage on these outcomes in individuals with medial KOA.

METHODS

A cohort of fifteen participants with confirmed medial compartment KOA (2 males, 13 females, age: 61.33 (6.16) years; height: 1.62 (0.06) m; mass: 65.39 (4.04) kg; BMI: 24.74 (4.04) kg/m2) was given a six-week massage. Outcomes assessed pre- and post-intervention were: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, temporal-spatial variables, knee joint kinematics and kinetics in sagittal, frontal, and transverse planes, vertical ground reaction force (GRF), and knee antagonist muscle co-contraction during gait. The paired t-test were used for statistical analysis.

RESULTS

Fifteen participants completed the study. Significant improvements were observed in WOMAC scores (pain, stiffness, function, and total), walking speed, step length, 1st peak GRF, sagittal plane knee joint range of motion during stance, and medial muscle co-contraction in early and mid-stance (p < 0.05). However, no significant change was found in EKAM and knee adduction angular impulse (KAAI) (p > 0.05).

CONCLUSION

Massage therapy, as a stand-alone treatment, reduces pain, improves function, and decreases medial muscle co-contraction in individuals with medial KOA. Although EKAM did not change, the results suggest a reduction in medial muscle co-contraction might be a mechanism by which pain is improved.

Exploring heterogeneity in coxarthrosis medication use patterns before total hip replacement: a State Sequence Analysis

OBJECTIVE

Evidence of geographical variation in total hip replacement (THR) and deviations from treatment guidelines persists. In this exploratory study, we aim to gain an in-depth understanding of patients' healthcare trajectories by identifying and visualising medication use patterns in coxarthrosis patients before surgery. We examine their association with patient characteristics and THR, and compare them with recommendations on mild analgesics, opioid prescription and exhaustion of conservative therapy.

METHODS

In this exploratory study, we apply State Sequence Analysis (SSA) on German health insurance data (2012-2015). We analyse a cohort of coxarthrosis patients, half of whom underwent THR after a 1 year observation period and half of whom did not undergo surgery until at least 1 year after the observation period. Hierarchical states are defined based on prescriptions. We construct sequences, calculate sequence similarity using optimal matching and identify medication use patterns via clustering. Patterns are visualised, descriptive statistics are presented and logistic regression is employed to investigate the association of medication patterns with subsequent THR.

RESULTS

Seven distinct medication use patterns are identified, correlating strongly with patient characteristics and subsequent THR. Two patterns leading to THR demonstrate exhaustion of pharmacological therapy. Opioid use is concentrated in two small patterns with low odds for THR. The most frequent pattern lacks significant pharmacological therapy.

CONCLUSIONS

This SSA uncovers heterogeneity in medication use patterns before surgery in coxarthrosis patients. Cautious opioid handling and adherence to a stepped prescription approach are observed, but many patients display low medication therapy usage and lack evidence of exhausting conservative options before surgery.

Arthroscopic surgery is not superior to conservative treatment in knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trails

BACKGROUND

Studies comparing the effectiveness of arthroscopic knee surgery and conservative treatment on knee osteoarthritis (OA) came up with inconsistent results. Systematic review on this topic still is still lacking. This systematic review and meta-analysis aimed to evaluate the effectiveness of arthroscopic knee surgery on knee OA, compared to conservative treatments.

MATERIALS AND METHODS

Literature searches were performed in PubMed, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) published before on 1st July 2024. Studies comparing the effectiveness of arthroscopy and conservative treatments only on knee OA were included. Quality of included studies was evaluated by risk of bias 2 (ROB2). Long-term results in terms of pain relief, functional recovery and patients reported satisfaction were meta-analyzed to evaluate the therapeutic effectiveness.

RESULTS

Ten studies were included in this review, among which only 1 was considered as low risk of bias. Five studies were involved in meta-analyses and no difference was found in therapeutic effectiveness of arthroscopic surgery and conservative treatment on knee OA, in the evaluation of VAS (p = 0.63), WOMAC (p = 0.38), SF-36 (p = 0.74) and patient satisfaction (p = 0.07).

CONCLUSION

The evidence does not support the effectiveness of arthroscopic knee surgery compared to conservative treatments in knee OA.

Determining Appropriateness of Total Joint Arthroplasty for Hip and Knee Osteoarthritis: A Patient-Centred Conceptual Model

INTRODUCTION

Total joint arthroplasty (TJA) for osteoarthritis is one of several treatment options with benefits and harms that patients value differently. However, the process for determining TJA appropriateness does not sufficiently acknowledge patient perspectives. The aim of this paper is to propose an evidence-informed patient-centred conceptual model for elective TJA appropriateness for hip and knee osteoarthritis.

METHODS

Our interprofessional team developed a conceptual model for determining the appropriateness of adults considering elective TJA. The model was informed by a review of the evidence, a qualitative study we conducted with adults who underwent TJA for osteoarthritis to determine barriers and facilitators to the use of appropriateness criteria, and the research and clinical experience of team members.

RESULTS

Appropriateness is providing health services (e.g., TJA) with net benefits to the right patient at the right time. The proposed Patient-centred Elective TJA Appropriateness Conceptual Model involves three key steps. First, assess adults with osteoarthritis to determine eligibility for TJA. Second, acknowledge the patient's informed preferences including their expectations and goals. Third, explore and support their mental and physical readiness for TJA. Given that osteoarthritis is a chronic condition, these steps can be revisited over time with patients.

DISCUSSION AND CONCLUSION

Our proposed conceptual model reconceptualises the appropriateness of TJA to be more patient-centred. Hence, this approach has the potential to be a more inclusive approach and ensure patients undergoing TJA are eligible, ready to proceed, and achieve what matters most to them. Future research is needed to test and validate the model.

Use of Implementation Strategies to Promote the Uptake of Knee Osteoarthritis Practice Guidelines and Improve Patient Outcomes: A Systematic Review

OBJECTIVE

Translation of knee osteoarthritis (KOA) clinical practice guidelines (CPGs) to practice remains suboptimal. The primary purpose of this systematic review was to describe the use of implementation strategies to promote KOA CPG-recommended care.

METHODS

Medline (via PubMed), Embase, CINAHL, and Web of Science were searched from inception to February 23, 2023, and the search was subsequently updated and expanded on January 16, 2024. Implementation strategies were mapped per the Expert Recommendations for Implementing Change taxonomy. Risk of bias (RoB) was assessed using the Cochrane Effective Practice and Organisation of Care criteria. The review was registered prospectively (PROSPERO identifier: CRD42023402383).

RESULTS

Nineteen studies were included in the final review. All (100% [n = 4]) studies that included the domains of "provide interactive assistance," "train and educate stakeholders" (89% [n = 16]), "engage consumers" (87% [n = 13]), and "support clinicians" (79% [n = 11]) showed a change to provider adherence. Studies that showed a change to disability included the domains of "train and educate stakeholders," "engage consumers," and "adapt and tailor to context." Studies that used the domains "train and educate stakeholders," "engage consumers," and "support clinicians" showed a change in pain and quality of life. Most studies had a low to moderate RoB.

