Non-surgical treatment of osteoarthritis: a half century of "advances"

Pain relief following genicular nerve radiofrequency ablation: does knee compartment matter?

Aim: To investigate the effect of knee osteoarthritis (OA) compartment location on pain relief following genicular radiofrequency ablation. Materials & methods: A retrospective chart review was performed on 62 patients. Visual analog scale scores at 3 and 6 months post procedure were compared with baseline and between compartment groups. Results: Pain significantly improved for all patients at 3 and 6 months (p < 0.001 and p = 0.005, respectively). Medial compartment OA was a significant predictor of improvement at 3 months (p = 0.042). Patellofemoral compartment OA was a significant predictor for a higher visual analog scale at 3 months (p = 0.018). Conclusion: Compartmental location of knee OA impacts pain relief following genicular radiofrequency ablation. Future protocols could target nerves based on which compartments are more affected on imaging.

Healthcare resource utilization and costs by age and joint location among osteoarthritis patients in a privately insured population

AIMS

To compare healthcare resource utilization and costs between patients aged 18-64 years with osteoarthritis (OA) and matched controls without OA in a privately insured population.

METHODS

Patients with OA were selected from de-identified US-based employer claims (Q1:1999-Q3:2011). The index date was defined as the first OA diagnosis indicated by ICD-9-CM codes. One year before and after the index date were defined as the baseline and study periods, respectively. A second OA diagnosis during the study period was also required. Patients with OA were matched one-to-one on age, gender, index date, and minimum length of follow-up to controls without OA. Baseline characteristics and study period resource utilization and costs (2016 USD) were compared between cohorts.

RESULTS

This study identified 199,539 patients with OA (knee: 87,271, hip: 19,953, hand: 15,670, spine: 12,496). The average age was 54 years, and 58% were female. OA patients had higher healthcare resource utilization than matched controls in inpatient, emergency room, and outpatient settings (p < .001 for all). Further, patients with OA had 4-times the excess total medical costs of their matched controls ($14,521 vs $3,629; p < .001). Patients with hip OA had the highest medical costs among all joint locations. Outpatient and pharmacy costs were similar among patients with knee, hip, and hand OA, but higher in patients with spine OA. In sub-group analyses, older patients (45-64 years old) had higher costs.

LIMITATIONS

This sample, obtained using claims data, only includes patients who were actively seeking care for OA and were likely symptomatic. Asymptomatic patients would likely not be captured in this analysis.

CONCLUSIONS

Patients with OA incur greater healthcare resource utilization and costs than patients without OA, with substantial variation by joint location.

Effects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty — a randomized controlled trial

Objective: To compare the acute effects of acupuncture with sham acupuncture on knee pain, range of motion and ambulation in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty, when added to a standard postoperative physiotherapy programme.

Design: Prospective patient- and assessor-blinded randomized controlled trial.

Setting: Acute inpatient physiotherapy department.

Patients: Thirty patients (24 women and 6 men) undergoing bilateral total knee arthroplasty were included for final analysis in the study.

Interventions: Both groups received a standard postoperative physiotherapy programme. Each patient was also given either 10 sessions of acupuncture or sham acupuncture within two weeks.

Main outcome measures: The primary outcome measures were the levels of pain at rest and at maximum after exercise measured by the numeric pain rating scale. Other outcome measures included active and passive ranges of knee motion measured by standard goniometer, and ambulation measured by the timed up-and-go test.

Results: Thirty-six patients were recruited at the start of the study with 18 patients allocated to the acupuncture group and another 18 patients to the sham acupuncture group. On postoperative day 15, there were 30 patients with complete data; three patients in each group dropped out from the study. The mean differences (95% confidence interval (CI)) in overall averages of postoperative mean pain levels were 0.4 (—0.6 to 1.3) and —0.8 (—2.0 to 0.4) at rest and at maximum respectively. There were no significant differences in the active and passive ranges of knee motion and the time for the timed up-and-go test between the two groups.

Conclusion: There is no difference between the acute effects of acupuncture and sham acupuncture in addition to standard postoperative physiotherapy programme in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty.

