Intra-Articular Injection of Botulinum Toxin for the Treatment of Knee Osteoarthritis: A Systematic Review of Randomized Controlled Trials

Ultrasound-guided gluteal nerves electrical stimulation to enhance strength and power in individuals with chronic knee pain: a randomized controlled pilot trial

Introduction

Various pathophysiological contexts can be accompanied by weakness, arthrogenic muscle inhibition, and even disability. In this scenario, peripheral nerve stimulation has been studied not only for pain management but also for the improvement of neuromuscular parameters. For this purpose, the use of Transcutaneous Electrical Nerve Stimulation (TENS) has typically been investigated, but recently, the use of ultrasound-guided percutaneous peripheral nerve stimulation (pPNS) has gained popularity. In this regard, electrical stimulation has a predisposition to activate Type II muscle fibers and has been shown to be capable of generating short-term potentiation by increasing calcium sensitivity. However, the evidence of pPNS applied in humans investigating such variables is rather limited.

Objectives

This pilot study aimed to assess the feasibility of the methodology and explore the potential of pPNS in enhancing hip extension performance in individuals suffering from knee pain, comparing it with TENS.

Methods

Twelve participants were divided into pPNS and TENS groups, undergoing pre- and post-intervention assessments of peak concentric power (W), strength (N), execution speed (m/s), and one-repetition maximum (1RM) (kg) estimation. For pPNS, two needles were positioned adjacent to the superior and inferior gluteal nerves under ultrasound guidance. For TENS, electrodes were positioned between the posterosuperior iliac spine and the ischial tuberosity, and halfway between the posterosuperior iliac spine and the greater trochanter. The interventions consisted of 10 stimulations of 10 s at a frequency of 10 Hz with a pulse width of 240 μs, with rest intervals of 10 s between stimulations.

Results

Peripheral nerve stimulation significantly improved concentric power at 30% (p = 0.03) and 50% (p = 0.03) of 1RM, surpassing TENS, which showed minimal changes. No significant strength differences were observed post-intervention in either group.

Conclusion

This work presents evidence where pPNS applied to the gluteal nerves results in an enhanced performance of hip extension at submaximal loads. However, this improvement does not seem to be reflected in short-term changes in the estimation of the 1RM by the force-velocity profile.

The effect of dextrose prolotherapy on patients diagnosed with knee osteoarthritis: A comprehensive systematic review and meta-analysis of interventional studies

Background and Aims

The primary objective of this systematic review and meta-analysis was to assess the impact of dextrose prolotherapy on individuals diagnosed with knee osteoarthritis (KOA).

Methods

To conduct a thorough investigation, a variety of leading international databases were checked, including PubMed (Medline), Scopus, Web of Sciences, EMBASE (Elsevier), ClinicalTrials.gov, and the Cochrane Library. The search covered a period from January 2000 to the end of June 2023, which facilitated the collection of relevant studies.

Results

The findings of the study revealed that when the studies utilizing the Western Ontario McMaster Universities Index tool (WOMAC) were combined, patients with KOA who received prolotherapy experienced an improvement in function compared with those who received other treatments (SMD: 0.20; 95% Confidence Interval [1]: -0.11, 0.51; p value SMD = 0.221; I 2: 78.49%; p heterogeneity < 0.001). Additionally, there was a decrease in mean pain and stiffness among patients who received prolotherapy compared with those who received other treatments or a placebo [(SMD: -0.95; 95% CI: -1.14, -0.76; p value SMD < 0.001; I 2: 59.35%; p heterogeneity = 0.070) and (SMD: -0.21; 95% CI: -0.32, -0.10; p value SMD < 0.001; I 2: 88.11%; p heterogeneity < 0.001)]. Furthermore, based on the Visual Analog Scale (VAS) score, there was a reduction of 0.81 units out of 10 in mean pain for patients with KOA who received prolotherapy (SMD: -0.81; 95% CI: -5.63, 4.10; p value SMD = 0.693; I 2: 48.54%; p heterogeneity = 0.08).

Conclusion

Drawing from the data analysis performed in this meta-analysis, it is apparent that dextrose prolotherapy exhibits promising effectiveness in reducing joint pain and stiffness, as well as improving functional performance in individuals suffering from KOA. Furthermore, it is recommended that forthcoming studies incorporate follow-up periods to guide decisions concerning the duration of prolotherapy's effects.

Demonstrating the effectiveness of intra-articular prolotherapy combined with peri-articular perineural injection in knee osteoarthritis: a randomized controlled trial

BACKGROUND

This study aimed to compare the efficacy of intra-articular prolotherapy (IG) combined with peri-articular perineural injection (PG) in the management of knee osteoarthritis (KOA).

