The use of topical diclofenac for pain in osteoarthritis of the knee: a review

Osteoarthritis (OA) is a common complaint that affects millions of people worldwide. As there is no cure for OA, drug treatment is the main form of management. This can be achieved through the use of analgesics and anti-inflammatory drugs such as the NSAID diclofenac sodium. The chronic use of diclofenac sodium can lead to adverse gastrointestinal problems. The use of a topical formulation of diclofenac sodium aims to reduce this problem. Evidence from four randomized controlled trails of the efficacy and safety of topical diclofenac sodium as a method of pain relief for the treatment of OA of the knee is presented and discussed. Findings imply that topical diclofenac sodium is an efficacious and safe method of pain control in patients with OA of the knee.     

Treatment of Knee Osteoarthritis in Relation to Hamstring and Quadriceps Strength

[Purpose] To assess the effect of hamstring and quadriceps strengthening exercises on pain intensity, gait velocity, maximum isometric strength, and activities of daily living of patients with knee osteoarthritis (OA). [Subjects and Methods] A total of 20 patients with knee OA, 50 to 65 years of age (57.65 ± 4.78 years), received hot packs, strengthening exercises for the quadriceps and the hamstring muscles and stretching exercises for hamstring muscles. Outcome measures included: the Western Ontario and McMaster Universities OA index questionnaire (WOMAC) scores for assessing health status and health outcomes of knee OA; self-reported pain intensity scores, measured using a visual analogue scale; the 50 ft walk test (a measure of gait velocity and function); and handheld dynamometry (a tool used to measure maximum isometric strength of knee extension and flexion). [Results] There was a significant difference between pre- and post-intervention measures of pain intensity, 50 ft walk times, hamstring strength, and quadriceps strength. Significant differences in WOMAC measures were also observed in the subscales of pain, stiffness and physical function, as well as WOMAC total scores. [Conclusion] Strengthening the hamstring muscles in addition to strengthening the quadriceps muscles proved to be beneficial for perceived knee pain, range of motion, and decreasing the limitation of functional performance of patients with knee OA.Key words: Hamstring/quadriceps ratio, Knee pain, Osteoarthritis     

Phonophoresis of Phyllanthus amarus nanoparticle gel improves functional capacity in individuals with knee osteoarthritis: A randomized controlled trial

ObjectiveThis study examined the effects of treatment with Phyllanthus amarus nanoparticle gel applied by phonophoresis (PP) and ultrasound therapy (UT) in patients with symptomatic knee osteoarthritis (OA) using a randomized, double-blind, controlled trial.MethodsPatients with knee OA (n = 40; mean age ± SD, 64.30 ± 9.71 years), who had visual analogue scale (VAS) scores for knee pain intensity of 68.00 ± 9.58 (UT group) and 71.00 ± 8.74 (PP group, respectively) before treatment, were randomly allocated into two groups. Both groups were treated with an ultrasound program in continuous mode, 1.0 W/cm², 10 min per session, for 10 sessions. Nanoparticles of P. amarus were used in the PP group, whereas a nondrug coupling gel was used in the UT group. The 6-min walk test (6-MWT) was performed to evaluate functional capacity. The VAS and the 6-MWT were evaluated before and after 10 treatment sessions in both groups using a double-blind procedure.ResultsVAS and 6-MWT showed significant improvement after treatment in both groups (p < 0.05). The PP group showed more significant effects than the UT group, in terms of both reducing the VAS pain score (p < 0.05) and improving 6-MWT (p < 0.05).ConclusionsPP is suggested as an effective method for the treatment of symptomatic knee OA for reducing pain and improving functional capacity.     