COMPARISON OF THE EFFECT OF AQUATIC PHYSICAL THERAPY AND CONVENTIONAL PHYSICAL THERAPY IN PATIENTS WITH LUMBAR SPINAL STENOSIS (A RANDOMIZED CONTROLLED TRIAL)

Purpose: To assess and compare the effect of aquatic and conventional physical therapy, two well-known non-operative therapeutic options in patients with lumbar spinal stenosis (LSS). Methods: 50 patients with low back pain and the diagnosis of LSS were recruited in this prospective parallel randomized controlled trial. Patients in group one were enrolled in aquatic therapy program and those in group two attended physical therapy sessions through application of physical modalities and receiving a home-based exercise program. Pain and walking ability were measured in each group before therapy, immediately after therapy and three months later. Results: Patients in both groups improved regarding pain either assessed immediately after therapy (repeated measure test, p < 0.001) or three months later (Wilcoxon test, p < 0.001 for group one and p = 0.005 for group two). Functioning improved in both groups (repeated measure test, p < 0.001) but this advantage did not remain significant after three months follow up in group two (repeated measure test, p = 0.002 in group one and p = 0.181 in group two). Patients in group one had significantly more favorable outcome than group two regarding functioning (independent samples t-test, p = 0.02) and pain (Mann–Whitney test, p = 0.001); however, this superiority didn't sustain in long term follow up. Conclusion: Aquatic therapy can provide greater short term improvement in pain and functioning than conventional physical therapy in patients with LSS especially those with limited capability for exercise on land.

Synovial joints: from development to homeostasis

Synovial joint morphogenesis occurs through the condensation of mesenchymal cells into a non-cartilaginous region known as the interzone and the specification of progenitor cells that commit to the articular fate. Although several signaling molecules are expressed by the interzone, the mechanism is poorly understood. For treatments of cartilage injuries, it is critical to discover the presence of joint progenitor cells in adult tissues and their expression gene pattern. Potential stem cell niches have been found in different joint regions, such as the surface zone of articular cartilage, synovium, and groove of Ranvier. Inherited joint malformations as well as joint-degenerating conditions are often associated with other skeletal defects and may be seen as the failure of morphogenic factors to establish the correct microenvironment in cartilage and bone. Therefore, exploring how joints form can help us understand how cartilage and bone are damaged and develop drugs to reactivate this developing mechanism.

Meniscal transection rather than excision increases pain behavior and structural damage in experimental osteoarthritis in mice

OBJECTIVE

To evaluate pain behavior and structural damage in mice subjected to either meniscal transection or removal.

METHODS

Mice (10/group) were subjected to transection of the medial collateral and anterior cruciate ligaments (ACLT/MCLT) followed by either transection (meniscotomy) or removal (meniscectomy) of the medial meniscus. A control group was subjected only to transection of the ligaments. Pain was assessed using the electronic pressure-meter paw test. Cell influx, measured in joint exudates, and joint histopathology were assessed after 49 days. Four other groups subjected to meniscotomy received indomethacin, the inducible nitric oxide synthase (iNOS) inhibitor 1400W, morphine or the vehicles.

RESULTS

Both meniscotomy and meniscectomy groups displayed persistent and significant increase in pain behavior as compared to controls, being significantly more severe in the former. Cell influx was more intense in the meniscotomy as compared to the meniscectomy group. Structural damage at the tibia, but not at the femur, was also more severe in the meniscotomy group. Indomethacin and 1400W partially but significantly reduced pain whereas morphine abrogated pain behavior in meniscotomized mice.

CONCLUSION

Meniscal transection rather than resection promotes more severe pain and structural damage in mice. Administration of opioids, cyclooxygenase and nitric oxide (NO) synthase inhibitors provide analgesia in this model. Careful description of the structures damaged is crucial when reporting experimental osteoarthritis (OA).

Patients' values and preferences of the expected efficacy of hip arthroscopy for osteoarthritis: a protocol for a multinational structured interview-based study combined with a randomised survey on the optimal amount of information to elicit preferences

INTRODUCTION

Symptomatic hip osteoarthritis (OA) is a disabling condition with up to a 25% cumulative lifetime risk. Total hip arthroplasty (THA) is effective in relieving patients' symptoms and improving function. It is, however, associated with substantial risk of complications, pain and major functional limitation before patients can return to full function. In contrast, hip arthroscopy (HA) is less invasive and can postpone THA. However, there is no evidence regarding the delay in the need for THA that patients would find acceptable to undergoing HA. Knowing patients' values and preferences (VP) on this expected delay is critical when making recommendations regarding the advisability of HA. Furthermore, little is known on the optimal amount of information regarding interventions and outcomes needed to present in order to optimally elicit patients' VP.

