Blood-nourishing and hard-softening capsule costs less in the management of osteoarthriticknee pain : A randomized controlled trial

The blood-nourishing and hard-softening (BNHS) capsule is a traditional Chinese formula used in the symptomatic treatment of inflammation and pain. We conducted this randomized controlled trial to compare the efficacy of BNHS with other commonly prescribed drugs. We recruited 120 patients from two teaching hospitals; 30 patients in each hospital were randomly assigned to receive BNHS. In one hospital, the 30 controls were given another traditional Chinese drug; whereas a Western medicine (chondroprotection drug/Viartril-s) was used as the control in the other hospital. Intervention was carried out over a period of 4 weeks. Primary outcome measures included self-reported pain level, and changes in stiffness and functional ability as measured by the Western Ontario McMaster Universities Osteoarthritis (WOMAC) index. Mixed models were used for statistical analysis. Substantial improvements in disease-specific symptoms were observed, after 4 weeks of treatment, in patients taking BNHS capsules. As assessed by the WOMAC index, pain level of the BNHS group decreased by 57% [95% confidence interval (CI) = 50, 63], stiffness by 63% (95% CI = 55, 71) and functional ability increased by 56% (95% CI = 50, 63). No significant differences were found in any of the outcome measures between the BNHS group and either of the comparison groups. No severe adverse effects were reported. However, this study lacked a placebo group; therefore, we conclude that BNHS appears to be as effective as commonly prescribed medicines for the relief of pain and dysfunction in knee osteoarthritis patients, but costs a lot less than other Western and herbal drugs in the study.

Endogenous parathyroid hormone is associated with reduced cartilage volume in vivo in a population-based sample of adult women

Objectives Animal and in vitro studies suggest that parathyroid hormone (PTH) may affect articular cartilage. However, little is known of the relationship between PTH and human joints in vivo.

Design Longitudinal.

Setting Barwon Statistical Division, Victoria, Australia.

Participants 101 asymptomatic women aged 35–49 years (2007–2009) and without clinical knee osteoarthritis, selected from the population-based Geelong Osteoporosis Study.

Risk factors Blood samples obtained 10 years before (1994–1997) and stored at −80°C for random batch analyses. Serum intact PTH was quantified by chemiluminescent enzyme assay. Serum 25-hydroxyvitamin D (25(OH)D) was assayed using equilibrium radioimmunoassay. Models were adjusted for age, bone area and body mass index; further adjustment was made for 25(OH)D and calcium supplementation.

Outcome Knee cartilage volume, measured by MRI.

Results A higher lnPTH was associated with reduced medial—but not lateral—cartilage volume (regression coefficient±SD, p value: −72.2±33.6 mm3, p=0.03) after adjustment for age, body mass index and bone area. Further sinusoidal adjustment (−80.8±34.4 mm3, p=0.02) and 25(OH)D with seasonal adjustment (−72.7±35.1 mm3, p=0.04), calcium supplementation and prevalent osteophytes did not affect the results.

Conclusions A higher lnPTH might be detrimental to knee cartilage in vivo. Animal studies suggest that higher PTH concentrations reduce the healing ability of cartilage following minor injury. This may be apparent in the presence of increased loading, which occurs in the medial compartment, placing the medial cartilage at higher risk for injury.

The global burden of musculoskeletal conditions for 2010: an overview of methods.

The objective of this paper is to provide an overview of methods used for estimating the burden from musculoskeletal (MSK) conditions in the Global Burden of Diseases 2010 study. It should be read in conjunction with the disease-specific MSK papers published in Annals of Rheumatic Diseases. Burden estimates (disability-adjusted life years (DALYs)) were made for five specific MSK conditions: hip and/or knee osteoarthritis (OA), low back pain (LBP), rheumatoid arthritis (RA), gout and neck pain, and an 'other MSK conditions' category. For each condition, the main disabling sequelae were identified and disability weights (DW) were derived based on short lay descriptions. Mortality (years of life lost (YLLs)) was estimated for RA and the rest category of 'other MSK', which includes a wide range of conditions such as systemic lupus erythematosus, other autoimmune diseases and osteomyelitis. A series of systematic reviews were conducted to determine the prevalence, incidence, remission, duration and mortality risk of each condition. A Bayesian meta-regression method was used to pool available data and to predict prevalence values for regions with no or scarce data. The DWs were applied to prevalence values for 1990, 2005 and 2010 to derive years lived with disability. These were added to YLLs to quantify overall burden (DALYs) for each condition. To estimate the burden of MSK disease arising from risk factors, population attributable fractions were determined for bone mineral density as a risk factor for fractures, the occupational risk of LBP and elevated body mass index as a risk factor for LBP and OA. Burden of Disease studies provide pivotal guidance for governments when determining health priority areas and allocating resources. Rigorous methods were used to derive the increasing global burden of MSK conditions.

