Similar Effects of Exercise Therapy, Nonsteroidal Anti-inflammatory Drugs, and Opioids for Knee Osteoarthritis Pain: A Systematic Review with Network Meta-analysis

Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review 5-year update

Objective

This umbrella review aimed to summarize (and update) the effectiveness of non-pharmacological and non-surgical interventions for patients with knee osteoarthritis.

Methods

The study followed the PRISMA guidelines. Manual and electronic databases were searched, to identify systematic reviews, following the P (knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C (pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical conservative treatments) O (pain, function, quality of life, and other knee-specific measures) model. The quality of evidence was assessed using the R-AMSTAR checklist and GRADE principles.

Results

The search yielded 4086 records, of which 61 met the eligibility criteria. After evaluation with R-AMSTAR, four systematic reviews were excluded, resulting in 57 included systematic reviews, with an overall score of 29.6. The systematic reviews were published between 2018 and 2022 (29.8% in 2022), conducted in 19 countries (52.6% in China), and explored 24 distinct interventions. The systematic reviews encompassed 714 trials (mean of 13 ​± ​7.7 studies per systematic review), and 59,343 participants (mean 1041 ​± ​1002 per systematic review, and 82 ​± ​59.2 per study). The majority of participants were older obese women (61.6 ​± ​4.2 years, 30.2 ​± ​3.6 ​kg/m2, 70%, respectively).

Conclusions

Based on the systematic reviews findings, Diet Therapy, Patient Education, and Resistance Training are strongly supported as core interventions for managing patients with knee osteoarthritis. Aquatic Therapy, Balance Training, Balneology, Dietary Supplements, Extracorporeal Shockwave Therapy, and Tai Ji show moderate support. For other interventions, the evidence quality was low, results were mixed or inconclusive, or there was not sufficient efficacy to support their use.

Gill M, Page GL, Pope A, Measom GJ, Hager RL, Seeley MK. Serum Cartilage Oligomeric Matrix Protein Concentration Increases More After Running Than Swimming for Older People

BACKGROUND

Knee osteoarthritis is common in older people. Serum cartilage oligomeric matrix protein (sCOMP) is a biomarker of knee articular cartilage metabolism. The purpose of this study was 2-fold: to (1) determine acute effects of running and swimming on sCOMP concentration in older people; and (2) investigate relationships between sCOMP concentration change due to running and swimming and measures of knee health in older people.

HYPOTHESES

Running would result in greater increase in sCOMP concentration than swimming, and increase in sCOMP concentration due to running and swimming would associate positively with measures of poor knee health.

STUDY DESIGN

Cross-sectional.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 20 participants ran 5 km and 19 participants swam 1500 m. sCOMP concentration was measured immediately before, immediately after, and 15, 30, and 60 minutes after running or swimming. sCOMP concentration change due to running and swimming was compared. Correlations between sCOMP concentration change due to running and swimming, and other measures of knee health were evaluated, including the Tegner Activity Scale and Knee injury and Osteoarthritis Outcome Score.

RESULTS

sCOMP concentration increased 29% immediately after running, relative to baseline, but only 6% immediately after swimming (P < 0.01). No significant relationship was observed between acute sCOMP change due to running and swimming, and observed measures of knee health (P > 0.05). Participants with clinically relevant knee symptoms exhibited greater sCOMP concentration before and after running and swimming (P = 0.03) and had greater body mass (P = 0.04).

CONCLUSION

Running results in greater acute articular cartilage metabolism than swimming; however, the chronic effects of this are unclear. Older people with clinically relevant knee symptoms possess greater sCOMP concentration and are heavier, independent of exercise mode and physical activity level.

CLINICAL RELEVANCE

These results describe the effects of exercise (running and swimming) for older physically active persons, with and without knee pain.

The efficacy of gabapentin supplementation for pain control after lumbar laminectomy and discectomy: A meta-analysis study

BACKGROUND

Gabapentin supplementation may have some potential in pain control after lumbar laminectomy and discectomy, and this meta-analysis aims to explore the impact of gabapentin supplementation on postoperative pain management for lumbar laminectomy and discectomy.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched, and we included randomized controlled trials assessing the effect of gabapentin supplementation on the pain control of lumbar laminectomy and discectomy.

RESULTS

Five randomized controlled trials were finally included in the meta-analysis. Overall, compared with control intervention for lumbar laminectomy and discectomy, gabapentin supplementation was associated with significantly lower pain scores at 2 hours (MD = -2.75; 95% CI = -3.09 to -2.41; P < .00001), pain scores at 4 hours (MD = -2.28; 95% CI = -3.36 to -1.20; P < .0001), pain scores at 24 hours (MD = -0.70; 95% CI = -0.86 to -0.55; P < .00001) and anxiety score compared to control intervention (MD = -1.32; 95% CI = -1.53 to -1.11; P < .00001), but showed no obvious impact on pain scores at 12 hours (MD = -0.58; 95% CI = -1.39 to 0.22; P = .16). In addition, gabapentin supplementation could significantly decrease the incidence of vomiting in relative to control intervention (OR = 0.31; 95% CI = 0.12-0.81; P = .02), but they had similar incidence of nausea (OR = 0.51; 95% CI = 0.15-1.73; P = .28).