METHODS AND ANALYSIS

We will perform a multinational, structured interview-based survey of preference in delay time for THA among patients with non-advanced OA who failed to respond to conservative therapy. We will combine these interviews with a randomised trial addressing the optimal amount of information regarding the interventions and outcomes required to elicit preferences. Eligible patients will be randomly assigned (1 : 1) to either a short or a long format of health scenarios of THA and HA. We will determine each patient's VP using a trade-off and anticipated regret exercises. Our primary outcomes for the combined surveys will be: (1) the minimal delay time in the need for THA surgery that patients would find acceptable to undertaking HA, (2) patients' satisfaction with the amount of information provided in the health scenarios used to elicit their VPs.

ETHICS AND DISSEMINATION

The protocol has been approved by the Hamilton Integrated Research Ethics Board (HIREB13-506). We will disseminate our study findings through peer-reviewed publications and conference presentations, and make them available to guideline makers issuing recommendations addressing HA and THA.

Effects of sesame seed supplementation on lipid profile and oxidative stress biomarkers in patients with knee osteoarthritis

BACKGROUND

This study was designed to assess the effect of sesame seed on lipid profile and oxidative stress biomarkers in knee osteoarthritis (OA) patients.

METHODS

Fifty patients with knee OA were allocated into two groups receiving 40 g of sesame seed daily along with standard medical therapy (n=25) or stan-dard treatment (n=25) for two months. Serum total antioxidant capacity, ma-londialdehyde (MDA) and lipid profile (total cholesterol (TC), HDL-cholesterol, LDL-cholesterol, triglycerides) were measured.

RESULTS

After the intervention period two months of study, serum TC, LDL-cholesterol and MDA decreased significantly in the sesame group (P<0.05), while no significant difference in serum values of lipid profile and oxidative stress parameters was seen in the control group (P>0.05). There was no signifi-cant difference in pre and post-treatment values of lipid profile and oxidative parameters between the two groups (P>0.05).

CONCLUSION

Current study showed a positive effect of sesame seed in improv-ing lipid profile and oxidative stress in patients with knee OA and indicated the fact that sesame seed might be of help to reduce oxidative stress in OA patients.

A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument

Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

"Bedside-to-Bench" Behavioral Outcomes in Animal Models of Pain: Beyond the Evaluation of Reflexes

Despite the myriad promising new targets and candidate analgesics recently identified in preclinical pain studies, little translation to novel pain medications has been generated. The pain phenotype in humans involves complex behavioral alterations, including changes in daily living activities and psychological disturbances. These behavioral changes are not reflected by the outcome measures traditionally used in rodents for preclinical pain testing, which are based on reflexes evoked by sensory stimuli of different types (mechanical, thermal or chemical). These measures do not evaluate the impact of the pain experience on the global behavior or disability of the animals, and therefore only consider a limited aspect of the pain phenotype. The development of relevant new outcomes indicative of pain to increase the validity of animal models of pain has been increasingly pursued over the past few years. The aim has been to translate “bedside-to-bench” outcomes from the human pain phenotype to rodents, in order to complement traditional pain outcomes by providing a closer and more realistic measure of clinical pain in rodents. This review summarizes and discusses the most important nonstandard outcomes for pain assessment in preclinical studies. The advantages and drawbacks of these techniques are considered, and their potential impact on the validation of potential analgesics is evaluated.

The effects of self-massage on osteoarthritis of the knee: a randomized, controlled trial

Introduction

Recent research has provided a rationale for the efficacy and use of massage therapy in the management of knee osteoarthritis (OA) symptoms. Additionally, research has also implicated the role of the quadriceps muscles in the genesis of knee OA. Although both areas of research have demonstrated strong evidence that the muscles and massage therapy may affect knee OA symptoms, self-massage applied on the quadriceps muscle has received no attention.

