The association of prevalent medial meniscal pathology with cartilage loss in the medial tibiofemoral compartment over a 2-year period

Objective: To investigate the association of different types of magnetic resonance imaging (MRI)-detected medial meniscal pathology with subregional cartilage loss in the medial tibiofemoral compartment. Methods: A total of 152 women aged >= 40 years, with and without knee osteoarthritis (OA) were included in a longitudinal 24-month observational study. Spoiled gradient recalled acquisitions at steady state (SPGR) and T2-weighted fat-suppressed MRI sequences were acquired. Medial meniscal status of the anterior horn (AH), body, and posterior horn (PH) was graded at baseline: 0 (normal), 1 (intrasubstance meniscal signal changes), 2 (single tears), and 3 (complex tears/maceration). Cartilage segmentation was performed at baseline and 24-month follow-up in various tibiofemoral subregions using computation software. Multiple linear regression models were applied for the analysis with cartilage loss as the outcome. In a first model, the results were adjusted for age and body mass index (BMI). In a second model, the results were adjusted for age, BMI and medial meniscal extrusion. Results: After adjusting for age, BMI, and medial meniscal extrusion, cartilage loss in the total medial tibia (MT) (0.04 mm, P=0.04) and the external medial tibia (eMT) (0.068 mm, P=0.04) increased significantly for compartments with grade 3 lesions. Cartilage loss in the total central medial femoral condyle (cMF) (0.071 mm, P=0.03) also increased significantly for compartments with grade 2 lesions. Cartilage loss at the eMT was significantly related to tears of the PH (0.074 mm; P=0.03). Cartilage loss was not significantly increased for compartments with grade 1 lesions. Conclusion: The protective function of the meniscus appears to be preserved in the presence of intrasubstance meniscal signal changes. Prevalent single tears and meniscal maceration were found to be associated with increased cartilage loss in the same compartment, especially at the PH. (C) 2009 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Mechanical effects on the skeleton: Are there clinical implications?

The basic morphology of the skeleton is determined genetically, but its final mass and architecture are modulated by adaptive mechanisms sensitive to mechanical factors. When subjected to loading, the ability of bones to resist fracture depends on their mass, material properties, geometry and tissue quality. The contribution of altered bone geometry to fracture risk is unappreciated by clinical assessment using absorptiometry because it fails to distinguish geometry and density. For example, for the same bone area and density, small increases in the diaphyseal radius effect a disproportionate influence on torsional strength of bone. Mechanical factors are clinically relevant because of their ability to influence growth, modeling and remodeling activities that can maximize, or maintain, the determinants of fracture resistance. Mechanical loads, greater than those habitually encountered by the skeleton, effect adaptations in cortical and cancellous bone, reduce the rate of bone turnover, and activate new bone formation on cortical and trabecular surfaces. In doing so, they increase bone strength by beneficial adaptations in the geometric dimensions and material properties of the tissue. There is no direct evidence to demonstrate anti-fracture efficacy for mechanical loading, but the geometric alterations engendered undoubtedly increase the structural properties of bone as an organ, increasing the resistance to fracture. Like all interventions, issues of safety also arise. Physical activities involving high strain rates, heavy lifting or impact loading may be detrimental to the joints, leading to osteoarthritis; may stimulate fatigue damage leading with some to stress fractures; or may interact pharmaceutical interventions to increase the rate of microdamage within cortical or trabecular bone.

A efectividade de um programa de exercícios terapêuticos na doença osteo-articular no idoso