CONCLUSION

Implementation strategies have the potential to impact clinician uptake of CPGs and patient-reported outcomes. The implementation context, using an active learning strategy with a patient partner, restructuring funding models, and integrating taxonomies to tailor multifaceted strategies should be prioritized. Further experimental research is recommended to determine which implementation strategies are most effective.

Holistic Care for People Living With Chronic Musculoskeletal Pain: The Relevance and Importance of Sexual Function

People living with chronic primary or secondary musculoskeletal pain conditions such as low back pain, fibromyalgia, and inflammatory arthritis typically experience wide-ranging impacts on their physical function, activity participation, and psychosocial wellbeing. These can extend to negative impacts on a person's sexual function and their intimate relationships. While sexual function is an important component of wellbeing, it is often not considered within musculoskeletal pain care. Without awareness or targeted training, physical therapists may lack the confidence and skills to screen, assess, and manage the impacts that pain may be having on a person's sexual function and can miss the opportunity to tailor their care and optimize wellbeing. This article seeks to raise awareness among physical therapists of how living with chronic musculoskeletal pain can impact a person's sexual function and intimate relationships, and provide guidance on how to consider these issues within a person-centered approach to care. It describes why considering sexual function and intimate relationship issues as part of a person's lived musculoskeletal pain experience may be relevant, outlines the use of validated patient-reported outcome measures to assess sexual dysfunction, and suggests practical strategies for sensitively raising sexual function in consultations. Management approaches and possible referral pathways are also presented, to assist physical therapists in understanding available care options. This article seeks to support holistic care by improving physical therapists' knowledge and understanding of sexual dysfunction and its management in people living with chronic musculoskeletal pain.

IMPACT

Considering sexual function as a valued functional activity, together with other activities of daily living, will assist physical therapists to provide more holistic and person-centered care. This article covers the main considerations for raising sexual function and intimate relationship issues with people living with chronic musculoskeletal pain, as well as management options and potential referral pathways. Physical therapists are encouraged to seek targeted training to improve their confidence and skills in this area, and to use inclusive, respectful language for discussions around sexual function and intimate relationships.

Proteomic and lipidomic landscape of the infrapatellar fat pad and its clinical significance in knee osteoarthritis

Osteoarthritis (OA) is a prevalent joint disease that can be exacerbated by lipid metabolism disorders. The intra-articular fat pad (IFP) has emerged as an active participant in the pathological changes of knee OA (KOA). However, the proteomic and lipidomic differences between IFP tissues from KOA and control individuals remain unclear. Samples of IFP were collected from individuals with and without OA (n = 6, n = 6). Subsequently, these samples underwent liquid chromatography/mass spectrometry-based label-free quantitative proteomic and lipidomic analysis to identify differentially expressed proteins (DEPs) and lipid metabolites (DELMs). The DEPs were further subjected to enrichment analysis, and hub DEPs were identified using multiple algorithms. Additionally, an OA diagnostic model was constructed based on the identified hub DEPs or DELMs. Furthermore, CIBERSORT was utilized to investigate the correlation between hub protein expression and immune-related modules in IFP of OA. Our results revealed the presence of 315 DEPs and eight DELMs in IFP of OA patients compared to the control group. Enrichment analysis of DEPs highlighted potential alterations in pathways related to coagulation, complement, fatty acid metabolism, and adipogenesis. The diagnostic model incorporating four hub DEPs (AUC = 0.861) or eight DELMs (AUC = 0.917) exhibited excellent clinical validity for diagnosing OA. Furthermore, the hub DEPs were found to be associated with immune dysfunction in IFP of OA. This study presents a distinct proteomic and lipidomic landscape of IFP between individuals with OA and those without. These findings provide valuable insights into the molecular changes associated with potential mechanisms underlying OA.

The Effectiveness of a Single Hyaluronic Acid Injection in Improving Symptoms and Muscular Strength in Patients with Knee Osteoarthritis: A Multicenter, Retrospective Study

Knee osteoarthritis (KOA) is a progressive and multifactorial disease that leads to joint pain, muscle weakness, physical disability, and decreased quality of life. In KOA, the quantity of hyaluronic acid (HA) and the molecular weight (MW) are decreased, leading to joint pain due to increased wear of the knee articular cartilage. Arthrogenic muscle inhibition, which is usually found in patients with KOA, is associated with joint inflammation, pain, and swelling, also causing muscle atrophy, primarily of the anterior thigh muscles, and hindering the rehabilitation process. The aim of our work was to determine if a single HA infiltration could minimize the effects of arthrogenic muscle inhibition in patients with KOA in the short term, using isokinetic dynamometry to evaluate the strength of the knee extensor and flexor muscles of the thigh. Thirty patients with KOA who underwent both clinical and isokinetic assessment, and that received a single injection of HA, were retrospectively included. Our results showed that a single intra-articular injection of HA significantly reduces pain and improves joint function at four weeks, while non-statistically significant improvements were observed for the reference isokinetic parameter (maximum torque) at both 90°/s and 180°/s. Further high-quality studies are necessary to confirm the results of our study.

"It's a Very Good Second Option": Older Adults' Experience of Telehealth

INTRODUCTION

The growing ability to provide online services has enabled the proliferation of exercise-based telehealth interventions; however, adoption in older adults may be impacted by low digital literacy and "technophobia."

OBJECTIVES

The aim of this study was to explore the experience of community and aged-care dwelling older adults following exercise-based telehealth services to provide insights that could guide future telehealth exercise delivery.

DESIGN

Semi-structured interviews for qualitative analysis.

METHODS

Participants (age ≥60) who had completed at least one online exercise session from a registered health professional were recruited through a combination of purposeful and snowball sampling methods via their exercise facility or provider. A semi-structured interview guide was used by 2 interviewers to investigate participants' experiences and a "critical friends" approach used to identify common themes.

RESULTS

Thirteen interviews with 21 participants were conducted from 2 different facilities. Analysis identified meaning units within 3 themes and subthemes. Technology subthemes related to digital confidence prior to telehealth and changes during interventions, as well as the usability of technology for telehealth. Clinical practice subthemes described the different motivations to exercise, perceived benefits of telehealth, important implications for practitioners, and perceptions of safety. The social connection theme related to the social benefits of telehealth.

CONCLUSIONS

Older adults in our sample were technologically confident and capable of performing exercise sessions delivered via telehealth. They notice benefits from this form of exercise delivery however, prefer face-to-face exercise delivery.