METHODS

A total of 60 patients with the diagnosis of KOA were included in this double-blinded randomized controlled clinical trials. The inclusion criteria were as follow: (1) 48-80 years old; (2) the diagnose of KOA; (3) the grade 2 and 3 of the Kellgern-Lawrence grading scale; (4) the pain, crepitation, and knee joint stiffness continuing for 3 months at least. The main exclusion criteria were as follow: (1) any infection involving the knee skin; (2) history of any Influencing factors of disease. All patients were divided into three groups and received either IG, PG and I + PG under the ultrasound guidance and the 2, 4 and 8 weeks follow-up data of patients were available. (IG n = 20 or PG n = 20, I + PG n = 20). Visual Analogue Scale (VAS), The Western Ontario McMaster University Osteoarthritis Index (WOMAC) and the pressure pain threshold (PPT) were used as outcome measures at baseline, 2, 4 and 8 weeks.

RESULTS

There were no statistically significant differences in terms of age, sex, BMI, duration of current condition and baseline assessments of pain intensity, WOMAC scores and PPT. After treatment, the improvement of VAS activity, WOMAC and PPT values was showed compared with pre-treatment in all groups (p < 0.05). At 4 and 8 weeks after treatment, the VAS and WOMAC scores of the I + PG were significantly lower than those of the PG or IG, and the difference was statistically significant (p < 0.05). The PPT values of PG and I + PG were significantly improved compared to IG at 2, 4, and 8 weeks after treatment.

CONCLUSION

The ultrasound guided I + PG of 5% glucose seem to be more effective to alleviate pain and improve knee joint function than single therapy in short term. Clinical rehabilitators could clinically try this combination of I + PG to improve clinical symptoms in patients with KOA.

Safety and Efficacy of Hybrid Cooperative Complexes of Sodium Hyaluronate and Sodium Chondroitin for the Treatment of Patients with Symptomatic Knee Osteoarthritis

INTRODUCTION

Knee osteoarthritis (KOA) represents a widespread degenerative disease that causes pain and motor disability. Conservative treatments mainly focus on relieving symptoms, improving joint function, and trying to delay surgery. Safety and efficacy of hybrid cooperative complexes (2.4% sodium hyaluronate and 1.6% sodium chondroitin; HA-SC) for symptomatic KOA were investigated in a single-arm, prospective, pilot study.

METHODS

Patients with a visual analogue scale (VAS) pain score ≥ 4 and Kellgren-Lawrence Grade < 4 received a single intraarticular HA-SC injection. Patients with a VAS score change from baseline ≤ 1 received a second injection at day 30. Device-related adverse events (DR-AEs)/adverse events (AEs) were primary endpoints. Secondary endpoints included Western Ontario and McMaster Universities Osteoarthritis Index LK 3.1 (WOMAC LK 3.1), VAS, patient global assessment of disease status (PtGA), and patient proportion needing a second injection.

RESULTS

Of 83 patients with KOA (Kellgren-Lawrence Grade, 2-3), 34.9% had DR-AEs at day 7. No serious DR-AEs/AEs were reported. A significant (P < 0.0001) reduction over time in VAS pain score plus WOMAC pain, stiffness, physical function limitation, and total scores was reported. Median PtGA scores indicated a 'slight improvement' at most follow-up visits. Only 18.1% of patients required a second injection.

CONCLUSIONS

A single intraarticular HA-SC injection was safe, well-tolerated, and did not lead to major deterioration in terms of reducing knee pain, stiffness, and physical function limitation in patients with symptomatic KOA.

Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials

BACKGROUND AND OBJECTIVE

Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS.

DATABASES AND DATA TREATMENT

A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain").

RESULTS

Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life.

CONCLUSION

The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach.

SIGNIFICANCE

The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Evaluation of single and multiple hyaluronic acid injections at different concentrations with high molecular weight in the treatment of knee osteoarthritis

BACKGROUND

Knee osteoarthritis is severe progressive and most commonly diagnosed articular disease and its incidence is increasing around the world depending on age. This pathologic condition which limits daily activity of patients can be characterized by degeneration of cartilage and inflammation. Although non-steroidal anti-inflammatory (NSAII) agents and other analgesics are routinely used treatment options, the potential effects of intraarticular injections including hyaluronic acid (HA) have also been demonstrated by various studies. However, few studies compare the efficacy of a single high molecular weight (HMW) high dose and a triple HMW low dose. This study aimed to compare the efficacy of single high molecular weight (HMW) high dose (2 mL / 60 mg) and triple HMW low dose (2 mL /30 mg) intra-articular injection of HA in knee osteoarthritis (OA) patients by evaluating function and pain parameters during 12 months.