RESUMO: O presente estudo teve como objectivo avaliar a efectividade de um programa de intervenção de fisioterapia comparativamente ao tratamento conservador (calor húmido, ultra-som e massagem), relativamente à dor e capacidade funcional, no utente idoso com doença osteoarticular do joelho. A amostra foi aleatória, tendo sido seleccionados 20 utentes que respeitaram os critérios de inclusão, e que foram distribuídos aleatoriamente pelos dois grupos de tratamento, 9 no grupo A (experimental) e 11 no grupo B (controle). Todos os utentes deram o seu consentimento informado. Trata-se de um estudo experimental, controlado aleatorizado (RCT). A intervenção em estudo consistiu em 15 sessões de tratamento individuais, efectuadas 3 vezes por semana. O programa terapêutico efectuado pelo grupo A incluiu o tratamento conservador (20 minutos calor húmido, 5 minutos ultra-som (contínuo; 1,5W/cm2) e aproximadamente 10 minutos de massagem local) e o protocolo de exercícios terapêuticos em estudo. Este protocolo de exercícios foi progredindo semanalmente em termos da sua intensidade. Os utentes do Grupo B efectuaram apenas o tratamento conservador (tal como no grupo A). Para avaliar a dor e a capacidade funcional foi utilizado o Questionário knee Injury and Osteoarthritis Outcome Score. A análise dos resultados foi realizada através dos testes Mann-Whitney e Kruskal-Wallis para a comparação entre grupos. Os resultados sugerem não haver diferenças estatisticamente significativos entre os grupos, embora o grupo de controle tenha obtido melhores resultados. O grupo B apresentou uma diminuição da dor de 17,33, comparativamente aos valores de -3,00 no grupo A (p=0,101), e melhoria da capacidade funcional de 13,00, mantendo-se a capacidade funcional igual, no grupo A (0,00) p=0,080). Estes resultados parecem sugerir que não há diferenças significativas entre as duas modalidades de intervenção, realçando a necessidade de continuar a investigar este protocolo de exercícios e a sua efectividade.-----------------ABSTRACT: The aims of this study was to evaluate the effectiveness of a treatment program compared with conventional treatment (post hoots, ultrasound and massage), for the outcomes pain and functional ability in elderly with knee osteoarthritis. The sample was non-probability, and 20 patients have been selected that fulfilled the criteria for inclusion and who were randomly assigned to the two treatment groups, in group A and 11 in group B. All of the patients gave their informed consent. This is an experimental, randomized controlled trial (RCT) with blinded assessment, of comparative design. This study protocol program was carry out in 15 individual treatment sessions, 3x per week. The therapeutic program made by group A consisted of the performance of conservative treatment: 20 minutes of hot packs, 5 minutes of ultrasound (continuous, 1.5 W/cm2) and 10 minutes of massage plus the exercise protocol therapy consisted of: isometric exercises of quadriceps contractions, muscle strengthening for knee and aerobic training. This exercise protocol was progressing every week in terms of its intensity. The users in Group B, only made the conservative treatment (such as in group A). In this study there were evaluated the pain and functional capacity, assessed by questionnaire knee Injury Osteoarthritis Outcome Score. For comparison between groups were used Mann-Whitney and Kruskal-Wallis tests. The results revealed that in group B was that it obtained better results, although they are not statistical significance. The group B show a decrease in pain of 17.33 compared to -3.00 in group A (p = 0.101), and improved capacity functional of 13.00, keeping in group A (0.00) (p = 0.080). However, the differences are not statistically significant. These results show that there are not statistically significant in both treatments, but more studies are needed.

Efetividade da intervenção conservadora e de um programa de exercício físico no solo na osteoartrose do joelho

RESUMO: Objectivo: O estudo do efeito da fisioterapia e do exercício em diversos indicadores relacionados com a osteoartrose do joelho tem evidenciado efeitos benéficos em utentes com esta condição. Nesta sequência, pretendeu-se avaliar a efetividade da intervenção conservadora em conjunto com um programa de exercícios ao nível da dor, rigidez, amplitude articular, função física e qualidade de vida em utentes com osteoatrose do joelho a curto prazo, quando comparado com a intervenção recomendada. A prática clínica atual em Portugal, sob prescrição, desenvolve-se de acordo com o padrão que se pretende investigar. Metodologia: Trata-se de um estudo quasi-experimental controlado e sem aleatorização. Os utentes da Clínica FPM (n=20; 35,0% homens, 65,0% mulheres) sujeitos à intervenção conservadora (calor húmido, ultra-som e massagem) em conjunto com um programa de exercício no solo, durante um período de 4 semanas com frequência diária, integram o grupo experimental e os utentes inscritos no programa de exercício a solo do “Viver Activo” no Leirisport (n=21; 23,8% homens, 76,2% mulheres), num período de 8 semanas com frequência bi-semanal são considerados como grupo de controlo. Os instrumentos de medida aplicados foram o Knee Outcome Osteoarthritis Score (KOOS) para os outcomes dor, rigidez, função física e qualidade de vida e a goniometria para a amplitude articular. Resultados: Em ambos os grupos foram observados aumentos significativos em todos os outcomes avaliados pelo KOOS (dor, rigidez, função física e qualidade de vida) e pela goniometria (amplitude articular) num período de 4 e 8 semanas. Quando comparada a evolução do grupo experimental com a do grupo controlo, verifica-se que as diferenças significativas ocorrem na flexão (p <0,05) (maior evolução para o grupo experimental), e na dor (p <0,05) (maior evolução para o grupo controlo). Nos outcomes rigidez, função física e qualidade de vida foi ainda possível identificar resultados positivos que sugerem possíveis benefícios da intervenção em grupo para os sujeitos a ela submetidos. Discussão e Conclusão: Estes resultados sugerem que a intervenção clínica individualizada é mais efectiva do que a intervenção em grupo no aumento da amplitude articular do joelho em utentes com osteoartrose a curto prazo. No entanto, para os outcomes dor, rigidez, função física e qualidade de vida, a intervenção em grupo parece ser clinicamente e estatisticamente melhor. A relevância deste estudo afirma-se ao demonstrar que utentes com osteoartrose do joelho que integrem um programa de exercício em grupo beneficiam de melhorias importantes. Ao adicionar sessões de fisioterapia para realização de intervenção conservadora individualizada e exercícios supervisionados agrega um maior alívio sintomático.-------- ABSTRACT: Study of physical therapy and exercise into several indicators associated to knee osteoarthritis has shown positive effects in subjects within this condition. According to the study it has been evaluated the effectiveness of a conservative intervention along with a exercise program directed to pain, stiffness, range of motion, physical function and quality of life of patients with knee osteoarthritis in a short term when compared with the recommended intervention. Under prescription the current clinical practice in Portugal is developed according to the pattern to investigate. Methodology: This is a quasi-experimental controlled study without randomization. The subjects of FPM Clinic (n= 20, 35.0% men, 65.0% women) were submitted to the conservative intervention (hot pack, ultrasound and massage) with a land exercise program during a 4 week-period (all-weekly) were assigned in the experimental group. Patients signed in the land exercise program of "Active Living" in Leirisport (n = 21, 23.8% men, 76.2% women) a 8 week-period (bi-weekly) were assigned as control group. Outcomes were measured by the Knee Outcome Osteoarthritis Score (KOOS) for pain, stiffness, physical function and quality of life. Goniometry was used for range of motion. Results: Both treatment groups obtained successful outcomes measured by significant reductions in KOOS scores and improvement in goniometry in a 4 and 8-week period. When compared the evolution of the experimental group with the control group it appears that significant differences occur in the range of motion (p <0.05) (further progress in the experimental group), and pain (p <0.05) (further evolution for the control group). In outcomes stiffness, physical function and quality of life was possible to identify positive results that suggest potential benefits of intervention for the submitted subjects. Discussion and Conclusion: These results suggest that individualized clinical intervention is more effective than group intervention in range of motion improving in patients with knee osteoarthritis in a 4-week period. However outcomes for pain, stiffness, physical function and quality of life appear to be clinically and statistically better for the group intervention. The significance of this study is essencial because it demonstrates that patients with knee osteoarthritis who incorporate an exercise program in group reveal improvements. When adding physical therapy sessions with individual conservative intervention and supervised exercises the result is an improvement of symptomatic relief.