CONCLUSIONS

Gabapentin supplementation benefits to pain control after lumbar laminectomy and discectomy.

Modulating the Expression of Exercise-induced lncRNAs: Implications for Cardiovascular Disease Progression

Recent research shows exercise is good for heart health, emphasizing the importance of physical activity. Sedentary behavior increases the risk of cardiovascular disease, while exercise can help prevent and treat it. Additionally, physical exercise can modulate the expression of lncRNAs, influencing cardiovascular disease progression. Therefore, understanding this relationship could help identify prospective biomarkers and therapeutic targets pertaining to cardiovascular ailments. This review has underscored recent advancements concerning the potential biomarkers of lncRNAs in cardiovascular diseases, while also summarizing existing knowledge regarding dysregulated lncRNAs and their plausible molecular mechanisms. Additionally, we have contributed novel perspectives on the underlying mechanisms of lncRNAs, which hold promise as potential biomarkers and therapeutic targets for cardiovascular conditions. The knowledge imparted in this review may prove valuable in guiding the design of future investigations and furthering the understanding of lncRNAs as diagnostic, prognostic, and therapeutic biomarkers for cardiovascular diseases.

Physical Therapist and Patient Perspectives on Mobile Technology to Support Home Exercise Prescription for People With Arthritis: A Qualitative Study

Introduction Mobile applications (apps) for exercise prescription may enhance communication between healthcare providers and patients while addressing common barriers to exercise among people with osteoarthritis. However, little is known about preferences and barriers to the use of mobile apps by physical therapists or people aging with osteoarthritis. Therefore, we aimed to examine physical therapist and patient perspectives on mobile apps to support physical therapist-prescribed home exercise for people with osteoarthritis. Methods Eighteen physical therapists and 17 individuals with a history of physical therapy for osteoarthritis participated in the study. Focus groups (n = 6, three each with physical therapists and patients) were conducted to gather perspectives on three commercially available mobile apps designed for physical therapy exercise prescription. Semi-structured questions assessed feature preferences, ease of use, exercise completion support, clinical feasibility, and potential barriers and facilitators to using the apps. Recordings of the focus groups were transcribed verbatim. The study team iteratively coded transcripts using thematic analysis. Results Perspectives of patients and physical therapists intersected but differed on the mobile apps. All patients preferred video exercise prescription over traditional methods and both patients and therapists predicted challenges and opportunities with mobile communication. Four themes emerged: accountability, data-driven, communication boost, and duality of technology. Facilitators of home exercise through mobile apps included exercise tracking, feedback loop, personalization, and the potential for reduced in-person visits. Barriers included technological challenges, complex interface design, lack of universal applicability, and security concerns. Conclusion Mobile app technology has the potential to support exercise adherence for people with osteoarthritis. However, patients' and therapists' perspectives differ and highlight numerous challenges that limit the universal clinical adoption of this technology. While physical therapists acknowledged the potential to improve the rehabilitation experience with mobile apps, there was concern about reimbursement and time constraints in the current fee-for-service environment.

Use of prescribed analgesics before and after exercise therapy and patient education in patients with knee or hip osteoarthritis

The aim of this study was to investigate utilisation patterns of prescribed analgesics before, during, and after an exercise therapy and patient education program among patients with knee or hip osteoarthritis. This cohort study is based on data from the nationwide Good Life with osteoarthritis in Denmark (GLA:D®) patient-register linked with national health registries including data on prescribed analgesics. GLA:D® consists of 8-12 weeks of exercise and patient education. We included 35,549 knee/hip osteoarthritis patients starting the intervention between January 2013 and November 2018. Utilisation patterns the year before, 3 months during, and the year after the intervention were investigated using total dispensed defined daily doses (DDDs) per month per 1000 population as outcome. During the year before the intervention, use of prescribed paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), and opioids increased with 85%, 79% and 22%, respectively. During the intervention, use of paracetamol decreased with 16% with a stable use the following year. Use of NSAIDs and opioids decreased with 38% and 8%, respectively, throughout the intervention and the year after. Sensitivity analyses indicated that the prescription of most analgesics changed over time. For paracetamol, NSAIDs, and opioids, 10% of analgesic users accounted for 45%, 50%, and 70%, respectively, of the total DDDs dispensed during the study period. In general, analgesic use increased the year before the intervention followed by a decrease during the intervention and the year after. A small proportion of analgesic users accounted for half or more of all paracetamol, NSAIDs, and opioids dispensed during the study period.