Comorbidities in Patients With End-Stage Knee OA: Prevalence and Effect on Physical Function

ObjectiveTo investigate the prevalence of comorbidities and their effect on physical function, quality of life (QOL), and pain, in patients with end-stage knee osteoarthritis (OA).DesignA cross-sectional study.SettingA rehabilitation facility at university hospital.ParticipantsPatients (N=577; 503 women and 74 men) diagnosed with end-stage knee OA between October 2013 and June 2018.InterventionNot applicable.Main Outcome MeasuresComorbidities were as follows: osteoporosis, presarcopenia, degenerative spine disease, diabetes, and hypertension. All patients completed the following performance-based physical function tests: stair-climbing test (SCT), 6-minute walk test (6MWT), timed Up and Go (TUG) test, and gait analysis. Self-reported physical function and pain were measured using Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) and a visual analog scale (VAS), respectively, and self-reported QOL was measured using EuroQoL 5 dimensions (EQ-5D) questionnaire.ResultsUnivariate analyses revealed that patients with osteoporosis had significantly higher scores in SCT ascent, SCT descent, TUG, WOMAC pain tests, and lower scores in 6MWT, gait speed, and cadence tests than those without osteoporosis. Patients with presarcopenia recorded higher scores in SCT ascent, TUG, EQ-5D, and lower scores in 6MWT and gait speed tests than those without presarcopenia. Patients with degenerative spine disease showed higher scores in WOMAC pain and lower scores in gait speeds than those without degenerative spine disease. Patients with diabetes showed higher scores in SCT ascent than those without diabetes, and patients with hypertension showed lower scores in 6MWT than those without hypertension. After adjusting age, sex, and body mass index, SCT descent retained significant association with osteoporosis, SCT ascent showed independent association with presarcopenia and diabetes, and WOMAC pain revealed significant association with degenerative spine disease.ConclusionThe results confirm associations between comorbidities, performance-based and self-reported physical functions, and QOL in patients with end-stage knee OA.     

The efficacy of high- and low-dose curcumin in knee osteoarthritis: A systematic review and meta-analysis

ObjectivesThe aim of this study was to critically appraise and evaluate effects of low- and high-dose curcuminoids on pain and functional improvement in patients with knee osteoarthritis (OA) and to compare adverse events (AEs) between curcuminoids and non-steroid anti-inflammatory drugs (NSAIDs).MethodsWe systematically reviewed all randomized controlled trials (RCTs) on curcuminoids in knee osteoarthritis from the PubMed, Embase, Cochrane Library, AMED, Cinahl, ISI Web of Science, Chinese medical database, and Indian Scientific databases from inception to June 21, 2021.ResultsWe included eleven studies with a total of 1258 participants with primary knee OA. The meta-analysis results showed that curcuminoids were significantly more effective than comparators regarding visual analogue scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scores. However, no significant difference in pain relief or AEs between the high-dose (daily dose ≥1000 mg or total dose ≥42 gm) and low-dose (daily dose <1000 mg or total dose <42 gm) curcuminoid treatments was observed. When comparing curcumininoids versus NSAIDs, a significant difference in VAS pain was found. For AE analysis, three of our included studies used NSAIDs as comparators, with all reporting higher AE rates in the NSAID group, though significance was reached in only one study.ConclusionsThe results of our meta-analysis suggest that low- and high-dose curcuminoids have similar pain relief effects and AEs in knee OA. Curcuminoids are also associated with better pain relief than NSAIDs; therefore, using curcuminoids as an adjunctive treatment in knee OA is recommended.     

Disability in end-stage knee osteoarthritis

Objective. To examine the attributes of disability in end-stage knee osteoarthritis (OA) by analyzing the relationships between self-reported disability and objectively measured physical function after controlling pain, personal characteristic factors, and pathophysiological factors.

Methods. The present study adopted a cross-sectional design. The subjects (n=88, aged 60–80 years) were scheduled for primary unilateral total knee arthroplasty (TKA) due to knee OA. Self-reported disability and pain were measured with the Western Ontario and McMaster Universities OA Index (WOMAC) and the RAND 36-item Health Survey 1.0 (RAND-36). Physical performance tests included a 15-m walk test and stair performance. Knee isometric muscle strength was measured. A clinical examination included analyses of comorbidity, body mass index (BMI), and a detailed knee examination: The flexion range of motion (ROM) was measured; the presence of varus/valgus malalignments and antero-posterior laxity was assessed. Radiographs were analyzed with the Kellgren-Lawrence grading scale.