Efectividade de um programa de exercício aquático na osteoartrose do joelho

RESUMO: A osteoartrose do joelho é uma condição clínica cuja prevalência tem aumentado nos últimos anos na população idosa. Trata-se de uma condição que pode ser bastante incapacitante para o idoso, gerando um forte impacto social e económico. O exercício aquático tem sido identificado como um factor de promoção da melhoria do quadro clínico nesta população, mas a sua efectividade não está, ainda, determinada. Objectivo: investigar a efectividade, a curto e médio prazo, de um programa de exercício aquático, realizado em grupo, com a duração de 8 semanas, na amplitude articular, dor e rigidez do joelho, e na função física e qualidade de vida, em idosos com osteoartrose do joelho. Metodologia: Recorreu-se a um estudo quase-experimental, double-blind, controlado, sem aleatorização, cuja amostra, constituída por 43 sujeitos, foi selecionada por conveniência. Os sujeitos do grupo experimental (n=22) foram submetidos ao programa de exercício aquático e os do grupo de controlo (n=21) foram submetidos ao programa de exercício no solo. Ambos os programas foram definidos de acordo com as recomendações internacionais para a prática de exercício físico em idosos com osteoartrose (Arthritis Foundation, 2009a, 2009b). Todo o grupo foi avaliado no início do programa, no final do mesmo (8 semanas) e após 6 semanas de follow-up, nos seguintes indicadores: amplitude articular do joelho (através do goniómetro), dor, rigidez, função e qualidade de vida (através do KOOS). Resultados: A amostra deste estudo foi constituída por sujeitos maioritariamente do género feminino (76,7%), com uma média de 72,7 anos (DP=5,49). O programa de exercício aquático implementado demonstrou um aumento da amplitude articular passiva de flexão (p<0,0001) e extensão (p=0,016) do joelho, uma diminuição da dor e da rigidez articular (p<0,0001), um aumento da função nas AVD’s (p<0,0001) e no desporto/lazer (p=0,031), e ainda, um aumento da qualidade de vida (p<0,0001). Contudo, apenas os níveis de amplitude articular passiva de extensão do joelho (p=0,083) e de função no desporto/lazer (p=0,244) se mantiveram ao longo das seis semanas de follow-up. Conclusões: Apesar de algumas limitações, considera-se que este estudo é de grande importância para a comunidade científica e para os fisioterapeutas preocupados com a crescente prevalência da osteoartrose e dos custos associados. O exercício aquático parece ser uma estratégia importante na melhoria do estado de saúde dos idosos com osteoartrose do joelho.----------------- ABSTRACT: The osteoarthritis of the knee is a clinical condition that has been increasing among the elderly population over the past few years. It’s a condition that can be fairly disabling to the elderly individual, and which generates a strong social and economic impact. Aquatic exercise has been named as a promotional factor in the improvement of the clinical picture in this population, but its effectiveness is yet to be determined. Objective: To investigate the effectiveness, in a short and medium term, of an aquatic exercise program undertaken by a group over eight weeks, in the joint amplitude, pain and stiffness of the knee, and in the physical function and quality of life in elderly people who suffer from knee osteoarthritis. Methodology: was used a double-blind, quasi-experimental study with no randomization and its 43 subjects were selected as a matter of convenience. The subjects of the experimental group (n=22) were subjected to an aquatic exercise program and those of the control group (n=21) were subjected to a land-based exercise program. Both programs have followed international recommendations on the practice of physical exercise in elderly people who suffer from osteoarthritis (Arthritis Foundation, 2009a, 2009b). The entire group was evaluated in the beginning and at the end of the program (8 weeks later), and after a 6 week follow-up, in these parameters: knee range of motion (through a goniometer), pain, stiffness, function and quality of life (through KOOS). Results: This sample was predominantly female (76,7%) with a mean age of 72,7 years (SD=5,49). Aquatic exercise resulted in increase of passive joint flexion (p<0,0001) and knee extension (p=0,016), in the decline of pain and stiffness (p<0,0001), in the increase of function in the ADLs (p<0,0001). However, only the knee extension amplitude (p=0,083) and the function in sports/leisure (p=0,244) were kept through the six-week follow-up. Conclusions: Despite some limitations, this study is of great importance to the community and to the physiotherapists concerned with the growing prevalence of osteoarthritis and the associated costs. Aquatic exercise appears to be an important strategy in the improvement of the health condition of patients who suffer from knee osteoarthritis.