METHODS

This is a single-center, retrospective clinical study that included and involved 128 patients. Group I (n=64) patients received triple 30 mg HA injections (SEMICAL®) with one-week intervals, while Group II (n=64) patients received a single 60 mg HA injection (SEMICAL®). Lequesne Index, WOMAC and VAS scores were recorded to assess pain and function during a 12-month period.

RESULTS

There was no significant difference in characteristics of patient demographics. Our finding indicate that WOMAC, VAS score, and Lequesne Index values during follow-up visits exhibited a decrease, signifying improvement in the clinical condition. Notably, scores were significantly more favorable with the 30 mg of HA injection compared to the 60 mg of HA injection.

CONCLUSION

This study suggests that the triple low-dose injection of HMW HA is more effective in improving WOMAC, VAS scores and Lequesne Index values than a single high-dose injection.

Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis

OBJECTIVE

There are many injectable treatments for knee osteoarthritis with different characteristics and effects, the aim is to understand which one can lead to better and safer results.

METHODS

The PRISMA principles were followed when doing the literature search. Web of Science databases, Embase, the Cochrane Library, PubMed, and the Wanfang database were searched to identified randomized controlled trials that assessed the efficacy of corticosteroids (CSC), platelet-rich plasma (PRP), hyaluronic acid (HA), and combination therapy in treating KOA. Risk of bias was assessed using the relevant Cochrane tools (version 1.0). The outcome measure included the visual analog scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, and treatment-related adverse events. The network meta-analysis was performed using STATA17 software and a Bayesian stratified random effects model.

RESULTS

Network meta-analysis using the Bayesian random-effects model revealed 35 studies with 3104 participants. PRP showed the best WOMAC score at a 3-month follow-up, followed by PRP + HA, HA, placebo, and CSC; PRP + HA scored the highest VAS, followed by PRP, CSC, HA, and placebo. PRP, CSC, HA, and placebo had the highest WOMAC scores six months following treatment; PRP + HA showed the best VAS scores. PRP showed the best WOMAC score at 12 months, followed by PRP + HA, HA, placebo, and CSC; The best VAS score was obtained with PRP, followed by PRP + HA, HA, and CSC. No therapy demonstrated a rise in adverse events linked to the treatment in terms of safety.

CONCLUSIONS

The current study found that PRP and PRP + HA were the most successful in improving function and alleviating pain after 3, 6, and 12 months of follow-up. CSC, HA, PRP, and combination therapy did not result in an increase in the incidence of treatment-related side events as compared to placebo.

The role of osteoarthritis severity, BMI and age on clinical efficacy of bone marrow aspirate concentrate in the treatment of knee osteoarthritis

Aim: The aim of this study was to assess whether BMI, severity of knee osteoarthritis, age and gender have any influence on the final clinical results of bone marrow aspirate concentrate injection. Method: A total of 111 study participants with painful knee osteoarthritis and different characteristics concerning before mentioned factors underwent bone marrow aspirate concentrate (BMAC) therapy and were followed up for 1 year. Result: Significant pain and functional improvement were observed in all participant groups. Participants' age and BMI did not influence the clinical outcome, but there was an influence of OA severity, especially among older patients. Conclusion: This study shows that BMAC therapy is effective. Younger patients with milder OA changes could be better candidates for long-lasting and more efficient BMAC therapy. Clinical Trial Registration: NCT03825133 (ClinicalTrials.gov).

Treatment with CR500® improves algofunctional scores in patients with knee osteoarthritis: a post-market confirmatory interventional, single arm clinical investigation

BACKGROUND

Knee osteoarthritis (OA) is a progressive and degenerative condition. Several pharmacological and non-pharmacological treatments are able to improve the OA symptoms and the structural characteristics of the affected joints. Among these, infiltrative therapy with hyaluronic acid (HA) is the most used and consolidated procedure for the pain management. The addition of skin conditioning peptides to HA promotes the cartilage remodeling processes and a better permeation of the HA-based gel containing a peptide mixture, CR500®. Furthermore, the topic route of administration is convenient over the routinely used intra-articular injective procedures. In this study, the effectiveness of CR500® was evaluated in terms of improvement of the algo-functional symptoms related to unilateral knee OA.

METHODS

38 mild and moderate OA patients were enrolled at a screening visit (V-1), treated at baseline visit (V1), and then continued the topical application of CR500® twice a week for 4 weeks, and followed-up for 3 visits (V2-V4) from week 2 to 4. Lequesne Knee Index (LKI) and Knee injury and Osteoarthritis Outcome Score (KOOS) were collected. Synovial fluid was collected and used for the quantification of neoepitope of type II collagen (C2C), C-terminal telopeptide of type II collagen (CTX-II), type II collagen propeptide (CPII), tumor necrosis factor alpha (TNFα) and HA. The expression of CD11c and CD206 was evaluated on cell pellets.