Results. In the linear regression model the WOMAC pain score, antero-posterior laxity of the knee, age, and BMI accounted for 54.8% of the variance in the WOMAC function score. In the bivariate analyses the WOMAC function score had a positive correlation with the 15-m walk (r_s=0.32, p=0.003), stairs up (r_s=0.40, p=0.001), and stairs down (r_s=0.38, p=0.001) tests, and a negative correlation with RPT extension (r_s=?0.45, p < 0.001) and RPT flexion (r_s=?0.39, p=0.001) of the affected side and RPT flexion (r_s=?0.39, p <0.001) of the contralateral side. The results of the physical performance tests also correlated with the RAND-36 Physical function (PF) score. Comorbid diseases and pain deteriorated the results of the physical performance tests and self-reported disability. Female gender deteriorated the results of the physical performance tests and the RAND-36 PF, but not the WOMAC function score. Malalignments, restriction in the flexion ROM of the knee, and the radiologic severity of knee OA did not affect self-reported disability.

Conclusion. Pain, BMI, and antero-posterior laxity of the knee joint were major attributes of self-reported disability. The negative effect of comorbid diseases and female gender on health-related quality of life was significant. The results of objectively measured physical performance tests correlated with self-reported disability.     

Topical therapies for knee osteoarthritis

Background: Symptomatic knee osteoarthritis (OA) involves millions of adults around the world.

Purpose: To analyze the effectiveness and tolerability of topical therapies and their contemporary placement in knee OA management criteria.

Methods: A Cochrane Library and PubMed (MEDLINE) search related to the role of topical therapies in knee OA was carried out.

Results: Many types of local therapy have been reported, including nonsteroidal anti-inflammatory drugs (NSAIDs) like diclofenac and ketoprofen; capsaicin, cream containing glucosamine sulfate, chondroitin sulfate, and camphor; nimesulide; civamide cream 0.075%; menthol; drug-free gel containing ultra-deformable phospholipid vesicles (TDT 064); 4Jointz utilizing Acteev technology; herbal therapies; gel of medical leech (Hirudo medicinalis) saliva extract; and gel prepared using Lake Urmia mud. One systematic review showed that topical diclofenac and topical ketoprofen can alleviate pain. However, another systematic review found that topical diclofenac and ketoprofen had limited efficacy in knee OA at 6 to 12 weeks. Many studies with a low level of evidence have reported some pain mitigation using the rest of aforementioned topical therapies.

Conclusions: Although some controversy exists on the role of topical NSAIDs, current management guidelines advise topical NSAIDs as an option and even first-line therapy for knee OA treatment, particularly among elderly patients. Topical NSAIDs may be contemplated as similar options to oral NSAIDs and are associated with fewer gastrointestinal complications when compared with oral NSAIDs. Caution should be taken with the use of both topical and oral NSAIDs, including close adherence to dosing regimens and monitoring, especially for patients with previous complications of NSAIDs. The role of other topical therapies needs further research.     

Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial

BACKGROUND AND PURPOSE: This study was designed to evaluate the effectiveness of hydrotherapy in subjects with osteoarthritis (OA) of the knee compared with subjects with OA of the knee who performed land-based exercises. SUBJECTS AND METHODS: Sixty-four subjects with OA of the knee were randomly assigned to 1 of 2 groups that performed exercises for 18 weeks: a water-based exercise group and a land-based exercise group. The outcome measures included a visual analog scale (VAS) for pain in the previous week, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), pain during gait assessed by a VAS at rest and immediately following a 50-foot (15.24-m) walk test (50FWT), walking time measured at fast and comfortable paces during the 50FWT, and the Lequesne Index. Measurements were recorded by a blinded investigator at baseline and at 9 and 18 weeks after initiating the intervention. RESULTS: The 2 groups were homogenous regarding all parameters at baseline. Reductions in pain and improvements in WOMAC and Lequesne index scores were similar between groups. Pain before and after the 50FWT decreased significantly over time in both groups. However, the water-based exercise group experienced a significantly greater decrease in pain than the land-based exercise group before and after the 50FWT at the week-18 follow-up. DISCUSSION AND CONCLUSION: Both water-based and land-based exercises reduced knee pain and increased knee function in participants with OA of the knee. Hydrotherapy was superior to land-based exercise in relieving pain before and after walking during the last follow-up. Water-based exercises are a suitable and effective alternative for the management of OA of the knee.     