Intervenção da fisioterapia em indíviduos com osteoartrose do joelho: características da prática clínica, resultados obtidos e fatores de prognóstico para os resultados de sucesso

RESUMO:Introdução: O conhecimento acerca da prática da Fisioterapia, bem como a influência das características dos indivíduos com Osteoartrose do joelho (OA) no prognóstico dos resultados alcançados com a Fisioterapia, tem sido alvo de estudo em vários países. No entanto em Portugal, estudos desta natureza são escassos ou inexistentes. Objetivo: Este trabalho teve dois principais objetivos: Por um lado pretendeu caracterizar a prática da Fisioterapia e determinar os seus resultados em indivíduos com OA do joelho ao nível da intensidade da dor, incapacidade funcional e perceção global de melhoria; Por outro, identificar fatores preditivos para os resultados de sucesso após a intervenção da Fisioterapia. Metodologia: Trata-se de um estudo de coorte prospetivo com 77 participantes que foram avaliados antes e após a intervenção (8 semanas), com um follow-up de 3 meses. Procedeu-se à caracterização da prática da Fisioterapia quanto às modalidades utilizadas, número de sessões de tratamento e duração do episódio de cuidados. Os resultados obtidos foram medidos após intervenção (8 semanas) e num follow-up (3 meses), através da Escala Numérica da Dor (END), da versão Portuguesa do Questionário Knee Injury and Osteoarthritis Outcome Score (KOOS-PT), e da versão Portuguesa da Patient Global Impression of Change Scale (PGIC-PT). As características sociodemográficas e clínicas foram incluídas como potenciais fatores de prognóstico com base no critério de pontuação ≥5 na PGIC-PT e a análise dos dados foi realizada através do método de regressão logística multivariado no sentido de identificar as associações entre as variáveis na baseline e as variáveis de resultado (p<0.05). Resultados: Os resultados obtidos revelaram que existe uma grande diversidade de modalidades e procedimentos terapêuticos realizados pelos fisioterapeutas no tratamento da OA do joelho (em média 4 modalidades por utente), sendo os exercícios, a eletroterapia e a terapia manual, as intervenções mais frequentemente realizadas. Os resultados da intervenção revelaram uma redução significativa da intensidade da dor e da incapacidade funcional (medida pelas diferentes dimensões da KOOS-PT) às 8 semanas e aos 3 meses (p=0,001). A probabilidade de obter bons resultados na percepção de melhoria para realizar actividades da vida diária, está significativamente associada com a pontuação na dimensão KOOS AVD (OR=1,106, 95% IC 1,056-1,159) e com a intensidade da dor, (OR=0,543, 95% IC 0,300-0,983), na baseline. A probabilidade de obter bons resultados na percepção de melhoria relativa à dor, está significativamente associada com a pontuação na dimensão KOOS DOR (OR=1,116, 95% IC 1,030-1,209), e dimensão KOOS ADL (OR=1,123, 95% IC 1,014-1,243), na baseline. Conclusões: Os resultados do presente estudo revelam que a intervenção em Fisioterapia em casos de OA do joelho, apesar de utilizar uma grande diversidade de modalidades terapêuticas, proporciona uma redução significativa dos níveis de dor e incapacidade funcional em utentes com OA do joelho. Os resultados do presente estudo sugerem ainda que o sucesso da intervenção pode ser predito a partir de variáveis clinicas na baseline.------------ABSTRACT:Introduction: The knowledge about the practice of physical therapy, as well as the influence of the characteristics of subjects with knee osteoarthritis (OA) in the prognosis of the results achieved with physiotherapy, have been studied in several countries. However in Portugal, such studies are scarce or nonexistent. Objective: This study had two main aims: on one hand sought to characterize the practice of physical therapy and determine their outcomes in subjects with OA of the knee joint at the level of pain intensity, functional disability and global perception of improvement; Secondly, to identify predictive factors for successful outcomes after the intervention of physiotherapy. Methods: This was a prospective cohort study with 77 participants who were evaluated before and after the intervention (8 weeks), with a follow-up of 3 months. Proceeded to characterize the practice of physical therapy as modalities used, number of treatment sessions and duration of the period of care. The results were measured after intervention (8 weeks) and a follow-up (3 months) by a Numerical Rating Scale (NRS), the Portuguese version of the Knee Injury and Osteoarthritis Questionnaire Outcome Score (KOOS-PT) and the Patient Global Impression of Change Scale- Portuguese Version (PGIC-PT). The sociodemographic and clinical characteristics were included as potential prognostic factors based on scoring criteria≥5 na PGIC-PT and data analysis was performed using the method of multivariate logistic regression to identify associations between variables at baseline and outcome variables (p<0.05). Results: The results revealed that there is a great diversity of modalities and therapeutic procedures performed by physiotherapists in the treatment of knee OA (average 4 per user modes), with exercises, electrotherapy and manual therapy interventions most frequently performed. The results of intervention showed a significant reduction in the severity of pain and functional disability (measured by the different dimensions of the KOOS-PT) at 8 weeks and at 3 months (p = 0.001). The probability of getting good results in the perception of improvement to perform activities of daily living, is significantly associated with scores on the dimension KOOS ADL (OR=1,106, 95% CI 1,056-1,159) and the intensity of pain (OR = 0.543, 95% CI 0.300 to 0.983) at baseline. The probability of getting good results in the perception of improvement of the pain is significantly associated with scores on the KOOS PAIN (OR = 1.116, 95% CI 1.030 to 1.209) and KOOS ADL (OR = 1.123, 95% CI 1.014 to 1.243) at the baseline. Conclusions: The results of this study show that Physiotherapy treatment in cases of knee OA, provide a significant reduction of pain and disability among users with knee OA, despite the wide variety of therapeutic modalities. The results of this study also suggest that the success of the intervention can be predicted from clinical variables at baseline.