Central and peripheral mechanism of MOTS-c attenuates pain hypersensitivity in a mice model of inflammatory pain

BACKGROUND

Inflammatory pain is caused by damaged tissue or noxious stimuli, accompanied by the release of inflammatory mediators that often leads to severe hyperalgesia and allodynia with limited therapy options. Recently, a novel mitochondrial-derived peptide (named MOTS-c) was reported to regulate obesity, metabolic homeostasis and inflammatory response. The aim of this study was to investigate the effects of MOTS-c and its related regulatory mechanisms involved in inflammatory pain.

METHODS

Male Kunming mice (8-10 weeks-old) were intraplantar injected with formalin, capsaicin, λ-Carrageenan and complete Freund adjuvant (CFA) to establish acute and chronic inflammatory pain. The effects of MOTS-c on the above inflammatory pain mice and its underlying mechanisms were examined by behavioral tests, quantitative polymerase chain reaction (qPCR), western blotting, enzyme linked immunosorbent assay (ELISA), immunohistochemistry (IHC) and immunofluorescence (IF).

RESULTS

Behavioral experiments investigated the potential beneficial effects of MOTS-c on multiple acute and chronic inflammatory pain in mice. The results showed that MOTS-c treatment produced potent anti-allodynic effects in formalin-induced acute inflammatory pain, capsaicin-induced nocifensive behaviors and λ-Carrageenan/CFA-induced chronic inflammatory pain model. Further mechanistic studies revealed that central MOTS-c treatment significantly ameliorated CFA-evoked the release of inflammatory factors and activation of glial cells and neurons in the spinal dorsal horn. Moreover, peripheral MOTS-c treatment reduced CFA-evoked inflammatory responses in the surface structure of hindpaw skin, accompanied by inhibiting excitation of peripheral calcitonin gene-related peptide (CGRP) and P2X3 nociceptive neurons.

CONCLUSIONS

The present study indicates that MOTS-c may serve as a promising therapeutic target for inflammatory pain.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis

BACKGROUND

Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids.

RESULTS

From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42).

CONCLUSIONS

For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

Targeting WNT signalling pathways as new therapeutic strategies for osteoarthritis

Osteoarthritis (OA) is a highly prevalent chronic joint disease and the leading cause of disability. Currently, no drugs are available to control joint damage or ease the associated pain. The wingless-type (WNT) signalling pathway is vital in OA progression. Excessive activation of the WNT signalling pathway is pertinent to OA progression and severity. Therefore, agonists and antagonists of the WNT pathway are considered potential drug candidates for OA treatment. For example, SM04690, a novel small molecule inhibitor of WNT signalling, has demonstrated its potential in a recent phase III clinical trial as a disease-modifying osteoarthritis drug (DMOAD). Therefore, targeting the WNT signalling pathway may be a distinctive approach to developing particular agents helpful in treating OA. This review aims to update the most recent progress in OA drug development by targeting the WNT pathway. In this, we introduce WNT pathways and their crosstalk with other signalling pathways in OA development and highlight the role of the WNT signalling pathway as a key regulator in OA development. Several articles have reviewed the Wnt pathway from different aspects. This candid review provides an introduction to WNT pathways and their crosstalk with other signalling pathways in OA development, highlighting the role of the WNT signalling pathway as a key regulator in OA development with the latest research. Particularly, we emphasise the state-of-the-art in targeting the WNT pathway as a promising therapeutic approach for OA and challenges in their development and the nanocarrier-based delivery of WNT modulators for treating OA.

miR-181a-5p targets DDX3X to inhibit the progression of osteoarthritis via NF-ΚB signaling pathway