Methods

Conducted at the Lourdes Wellness Center in Collingswood, NJ, the study investigated the outcomes of a self-massage intervention applied to the quadriceps muscle on reported pain, stiffness, physical function, and knee range of motion in adults with diagnosed knee OA. Forty adults with diagnosed knee OA were randomly assigned to either an intervention (n = 21) or a wait list control (n = 19) group. The participants applied a narrated 20-minute self-massage therapy twice weekly during ten supervised and three unsupervised intervention sessions. The control group had four supervised assessments with no intervention. Outcome measures were the Western Ontario and McMaster’s Osteoarthritis Index (WOMAC) and assessment of knee range of motion.

Results

Between-groups analyses of WOMAC pain, stiffness, function subscales, and total WOMAC scores indicated significant difference between groups (p < .05), n = 36). No significant differences were seen in range of motion.

Conclusions

The study demonstrated that participants who have OA of the knee benefit from the self-massage intervention therapy. Further studies are needed to clarify the long-term effects of self-massage on the progression and symptoms of knee OA.

Pain at Midlife

Although menopause is a normal developmental milestone through which all women pass, the transition has been long associated with chronic pain conditions that may be more accurately viewed as secondary to aging. Clinicians need to understand management of pain problems women may experience. This article examines pain syndromes including headache, back pain, osteoarthritis, pelvic pain, vulvo-vaginal pain, and burning mouth syndrome.

It's all in how you view it: pessimism, social relations, and life satisfaction in older adults with osteoarthritis

OBJECTIVES

Current treatments for osteoarthritis (OA) continue to leave those burdened by the condition with pain and disability which affects physical and psychological well-being. The present study examines other psychosocial factors, such as dispositional personality and social relationships, in order to investigate their influence on the well-being of 160 older adults with OA (80% women).

METHOD

Older adults were recruited for self-reported knee or hip OA. Participants completed self-report measures of optimism and pessimism, social support, social strain, and life satisfaction using the computer program MediaLab. Measures were taken twice 9-12 months apart.

RESULTS

Results showed that, both cross-sectionally and longitudinally, pessimism was related to lower social support and higher social strain. In addition, pessimism was mediated by social support in its relationship to life satisfaction.

DISCUSSION

Our models support the combined roles of pessimism and social support influencing life satisfaction over time. Future interventions may want to concentrate on improving the social relationships of people with OA to enhance psychological well-being.

A distinct cohort of progenitor cells participates in synovial joint and articular cartilage formation during mouse limb skeletogenesis

The origin, roles and fate of progenitor cells forming synovial joints during limb skeletogenesis remain largely unclear. Here we produced prenatal and postnatal genetic cell fate-maps by mating ROSA-LacZ-reporter mice with mice expressing Cre-recombinase at prospective joint sites under the control of Gdf5 regulatory sequences (Gdf5-Cre). Reporter-expressing cells initially constituted the interzone, a compact mesenchymal structure representing the first overt sign of joint formation, and displayed a gradient-like distribution along the ventral-to-dorsal axis. The cells expressed genes such as Wnt9a, Erg and collagen IIA, remained predominant in the joint-forming sites over time, gave rise to articular cartilage, synovial lining and other joint tissues, but contributed little if any to underlying growth plate cartilage and shaft. To study their developmental properties more directly, we isolated the joint-forming cells from prospective autopod joint sites using a novel microsurgical procedure and tested them in vitro. The cells displayed a propensity to undergo chondrogenesis that was enhanced by treatment with exogenous rGdf5 but blocked by Wnt9a over-expression. To test roles for such Wnt-mediated anti-chondrogenic capacity in vivo, we created conditional mutants deficient in Wnt/beta-catenin signaling using Col2-Cre or Gdf5-Cre. Synovial joints did form in both mutants; however, the joints displayed a defective flat cell layer normally abutting the synovial cavity and expressed markedly reduced levels of lubricin. In sum, our data indicate that cells present at prospective joint sites and expressing Gdf5 constitute a distinct cohort of progenitor cells responsible for limb joint formation. The cells appear to be patterned along specific limb symmetry axes and rely on local signaling tools to make distinct contributions to joint formation.