Intervenção da fisiopetarpia em indivíduos com osteoartrose do joelho: características da prática clínica e resultados obtidos em contexto de prática convencionada

RESUMO: Introdução: A osteoartrose do joelho em particular constitui uma das maiores causas de incapacidades no dia-a-dia, morbilidade e aumento dos custos de saúde na população, na medida em que é uma condição que quando sintomática progride para um padrão que incluí dor articular, perda de força, incapacidade para a marcha e redução da aptidão física. A sua prevalência aumenta com a idade, 7% entre pessoas dos 65-70 anos, e 11,2% para aqueles com 80 anos ou mais, pouco variando entre os estudos existentes. Um recente estudo da Organização Mundial da Saúde (OMS) refere que a osteoartrose é a quarta causa mais importante de incapacidade entre as mulheres e a oitava entre os homens. Objetivo do estudo: Descrever a intervenção da fisioterapia em contexto de prática clínica convencionada e os resultados obtidos em indivíduos com OA, ao nível da intensidade da dor, capacidade funcional e perceção global de melhoria. Desenho Metodológico: Trata-se de um Estudo de coorte prospetivo onde foram incluídos indivíduos de ambos os géneros, entre os 60 e os 80 anos, com osteoartrose do joelho referenciada clinicamente. Após o consentimento informado, os pacientes foram, avaliados em quatro momentos: num primeiro momento (T0), antes de iniciarem o tratamento; (T1) após 4 semanas do início do tratamento; (T2) coincidente com o final do tratamento; e (T3) 3 meses após o início do tratamento. Foi utilizado um Questionário de Caracterização Sócio-Demográfica e Clínica, a Escala numérica da dor – END, o questionário KOOS (Knee Injury and Osteoarthritis Outcome Score) e a versão portuguesa da Patient Global Impression Change (PGIC-PT). A base de seleção dos indivíduos foi realizada numa clínica convencionada do Algarve. Resultados: Foi observado um aumento significativo em todos os outcomes avaliados pelo KOOS, END e PGIC num período até 3 meses após a intervenção. Na avaliação da END em T3 o valor da média foi de 1,63(±0,71). Para o KOOS nas subescalas Sintomas foi de 87,60(±5,86), Dor 85,71(±3,99), AVD 78,23(±3,48), ADL 67,71(±7,16), QV 80,71(±9,14), para a PGIC-AVD 5,29(±0,57), PGIC-DOR 5,97(±0,61). Os resultados obtidos pelo teste de Friedman, revelaram um valor de p<0,005. Assim, a melhoria da incapacidade funcional reportada pelos participantes neste grupo é estatisticamente diferente, e de forma significativa nos diferentes momentos de recolha de dados, durante e após o tratamento (X2 (3)=208,862, p<0,005)/ (X2(3)=205,041, p<0,005). Por fim os valores do somatório dos participantes, que estão inseridos em no grupo dos “Bons Resultados”( ≥5) foi de 27,14% em T0 passando para 100,00% em T3, enquanto que o grupo dos “Maus Resultados”(<5) foi de 72,86% em T0 e 100% em T3. Conclusão: Os resultados do presente estudo sugerem que a intervenção da Fisioterapia efetuadas em clínicas convencionadas nos casos da Osteoartrose do joelho são efetivas na redução significativa dos níveis de dor e incapacidade funcional e na Perceção global de melhoria em pacientes com Osteoartrose do joelho. ---------- ABSTRACT: Introduction: Osteoarthritis of the knee in particular is a major cause of disabilities in their day-to-day morbidity and increased healthcare costs in the population, in that it is a disease that when symptomatic progresses to a pattern that included joint pain, strength loss, inability to walk and reduction of physical fitness. It is referred as a risk factor for falls and fractures. Its prevalence increases with age, 7% of people between 65-70 years, and 11.2% for those aged 80 or more, ranging from some existing studies. A recent study by the World Health Organization (WHO) reports that osteoarthritis is the fourth leading cause of disability among women and eighth among men. Objective: To describe the characteristics and the outcomes of the physiotherapy practice in patients with knee osteoarthritis. Methodology: A prospective cohort study, with 70 individuals, aged between 60 and 80 years with the diagnosis of knee osteoarthritis and referred to physiotherapy treatment, was carried out. After informed consent, patients were evaluated in four different moments: at baseline (T0), before starting treatment; 4 weeks after starting their treatment (T1); 8 weeks after starting their treatment (T2); and in a 3 months follow-up (T3). Patients were assessed for their socio-demographic and clinical characteristics, pain intensity (using the numeric pain rating scale- NRS), disability (using the Knee Injury and Osteoarthritis Outcome Score), and for their global impression of change (using the Portuguese version of the Patient Glogal Impression of Change scale). Results: The findings of this study indicate a significant increase in all outcomes assessed (pain, disability and global impression of change), during and after the physiotherapy treatment. At T3, the average value for the NRS was 1.63 (± 0.71). For KOOS in the symptoms subscales was 87.60 (± 5.86), pain 85.71 (± 3.99), ADL 78.23 (± 3.48), ADL 67.71 (± 7.16), QV 80.71 (± 9.14) for the PGIC-AVD 5.29 (± 0.57), PGIC-PAIN 5.97 (± 0.61). The results obtained though the Friedman test revealed a p-value <0.005. Thus, the improvement of functional capacity reported by participants in the group was statistically different at the different moments of data collection, during and after treatment (X 2 (3) = 208.862, p <0.005) / (X 2 (3) = 205.041, p <0.005). Conclusion: The results of this study show that the physiotherapy treatments made on agreed clinics in cases of osteoarthritis of the knee, are effective in significant reduction in the levels of pain and disability and in perception of overall improvement perception in patients with osteoarthritis of the Knee.