Photobiomodulation does not provide incremental benefits to patients with knee osteoarthritis who receive a strengthening exercises program: a randomized controlled trial

BackgroundThere is lack of agreement in the literature about the effectiveness of photobiomodulation (PBM) for reducing pain-related symptoms in patients with knee osteoarthritis (OA).ObjectiveTo evaluate whether PBM, when combined to exercises, provides incremental therapeutic benefits for pain, physical function, and quality of life (QoL) in patients with knee OA.MethodsA six-month double-blind placebo-controlled randomized trial was conducted. Patients with knee OA were randomly assigned to one of three treatment groups: Exercise, Exercise plus Active PBM, or Exercise plus Placebo PBM. Treatment was provided over an eight-week period, three times per week. The primary outcomes were pain at rest and upon movement, assessed by a visual analogue scale (VAS). WOMAC global score, QoL, and a core-set of performance-based tests were measured as secondary outcomes. All outcomes were collected at baseline, immediately after treatment, and after three- and six-month post-treatment.Results127 participants were allocated as follows: Exercise, N = 41; Exercise plus Active PBM, N = 44; and Exercise plus Placebo PBM, N = 42. There was no between-groups difference in improvement in pain, physical function, and QoL for all follow-up times. However, all groups presented significant, clinically relevant improvements in pain, physical function, and QoL immediately and three months after treatment compared with baseline measures.ConclusionPatients with knee OA who received a strengthening exercises program did not experience incremental benefits regarding pain, physical function, or QoL when adding PBM to their therapeutic exercises.     

Gait differs between unilateral and bilateral knee osteoarthritis

Creaby MW, Bennell KL, Hunt MA. Gait differs between unilateral and bilateral knee osteoarthritis.ObjectivesTo compare walking biomechanics in the most painful leg, and symmetry in biomechanics between legs, in individuals with (1) unilateral pain and structural osteoarthritis (OA), (2) unilateral pain, but bilateral structural OA, and (3) bilateral pain and structural OA and in (4) an asymptomatic control group.DesignCohort study.SettingLaboratory based.ParticipantsParticipants with symptomatic and/or radiographic medial tibiofemoral OA in one or both knees (n=91), and asymptomatic control participants (n=31).InterventionsNot applicable.Main Outcome MeasureThe peak knee adduction moment, peak knee flexion moment, knee varus-valgus angle, peak knee flexion angle, toe-out, and trunk lean were computed from 3-dimensional analysis of walking at a self-selected speed.ResultsAfter controlling for walking speed, greater trunk lean toward the more painful knee and reduced flexion in the more painful knee were observed in all OA groups compared with the control group. Between-knee asymmetries indicating greater varus angle and a lower external flexion moment in the painful knee were present in those with unilateral pain and either unilateral or bilateral structural OA. Knee biomechanics were symmetrical in those with bilateral pain and structural OA and in the pain free control group.ConclusionsThe presence of pain unilaterally appears to be associated with asymmetries in knee biomechanics. Contrary to this, bilateral pain is associated with symmetry. This suggests that the symptomatic status of both knees should be considered when contemplating unilateral or bilateral biomechanical interventions for medial knee OA.     

Effectiveness of Dry Needling Therapy on Pain,Hip Muscle Strength,and Physical Function in Patients With Hip Osteoarthritis: A Randomized Controlled Trial

ObjectiveTo investigate the short-term effects of dry needling (DN) on physical function, pain, and hip muscle strength in patients with hip osteoarthritis (OA).DesignA double-blind, placebo-control, randomized controlled trial.SettingPrivate practice physiotherapy clinic.ParticipantsPatients with unilateral hip OA (N=45) were randomly allocated to a DN group, sham DN group, or control group.InterventionsPatients in the DN and sham groups received 3 treatment sessions. Three active myofascial trigger points (MTrPs) were treated in each session with DN or a sham needle procedure. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae, and gluteus minimus muscles.Main Outcome MeasuresPhysical function was assessed with the Western Ontario and McMaster Universities (WOMAC) physical function subscale, the timed Up and Go test, and the 40-meter self-paced walk test. Intensity of hip pain related to physical function was evaluated using the visual analog scale and WOMAC pain subscale. The maximal isometric force of hip muscles was recorded with a handheld dynamometer.ResultsSignificant group by time interactions were shown for physical function, pain, and hip muscle force variables. Post hoc tests revealed a significant reduction in hip pain and significant improvements in physical function and hip muscle strength in the DN group compared with the sham and control groups. The DN group showed within- and between-groups large effect sizes (d>0.8).ConclusionsDN therapy in active MTrPs of the hip muscles reduced pain and improved hip muscle strength and physical function in patients with hip OA. DN in active MTrPs of the hip muscles should be considered for the management of hip OA.     