A 10-day course of SPA therapy is beneficial for people with severe knee osteoarthritis

The objective of this study was to test if spa therapy can play a role in the management of severe knee osteoarthritis (OA). Twenty patients with radiologically and clinically severe knee OA were randomly assigned into spa and drug therapy groups. Spa group (n = 10) traveled to a spa town and stayed at a hotel for a 10-day spa therapy course. They followed a balneotherapy regimen including thermal pool baths at 37 degrees C for 20 min two times daily. Drug therapy group (n = 10) stayed at home and followed their individually prescribed drug therapy (NSAIDs and paracetamol). Patients were assessed at baseline (week 0), after spa therapy at 2 weeks (week 2) and during follow-up period at 12 (week 12) and 24 (week 24) weeks by a blinded investigator. Patients assessed with Lequesne algofunctional index (LAFI), pain (visual analogue scale, VAS), patient's and investigator's global evaluation (VAS), ten-stairs stepping up and down time, 15 m walking time and three times squatting up and down time. Significant improvement in pain and LAFI scores were found at week 2, week 12 and week 24 in the spa therapy group compared to baseline. Comparing the two group differences, spa therapy was superior to drug therapy in pain reduction and in physician's global assessment at all time points. This superiority was also found in LAFI scores and patients' global assessments at week 12 and week 24. A 10-day course of spa therapy may be beneficial in short- and medium-term up to 24 weeks by reducing pain and improving functional status and overall well-being in patients with severe knee OA and may be considered as an effective therapeutic tool for such patients in countries like Turkey where it is widely available and (at least partly) reimbursed.

Transcription factor ERG and joint and articular cartilage formation during mouse limb and spine skeletogenesis

Articular cartilage and synovial joints are critical for skeletal function, but the mechanisms regulating their development are largely unknown. In previous studies we found that the ets transcription factor ERG and its alternatively-spliced variant C-1-1 have roles in joint formation in chick. Here, we extended our studies to mouse. We found that ERG is also expressed in developing mouse limb joints. To test regulation of ERG expression, beads coated with the joint master regulator protein GDF-5 were implanted close to incipient joints in mouse limb explants; this led to rapid and strong ectopic ERG expression. We cloned and characterized several mammalian ERG variants and expressed a human C-1-1 counterpart (hERG3Delta81) throughout the cartilaginous skeleton of transgenic mice, using Col2a1 gene promoter/enhancer sequences. The skeletal phenotype was severe and neonatal lethal, and the transgenic mice were smaller than wild type littermates and their skeletons were largely cartilaginous. Limb long bone anlagen were entirely composed of chondrocytes actively expressing collagen IX and aggrecan as well as articular markers such as tenascin-C. Typical growth plates were absent and there was very low expression of maturation and hypertrophy markers, including Indian hedgehog, collagen X and MMP-13. The results suggest that ERG is part of molecular mechanisms leading chondrocytes into a permanent developmental path and become joint forming cells, and may do so by acting downstream of GDF-5.

A quantitative approach to measure joint pain in experimental osteoarthritis--evidence of a role for nitric oxide

OBJECTIVES

To describe a method to study joint pain in experimental osteoarthritis (OA) and to study nitric oxide (NO) participation in experimental OA.

DESIGN

Rats were subjected to anterior cruciate ligament transection (ACLT) (OA group) of the right knee and evaluated during 28 days. A sham group was false operated and a naive group received no manipulation. Joint pain was measured by recording the time the right hind paw fails to touch the surface while walking. Cell influx (CI) and nitrite levels were measured in joint exudates. Expression of inducible NO synthase (iNOS) in synovia was detected by immunostaining. For the specific purpose of pharmacological manipulation, groups received either indomethacin (2 mg/kg/day s.c. (subcutaneous)), meloxicam (6 mg/kg/day s.c.), morphine (200 microg intra-articularly), the non-selective NOS inhibitor L-N(G)-nitroarginine methyl ester (L-NAME; 30 mg/kg/bid i.p. (intra-peritoneal)) or the selective iNOS inhibitor 1400W (0.5 mg/kg/day s.c.), given 30 min prior (prophylactic) or 4 days after (therapeutic) ACLT, until sacrifice, at 7 days. The respective non-treated groups received the vehicles.

RESULTS

The OA group developed joint pain, as compared to sham and control groups (P<0.05). Significantly increased nitrite levels and iNOS immunostaining were seen in the OA group. Both indomethacin and meloxicam inhibited joint pain (P<0.05). Morphine inhibited joint pain, whereas this effect was blocked by co-administration of the mu-opioid receptor naloxone. CI was similar among all groups. Prophylactic but not therapeutic L-NAME or 1400W reduced joint pain.