Tratamiento domiciliario de gonartrosis con parches de microcorrientes

Objective: To outline the treatment by patches of microcurrent at home of patients with disabling knee osteoarthritis to perform their activities of daily life and work. Material and methods: We selected 80 patients in the surgical waiting list for total knee arthroplasty. 40 of whom received active patch and 40 inactive. All were given exercise protocol knee. The variables analyzed were: pain (VAS), joint balance, muscular balance and quality of life (SF-12). Patients were reviewed after two months of treatment. Variables were analyzed with SPSS 17.0 statistical program. Results: Statistically significant results were obtained (p <0.05) for decrease in mean pain according to VAS scale. No significant differences for other variables were found. Conclusions: Microcurrent therapy could be an alternative in the treatment of knee osteoarthritis pain, with no differences with the traditional treatment.

Prótesis unicompartimental lateral de rodilla. Indicaciones, técnica y resultados a mediocorto plazo

Objectives: In patients with lateral osteoarthritis of the knee, use of external unicompartmental knee arthroplasty it is a well known surgical alternative, used by the minor trauma involved, short hospital stay and rapid recovery. The purpose of this study is to show the clinical outcomes to short-medium term of patients undergoing this procedure. Methods: we describe the technique used and the peculiarities of the prosthesis (A Mobile-bearing lateral unicompartmental knee replacement, Oxford Domed ®). This is an observational retrospective longitudinal study, of 15 arthroplasties performed in 13 women and 2 men, between 2010 and 2013, with a mean age of 60’7 years, with a diagnosis of lateral osteoarthritis of the knee, without involvement of the medial or patellofemoral compartment and cruciate ligaments functionally intact, with a mean follow up of 25 months. All patients complete the Oxford Knee Score and Visual Analog Scale (VAS) during the study. Results: The results are favorable, with an improvement of 6.60 points on the EVA, 3.73 for 1 in the postoperatory funcionality, the OKS very satisfactory with an average of 38 points over 50 and without any postoperative function surgical revision. Anserine tendinitis was observed in 20% of cases. Conclusions: The benefits of this surgery against their alternatives are assessed, and their potential drawbacks. External unicompartmental knee arthroplasty is an effective alternative in cases of knee osteoarthritis of the lateral compartment with no other associated injuries.