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.

Parâmetros do controle postural em mulheres idosas com ou sem histórico de quedas associadas ou não à osteoartrite de joelhos

OBJETIVOS: Comparar parâmetros estabilométricos de mulheres idosas com ou sem histórico de quedas associadas ou não à osteoartrite (OA) de joelhos. MÉTODOS: Cinquenta e seis idosas apresentando ou não histórico de quedas (Q) e OA de joelho unilateral e bilateral foram distribuídas da seguinte maneira: grupo QOA (n = 10), idosas com histórico de queda e OA de joelho; grupo QSOA (n = 11), idosas com histórico de queda e sem OA de joelho; grupo SQOA (n = 14), idosas sem histórico de quedas (SQ) e com OA de joelho; e grupo SQSOA (n = 21), idosas sem histórico de quedas e sem OA de joelho. Para análise do equilíbrio semiestático usando uma plataforma de força, foram avaliados os deslocamentos anteroposterior (DAP) e mediolateral (DML), as velocidades de oscilação anteroposterior (VAP) e mediolateral (VML) em quatro situações na postura ereta. As situações avaliadas foram as seguintes: 1) PFOA: sobre superfície fixa e olhos abertos; 2) PFOF: sobre superfície fixa e olhos fechados; 3) PIOA: sobre superfície instável e olhos abertos; 4) PIOF: sobre superfície instável e os olhos fechados. RESULTADOS: As idosas com OA de joelho apresentaram maior DAP em todas as situações analisadas (P < 0,05), ao passo que idosas com histórico de quedas apresentaram maior DML (P < 0,05). Não houve diferenças entre os grupos para VAP e VML (P > 0,05). CONCLUSÕES: A OA de joelho, por si, é um fator prejudicial no aumento de oscilação do centro de pressão (COP) na direção anteroposterior, enquanto o histórico de quedas, independente da presença de OA de joelhos, traz prejuízos ao controle postural na direção mediolateral.

Estudo comparativo do uso de meloxicam por via intra-articular e sistêmica no controle da osteoartrite experimentalmente induzida em joelho de coelhos

Objective: This study aimed to evaluate morphologic changes, as well as chondroprotective and intra-articular effects of meloxicam on joint repair in rabbits induced by experimental trochleoplasty, minimizing possible adverse side effects. Methods: Thirty-five rabbits were divided into four groups: the control group, which did not undergo surgery, and operated groups, which used different ways of administering the anti-inflammatory agent: systemic, 0.2 mg/kg; intra-articular, 0.5 mg/kg; positive group control, without meloxicam. Each operated group was divided according to the periods of 7 or 30 days evaluation after surgery. Results: Regarding macroscopic and histological evaluation of cartilage, after 30 days, most animals showed almost complete joint repair, the presence of few or no inflammatory cells; whereas part of the animals treated with meloxicam presented necrosis in the trochlear ridge and absence of inflammatory cells after 7 days. In positive control group, it was observed moderate inflammation and connective tissue proliferation. None of the animals in the operated groups showed irregularities 30 days after surgery. Conclusion: Either intra-articular or systemic, meloxicam revealed to be favorable to be used for joint repair and control of inflammatory reaction. © 2013 Sociedade Brasileira de Ortopedia e Traumatologia.