CONCLUSION

We describe a method to quantitate joint pain associated to weight bearing in the ACLT model. The joint pain is sensitive to classical antinociceptive compounds. NO release is associated to joint pain though NOS inhibition does not inhibit ongoing pain.

Tramadol for osteoarthritis

BACKGROUND

Tramadol is increasingly used for the treatment of osteoarthritis because, in contrast to nonsteroidal anti-inflammatory drugs (NSAIDs), tramadol does not produce gastrointestinal bleeding or renal problems, and does not affect articular cartilage.

OBJECTIVES

We sought to determine the analgesic effectiveness, the effect on physical function, the duration of benefit and the safety of oral tramadol in people with osteoarthritis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and LILACS databases up to August 2005.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that evaluated the effect of tramadol or tramadol plus paracetamol on pain levels and/or physical function in people with osteoarthritis. No language restriction was applied.

DATA COLLECTION AND ANALYSIS

We analyzed separately placebo-controlled and active-controlled studies. We used fixed-effect models for the meta-analyses as the results across studies were similar.

MAIN RESULTS

We included eleven RCTs with a total of 1019 participants who received tramadol or tramadol/paracetamol and 920 participants who received placebo or active-control. The placebo-controlled studies indicated that participants who received tramadol had less pain (-8.5 units on a 0 to 100 scale; 95% confidence interval (CI) -12.0 to -5.0) than patients who received placebo. This represents a 12% relative decrease in pain intensity from baseline. Participants who received tramadol had a 37% increase (95% CI 1.2 to 1.5) in the likelihood of reporting moderate improvement (number needed to treat to benefit = 6; 95% CI 4 to 9). Participants who received tramadol had 2.27 times the risk of developing minor adverse events and 2.6 times the risk of developing major adverse events, compared to participants who received placebo. Of every eight people who receive tramadol or tramadol/paracetamol, one will stop taking the medication because of adverse events, number needed to treat to harm (NNTH)= 8 (95% CI 7 to 12) for major adverse events. No conclusion could be drawn on how tramadol or tramadol/paracetamol compared with available pharmacological treatments because of the limited number of studies that evaluated such therapies.

AUTHORS' CONCLUSIONS

Tramadol or tramadol/paracetamol decreases pain intensity, produces symptom relief and improves function, but these benefits are small. Adverse events, although reversible and not life threatening, often cause participants to stop taking the medication and could limit tramadol or tramadol plus paracetamol usefulness.

Experience with a placebo-controlled randomized clinical trial of a disease-modifying drug for osteoarthritis: the doxycycline trial

Little effort has gone into the development of more effective analgesics for osteoarthritic pain. Efforts to improve symptomatic therapy for osteoarthritis have been deflected or diluted by a decision to pursue the development of disease-modifying OA drugs (DMOADs). These agents' main mechanism of action is directed not at the relief of joint pain but at slowing the progression of structural damage. This article describes the results of a recent randomized placebo-controlled designed to examine the DMOAD effect in humans of the tetracycline antibiotic doxycycline, and reviews the experience gained from other recent DMOAD trials in humans.

Viscosupplementation for the treatment of osteoarthritis of the knee

BACKGROUND

Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability.

OBJECTIVES

To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease, Euflexxa, Nuflexxa), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), Hyruan, NRD-101 (Suvenyl), Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum).

SEARCH STRATEGY

MEDLINE (up to January (week 1) 2006 for update), EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to December 2005 were handsearched.

SELECTION CRITERIA

RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997).

DATA COLLECTION AND ANALYSIS

Each trial was assessed independently by two reviewers for its methodological quality using a validated tool. All data were extracted by one reviewer and verified by a second reviewer . Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). However, where different scales were used to measure the same outcome, standardized mean differences (SMD) were used. Dichotomous outcomes were analyzed by relative risk (RR).

MAIN RESULTS

Seventy-six trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and eighteen months. Forty trials included comparisons of hyaluronan/hylan and placebo (saline or arthrocentesis), ten trials included comparisons of intra-articular (IA) corticosteroids, six trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs), three trials included comparisons of physical therapy, two trials included comparisons of exercise, two trials included comparisons of arthroscopy, two trials included comparisons of conventional treatment, and fifteen trials included comparisons of other hyaluronans/hylan. The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 28 to 54% for pain and 9 to 32% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses.