Work in inflammatory and degenerative joint diseases

This article focuses on work disability and sick leave and their cost; it also discusses the value of vocational rehabilitation programmes in rheumatic conditions such as rheumatoid arthritis, ankylosing spondylitis, hip and knee osteoarthritis. It acknowledges the importance of work not only for the worker who has one of these diseases but also for the public purse. Much can be done to improve the health of the persons and reduce their disability and its impact in the workplace which will have an important effect on their and their family's quality of life. It is important that neither rehabilitation nor vocational rehabilitation are regarded as bolt-on activities after drug treatment but are seen as an integral part of effective management. Publications dealing with return to work are relatively common in rheumatoid arthritis, less common in ankylosing spondylitis and relatively rare in osteoarthritis. Vocational rehabilitation programmes should aim to facilitate job retention or, failing that, to improve the ability to return to work. The process must be started with in the health arena and it has to be recognised that slow or poor practice in the health service can jeopardise the patient's work potential

L'arthroplastie totale de genou: évolution et résultats actuels

Avec 95% de bons résultats à 10 ans, on peut considérer aujourd'hui que l'arthroplastie totale du genou est un traitement fiable des gonarthroses chez des patients âgés à demande fonctionnelle raisonnable. Les quatre complications potentielles principales après la mise en place d'une prothèse totale du genou sont le descellement aseptique, l'infection, le manque de flexion et les douleurs persistantes. En cas de problème avec une prothèse totale du genou, il faut toujours exclure la présence d'une infection avant d'envisager une autre raison. Les innovations actuelles en arthroplastie du genou doivent viser à améliorer les résultats chez les patients jeunes et actifs i.e. tant au niveau de la conception des nouveaux implants, voire des matériaux plus résistants, que des techniques chirurgicales elles-mêmes. Total knee arthroplasty: current advances and results With a 95% success rate at 10 years, total knee arthroplasty can be regarded today as a reliable way of treating knee osteoarthritis in elderly patients with reasonable functional demands. The four main potential complications after placing of a total knee prosthesis are aseptic loosening, infection, lack of flexion and persistent pain. If a problem arises with a total knee prosthesis, infection must always be ruled out before considering other causes. Current innovations in knee arthroplasty should be aimed at improving results in young and active patients, i.e. in regard to both the design of new implants, or tougher materials, and to the surgical techniques themselves.

Radiography, computed tomography and magnetic resonance imaging at 0.5 Tesla of mechanically inducedosteoarthritis in rabbit knees

In the present experimental study we assessed induced osteoarthritis data in rabbits, compared three diagnostic methods, i.e., radiography (XR), computed tomography (CT) and magnetic resonance imaging (MRI), and correlated the imaging findings with those obtained by macroscopic evaluation. Ten young female rabbits of the Norfolk breed were used. Seven rabbits had the right knee immobilized in extension for a period of 12 weeks (immobilized group), and three others did not have a limb immobilized and were maintained under the same conditions (control group). Alterations observed by XR, CT and MRI after the period of immobilization were osteophytes, osteochondral lesions, increase and decrease of joint space, all of them present both in the immobilized and non-immobilized contralateral limbs. However, a significantly higher score was obtained for the immobilized limbs (XT: P = 0.016, CT: P = 0.031, MRI: P = 0.0156). All imaging methods were able to detect osteoarthritis changes after the 12 weeks of immobilization. Macroscopic evaluation identified increased thickening of joint capsule, proliferative and connective tissue in the femoropatellar joint, and irregularities of articular cartilage, especially in immobilized knees. The differences among XR, CT and MRI were not statistically significant for the immobilized knees. However, MRI using a 0.5 Tesla scanner was statistically different from CT and XR for the non-immobilized contralateral knees. We conclude that the three methods detected osteoarthritis lesions in rabbit knees, but MRI was less sensitive than XR and CT in detecting lesions compatible with initial osteoarthritis. Since none of the techniques revealed all the lesions, it is important to use all methods to establish an accurate diagnosis.

L’effet de la prothèse totale du genou sur la cinématique 3D : vers le développement de biomarqueurs mécaniques de la douleur

La prothèse totale du genou (PTG) est une chirurgie couramment pratiquée pour traiter les patients souffrant d’arthrose sévère du genou. Bien que cette technique chirurgicale soit efficace pour diminuer la douleur, améliorer la fonction du genou et rentable d’un point de vue socio-économique, un pourcentage non négligeable de patients n’est pas satisfait suite à la chirurgie, principalement due à une douleur persistante ou due à une perception d’avoir une mauvaise fonction articulaire, sans cause identifiée. Cependant, l’impact de cette chirurgie sur la cinématique tridimensionnelle (3D) du genou demeure mal compris. Dans le but de mieux comprendre pourquoi certains patients ressentent toujours de la douleur suite à cette chirurgie, cette étude analysera, dans un premier temps, l’effet prospectif de la chirurgie sur la cinématique 3D du genou. Puis dans un second temps, comparera la cinématique 3D de sujet souffrant de douleur à celle de sujets asymptomatiques suite à la prothèse. Pour parvenir à ces deux objectifs, deux études distinctes ont été entreprises. Une première étude prospective a porté sur l’évolution de la cinématique 3D du genou d’un groupe de 19 sujets, recrutés sur la liste d’attente pour prothèse totale du genou de deux chirurgiens du CHUM, hôpital Notre-Dame, puis la cinématique a été comparée avec un groupe contrôle de 17 sujets avec des genoux sains. Une seconde étude a comparé la cinématique 3D de 20 sujets souffrant de douleur post-PTG avec 20 sujets avec des genoux asymptomatiques suite à leur chirurgie. La première étude a permis de montrer que la cinématique dans le plan frontal suite à la prothèse totale du genou était corrigée vers celle des sujets sains. Contrairement à celle mesurée dans les autres plans (sagittal et axial) qui, malgré de petites corrections, demeure différente de la cinématique des sujets sains. La seconde étude a permis d’identifier un marqueur biomécanique de la douleur chez les sujets souffrant de douleur post-PTG. Effectivement, contrairement aux sujets asymptomatiques, suite à leur chirurgie, les patients souffrants de douleur marchent avec une contracture en flexion plus importante tout au long de la phase d’appui. Les résultats de ces deux études tendent à montrer que la prothèse totale du genou modifie la cinématique 3D du genou, sans toutefois redevenir semblable à celle d’un genou normal. De plus, certains marqueurs biomécaniques peuvent être associés à de la douleur suite à la chirurgie. Une meilleure compréhension de l’impact de la PTG sur la cinématique 3D du genou permettra d’offrir de meilleurs traitements en préparation et après la chirurgie et pourrait mener à de nouveaux designs de prothèses.