Osteoarthritis (OA) is the most common age-related joint disease, characterized by chronic inflammation, progressive articular cartilage destruction and subchondral osteosclerosis. More and more evidence showed that microRNAs (miRNAs) play a key role in various diseases, but the specific mechanism of miRNAs in OA is not clear. The purpose of this study was to investigate the expression level and role of miR-181a-5p in OA and its related mechanism. Here we identified the key gene DEAD-box RNA helicase 3X (DDX3X) in the OA dataset by bioinformatics analysis. At the same time, miRNAs targeting DDX3X were screened, and miR-181a-5p was selected as the next research object. Then we used different concentrations of interleukin-1 beta (IL-1β)-induced in vitro model of arthritis, and found that IL-1β can stimulate cells to release nitric oxide. The expression levels of miR-181a-5p and DDX3X in mouse chondrocyte cell line ATDC5 induced by IL-1β at a concentration of 10ug/mL were detected by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). IL-1β induced a decrease in the expression of miR-181a-5p and an increase in the expression of DDX3X in ATDC5 cells. mimic miR-181a-5p or inhibitor miR-181a-5p were transfected into ATDC5 cells, and the levels of inflammatory mediators in the cells were detected by enzyme-linked immunosorbent assay, and the results showed that miR-181a-5p could reduce the release of tumor necrosis factor-α, IL-1β, IL-6 and inducible nitric oxide nitric oxide synthase in a cellular model of arthritis. Luciferase reporter assays confirmed that the miR-181a-5p binding site was in the DDX3X gene 3'-untranslated region (3'-UTR), and DDX3X was negatively regulated by miR-181a-5p. Rescue assays confirmed that miR-181a-5p reduced the expression of DDX3X by targeting the 3'-UTR region of DDX3X, thereby reducing the release of inflammatory factors. Finally, in this paper, western blot was used to detect the mechanism of miR-181a-5p regulating OA. The results showed that interfering with the expression of miR-181a-5p could up-regulate the expression of DDX3X protein, increase the expression of nuclear factor- kappaB (NF-κB) related proteins, and reduce the inflammatory response of OA, thereby increasing the secretion of the matrix proteinases MMP-3 and MMP-13. Taken together, the results of the study suggested that miR-181a-5p may be a promising therapeutic target for the treatment of human OA.

Effect of knee arthroscopic debridement combined with peripatellar denervation on restoration of knee function in patients with knee osteoarthritis

BACKGROUND

This research examines knee osteoarthritis (OA), a prevalent orthopedic disease marked by cartilage degeneration and chronic synovitis, leading to pain, restricted mobility, and eventual loss of knee function. Notably, patellofemoral osteoarthritis constitutes a significant proportion of knee OA cases. Our study aims to assess the impact of knee arthroscopic debridement coupled with peripatellar denervation on restoring knee function in OA patients and analyze the risk factors affecting treatment outcomes. By doing so, we hope to contribute to the informed selection of clinical treatment plans, addressing a disease that, if untreated, significantly impairs patients' quality of life.

METHODS

A total of 211 patients with knee osteoarthritis treated in our hospital from June 2020 to June 2022 were analyzed retrospectively. Among them, 116 patients received arthroscopic knee debridement treatment alone as the control group, and 95 in the observation group were combined with denervation treatment based on the control group. The clinical efficacy of the two groups of patients after treatment was evaluated, and patients' pain was counted using the pain visual analogue score (VAS) method. The knee range of motion (ROM) was used to count the mobility of the patients and to compare the operative time, intraoperative perfusion volume, and length of stay between the two groups. According to the effectiveness after treatment, patients were divided into the improvement group (effective + markedly effective) and the non-improvement group, and the risk factors affecting the clinical efficacy of patients after treatment were analyzed by logistic regression.

RESULTS

The total treatment efficiency of patients in the control group was lower than that of those in the observation group (P < 0.05). There was no difference in intraoperative perfusion volume and length of stay between patients in both groups (P > 0.05). However, the operative time was shorter in the control group compared with that in the observation group (P < 0.001). The post-treatment VAS scores of patients in the observation group were lower than those in the control group, while the ROM scores were higher than those of the control group (P < 0.001). Age, BMI, and preoperative VAS score were found to be independent risk factors for patient outcome by logistic regression analysis (P < 0.05).

CONCLUSION

knee arthroscopic debridement combined with peripatellar denervation has a significant improvement in the restoration of knee function in patients with knee osteoarthritis and reduces their level of pain.

Comparative efficacy of exercise therapy and oral non-steroidal anti-inflammatory drugs and paracetamol for knee or hip osteoarthritis: a network meta-analysis of randomised controlled trials

OBJECTIVE

Clinical guidelines recommend exercise as a core treatment for knee or hip osteoarthritis (OA). However, how its analgesic effect compares to analgesics, for example, oral non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol-the most commonly used analgesics for OA, remains unknown.

DESIGN

Network meta-analysis.

DATA SOURCES

PubMed, Embase, Scopus, Cochrane Library and Web of Science from database inception to January 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials (RCTs) comparing exercise therapy with oral NSAIDs and paracetamol directly or indirectly in knee or hip OA.

RESULTS

A total of n=152 RCTs (17 431 participants) were included. For pain relief, there was no difference between exercise and oral NSAIDs and paracetamol at or nearest to 4 (standardised mean difference (SMD)=-0.12, 95% credibility interval (CrI) -1.74 to 1.50; n=47 RCTs), 8 (SMD=0.22, 95% CrI -0.05 to 0.49; n=2 RCTs) and 24 weeks (SMD=0.17, 95% CrI -0.77 to 1.12; n=9 RCTs). Similarly, there was no difference between exercise and oral NSAIDs and paracetamol in functional improvement at or nearest to 4 (SMD=0.09, 95% CrI -1.69 to 1.85; n=40 RCTs), 8 (SMD=0.06, 95% CrI -0.20 to 0.33; n=2 RCTs) and 24 weeks (SMD=0.05, 95% CrI -1.15 to 1.24; n=9 RCTs).