Decadal analysis of efficacy and safety profiles of mesenchymal stem cells from varied sources in knee osteoarthritis patients: A systematic review and network meta-analysis

OBJECTIVE

Knee Osteoarthritis (KOA) is a debilitating degenerative joint ailment afflicting millions of patients. Numerous studies have assessed the efficacy of mesenchymal stem cells (MSCs) derived from various sources for KOA treatment, yet direct comparisons are scarce and inconsistent. Furthermore, network meta-analysis (NMA) conclusions require updating, while the safety of MSCs therapy remains contentious. This study evaluates therapeutic approaches involving MSCs from different sources in patients with KOA through randomized controlled trials (RCTs) and cohort studies. The objective is to compare the effectiveness and safety of MSCs strategies from various sources for KOA treatment.

METHODS

A systematic literature review was conducted to identify RCTs and cohort studies comparing different sources of MSCs in KOA patients. A randomized effects network meta-analysis was used to concurrently evaluate both direct and indirect comparisons across all protocols.

RESULTS

The NMA included 16 RCTS and reported 1005 participants. Adipose-derived mesenchymal stem cells (AD-MSCs) were the most effective treatment, showing significant improvements in the Visual Analogue Scale (VAS), the Short Form 36 (SF-36 scale), the International Knee Literature Committee Knee Evaluation Scale (IKDC subjective scores), and the Knee Injury and OA Outcome Score (KOOS). The probabilities are P = 85.3, P = 70.5, P = 88 and P = 87, respectively. Compared with placebo, AD-MSCs resulted in a VAS Score (SMD 0.97; 95%CI 0.37, 1.57), IKDC subjective scores (SMD -0.71; 95%CI -1.20, -0.21) was significantly reduced. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) showed significant improvements in the University of Western Ontario and McMaster University OA (WOMAC) (P = 91.4). Compared with placebo, UC-MSCs had a higher WOMAC Score (SMD 1.65; 95%CI 0.27, 3.03) and ranked first. Compared with MSCs, placebo emerged as the safer option (P = 74.9), with a notable reduction in AEs associated with HA treatment (RR 0.77; 95%CI 0.61, 0.97). AD-MSCs were found to have the least favorable impact on AEs with a probability of P = 13.3.

CONCLUSIONS

This network meta-analysis established that MSCs offer pain relief and enhance various knee scores in KOA patients compared to conventional treatment. It also identifies other therapeutic avenues warranting further exploration through high-quality studies. Nonetheless, it underscores the necessity to emphasize the potential complications and safety concerns associated with MSCs.

Advancements in pH-Responsive nanoparticles for osteoarthritis treatment: Opportunities and challenges

Osteoarthritis (OA) is a degenerative disease linked to aging and obesity. The global aging population has led to an increasing number of OA patients, imposing a significant economic burden on society. Traditional drugs treatment methods often fail to achieve satisfactory outcomes. With the rapid advancement of nanomaterial delivery systems, numerous studies have focused on utilizing nanomaterials as carriers to achieve efficient OA treatment by effectively loading and delivering bioactive ingredients (e.g., drugs, nucleic acids) tailored to the unique pathological conditions, such as the weakly acidic microenvironment of synovial fluid in OA patients. This review highlights the latest advancements in the use of pH-responsive nanoparticles for OA treatment, emphasizing the principle of targeted drug delivery leveraging the acidic microenvironment of inflamed joints. It further discusses the composition, synthesis, response mechanism, target selection, application, and recent research findings of nanoparticles, while also addressing the challenges and future directions in this promising field.

siRNA therapy in osteoarthritis: targeting cellular pathways for advanced treatment approaches

Osteoarthritis (OA) is a common joint disorder characterized by the degeneration of cartilage and inflammation, affecting millions worldwide. The disease's complex pathogenesis involves various cell types, such as chondrocytes, synovial cells, osteoblasts, and immune cells, contributing to the intricate interplay of factors leading to tissue degradation and pain. RNA interference (RNAi) therapy, particularly through the use of small interfering RNA (siRNA), emerges as a promising avenue for OA treatment due to its capacity for specific gene silencing. siRNA molecules can modulate post-transcriptional gene expression, targeting key pathways involved in cellular proliferation, apoptosis, senescence, autophagy, biomolecule secretion, inflammation, and bone remodeling. This review delves into the mechanisms by which siRNA targets various cell populations within the OA milieu, offering a comprehensive overview of the potential therapeutic benefits and challenges in clinical application. By summarizing the current advancements in siRNA delivery systems and therapeutic targets, we provide a solid theoretical foundation for the future development of novel siRNA-based strategies for OA diagnosis and treatment, paving the way for innovative and more effective approaches to managing this debilitating disease.

Appraisal of quality and analysis of the similarities and differences between osteoarthritis Clinical Practice Guideline recommendations: A systematic review

OBJECTIVE

Clinical Practice Guidelines (CPGs) aim to support management of hip and knee osteoarthritis (OA), but recommendations are often conflicting and implementation is poor, contributing to evidence-to-practice gaps. This systematic review investigated the contextual and methodological factors contributing to conflicting recommendations for hip and knee OA.

METHOD

Our systematic review appraised CPGs for managing hip and knee OA in adults ≥18 years (PROSPERO CRD42021276635). We used AGREE-II and AGREE-REX to assess quality and extracted data on treatment gaps, conflicts, biases, and consensus. Heterogeneity of recommendations was determined using Weighted Fleiss Kappa (K). The relationship between (K) and AGREE-II/AGREE-REX scores was explored.

RESULTS

We identified 25 CPGs across eight countries and four international organisations. The ACR, EULAR, NICE, OARSI and RACGP guidelines scored highest for overall AGREE-II quality (83%). The highest overall AGREE-REX scores were for BMJ Arthroscopy (80%), RACGP (78%) and NICE (76%). CPGs with the least agreement for pharmacological recommendations were ESCEO and NICE (-0.14), ACR (-0.08), and RACGP (-0.01). The highest agreements were between RACGP and NICE (0.53), RACGP and ACR (0.61), and NICE and ACR (0.91). Decreased internal validity determined by low-quality AGREE scores(<60%) in editorial independence were associated with less agreement for pharmacological recommendations.

CONCLUSION

There were associations between guideline quality and agreement scores. Future guideline development should be informed by robust evidence, editorial independence and methodological rigour to ensure a harmonisation of recommendations. End-users of CPGs must recognise the contextual factors associated with the development of OA CPGs and balance these factors with available evidence.

Physical activity and pain in people with and without cancer

BACKGROUND

Performing physical activity may provide analgesic benefit, although this effect is more established for noncancer pain rather than cancer pain. The relationship between physical activity and pain outcomes in adults with and without a history of cancer was examined.

METHODS

Totals of 51,439 adults without a cancer history and 10,651 adults with a cancer history from the Cancer Prevention Study II Nutrition Cohort were included. Exposures included self-reported moderate to vigorous physical activity (MVPA) as well as 2-year change in MVPA. Pain outcomes included pain intensity (primary outcome) and analgesic use (secondary outcome).