Factores asociados a mortalidad en pacientes colombianos con enfermedades autoinmunes en la unidad de cuidado intensivo, de un hospital de tercer nivel en Bogotá Colombia

Antecedentes: El interés en las enfermedades autoinmunes (EA) y su desenlace en la unidad de cuidado intensivo (UCI) han incrementado debido al reto clínico que suponen para el diagnóstico y manejo, debido a que la mortalidad en UCI fluctúa entre el 17 – 55 %. El siguiente trabajo representa la experiencia de un año de nuestro grupo en un hospital de tercer nivel. Objetivo: Identificar factores asociados a mortalidad particulares de los pacientes con enfermedades autoinmunes que ingresan a una UCI, de un hospital de tercer nivel en Bogotá, Colombia. Métodos: El uso de análisis de componentes principales basado en el método descriptivo multivariado y análisis de múltiple correspondencia fue realizado para agrupar varias variables relacionadas con asociación significativa y contexto clínico común. Resultados: Cincuenta pacientes adultos con EA con una edad promedio de 46,7 ± 17,55 años fueron evaluados. Los dos diagnósticos más comunes fueron lupus eritematoso sistémico y esclerosis sistémica, con una frecuencia de 45% y 20% de los pacientes respectivamente. La principal causa de admisión en la UCI fue la infección seguido de actividad aguda de la EA, 36% y 24% respectivamente. La mortalidad durante la estancia en UCI fue del 24%. El tiempo de hospitalización antes de la admisión a la UCI, el choque, soporte vasopresor, ventilación mecánica, sepsis abdominal, Glasgow bajo y plasmaféresis fueron factores asociados con mortalidad. Dos fenotipos de variables fueron definidos relacionadas con tiempo en la UCI y medidas de soporte en UCI, las cuales fueron asociadas supervivencia y mortalidad. Conclusiones: La identificación de factores individuales y grupos de factores por medio del análisis de componentes principales permitirá la implementación de medidas terapéutica de manera temprana y agresiva en pacientes con EA en la UCI para evitar desenlaces fatales.

Desenlaces clínicos del cuidado perioperatorio de reemplazos articulares según grupos relacionados de diagnóstico en un hospital de cuarto nivel

Introducción Los Grupos Relacionados de Diagnóstico (GRD) se han usado para determinar la calidad de la atención en varios sistemas de salud. Esto ha llevado a que se obtengan resultados en el mejoramiento continuo de la atención y del cuidado. El objetivo de este estudio es determinar desenlaces clínicos de los pacientes a quienes se les había realizado reemplazo de articulares según la complejidad clínica definida mediante GRD. Métodos Se realizó un estudio longitudinal descriptivo en el cual se incluyeron todos los pacientes que tuvieron cirugía de reemplazo total de hombro, cadera y rodilla entre 2012 y 2014. Se realizó la estratificación de los pacientes de acuerdo a tres niveles de complejidad dados por el sistema de GRD y se determinaron las proporciones de pacientes para las variables de estancia hospitalaria, enfermedad trombo-embólica, cardiovascular e infección del sitio operatorio. Resultados Se realizaron en total 886 reemplazos articulares de los cuales 40 (4.5%) presentaron complicaciones. Los eventos más frecuentes fueron las complicaciones coronarias, con una presencia de 2.4%. El GRD1, sin complicaciones ni comorbilidades, fue el que presentó mayor número de eventos. La estancia hospitalaria fue de 3.8 a 9.3 días para todos los reemplazos. Conclusiones Contrario a lo planteado en la hipótesis de estudio, se encontró que el primer GRD presentó el mayor número de complicaciones, lo que puede estar relacionado con el tamaño del grupo. Es necesario realizar nuevas investigaciones que soporten el uso de los GRD como herramienta para evaluar desenlaces clínicos.