CONCLUSIONS

Exercise has similar effects on pain and function to that of oral NSAIDs and paracetamol. Given its excellent safety profile, exercise should be given more prominence in clinical care, especially in older people with comorbidity or at higher risk of adverse events related to NSAIDs and paracetamol.CRD42019135166.

Opioid Initiation Within One Year After Starting a Digital Musculoskeletal (MSK) Program: An Observational, Longitudinal Study with Comparison Group

Background

In-person, conservative care may decrease opioid use for chronic musculoskeletal (MSK) pain, but the impact of digitally delivered conservative care on opioid use is unknown. This study examines associations between a digital MSK program and opioid initiation and prescriptions among opioid naive adults with chronic MSK pain.

Methods

This observational study used commercial medical and pharmacy claims data to compare digital MSK program members to matched physical therapy (PT) patients. Outcomes were any opioid prescriptions and opioid prescriptions per 100 participants within the 12-months after starting a digital MSK program. After propensity-score matching, we conducted multivariate regression models that controlled for demographic, comorbidity, and baseline MSK healthcare use.

Results

The study included 4195 members and 4195 matched PT patients. For opioid initiation, 7.89% (95% Confidence Interval [CI]: 7.07%, 8.71%) of members had opioid prescriptions within 12 months after starting the digital MSK program versus 13.64% (95% CI: 12.60%, 14.67%) of matched PT patients (p < 0.001). Members had significantly fewer opioid prescriptions (16.73 per 100 participants; 95% CI: 14.11, 19.36) versus PT patients (22.36 per 100 participants; 95% CI: 19.99, 24.73). Members had lower odds (OR: 0.52, 95% CI: 0.45, 0.60) of initiating opioids and significantly fewer prescriptions per 100 participants (beta: -6.40, 95% CI: -9.88, -2.93) versus PT patients after controlling for available confounding factors.

Conclusion

An MSK program that delivers conservative care digitally may be a promising approach for decreasing opioid initiation among individuals with chronic MSK pain given the limitations of the observational design and matching on only available covariates.

Predictors of Multiwave Opioid Use Among Older American Adults

Background and Objectives

Despite limited analgesic benefits, long-term opioid therapy (L-TOT) is common among older adults with chronic pain. Extended opioid use poses a threat to older adults as aging metabolisms retain opioids for longer, increasing the risk of injury, overdose, and other negative health outcomes. In contrast to predictors of general opioid use, predictors of L-TOT in older adults are not well documented. We aimed to identify such predictors using all available data on self-reported opioid use in the Health and Retirement Study.

Research Design and Methods

Using 5 waves of data, respondents (N = 10,713) aged 51 and older were identified as reporting no opioid use (n = 8,621), a single wave of use (n = 1,410), or multiple waves of use (n = 682). We conducted a multinomial logistic regression to predict both single- and multiwave opioid use relative to no use. Demographic, socioeconomic, geographic, health, and health care-related factors were included in our model.

Results

Multivariable findings show that, relative to nonusers, both single- and multiwave users were significantly more likely to be younger (relative risk ratio [RRR] = 1.33; RRR = 2.88); report lower household wealth (RRR = 1.47; RRR = 2.88); live in the U.S. Midwest (RRR = 1.29; RRR = 1.56), South (RRR = 1.34; RRR = 1.58), or West (RRR = 1.46; RRR = 2.34); experience interfering pain (RRR = 1.59; RRR = 3.39), back pain (RRR = 1.35; RRR = 1.53), or arthritic pain (RRR = 1.46; RRR = 2.32); and see the doctor frequently (RRR = 1.50; RRR = 2.02). Multiwave users were less likely to be Black (RRR = 0.69) or Hispanic (RRR = 0.45), and less likely to be never married (RRR = 0.52).

Discussion and Implications

We identified demographic, socioeconomic, geographic, and health care-related predictors of chronic multiyear opioid use. Our focus on individuals taking opioids for this extended duration is novel. Differences in opioid use by geographic region and frequency of doctor visits particularly warrant attention from policy-makers and researchers. We make additional recommendations based on a sensitivity analysis limited to 2016-2020 data.

Combining biomechanical stimulation and chronobiology: a novel approach for augmented chondrogenesis?