RESULTS

MVPA was inversely associated with pain intensity for adults with (odds ratio [OR], 0.84 [≥15 metabolic equivalent of task (MET) h/week vs. <7.5 MET h/week]; 95% confidence interval [CI], 0.76-0.93) and without (OR, 0.79; 95% CI, 0.75-0.82) a history of cancer. Compared to remaining inactive, participants who became sufficiently active (cancer: OR, 0.76; 95% CI, 0.68-0.86; no cancer: OR, 0.73; 95% CI, 0.69-0.77), became inactive (cancer: OR, 0.79; 95% CI, 0.71-0.88; no cancer: OR, 0.84; 95% CI, 0.80-0.89), or remained sufficiently active (cancer: OR, 0.66; 95% CI, 0.60-0.72; no cancer: OR, 0.62; 95% CI, 0.60-0.65) also reported less pain. Physical activity was not related to analgesic use.

CONCLUSIONS

The relationship between physical activity and pain intensity was not substantially different between people with and without a history of cancer. Cancer survivors who perform more activity, or who increase their activity, may experience less pain than cancer survivors who consistently perform less.

PLAIN LANGUAGE SUMMARY

People who have had cancer often experience ongoing pain. Being physically active may help reduce the intensity of the pain they experience.

Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system

Objective

Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center.

Design

This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability.

Results

Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p ​= ​0.002). BMI did not significantly change (p ​= ​0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 ​h weekly) and serving 953 patients over four years demonstrated OAMP sustainability.

Conclusions

OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.

Usability Assessment of Technologies for Remote Monitoring of Knee Osteoarthritis

Goal: To evaluate the usability of different technologies designed for a remote assessment of knee osteoarthritis. Methods: We recruited eleven patients affected by mild or moderate knee osteoarthritis, eleven caregivers, and eleven clinicians to assess the following technologies: a wristband for monitoring physical activity, an examination chair for measuring leg extension, a thermal camera for acquiring skin thermographic data, a force balance for measuring center of pressure, an ultrasound imaging system for remote echographic acquisition, a mobile app, and a clinical portal software. Specific questionnaires scoring usability were filled out by patients, caregivers and clinicians. Results: The questionnaires highlighted a good level of usability and user-friendliness for all the technologies, obtaining an average score of 8.7 provided by the patients, 8.8 by the caregivers, and 8.5 by the clinicians, on a scale ranging from 0 to 10. Such average scores were calculated by putting together the scores obtained for the single technologies under evaluation and averaging them. Conclusions: This study demonstrates a high level of acceptability for the tested portable technologies designed for a potentially remote and frequent assessment of knee osteoarthritis.

Implications of Stabilometric Assessment in Determining Functional Deficits in Patients with Severe Knee Osteoarthritis: Observational Study

Background: Osteoarthritis is one of the most frequent joint disorders in the world. The specialists in the field strongly support the role of physical exercise as a key component in the holistic management of arthrosis. The aim of the current study was to identify and assess the functional deficit of these patients and to identify means to alleviate it through pre-surgery physiotherapy programs. Methods: The study was conducted on two samples of patients: a witness sample, encompassing 126 subjects without pathologies at the level of their lower limbs, and a study sample, formed of 116 subjects diagnosed with severe gonarthrosis with total knee arthroplasty indication. The assessment protocol was accomplished with the GPS 400 stabilometric platform. Results: The barycenter differences within the support polygon, recorded for the two samples within sagittal deviation, emphasize that the barycenter shifting mainly towards the healthy lower limb will demand, from the individual, more intense rebalancing postural reactions that will place the center-of-gravity projection in the sagittal plane, closer to the central area of the support polygon. Conclusions: In the case of gonarthrosis and other joint disorders, the use of functional testing to assess body weight distribution and center-of-gravity imbalances represents a promising direction in the research on and management of these disorders, providing essential information for functional diagnosing and thus enabling the elaboration and monitoring of individualized functional rehabilitation plans.

Evaluation of Dynamic Effects of Depressive Symptoms on Physical Function in Knee Osteoarthritis

OBJECTIVE

To assess how changes in depressive symptoms influence physical function over time among those with radiographic knee osteoarthritis (OA).

METHODS

Participants from the Osteoarthritis Initiative with radiographic knee OA (n = 2,212) and complete data were identified at baseline. Depressive symptoms were assessed as a time-varying score at baseline and the first three annual follow-up visits using the Center for Epidemiological Studies Depression Scale (CES-D) Scale. Physical function was measured at the first four follow-up visits using 20-meter gait speed meters per second. The following two marginal structural models were fit: one assessing the main effect of depressive symptoms on gait speed and another assessing time-specific associations.

RESULTS

Time-adjusted results indicated that higher CES-D scores were significantly associated with slower gait speed (-0.0048; 95% confidence interval -0.0082 to -0.0014), and time-specific associations of CES-D were largest during the first follow-up interval (-0.0082; 95% confidence interval -0.0128 to -0.0035). During subsequent follow-up time points, the influence of depressive symptoms on gait speed diminished.

CONCLUSION

The negative effect of depressive symptoms on physical function may decrease over time as knee OA progresses.

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DA.

Physiotherapists' perceptions and barriers to use of telerehabilitation for exercise management of people with knee osteoarthritis in Sri Lanka

PURPOSE

To assess physiotherapists' perceptions and barriers to using telerehabilitation via video and telephone for exercise management for people with knee osteoarthritis (OA) in Sri Lanka.

MATERIALS AND METHODS

Currently registered and practising Sri Lankan physiotherapists who care for knee OA patients were invited to participate in a cross-sectional online survey framed according to a previous study. A logistic regression analysis was used to assess the effect of physiotherapists' characteristics on their interest in telerehabilitation.

RESULTS

A total of 268 physiotherapists completed the survey, which was broadly representative of locations and work settings across Sri Lanka. Only three out of 16 statements received majority agreement; these were that telephone-delivered care would save patients' time (72%), save money (68%) and improve patients' privacy (67%). There was a consensus that video-based care would save money (79%), and many favoured this medium over telephone-delivered care. Lack of experience with telerehabilitation was associated with reduced interest in telephone-delivered care. Increased interest in video-based care was associated with frequent care of knee OA patients. Most physiotherapists perceived technical issues with telerehabilitation as a significant barrier to implementing it.

CONCLUSIONS

Physiotherapists perceived video-based telerehabilitation more positively than care over the telephone. Reduced interest in telerehabilitation was associated with having no prior experience with it. Moreover, technical issues with telerehabilitation were perceived as the main barrier to its use. A training programme for physiotherapists, appropriate guidelines and a framework for better implementing telereahabilitation may yield substantial benefits for knee OA patients.IMPLICATIONS FOR REHABILITATIONPhysiotherapists in Sri Lanka perceive telerehabilitation for exercise management for knee OA patients positively.Telerehabilitation via video or telephone is a viable option for delivering exercise management for knee OA patients in Sri Lanka.The widespread practice of telerehabilitation by physiotherapists in Sri Lanka requires appropriate strategies to mitigate barriers to its implementation.