AUTHORS' CONCLUSIONS

Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.2 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.2 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

Mechanisms of synovial joint and articular cartilage formation: recent advances, but many lingering mysteries

Synovial joints are elegant, critically important, and deceptively simple biomechanical structures. They are comprised of articular cartilage that covers each end of the opposing skeletal elements, synovial fluid that lubricates and nourishes the tissues, ligaments that hold the skeletal elements in check, and a fibrous capsule that insulates the joints from surrounding tissues. Joints also exhibit an exquisite arrays of shapes and sizes, best exemplified by the nearly spherical convex femoral head articulating into a nearly spherical concave hip acetabulum, or a phalangeal joint with two condyles on the distal side articulating in reciprocally-shaped sockets on the opposing proximal side. Though few in number, joint tissues are highly specialized in structure and function. This is illustrated by articular cartilage with its unique extracellular matrix, unique biomechanical resilience, its largely avascular nature, and its ability to persist through life with minimal turnover of its cells and components. The fact that interest in synovial joints has remained unabated for decades is a reflection of their fundamental importance for organism function and quality of life, and for their susceptibility to a variety of acquired and congenital conditions, most importantly arthritis. This has led to many advances in this field that encompass molecular genetics to biomechanics to medicine. Regrettably, what continues to be poorly understood are the mechanisms by which synovial joints actually form in the developing embryo. If available, this information would be not only of indisputable biological interest, but would also have significant biomedical ramifications, particularly in terms of designing novel tissue regeneration or reconstruction therapies. This review focuses on recent advances in understanding the mechanisms of synovial joint formation in the limbs, and places and discusses the information within the context of classic studies and the many mysteries and questions that remain unanswered.

Cost effectiveness of a two-year home exercise program for the treatment of knee pain

OBJECTIVE

To assess the cost effectiveness of a 2-year home exercise program for the treatment of knee pain.

METHODS

A total of 759 adults aged > or = 45 years were randomized to receive exercise therapy, monthly telephone contact, exercise therapy and telephone contact, or no intervention. Efficacy was measured using self-reported knee pain at 2 years. Costs to both the National Health Service and to the patient were included.

RESULTS

Exercise therapy was associated with higher costs and better effectiveness. Direct costs for the interventions were pound 112 for the exercise program and pound 61 for the monthly telephone support. Participants allocated to receive exercise therapy were significantly more likely to incur higher medical costs than those in the no-exercise groups (mean difference pound 225; 95% confidence interval pound 218, pound 232; P < 0.001).

CONCLUSION

Exercise therapy is associated with improvements in knee pain, but the cost of delivering the exercise program is unlikely to be offset by any reduction in medical resource use.

Viscosupplementation for the treatment of osteoarthritis of the knee

BACKGROUND

Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability.

OBJECTIVES

To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), NRD-101, Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum).

SEARCH STRATEGY

MEDLINE, EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to April 2004 were handsearched.

SELECTION CRITERIA

RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997).

DATA COLLECTION AND ANALYSIS

Each trial was assessed independently by two reviewers (NB, JC) for its methodological quality using a validated tool. All data were extracted by one reviewer (JC) and verified by a second reviewer (VR). Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). Dichotomous outcomes were analyzed by relative risk (RR).

MAIN RESULTS

Sixty-three trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and one year. Thirty-seven trials included comparisons of hyaluronan/hylan and placebo, nine trials included comparisons of intra-articular (IA) corticosteroids, and five trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs). The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 11 to 54% for pain and 9 to 15% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses.

AUTHORS' CONCLUSIONS

Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that based on non-randomised groups, the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.1 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.1 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events. In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

Tratamiento farmacológico de la artrosis. Expectativas y realidades

In order to assess agent with modulating properties of the course of the arthrosic condition, the so-called SYSADOA (Symptomatic Slow Acting Drugs for Osteoarthritis) and "structure modifiers" have been defined. Glucosamine sulfate, chrondroitin sulfate and diacerein have been considered among these agents. Based on the published data and according to the evidence available, the SYSADOA have symptomatic effects and can modify the structure. However, although there is scientific evidence for the use of these drugs in arthrosis treatment, the limited intensity of their action over the placebo makes it necessary to evaluate the clinical relevance of their application before recommending their generalized use.