Quadriceps strengthening exercises may not change pain and function in knee osteoarthritis

It is believed that Quadriceps strength training may reduce pain and improve functional activity in patients with knee osteoarthritis (OA). This improvement is generally attributed to an increase in quadriceps strength. This study investigated whether quadriceps muscle strength increases with decreasing pain, improving functional activity in knee OA. Twenty-four patients with knee OA participated in an 8-week treatment protocol including traditional physical therapy and strength training 3 sessions per week. Measurements were conducted before and after the intervention and included the peak torque of quadriceps muscle, pain by visual analogue scale (VAS), short Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and functional activity by the 2 minute walking test (2MWT) and time up & go test (TUGT). After the intervention, analysis of data illustrated that changes in quadriceps muscle strength correlated with changes in VAS (r² = 0.310, p = 0.005), WOMAC (r² < 0.278, p < 0.008) and 2MWT (r² < 0.275, p < 0.009) significantly, although the correlation slope was negligible. No correlation was found between muscle strength and TUGT. However, the strength training significantly improved quadriceps muscle strength (p = 0.013), pain and functional activity (p = 0.000). This study showed that reduction in pain and improvement in functional activity occurs independently from an increase in quadriceps muscle strength in knee OA. It seems that increased quadriceps muscle strength may not be a cause of improvement in pain and functional activity in knee OA.     

Comparative assessment of the effectiveness and tolerability of lornoxicam 8 mg BID and diclofenac 50 mg TID in adult indian patients with osteoarthritis of the hip or knee: A 4-week, double-blind, randomized, comparative, multicenter study

Background: Reports of cardiovascular adverse events (AEs) associated with the use of cyclooxygenase-2 inhibitors for the treatment of osteoarthritis (OA) have prompted the quest for a better-tolerated NSAID.Objective: The aim of this study was to compare the effectiveness and tolerability of lornoxicam 8 mg BID and diclofenac 50 mg TID in adult Indian patients with OA of the hip or knee.Methods: This 4-week, double-blind, randomized, comparative, multicenter study was undertaken to compare oral lornoxicam and diclofenac in patients with OA. Patients who met the selection criteria were enrolled consecutively from the outpatient clinics of each of the participating hospitals in India. Participants completed the Western Ontario and McMasters Individual Osteoarthritis Index (WOMAC-OA), WOMAC Composite Index (WOMAC-CI) (for pain, stiffness, and physical function), and a 10-cm visual analog scale (VAS) (0-10 where 0 = no pain and 10 = worst possible pain or severe or excruciating pain) at each study visit (weeks 0 [baseline], 2, and 4 [or at early termination]). Patients' and physicians' global assessments of arthritis control were measured at each study visit when laboratory and clinical AEs were also monitored. The primary end points were the WOMAC-OA, the WOMAC-CI, and VAS scores for pain among the patients who completed the study.Results: Of the 273 patients (159 men, 114 women; mean [SD] age, 44.73 [10.72] years; range, 28-68 years) enrolled in the study, 13 (7 in the lornoxicam group and 6 in the diclofenac group) were lost to follow-up and their effectiveness and tolerability results were not included in the study analysis. Over the 4-week study period, both drugs provided significant (P < 0.05) sustained relief of OA symptoms compared with baseline. Compared with baseline, the mean pain score (WOMAC-CI) decreased 90.6% (13.88 [4.47] vs 1.30 [1.49]; P < 0.05) in the lornoxicam group and 88.9% (14.15 [4.56] vs 1.57 [1.49]; P < 0.05) in the diclofenac group after 4 weeks of treatment. After 4 weeks of treatment, the VAS pain score decreased from baseline 83.1% (8.04 [2.70] vs 1.36 [1.43]; P < 0.05) in the lornoxicam group and 79.3% (7.98 [2.98] vs 1.65 [1.47]; P < 0.05) in the diclofenac group. Compared with baseline, the improvement rated at 2 weeks was not significantly different between the 2 groups. Lornoxicam and diclofenac were well tolerated. The rate of mild to moderate adverse gastrointestinal events was not significantly different in the lornoxicam group compared with the diclofenac group (14.6% vs 18.4%). Similarly, overall tolerability between the 2 groups was not significantly different. None of the patients experienced cardiovascular AEs (eg, edema or increased blood pressure).Conclusion: The results of the present study suggest that lornoxicam was comparable to diclofenac in effectiveness and tolerability after 4 weeks of treatment in these adult Indian patients with OA of the hip or knee who completed the study.     