Elucidating Cyathula Officinals' mechanism in osteoarthritis treatment: Network pharmacology and empirical evidence on anti-inflammatory actions

In this study, we explored the therapeutic potential of Cyathula Officinals (CNX) in Knee Osteoarthritis (KOA) treatment. Utilizing network pharmacology and in vitro experiments, we identified active ingredients, action targets and pathways in CNX. Our analysis, integrating databases like TCMSP, SwissTarget Prediction, Genecards, CTD, STRING, and DAVID, highlighted 396 action targets and 283 disease targets, pinpointing 64 intersection genes linked to KOA. The significant involvement of the MAPK and NF-κB pathways in CNX's anti-inflammatory action was validated through qPCR, which might underlie CNX's efficacy in inhibiting chondrocyte apoptosis and IL-6 expression. These findings suggest CNX's potential in KOA management, offering insights for its clinical application.

Effect of blood flow restriction with low-intensity resistance training in patients with osteoarthritis and rheumatoid arthritis: a systematic review and meta-analysis based on randomized controlled trials

PURPOSE

This study evaluated the effects of blood flow restriction with low-intensity resistance training (BFR + LIRT) on pain, adverse events, muscle strength, and function in patients with osteoarthritis (OA) and rheumatoid arthritis (RA) through a systematic review and meta-analysis.

METHODS

This study adhered to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 (PRISMA 2020) and applied the A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR2) standards to ensure the high quality of the systematic review. A comprehensive literature search was conducted until August 2023 using four selected keywords (osteoarthritis, rheumatoid arthritis, blood flow restriction training, and resistance training) across five search engines (PubMed, Embase, Web of Science, CENTRAL, and PEDro).

RESULTS

Ten studies were analyzed. The results showed that BFR + LIRT had similar effects on pain, risk of adverse events, muscle strength, self-reported function, and physical function compared with resistance training (RT).

CONCLUSION

This systematic review and meta-analysis further support the potential of BFR + LIRT in the disease management of patients with OA or RA. According to this analysis, BFR + LIRT had a lower risk of adverse events than high-intensity resistance training (HIRT) and may be a safer training modality. BFR + LIRT offers greater advantages in improving physical function than LIRT and was able to provide similar benefits to HIRT without increasing the training load. These findings suggest that BFR + LIRT is a safe and effective strategy for treating patients with OA or RA. However, owing to the limited number of studies covered in this analysis, additional higher-quality studies are needed to strengthen this conclusion.

Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND

Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type.

METHODS

Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities.

RESULTS

Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial).

CONCLUSIONS

Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Transient receptor potential vanilloid 1: A potential therapeutic target for the treatment of osteoarthritis and rheumatoid arthritis

This study aims to determine the molecular mechanisms and analgesic effects of transient receptor potential vanilloid 1 (TRPV1) in the treatments of osteoarthritis (OA) and rheumatoid arthritis (RA). We summarize and analyse current studies regarding the biological functions and mechanisms of TRPV1 in arthritis. We search and analyse the related literature in Google Scholar, Web of Science and PubMed databases from inception to September 2023 through the multi-combination of keywords like 'TRPV1', 'ion channel', 'osteoarthritis', 'rheumatoid arthritis' and 'pain'. TRPV1 plays a crucial role in regulating downstream gene expression and maintaining cellular function and homeostasis, especially in chondrocytes, synovial fibroblasts, macrophages and osteoclasts. In addition, TRPV1 is located in sensory nerve endings and plays an important role in nerve sensitization, defunctionalization or central sensitization. TRPV1 is a non-selective cation channel protein. Extensive evidence in recent years has established the significant involvement of TRPV1 in the development of arthritis pain and inflammation, positioning it as a promising therapeutic target for arthritis. TRPV1 likely represents a feasible therapeutic target for the treatment of OA and RA.

Transforming growth factor beta signaling and craniofacial development: modeling human diseases in zebrafish

Humans and other jawed vertebrates rely heavily on their craniofacial skeleton for eating, breathing, and communicating. As such, it is vital that the elements of the craniofacial skeleton develop properly during embryogenesis to ensure a high quality of life and evolutionary fitness. Indeed, craniofacial abnormalities, including cleft palate and craniosynostosis, represent some of the most common congenital abnormalities in newborns. Like many other organ systems, the development of the craniofacial skeleton is complex, relying on specification and migration of the neural crest, patterning of the pharyngeal arches, and morphogenesis of each skeletal element into its final form. These processes must be carefully coordinated and integrated. One way this is achieved is through the spatial and temporal deployment of cell signaling pathways. Recent studies conducted using the zebrafish model underscore the importance of the Transforming Growth Factor Beta (TGF-β) and Bone Morphogenetic Protein (BMP) pathways in craniofacial development. Although both pathways contain similar components, each pathway results in unique outcomes on a cellular level. In this review, we will cover studies conducted using zebrafish that show the necessity of these pathways in each stage of craniofacial development, starting with the induction of the neural crest, and ending with the morphogenesis of craniofacial elements. We will also cover human skeletal and craniofacial diseases and malformations caused by mutations in the components of these pathways (e.g., cleft palate, craniosynostosis, etc.) and the potential utility of zebrafish in studying the etiology of these diseases. We will also briefly cover the utility of the zebrafish model in joint development and biology and discuss the role of TGF-β/BMP signaling in these processes and the diseases that result from aberrancies in these pathways, including osteoarthritis and multiple synostoses syndrome. Overall, this review will demonstrate the critical roles of TGF-β/BMP signaling in craniofacial development and show the utility of the zebrafish model in development and disease.

Enhanced recovery after surgery combined with quantitative rehabilitation training in early rehabilitation after total knee replacement: a randomized controlled trial

BACKGROUND

The number of patients undergoing total knee replacement (TKR) is increasing yearly; however, there is still a relative lack of specific, individualized, and standardized protocols for functional exercise after TKR. Quantitative rehabilitation training was developed to improve the recovery of postoperative joint function, increase patient satisfaction, shorten the length of the hospital stay, improve the quality of life, and promote rapid patient recovery.

AIM

We aimed to compare the effectiveness of quantitative rehabilitation training based on the enhanced recovery after surgery (ERAS) concept with conventional rehabilitation training in the early rehabilitation of patients with TKR.

DESIGN

This was a single-centre, prospective, randomized controlled trial.

SETTING

Inpatient department.

POPULATION

Participants were patients who underwent unilateral total knee replacement.