The unique structure and composition of articular cartilage is critical for its physiological function. However, this architecture may get disrupted by degeneration or trauma. Due to the low intrinsic regeneration properties of the tissue, the healing response is generally poor. Low-grade inflammation in patients with osteoarthritis advances cartilage degradation, resulting in pain, immobility, and reduced quality of life. Generating neocartilage using advanced tissue engineering approaches may address these limitations. The biocompatible microenvironment that is suitable for cartilage regeneration may not only rely on cells and scaffolds, but also on the spatial and temporal features of biomechanics. Cell-autonomous biological clocks that generate circadian rhythms in chondrocytes are generally accepted to be indispensable for normal cartilage homeostasis. While the molecular details of the circadian clockwork are increasingly well understood at the cellular level, the mechanisms that enable clock entrainment by biomechanical signals, which are highly relevant in cartilage, are still largely unknown. This narrative review outlines the role of the biomechanical microenvironment to advance cartilage tissue engineering via entraining the molecular circadian clockwork, and highlights how application of this concept may enhance the development and successful translation of biomechanically relevant tissue engineering interventions.

Variation in the utilisation of physiotherapy in patients with advanced knee osteoarthritis prior to total knee arthroplasty a systematic review

INTRODUCTION

Due to demographic changes and increasing knee osteoarthritis (KOA) prevalence, the incidence of total knee arthroplasties (TKA) is constantly rising. Clinical practice guidelines for the treatment of KOA unanimously recommend non-surgical interventions such as exercise, education, and weight reduction in overweight patients. The aim of this systematic review is to determine the proportion of patients with end-stage KOA who attended physiotherapy (PT) prior to TKA.

METHODS

A systematic literature search was carried out in the medical databases MEDLINE (via Pubmed), PEDro, and EBSCO in August of 2022. Studies were included regardless of their design, if they reported the proportion of patients with a diagnosis of primary KOA, who participated in PT prior to undergoing TKA. Study quality assessment was performed by two independent authors using the Joanna Briggs Institutes Checklist for studies reporting prevalence data. Results were presented by using a narrative synthesis.

RESULTS

Eighteen studies, comprising 579,718 patients, were identified in this systematic review. PT utilisation prior to TKA ranged from 10% to 73% for patients with advanced KOA. Only two studies showed PT utilisation rates of 60% or higher. Female gender, higher income, better socioeconomic status, higher education levels, older age were associated with PT utilisation. Data for other predicting factors was conflicting.

DISCUSSION

This review shows substantial variation in the utilisation of PT in patients with end-stage KOA. This is concerning, considering the uniform recommendation from clinical practice guidelines for non-surgical treatments like exercise and education in patients with KOA, which are mostly provided by physiotherapists.

Exercise Therapy for Knee and Hip Osteoarthritis: Is There An Ideal Prescription?

Purpose of review

Exercise therapy is the first line treatment for patients with knee and hip osteoarthritis (OA) but is consistently underutilized. In this review, we aim to provide health care professionals with an overview of the latest evidence in the areas of exercise therapy for OA, which can serve as a guide for incorporating the ideal exercise therapy prescription in the overall management plan for their patients with OA.

Recent findings

Evidence continues to be produced supporting the use of exercise therapy for all patients with knee or hip OA. Ample evidence exists suggesting exercise therapy is a safe form of treatment, for both joint structures and the patient overall. Several systematic reviews show that exercise therapy is likely to improve patient outcomes, regardless of disease severity or comorbidities. However, no single type of exercise therapy is superior to others.

Summary

Health care practitioners and patients should be encouraged to incorporate exercise therapy into treatment plans and can be assured of the safety profile and likelihood of improvement in important patient outcomes. Since no single exercise therapy program shows vastly superior benefit, patient preference and contextual factors should be central to the shared decision-making process when selecting and individualising appropriate exercise therapy prescriptions.

Osteoarthritis year in review 2022: epidemiology & therapy

This 'Year in Review' provides a synopsis of key research themes and individual studies from the clinical osteoarthritis (OA) field, focused on epidemiology and therapy. The electronic database search for the review was adapted from the 2021 year in review search, to increase search specificity for relevant study designs, and was conducted in Medline, Embase and medRxiv (31^st March 2021 to 4^th March 2022). Following screening for eligibility, studies were grouped according to their key research design, including reviews, cohorts and randomised trials. 11 key themes emerged, including the importance of several comorbidities in predicting OA incidence and prevalence, surgical approaches that can reduce the risk of post-traumatic OA, the heterogenous but nevertheless relatively stable nature of OA subgroup trajectories, the paucity of robust studies particularly of surgery for OA and the very modest benefit of many therapies under evaluation in trials. A particular interest of the authors was to consider whether new studies are helping determine how to better ensure the right patient with OA is matched to the right treatment at the right time. There are several new studies developing improved predictive models through big data analytics and machine learning which show promise, need validation, and may support new approaches to stratified care.

Do imaging findings modify the effect of non-surgical treatment in patients with knee and hip osteoarthritis? A systematic literature review

OBJECTIVES

To review the available evidence on diagnostic imaging findings in knee and hip osteoarthritis (OA) as treatment effect modifiers in non-surgical OA interventions.