The Effect of Therapeutic Ultrasound on Pain and Physical Function in Patients with Knee Osteoarthritis

Osteoartritis (OA) is one of the most frequent causes of pain, loss of function and disability in adults. The prevalence of OA is expected to increase substantially in the future. Knee OA is the most common subset of OA. Therapeutic ultrasound (US) is one of several physical therapy modalities suggested for the management of pain and loss of function due to OA. The purpose of our study was to investigate the efficacy of US therapy in reducing pain and functional loss and improving the quality of life in patients with knee OA in comparison to sham US therapy. The study involved 62 patients. The patients were randomly divided into two groups. The patients in group 1 (n = 30) were administered 1 W/cm², 1 MHz continuous US, and the patients in group 2 (n = 32) were administered sham US. The US treatment was applied for 8 min to each knee, 16 min in total, 5 d a wk, for a total of 10 sessions during 2 wk. The patients were evaluated immediately after treatment and 1 mo after therapy according to the visual analog scale (VAS), night pain, range of motion, morning stiffness, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne and Short Form-36 (SF-36) scales and 6 min walking distance. Improvement in pain and joint functions was observed in both groups according to the evaluation immediately after treatment and at 1 mo after the therapy. According to the evaluation results immediately after treatment, there was significant improvement in all pain scales (VAS, WOMAC, Lequesne, SF-36), morning stiffness and 6 min walking distance in patients receiving real US treatment (p < 0.05), but only in some pain scales (VAS, WOMAC) and functions in the group receiving sham US (p < 0.05). Significantly better improvement was observed in some pain scales (SF-36), functions (WOMAC, SF-36) and 6 min walking distance in the real US group. At 1 mo after therapy, no significant difference was observed between groups except for improvement in night pain in the real US group. In conclusion, US therapy has been found to be effective in reducing pain and improving physical function in the short term, but this positive effect was not persistent in the long term. However, we believe that the results of our study may contribute to ongoing research for the treatment of patients with knee OA, and further systematic investigation on larger patient populations may delineate the role of US in knee OA treatment.     

Efficacy and safety of extended-release, once-daily tramadol in chronic pain: a randomized 12-week clinical trial in osteoarthritis of the knee

The efficacy and safety of a once-daily extended-release formulation of tramadol hydrochloride (tramadol ER) was evaluated in patients with moderate to severe chronic pain of osteoarthritis (OA). This was a randomized, double-blind, placebo-controlled, parallel-group, 12-week study. Eligible patients with radiographically confirmed OA of the knee meeting the American College of Rheumatology diagnostic criteria, defined by knee pain and presence of osteophytes, plus at least age >50 years, morning stiffness <30 minutes in duration, and/or crepitus, entered a 2-7 day washout period during which all analgesics were discontinued. When pain at the index knee joint reached > or =40 mm (0-100 mm VAS), patients were randomized to tramadol ER or placebo. Tramadol ER was initiated at 100 mg QD and increased to 200 mg QD by the end of 1 week of treatment. After the first week, further increases to tramadol ER 300 mg or 400 mg QD were allowed. Outcome measures included Arthritis Pain Intensity Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Arthritis Scale (WOMAC) Pain, Stiffness, Physical Function VAS subscales, Patient and Physician Global Assessment of Therapy, Sleep, dropouts due to insufficient therapeutic effect, and adverse events. Two hundred forty-six patients were randomized (tramadol ER 124, placebo 122). There were no baseline differences between the two treatments. The mean age was 61 years, mean duration of OA 12.9 years, and the mean tramadol ER dose was 276 mg QD. All efficacy outcome measures favored tramadol ER over placebo. On the primary outcome variable of average change from baseline in Arthritis Pain Intensity VAS over 12 weeks, tramadol ER was superior to placebo (least squares mean change from baseline: 30.4 mm vs. 17.7 mm, P < 0.001). Significant differences from placebo were evident at week 1, the first post-treatment visit. Similarly, outcomes on the WOMAC Pain, Stiffness and Physical Function subscales, the WOMAC Composite Scale, dropouts due to insufficient therapeutic effect, Patient and Physician Global Assessment of Therapy, and Sleep were all significantly better with tramadol ER than placebo (P < 0.001 to < 0.05). Treatment with tramadol ER results in statistically significant and clinically important and sustained improvements in pain, stiffness, physical function, global status, and sleep in patients with chronic pain. A once-a-day formulation of tramadol has the potential to provide patients increased control over the management of their pain, fewer interruptions in sleep and improved compliance.     