METHODS

Based on the ERAS concept, a quantitative rehabilitation training program was developed for the quantitative group, and the control group underwent conventional rehabilitation training. Seventy-eight patients undergoing TKR were randomly divided into two blinded groups: the quantitative rehabilitation group and the conventional rehabilitation group. The analysis was performed according to per-protocol practice. The primary outcome metric was the Hospital for Special Surgery Knee Score (HSS Score), and secondary outcomes included patient satisfaction, Visual Analog Pain Score (VAS), time to get out of bed for the first time after surgery, 6-minute-walk test (6MWT), quality-of-life score (SF-36), and number of days in the hospital. The incidence of postoperative complications was also recorded.

RESULTS

There was no significant difference in HSS scores between the two groups before surgery (P=0.967), but the quantitative rehabilitation training group had significantly higher scores at two weeks (P=0.031), 3 months (P<0.01), and 12 months (P<0.01) after surgery than did the conventional rehabilitation training group, and both groups had higher HSS scores than before surgery. The quantitative training group had significantly higher VAS scores at 24 hours and three days postoperatively than the conventional training group (P<0.01), while there was no statistical significance at any other time points. The quantitative rehabilitation group had an earlier time to get out of bed for the first time after surgery (P<0.01), a longer 6MWT distance (P=0.028), and higher patient satisfaction and quality of life scores (SF-36) (P<0.01) that did the control group. The number of days in the hospital was lower in the quantitative training group than in the control group (P<0.001). There was no significant difference in the incidence of postoperative complications between the two groups.

CONCLUSIONS

Compared with conventional rehabilitation training, quantitative rehabilitation training based on the ERAS concept was found to be safe and effective and can accelerate the recovery of joint function after surgery, shorten hospitalization time, improve patient satisfaction, and promote rapid recovery.

CLINICAL REHABILITATION IMPACT

The quantitative rehabilitation training based on the ERAS concept provides a new program for rehabilitation exercises after total knee arthroplasty, which is safe and reliable, accelerates the recovery of joint function, and should be considered for clinical promotion.

Effects of Analgesics on Self-Reported Physical Function and Walking Ability in People With Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Hip and knee osteoarthritis are among the leading causes of global disability, and one of the main aims of the management is to improve physical function. The objective of this review was to investigate the effect of analgesics on physical function (self-reported physical function and walking ability).

METHODS

A systematic review and meta-analysis of the findings were performed. Randomized controlled trials investigating the effect of analgesics on self-reported physical function and walking ability were included. Analgesics were orally administered acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), or opioids. Data were pooled in a random-effects model, and the standardized mean difference (SMD) with 95% CI was calculated (SMDs: 0.2-0.4 = small, 0.5-0.7 = medium, and ≥0.8 = large effect sizes). The quality of the evidence was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A total of 1454 studies were identified, of which 33 were included. On self-reported physical function, the results showed low- to moderate-quality evidence for a small beneficial effect of acetaminophen (SMD = -0.13 [95% CI = -0.26 to 0.00]), NSAIDs (SMD = -0.32 [95% CI = -0.37 to -0.27]), or opioids (SMD = -0.20 [95% CI = -0.32 to -0.09]). There was moderate-quality evidence for a small effect of NSAIDs on pain during walking (SMD = -0.34 [95% CI = -0.45 to -0.23]).

CONCLUSION

In people with hip or knee osteoarthritis, there was low- to moderate-quality evidence for small beneficial effects of analgesics on physical function and walking ability.

IMPACT

Analgesics may improve physical function by reducing pain during exercise and walking.

Effect of 4 weeks vs 8 weeks of acupuncture for knee osteoarthritis in China: protocol for a randomised controlled trial

INTRODUCTION

Knee osteoarthritis represents the prevalent and incapacitating disease. Acupuncture, a widely used clinical treatment for knee osteoarthritis, has been shown to ameliorate pain and enhance joint function in affected individuals. However, there is a lack of evidence comparing different courses of acupuncture for knee osteoarthritis. In this trial, we will assess the effect of 4 weeks vs 8 weeks of acupuncture in patients with knee osteoarthritis.

METHODS AND ANALYSIS

The protocol is a pragmatic, parallel, two-arm randomised controlled trial, with the data analyst and assessor being blinded. 148 eligible patients with knee osteoarthritis will be randomly allocated in a 1:1 ratio to receive 4-week or 8-week acupuncture. Electroacupuncture will be administered three times per week for 4 or 8 weeks, respectively. Patients with knee osteoarthritis in both groups will be followed up to 26 weeks. The primary outcome is the response rate at week 26, and secondary outcomes include knee joint pain, knee joint function, knee joint stiffness, quality of life, patient global assessment, the Osteoarthritis Research Society International response rate and rescue medicine. A cost-effectiveness analysis will be carried out over 26 weeks.

ETHICS AND DISSEMINATION

The protocol has been approved by the Medical Ethical Committee of Beijing University of Chinese Medicine (2023BZYL0506). The study findings will be disseminated through presentation in a medical journal. Additionally, we plan to present them at selected conferences and scientific meetings.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trials Registry (ChiCTR2300073383; https://www.chictr.org.cn/showproj.html?proj=199310).

Investigating the causal relationship between physical activity and incident knee osteoarthritis: a two-sample Mendelian randomization study

There is evidence that physical activity (PA) has a long-term positive impact on disease. Whether PA is a risk factor for knee osteoarthritis (OA) is still controversial. The purpose of this study was to explore whether there is a causal relationship between PA and knee OA. We extracted PA and knee OA data from genome-wide association study (GWAS) databases. We used single-nucleotide polymorphisms (SNPs) as instrumental variables. We performed MR analysis by random-effects inverse-variance weighting (IVW), MR‒Egger, weighted median, simple mode, and weighted mode methods. We evaluated the stability and reliability of the results through sensitivity analysis. There was no significant association between PA and knee OA (p > 0.05). We did not detect any pleiotropy (MR‒Egger intercept test et al.: p > 0.05). The sensitivity analysis confirmed our results (p > 0.05). There is no causal relationship between PA and knee OA.

Poly-beta-amino-ester licofelone conjugates development for osteoarthritis treatment

Disease-modifying osteoarthritis drugs (DMOADs) are a new therapeutic class for osteoarthritis (OA) prevention or inhibition of the disease development. Unfortunately, none of the DMOADs have been clinically approved due to their poor therapeutic performances in clinical trials. The joint environment has played a role in this process by limiting the amount of drug effectively delivered as well as the time that the drug stays within the joint space. The current study aimed to improve the delivery of the DMOADs into cartilage tissue by increasing uptake and retention time of the DMOADs within the tissue. Licofelone was used a model DMOAD due to its significant therapeutic effect against OA progression as shown in the recent phase III clinical trial. For this purpose licofelone was covalently conjugated to the two different A16 and A87 poly-beta-amino-ester (PBAEs) polymers taking advantage of their hydrolysable, cytocompatible, and cationic nature. We have shown cartilage uptake of the licofelone-PBAE conjugates increased 18 times and retention in tissues was prolonged by 37 times compared to the equivalent dose of the free licofelone. Additionally, these licofelone conjugates showed no detrimental effect on the chondrocyte viability. In conclusion, the cationic A87 and A16 PBAE polymers increased the amount of licofelone within the cartilage, which could potentially enhance the therapeutic effect and pharmacokinetic performance of this drug and other DMOADs clinically.