Estudo do efeito de diferentes protocolos fisioterapêuticos no tratamento da osteoartrite de joelho

Pós-graduação em Saúde Coletiva - FMB

Fatores indutores e supressores da eritropoiese em caninos doentes renais crônicos

Pós-graduação em Cirurgia Veterinária - FCAV

Risk factors for magnetic resonance imaging-detected patellofemoral and tibiofemoral cartilage loss during a six-month period: The Joints On Glucosamine study

Objective To assess several baseline risk factors that may predict patellofemoral and tibiofemoral cartilage loss during a 6-month period. Methods For 177 subjects with chronic knee pain, 3T magnetic resonance imaging (MRI) of both knees was performed at baseline and followup. Knees were semiquantitatively assessed, evaluating cartilage morphology, subchondral bone marrow lesions, meniscal morphology/extrusion, synovitis, and effusion. Age, sex, and body mass index (BMI), bone marrow lesions, meniscal damage/extrusion, synovitis, effusion, and prevalent cartilage damage in the same subregion were evaluated as possible risk factors for cartilage loss. Logistic regression models were applied to predict cartilage loss. Models were adjusted for age, sex, treatment, and BMI. Results Seventy-nine subregions (1.6%) showed incident or worsening cartilage damage at followup. None of the demographic risk factors was predictive of future cartilage loss. Predictors of patellofemoral cartilage loss were effusion, with an adjusted odds ratio (OR) of 3.5 (95% confidence interval [95% CI] 1.39.4), and prevalent cartilage damage in the same subregion with an adjusted OR of 4.3 (95% CI 1.314.1). Risk factors for tibiofemoral cartilage loss were baseline meniscal extrusion (adjusted OR 3.6 [95% CI 1.310.1]), prevalent bone marrow lesions (adjusted OR 4.7 [95% CI 1.119.5]), and prevalent cartilage damage (adjusted OR 15.3 [95% CI 4.947.4]). Conclusion Cartilage loss over 6 months is rare, but may be detected semiquantitatively by 3T MRI and is most commonly observed in knees with Kellgren/Lawrence grade 3. Predictors of patellofemoral cartilage loss were effusion and prevalent cartilage damage in the same subregion. Predictors of tibiofemoral cartilage loss were prevalent cartilage damage, bone marrow lesions, and meniscal extrusion.

Estudo da estabilidade dos componentes na artroplastia total do joelho sem cimento

OBJETIVO: Comparar dois métodos de avaliação da estabilidade dos componentes tibial e femoral nas artroplastias de joelho não cimentadas com plataforma rotatória. MÉTODOS: Para isso foram avaliados 20 pacientes (20 joelhos) através de uma análise de radiografias dinâmicas com intensificador de imagem e manobras de estresse em varo e valgo, que foram comparadas com radiografias estáticas em frente e perfil dos joelhos, analisadas por dois cirurgiões experientes, cegos um em relação ao outro. RESULTADOS: Os resultados das análises estáticas e dinâmicas foram comparados e demonstraram forte correlação estatística (p<0,001), utilizando-se o método Kappa de comparação. CONCLUSÃO: O componente tibial mostrou-se mais instável quando comparado com o componente femoral, tanto na análise estática, quanto na dinâmica. Nível de evidência IV, Série de Casos.

Health characteristics of older Australian dietary supplement users compared to non-supplement users

The aim of this study was to measure the prevalence of dietary and health supplement use among Australians aged 65 years and over, and to contrast the health differences between supplement users and non-supplement users. Data was obtained from 1,263 randomly selected older Australians, who provided general demographic data, in addition to information related to their health, symptoms experienced and uses of medication, including dietary supplements. Supplement use was reported by 43% of the sample (52% of females and 35% of males). This investigation has revealed distinct differences in the health profile of older supplement users compared to non-users. Although there was no difference in the number of visits to medical doctors or self-rated health status between supplement users and non-supplement users, supplement users were more likely to report arthritis and osteoporosis, and experience more symptoms and consume more medication than non-supplement users. In contrast, there was a reduced likelihood of taking a supplement for those with hypertension and by those using blood pressure medication and heart tablets. These results suggest that older dietary supplement users may benefit from education and professional advice to assist them make appropriate and informed choices, particularly if they expect these preparations to attenuate their health concerns.