Cross-cultural adaptation,reliability and validity of the Arabic version of the reduced Western Ontario and McMaster Universities Osteoarthritis index in patients with knee osteoarthritis

Purpose: We adapted the reduced Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index for the Arabic language and tested its metric properties in patients with knee osteoarthritis (OA). Methods: One hundred and twenty-one consecutive patients who were referred for physiotherapy to the outpatient department were asked to answer the Arabic version of the reduced WOMAC index (ArWOMAC). After the completion of the ArWOMAC, the intensity of knee pain and general health status were assessed using the visual analog scale (VAS) and the 12-item short form health survey (SF-12), respectively. A second assessment was performed at least 48?h after the first session to assess test–retest reliability. The test–retest reliability was quantified using the intra-class correlation coefficient (ICC), and Cronbach’s alpha was calculated to assess the internal consistency of the Arabic questionnaire. The construct validity was assessed using Spearman rank correlation coefficients. Results: The total ArWOMAC scale and pain and function subscales were internally consistent with Cronbach’s coefficient alpha of 0.91, 0.89 and 0.90, respectively. Test–retest reliability was good to excellent with ICC of 0.91, 0.89 and 0.90, respectively. SF-12 and VAS score significantly correlated with ArWOMAC index (p?Conclusions: The ArWOMAC index is a reliable and valid instrument for evaluating the severity of knee OA, with metric properties in agreement with the original version.

• Implications for Rehabilitation

• Although, the reduced WOMAC index has been clinically utilized within the Saudi population, the Arabic version of this instrument is not validated for an Arab population to measure lower limb functional disability caused by OA.

• The Arabic version of reduced WOMAC (ArWOMAC) index is a reliable and valid scale to measure lower limb functional disability in patients with knee OA.

• The ArWOMAC index could be suitable in Saudi Arabia and other Arab countries where the language, culture and the life style are similar.

     

玻璃酸钠关节腔灌注联合治疗膝骨关节炎疗效观察

目的观察玻璃酸钠关节腔灌注治疗对膝骨关节炎患者的疗效。方法将57例膝骨关节炎患者随机分为玻璃酸钠治疗组和常规治疗组,用VAS标准评估所有患者基线和5周、12周后20 m步行痛、关节触痛、WOMAC骨关节炎指数。结果在5周、12周后玻璃酸钠治疗组和常规治疗组患者20 m步行痛程度、关节触痛、WOMAC（VAS法）均较基线时有明显改善（P〈0.05）。5周、12周后玻璃酸钠治疗组的20 m步行痛程度、关节触痛、WOMAC（VAS）均较常规治疗组有明显改善（P〈0.05）。结论常规治疗能明显改善膝骨关节炎患者临床症状、提高患者生活质量,联合玻璃酸钠关节腔灌注疗效更佳。     

The psychometric properties of an Arabic numeric pain rating scale for measuring osteoarthritis knee pain

Purpose: The aims of this study were to translate the numeric rating scale (NRS) into Arabic and to evaluate the test–retest reliability and convergent validity of an Arabic Numeric Pain Rating Scale (ANPRS) for measuring pain in osteoarthritis (OA) of the knee.