Devices for osteoarthritis symptoms treatment: a patent review

INTRODUCTION

Osteoarthritis is a musculoskeletal disease that can lead to the loss and inability of those affected to perform normal daily functions, which leads to a decrease in quality of life. The main symptoms of osteoarthritis are tenderness, joint pain, stiffness, crepitus, limited movement, and local inflammation.

AREAS COVERED

The selected patents were deposited from 2010 to April 2022 involving 57 documents that were in line with the study objective in the final selection. The patents were classified in years, country, and applicants. Also, the therapeutic fields that presented the most documents were electrical stimulation, phototherapy, and ultrasound, followed by magnetic, electromagnetic, and thermotherapy. Therefore, the most current therapies used in the documents are already on the market.

EXPERT OPINION

Although the OA is cureless, non-surgical treatments are classified as the primary management approach for this disease. The pharmacological and non-pharmacological therapies are employed to reduce its prevalence and ensure the effectiveness of treatments. A strategy for relieving OA symptoms is non-pharmacological treatment, which can be based on exercise and patient education, combined with other alternative therapies. These therapies are used as supplements to the main OA treatments, enhancing the effectiveness of treatment outcomes.

Searching for Essential Genes and Targeted Drugs Common to Breast Cancer and Osteoarthritis

BACKGROUND

It is documented that osteoarthritis can promote the progression of breast cancer (BC).

OBJECTIVE

This study aims to search for the essential genes associated with breast cancer (BC) and osteoarthritis (OA), explore the relationship between epithelial-mesenchymal transition (EMT)- related genes and the two diseases, and identify the candidate drugs.

METHODS

The genes related to both BC and OA were determined by text mining. Protein-protein Interaction (PPI) analysis was carried out, and as a result, the exported genes were found to be related to EMT. PPI and the correlation of mRNA of these genes were also analyzed. Different kinds of enrichment analyses were performed on these genes. A prognostic analysis was performed on these genes for examining their expression levels at different pathological stages, in different tissues, and in different immune cells. Drug-gene interaction database was employed for potential drug discovery.

RESULTS

A total number of 1422 genes were identified as common to BC and OA and 58 genes were found to be related to EMT. We found that HDAC2 and TGFBR1 were significantly poor in overall survival. High expression of HDAC2 plays a vital role in the increase of pathological stages. Four immune cells might play a role in this process. Fifty-seven drugs were identified that could potentially have therapeutic effects.

CONCLUSION

EMT may be one of the mechanisms by which OA affects BC. Using the drugs can have potential therapeutic effects, which may benefit patients with both diseases and broaden the indications for drug use.

Recent advances in polymeric microparticle-based drug delivery systems for knee osteoarthritis treatment

Due to the poor bioavailability and high joint clearance of drugs, sustained delivery of therapeutic agents has proven difficult in the treatment of osteoarthritis (OA). Intra-articular (IA) drug delivery strategy is an attractive option for enhancing OA patients' prognosis, for which various polymer materials have been used as drug carriers due to their attractive delivery properties, to slow or even reverse the progress of OA by prolonging the duration of therapeutic agent residence in the joint. This article focuses on the recent developments in natural and synthetic polymer-based microsphere drug delivery systems for treating knee osteoarthritis. It evaluates the translational potential of some novel formulations for clinical application.

Reducing the burden of knee osteoarthritis through community pharmacy: Protocol for a randomised controlled trial of the Knee Care for Arthritis through Pharmacy Service

INTRODUCTION

Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio-economic wellbeing of those affected. Little community-based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Māori and non-Māori with knee OA in community pharmacy and providing co-ordinated, evidence- and community-based care may be a scalable, sustainable, equitable, effective and cost-effective approach to improve health and wellbeing.

AIM

Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee-related physical function and pain (co-primary outcomes). Secondary aims assess impacts on health-related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Māori.

METHODS AND ANALYSIS

A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12 months for Māori and non-Māori who have knee OA. Participants will be recruited in community pharmacies. Knee-related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee-related pain will be measured using an 11-point numeric pain rating scale. Primary outcome analyses will be conducted on an intention-to-treat basis using linear mixed models. Parallel within-trial health economic analysis and process evaluation will also be conducted.

ETHICS AND TRIAL DISSEMINATION

Ethical approval was obtained from the Central Health and Ethics Committee (2022-EXP-11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants.

Efficacy and safety of Gutong Patch compared with NSAIDs for knee osteoarthritis: A real-world multicenter, prospective cohort study in China

The Gutong Patch (GTP) is common in clinical practice for bone diseases. This study compared the efficacy and safety of GTP and nonsteroidal anti-inflammatory drugs (NSAIDs) for KOA patients from 35 medical centers assigned to GTP, selective COX-2 inhibitor (SCI), GTP + SCI, non-selective COX-2 inhibitor (NSCI), and GTP + NSCI groups. The visual analog scale (VAS) pain score, EuroQol-VAS, EuroQol 5D-3 L, time to articular pain relief / disappearance, and joint motion recovery were the efficacy assessments. Safety assessments included contact dermatitis, gastrointestinal disorders, etc. The p-value < 0.05 was considered statistically significant. After statistical analysis, the SCI and GTP + SCI groups showed better improvement of VAS than the GTP group; the time to articular pain relief in the NSCI group was shorter than that in GTP and SCI group; the time to joint motion recovery in the GTP + NSCI group was longer than that in the SCI group. Additionally, the improvement of the quality of life in all groups was significant after treatments. While the incidence of gastrointestinal adverse events in the NSAIDs group was higher than that in the GTP and GTP + NSAIDs groups. GTP and NSAIDs are effective for KOA patients, and GTP is more suitable for KOA patients with cardiovascular and gastrointestinal comorbidities. This study was approved by the Ethics Committee at Peking Union Medical College Hospital (HS-1766) and registered in the Chinese Clinical Trial Registry (ChiCTR2100046391).

Adding Behaviour-Change Counselling to an Exercise Program for Adults Preparing for Hip and Knee Arthroplasty Improves Psychological and Physical Wellness: Focus Group Reflections

PURPOSE

To explore participant experiences for people on an arthroplasty waitlist, randomised to an exercise and behaviour-change counselling program (ENHANCE). The ENHANCE program for arthroplasty patients was led by an accredited exercise physiologist who delivered an individually tailored and structured exercise program. Included in the exercise program were up to five in-person counselling sessions, based on the Health Action Process Approach (HAPA) applied specifically to people with osteoarthritis. Nine adults (mean 69.4 years) who were on the waiting list for a total hip or knee arthroplasty and who had completed a 12-week program (ENHANCE) as part of a randomised controlled trial were recruited for this study.