RESULTS

Three patients were excluded, thus 35 patients were included in the analysis. The treatment with CR500® was safe and well tolerated, with 7.9% patients had mild adverse events, not related to the device. The LKI total score showed a significant decrease from V1 to V4. KOOS score also showed a significant improvement of patient condition at V2, V3 and V4 in comparison with V1 for all subscales, except for KOOS sport subscale which improved only from V3. At V1 a negative correlation among KOOS pain subscale values and C2C, CPII and TNFα levels was observed, as well as a positive correlation between KOOS pain subscale and CD11c/CD206 ratio.

CONCLUSION

CR500® is safe and appear to be effective in improving pain and function in OA patients during the 4 weeks of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05661162. This trial was registered on 22/12/2022.

Ozone Therapy versus Hyaluronic Acid Injections for Pain Relief in Patients with Knee Osteoarthritis: Preliminary Findings on Molecular and Clinical Outcomes from a Randomized Controlled Trial

Ozone therapy (OT) is used for the treatment of multiple musculoskeletal disorders. In recent years, there has been a growing interest in its use for the treatment of osteoarthritis (OA). The aim of this double-blind randomized controlled trial was to evaluate the efficacy of OT compared with hyaluronic acid (HA) injections for pain relief in patients with knee OA. Patients with knee OA for at least three months were included and randomly assigned to receive three intra-articular injections of ozone or HA (once a week). Patients were assessed at baseline and at 1, 3, and 6 months after the injections for pain, stiffness, and function using the WOMAC LK 3.1, the NRS, and the KOOS questionnaire. Out of 55 patients assessed for eligibility, 52 participants were admitted to the study and randomly assigned into the 2 groups of treatment. During the study, eight patients dropped out. Thus, a total of 44 patients, reached the endpoint of the study at 6 months. Both Group A and B consisted of 22 patients. At 1-month follow-up after injections, both treatment groups improved statistically significantly from baseline in all outcomes measured. At 3 months, improvements remained similarly consistent for Group A and Group B. At 6-month follow-up, the outcomes were comparable between the 2 groups, showing only a worsening trend in pain. No significant differences were found between the two groups in pain scores. Both therapies have proven to be safe, with the few recorded adverse events being mild and self-limiting. OT has demonstrated similar results to HA injections, proving to be a safe approach with significant effects on pain control in patients affected by knee OA. Due to its anti-inflammatory and analgesic effects, ozone might be considered as a potential treatment for OA.

A scalable 12-week exercise and education programme reduces symptoms and improves function and wellbeing in people with hip and knee osteoarthritis

Introduction

Osteoarthritis is a chronic musculoskeletal condition that impacts more than 300 million people worldwide, with 43 million people experiencing moderate to severe disability due to the disease. This service evaluation provides the results from a tailored blended model of care on joint health, physical function, and personal wellbeing.

Methods

1,593 adult participants with osteoarthritis completed the Nuffield Health Joint Pain Programme between February 2019 and May 2022. The 12-week programme included two 40-min exercise sessions per week. All exercise sessions were conducted face-to-face and were followed by 20 min of education to provide information and advice on managing osteoarthritis.

Results

The 12-week joint pain programme significantly improved Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global scores (Week 0: 37.5 [17.2]; Week 12: 24.0 [16.6]; p < 0.001), as well as subscales for pain (Week 0: 7.6 [3.7]; Week 12: 4.9 [3.7]; p < 0.001), function (Week 0: 26.0 [13.0]; Week 12: 16.3 [12.4]; p < 0.001), and stiffness (Week 0: 3.9 [1.6]; Week 12: 2.8 [1.7]; p < 0.001). Significant improvements in health-related outcomes including systolic and diastolic blood pressure (Week 0: 139 [18] mmHg; Week 12: 134 [17] mmHg, and Week 0: 82 [11] mmHg; Week 12: 79 [19] mmHg; both p < 0.001), body mass index (Week 0: 29.0 [4.5] kg/m2; Week 12: 28.6 [4.4] kg/m2; p < 0.001), waist to hip ratio (Week 0: 0.92 [0.23]; Week 12: 0.90 [0.11], p < 0.01) and timed up and go (Week 0: 10.8 s [2.9]; Week 12: 8.1 s [2.0]; p < 0.001) were also observed. On completion of the joint pain programme, participants also reported significant improvements in all assessed aspects of self-reported wellbeing (all p < 0.001).

Discussion

With reductions in physical symptoms of osteoarthritis and improvements in personal wellbeing, the joint pain programme delivered by personal trainers in a gym-setting offers a nationally scalable, non-pharmacological treatment pathway for osteoarthritis.