Methods: The English version of the NRS was translated into Arabic as per the translation process guidelines for patient-rated outcome scales. One hundred twenty-one consecutive patients with OA of the knee who had experienced pain for more than 6 months were asked to report their pain levels on the ANPRS, visual analogue scale (VAS), and verbal rating scale (VRS). A second assessment was performed 48 h after the first to assess test–retest reliability. The test–retest reliability was calculated using the intraclass correlation coefficient (ICC_2,1). The convergent validity was assessed using Spearman rank correlation coefficient. In addition, the minimum detectable change (MDC) and standard error of measurement (SEM) were also assessed.

Results: The repeatability of ANPRS was good to excellent (ICC 0.89). The SEM and MDC were 0.71 and 1.96, respectively. Significant correlations were found with the VAS and VRS scores (p?<0.01).

Conclusions: The Arabic numeric pain rating scale is a valid and reliable scale for measuring pain levels in OA of the knee.

• Implications for Rehabilitation

• The Arabic Numeric Pain Rating Scale (ANPRS) is a reliable and valid instrument for measuring pain in osteoarthritis (OA) of the knee, with psychometric properties in agreement with other widely used scales.

• The ANPRS is well correlated with the VAS and NRS scores in patients with OA of the knee.

• The ANPRS appears to measure pain intensity similar to the VAS, NRS, and VRS and may provide additional advantages to Arab populations, as Arabic numbers are easily understood by this population.

     

Comparison of therapeutic duration of therapeutic ultrasound in patients with knee osteoarthritis

[Purpose] The aim of study was to compare different durations of ultrasound in patients with knee osteoarthritis. [Subjects and Methods] One hundred patients diagnosed with bilateral knee osteoarthritis (OA) were enrolled in this study. Patients were divided into two groups. The first group (G1) received 4 minutes of ultrasound. The second group (G2) received the exact same treatment, but the duration of ultrasound was longer at 8 minutes. Patients in both groups underwent a total of 10 ultrasound over 2 weeks. Following treatment, all patients provided self-evaluations of pain via the Visual Analog Scale (VAS), overall physical function with WOMAC, disability via the Lequesne index (Leq), and depressive symptoms with the Beck Depression Index (BDI). [Results] There were no significant differences in VAS, WOMAC Leq, and BDI values between groups 1 and 2. After treatment, VAS, WOMAC, Leq, and BDI values improved for both treatment groups. However, following treatment, G2 had significantly greater values for WOMAC functional and total scores than G1. No statistically significant differences were observed for VAS scores while inactive, WOMAC pain and stiffness scores, and BDI values after treatment between both groups. VAS pain scores while active and Leq index values were significantly lower in G1 than G2. [Conclusion] Patients in both groups demonstrated improved functionality, pain and psychological status following a consistent, 2-week regimen of 4-minute or 8-minute treatments with ultrasound. Yet, patients that experienced longer treatment durations of 8 minutes demonstrated better outcomes in pain and the ability to carry out activities of daily living.Key words: Knee, Ultrasound, Osteoarthritis     

Immediate preoperative outcomes of pain neuroscience education for patients undergoing total knee arthroplasty: A case series

Background: Standard preoperative education for total knee arthroplasty (TKA) has been shown to have no effect on postoperative outcomes. This may be because such education programs fail to educate patients about pain. Pain neuroscience education (PNE) focuses on teaching people more about pain from a neurobiological and neurophysiological perspective. Design and setting: Case Series. Aim: To determine the immediate effects, if any, of providing PNE before TKA surgery on patient self-report measures. Participants: Twelve patients (female = 10) prior to TKA for knee osteoarthritis (OA). Intervention: Preoperative educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet. Main outcome measures: Comparison of pre- and post-PNE self-report measures on knee pain (NPRS), Pain Catastrophization Scale (PCS), fear of movement (TSK), and beliefs about TKA; as well as three physical performance measures – knee flexion active range of motion, 40 m self-paced walk, and pressure pain threshold (PPT). Results: Immediately following the PNE, patients had statistically significant lower TSK scores, increased PPT, and improved beliefs about their upcoming surgery. There were no significant changes in knee pain, function, or flexion active range of motion. Conclusions: Results appear to suggest that immediately after PNE, patients scheduled for TKA had statistically significant changes in fear of movement, decreased sensitivity to pain and positive shifts in their beliefs about their future knee surgery. Larger trials with control/comparison groups are warranted to determine the true effects of preoperative PNE for patients about to undergo TKA.