Using patients' and rheumatologists' opinions to specify a short form of the WOMAC function subscale

Background: The WOMAC ( Western Ontario and McMaster Universities) function subscale is widely used in clinical trials of hip and knee osteoarthritis. Reducing the number of items of the subscale would enhance efficiency and compliance, particularly for use in clinical practice applications. Objective: To develop a short form of the WOMAC function subscale based on patients' and experts' opinions ( WOMAC function short form). Methods: WOMAC function subscale data ( Likert version) were obtained from 1218 outpatients with painful hip or knee osteoarthritis. These patients and their rheumatologists selected the five items that they considered most in need of improvement. The rheumatologists were asked to select the five items for which patients in general are the most impaired. Items that were least important to patients and experts, those with a high proportion of missing data, and those with a response distribution showing a floor or ceiling response were excluded, along with one of a pair of items with a correlation coefficient >0.75. Results: The WOMAC function short form included items 1, 2, 3, 6, 7, 8, 9, and 15 of the long form. The short form did not differ substantially from the long form in responsiveness ( standardised response mean of 0.84 v 0.80). Conclusions: A short form of the WOMAC function subscale was developed according to the views of patients and rheumatologists, based on the responses of 1218 patients and 399 rheumatologists. The clinical relevance and applicability of this WOMAC function subscale short form require further evaluation.

Multivariate Techniques in Biomechanical Analysis

This work outlines the theoretical advantages of multivariate methods in biomechanical data, validates the proposed methods and outlines new clinical findings relating to knee osteoarthritis that were made possible by this approach. New techniques were based on existing multivariate approaches, Partial Least Squares (PLS) and Non-negative Matrix Factorization (NMF) and validated using existing data sets. The new techniques developed, PCA-PLS-LDA (Principal Component Analysis – Partial Least Squares – Linear Discriminant Analysis), PCA-PLS-MLR (Principal Component Analysis – Partial Least Squares –Multiple Linear Regression) and Waveform Similarity (based on NMF) were developed to address the challenging characteristics of biomechanical data, variability and correlation. As a result, these new structure-seeking technique revealed new clinical findings. The first new clinical finding relates to the relationship between pain, radiographic severity and mechanics. Simultaneous analysis of pain and radiographic severity outcomes, a first in biomechanics, revealed that the knee adduction moment’s relationship to radiographic features is mediated by pain in subjects with moderate osteoarthritis. The second clinical finding was quantifying the importance of neuromuscular patterns in brace effectiveness for patients with knee osteoarthritis. I found that brace effectiveness was more related to the patient’s unbraced neuromuscular patterns than it was to mechanics, and that these neuromuscular patterns were more complicated than simply increased overall muscle activity, as previously thought.

Improving Patients’ Experience and Outcome of Total Joint Replacement: the RESTORE Programme

BACKGROUND: Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected. OBJECTIVE: To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR. METHODS: We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement. RESULTS: Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test. CONCLUSIONS: The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Estágio realizado no Programa Comunitário PLE²NO

A OA é a doença reumática mais comum no ser humano e uma doença crónica com impacto elevado na sociedade. Tem repercussões na saúde, ao nível da funcionalidade, comprometendo a realização das atividades da vida diária e a qualidade de vida dos indivíduos. Uma das articulações mais afetada pela OA é a articulação do joelho. O tratamento eficaz requer a combinação de tratamentos farmacológicos e não farmacológicos. Os tratamentos não farmacológicos, principalmente o exercício e a educação do doente têm vindo a ganhar importância, no que se refere ao controlo dos sintomas. A realização do estágio curricular surge no programa comunitário PLE²NO. O programa é considerado uma opção não farmacológica no tratamento e controlo dos sintomas da Osteoartrose (OA) no joelho. Os principais objetivos do estágio no PLE²NO consistiram: aquisição de conhecimentos teóricos relacionados com OA e práticos com vista ao aperfeiçoamento da prescrição do exercício; aquisição de competências essenciais à ótima liderança e comunicação com as pessoas e instituições envolvidas; prescrição de exercício a indivíduos com OA no joelho; cativar e motivar as pessoas para a prática de exercício; e determinar a eficácia de um programa de 3 meses de educação e exercício nos sintomas, aptidão física e qualidade de vida dos idosos com OA no joelho. Na aptidão física verificaram-se diferenças significativas na capacidade aeróbia, flexibilidade e velocidade da marcha. Nos indicadores de saúde houve melhoria em praticamente todos os parâmetros avaliados: mobilidade, cuidados pessoais, dor/mal-estar e sintomas de ansiedade/depressão. Assim, esta intervenção revelou-se ser uma mais-valia para o tratamento não farmacológico da osteoartrose do joelho a médio prazo.