METHODS

MEDLINE, Embase and The Cochrane Central Register of Controlled Trials were searched from the earliest records published to 22 March 2022. Studies in knee and hip OA reporting subgroup analyses in randomised controlled trials with imaging findings as potential treatment effect modifiers were included. Studies were critically appraised using the Cochrane risk of bias tool and a subgroup analysis quality assessment.

RESULTS

Of 10 014 titles and abstracts screened, eight studies met the inclusion criteria, six on knee OA and two on hip OA. The studies investigated effect modifiers in exercise therapy, intra-articular injections and unloading shoes. Imaging findings assessed as potential treatment effect modifiers were radiographic OA severity, hip effusion (ultrasound), bone marrow lesions and meniscal pathology (MRI). Two studies fulfilled the methodological quality criteria for assessing effect modification. One reported that radiographic knee OA severity modified the effect of unloading shoes on walking pain. Those with more severe radiographic knee OA had a greater response to shoe inserts. One reported no interaction between radiographic OA severity or joint effusion and the effect of intraarticular injections of corticosteroid or hyaluronic acid in hip OA, indicating no difference in response in people with greater hip joint effusion or radiographic OA severity compared with those with less severe joint disease.

CONCLUSION

Overall, methodological limitations and very few studies do not permit conclusions on diagnostic imaging findings as effect modifiers in non-surgical interventions in knee and hip OA.Radiographic severity of knee OA potentially modifies the effect of unloading shoes.

PROSPERO REGISTRATION NUMBER

CRD42020181934.

No evidence for stratified exercise therapy being cost-effective compared to usual exercise therapy in patients with knee osteoarthritis: Economic evaluation alongside cluster randomized controlled trial

BACKGROUND

A stratified approach to exercise therapy may yield superior clinical and economic outcomes, given the large heterogeneity of individuals with knee osteoarthritis (OA).

OBJECTIVE

To evaluate the cost-effectiveness during a 12-month follow-up of a model of stratified exercise therapy compared to usual exercise therapy in patients with knee OA, from a societal and healthcare perspective.

METHODS

An economic evaluation was conducted alongside a cluster-randomized controlled trial in patients with knee OA (n = 335), comparing subgroup-specific exercise therapy for a 'high muscle strength subgroup', 'low muscle strength subgroup', and 'obesity subgroup' supplemented by a dietary intervention for the 'obesity subgroup' (experimental group), with usual ('non-stratified') exercise therapy (control group). Clinical outcomes included quality-adjusted life years - QALYs (EuroQol-5D-5 L), knee pain (Numerical Rating Scale) and physical functioning (Knee Injury and Osteoarthritis Outcome Score in daily living). Costs were measured by self-reported questionnaires at 3, 6, 9 and 12-month follow-up. Missing data were imputed using multiple imputation. Data were analyzed through linear regression. Bootstrapping techniques were applied to estimate statistical uncertainty.

RESULTS

During 12-month follow-up, there were no significant between-group differences in clinical outcomes. The total societal costs of the experimental group were on average lower compared to the control group (mean [95% confidence interval]: € 405 [-1728, 918]), albeit with a high level of uncertainty. We found a negligible difference in QALYs between groups (mean [95% confidence interval]: 0.006 [-0.011, 0.023]). The probability of stratified exercise therapy being cost-effective compared to usual exercise therapy from the societal perspective was around 73%, regardless of the willingness-to-pay threshold. However, this probability decreased substantially to 50% (willingness-to-pay threshold of €20.000/QALY) when using the healthcare perspective. Similar results were found for knee pain and physical functioning.

CONCLUSIONS

We found no clear evidence that stratified exercise therapy is likely to be cost-effective compared to usual exercise therapy in patients with knee OA. However, results should be interpreted with caution as the study power was lower than intended, due to the Coronavirus disease (COVID-19) pandemic.

Osteoarthritis as an Umbrella Term for Different Subsets of Humans Undergoing Joint Degeneration: The Need to Address the Differences to Develop Effective Conservative Treatments and Prevention Strategies

Osteoarthritis (OA) of joints such as the knee and hip are very prevalent, and the number of individuals affected is expected to continue to rise. Currently, conservative treatments after OA diagnosis consist of a series of increasingly invasive interventions as the degeneration and pain increase, leading very often to joint replacement surgery. Most interventions are focused on alleviating pain, and there are no interventions currently available that stop and reverse OA-associated joint damage. For many decades OA was considered a disease of cartilage, but it is now considered a disease of the whole multi-tissue joint. As pain is the usual presenting symptom, for most patients, it is not known when the disease process was initiated and what the basis was for the initiation. The exception is post-traumatic OA which results from an overt injury to the joint that elevates the risk for OA development. This scenario leads to very long wait lists for joint replacement surgery in many jurisdictions. One aspect of why progress has been so slow in addressing the needs of patients is that OA has been used as an umbrella term that does not recognize that joint degeneration may arise from a variety of mechanistic causes that likely need separate analysis to identify interventions unique to each subtype (post-traumatic, metabolic, post-menopausal, growth and maturation associated). A second aspect of the slow pace of progress is that the bulk of research in the area is focused on post-traumatic OA (PTOA) in preclinical models that likely are not clearly relevant to human OA. That is, only ~12% of human OA is due to PTOA, but the bulk of studies investigate PTOA in rodents. Thus, much of the research community is failing the patient population affected by OA. A third aspect is that conservative treatment platforms are not specific to each OA subset, nor are they integrated into a coherent fashion for most patients. This review will discuss the literature relevant to the issues mentioned above and propose some of the directions that will be required going forward to enhance the impact of the research enterprise to affect patient outcomes.