METHODS

Two focus groups were conducted to explore participant experiences of ENHANCE. Data were analysed using inductive thematic analysis with constructs of the HAPA (motivational and volitional factors) as a framework.

RESULTS

We identified three themes (1) 'The structured program addressed inactivity and improved feelings of wellness and preparation for the operation'. The benefits were not only physical, but psychological and were contextualised in terms of preparation for the upcoming surgery. (2) 'People as enablers of participation': Participants identified that the attitude, and skill of the experienced instructor were supportive and motivating, especially in tailoring the intervention. Within the program, the support of the group was considered a positive attribute (3) 'Improved awareness changed attitudes to self-efficacy and perceived self-control'. Participants described an increased awareness of their condition and a better understanding of health expectations. They felt more control and ownership over their health journey.

CONCLUSION

Goal setting and social support were identified factors in a behaviour-change counselling program, delivered in conjunction with structured exercise that led to a positive experience. Improved psychological and physical health were described. Participants were better prepared for their upcoming surgery, with increased self efficacy and mastery to support long-term physical-activity engagement.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Intra-articular autologous conditioned serum and triamcinolone injections in patients with knee osteoarthritis: a controlled, randomized, double-blind study

OBJECTIVE

This study was performed to assess the impact of autologous conditioned serum (ACS) when added to preceding intra-articular glucocorticoid therapy on pain, function, and quality of life outcomes over 24 weeks.

METHODS

In this single-center, randomized controlled trial involving 40 patients with advanced knee osteoarthritis (Kellgren-Lawrence grades III and IV), ACS or saline placebo was injected after 40 mg triamcinolone acetonide (TA) intra-articular injection. Numerical rating scale (NRS) pain scores and Knee Injury and Osteoarthritis Outcome Score (KOOS) assessments were conducted at baseline and at weeks 3, 6, 12, and 24. The primary endpoint was the change in KOOS Pain at 24 weeks. Patient safety events were also monitored.

RESULTS

At week 24, TA + ACS significantly improved KOOS Pain, Symptoms, Activities of Daily Living, Quality of Life, and KOOS Sport scores. TA + ACS also outperformed TA + placebo in NRS pain scores (average and maximum intensity) at week 24 and NRS pain score (at rest) at weeks 12 and 24. The TA injection followed by ACS or placebo was well-tolerated.

CONCLUSION

ACS adds long-term pain relief and functional improvement to the short-term pain relief provided by glucocorticoids.

Challenges of transforming evidence-based management of osteoarthritis into clinical practice in rural central Western India. Perceptions of an educational program

PURPOSE

Osteoarthritis (OA) is a major threat to public health worldwide and is predicted to increase. Existing interventions to implement clinical practice guidelines (CPGs) seem to be used mainly in the Western world. We conducted a structured educational program on the evidence-based management of OA (BOA) for Indian physical therapists (PT). Our study aimed to describe Indian PTs' knowledge, attitudes and confidence on evidence-based management of OA, and their perceptions of a course on this subject.

METHODS

The 2-day course included didactic parts and practical skills training. Thirty-five PTs participated and answered a questionnaire. Fourteen of them participated in focus group interviews. Questionnaire data are presented as medians and full ranges. Manifest content analysis was used to analyze interview data that are presented as catagories illustrated by interview quotes. The formal ethics permission was granted.

RESULTS

74% of PTs agreed that radiography determines the type of treatment required, and 69% agreed that a prescription for exercise is enough to ensure adherence. PTs agreed (mean 5 on 6-point scale) that exercises increasing pain should be advised against. Confidence in guiding the physical activity was generally high (≥5 on 6-point scales). Five categories reflected participants' perceptions of the course content: Shift in management focus, Need for cultural adaptation, Importance of social support, Development of organization and collaboration, and Feelings of hesitation.

DISCUSSION

Our results indicate that in order to facilitate the implementation of CPGs, PT curricula may consider the inclusion of knowledge on CPGs, focus more on students' own reflections on transforming theory into practice, and incorporate training of basic skills required for implementation of self-management, body awareness, and neuromuscular fitness. If given access and mandates, PTs may play a major role in the early diagnosis and treatment of OA and thus contribute to the prevention of an epidemic of OA in India.

Advancing drug delivery to articular cartilage: From single to multiple strategies

Articular cartilage (AC) injuries often lead to cartilage degeneration and may ultimately result in osteoarthritis (OA) due to the limited self-repair ability. To date, numerous intra-articular delivery systems carrying various therapeutic agents have been developed to improve therapeutic localization and retention, optimize controlled drug release profiles and target different pathological processes. Due to the complex and multifactorial characteristics of cartilage injury pathology and heterogeneity of the cartilage structure deposited within a dense matrix, delivery systems loaded with a single therapeutic agent are hindered from reaching multiple targets in a spatiotemporal matched manner and thus fail to mimic the natural processes of biosynthesis, compromising the goal of full cartilage regeneration. Emerging evidence highlights the importance of sequential delivery strategies targeting multiple pathological processes. In this review, we first summarize the current status and progress achieved in single-drug delivery strategies for the treatment of AC diseases. Subsequently, we focus mainly on advances in multiple drug delivery applications, including sequential release formulations targeting various pathological processes, synergistic targeting of the same pathological process, the spatial distribution in multiple tissues, and heterogeneous regeneration. We hope that this review will inspire the rational design of intra-articular drug delivery systems (DDSs) in the future.

Knee osteoarthritis: Current status and research progress in treatment (Review)

Knee osteoarthritis (KOA) is a common chronic articular disease worldwide. It is also the most common form of OA and is characterized by high morbidity and disability rates. With the gradual increase in life expectancy and ageing population, KOA not only affects the quality of life of patients, but also poses a burden on global public health. OA is a disease of unknown etiology and complex pathogenesis. It commonly affects joints subjected to greater loads and higher levels of activity. The knee joint, which is the most complex joint of the human body and bears the greatest load among all joints, is therefore most susceptible to development of OA. KOA lesions may involve articular cartilage, synovium, joint capsule and periarticular muscles, causing irreversible articular damage. Factors such as mechanical overload, inflammation, metabolism, hormonal changes and ageing serve key roles in the acceleration of KOA progression. The clinical diagnosis of KOA is primarily based on combined analysis of symptoms, signs, imaging and laboratory examination results. At present, there is no cure for KOA and the currently available therapies primarily focus on symptomatic treatment and delay of disease progression. Knee replacement surgery is typically performed in patients with advanced disease. The current study presents a review of epidemiological characteristics, risk factors, histopathological manifestations, pathogenesis, diagnosis, treatment modalities and progress in KOA research.