Acupotomy combined with intra-articular injection of sodium hyaluronate in the treatment of knee osteoarthritis

This retrospective study aimed to compare the effects of acupotomy combined with intra-articular injection of sodium hyaluronate (IA-SH) for the treatment of knee osteoarthritis (KOA). Eighty electronic medical records of patients with KOA were retrospectively analyzed. The patients were divided into an intervention group (n = 40, acupotomy plus IA-SH) and a control group (n = 40, IA-SH). Outcome measures included the visual analog scale, the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and adverse events. Outcome data were collected and analyzed before and after treatment. The results of this study showed that there was a greater reduction in the visual analog scale (P < .01) and WOMAC scores (pain, P < .01; stiffness, P < .01; function, P < .01; total, P < .01) in the intervention group than in the control group. In addition, there were no significant differences in adverse events between the 2 groups. In this study, the effects of acupotomy plus IA-SH were superior to those of IA-SH alone for the treatment of patients with KOA. Further prospective studies are required to confirm these findings.

The Effect of Core Stabilization Training on Improving Gait and Self-Perceived Function in Patients with Knee Osteoarthritis: A Single-Arm Clinical Trial

The treatment of patients with knee osteoarthritis is typically focused on the involved lower extremity. There is a gap in the literature concerning the effectiveness of core stabilization training on the treatment of patients with knee osteoarthritis. This investigation aimed to determine whether core stabilization improved the gait and functional ability of patients with knee osteoarthritis. Eighteen participants with knee osteoarthritis completed the six-week core stabilization intervention. Participants completed the gait motion analysis and the Knee Injury and Osteoarthritis Outcome Score to assess self-perceived function, pre- and post-intervention. Gait speed improved (p = 0.006, d = 0.59), while the external knee adduction moment decreased (p = 0.034, d = −0.90). Moreover, self-reported function improved (p < 0.001, d = 1.26). The gait speed and external knee adduction moment changes met minimal detectable change thresholds, while gait speed also met the minimal clinically important difference. A six-week core stabilization program can thus improve gait speed and reduce the external knee adduction moment, which is tied to disease progression. Increased functional scores post-intervention indicate an important clinical improvement. Core stabilization training is a safe and potentially effective treatment option for this population.

Colchicine versus Physical Therapy in Knee Osteoarthritis

Background: The treatment of osteoarthritis remains a major challenge due to the unavailability of a disease-modifying medication and the limitations of current therapeutic perspectives, which mainly target the symptoms, not the disease itself. The purpose of our study is to compare the efficacy of colchicine treatment versus physical therapy. Methods: The study included 62 patients diagnosed with knee osteoarthritis (KOA) according to the American College of Rheumatology (ACR) criteria, hospitalized within the time frame of October 2020−March 2022 in the Department of Rehabilitation Medicine and Physical Therapy of the Emergency Clinical County Hospital of Craiova. The participants were randomly divided into two groups. The observation period was 16 weeks long. The first group (31 patients) received colchicine at a dosage of 1 mg/day together with analgesics (acetaminophen < 2 g/day), while the second group (31 patients) received analgesics (acetaminophen < 2 g/day) together with a 16-week plan of physiotherapy. Results: Group II, in which patients underwent physical therapy, demonstrated a statistically significant decrease in both left (p < 0.001) and right (p = 0.012) knee VAS and WOMAC (p = 0.038) scores at 16 weeks, compared to the group treated with colchicine. Regarding the MSUS examination at 16 weeks, there were no significant changes in the structural abnormalities and no improvement in cartilage aspect or thickness. Higher BMI was associated with higher WOMAC score (p = 0.012), but not with higher VAS score (p = 0.062). Cholesterol and triglyceride levels were associated with high WOMAC (p < 0.001; p = 0.021) and high VAS (p = 0.023; p < 0.001) scores. Conclusions: Our study monitored VAS and WOMAC scores in two groups of patients with KOA, showing that physical therapy is more effective than colchicine in reducing symptoms. We found no statistically significant difference in musculoskeletal ultrasound (MSUS) feature improvement during the 16-week study.