Best-practice clinical management of flares in people with osteoarthritis: A scoping review of behavioral,lifestyle and adjunctive treatments

IntroductionTransient episodes of increased pain, stiffness or swelling are common in people with osteoarthritis (OA). Yet, evidence-based management strategies for lessening the impact of OA flares are rarely covered in clinical guidelines and have been identified as a gap by clinicians delivering OA care. We aimed to identify evidence on behavioral, lifestyle or other adjunctive flare management strategies that could be used by clinicians or consumers.Materials and methodsA literature search between 1990-2020 was performed in three databases using a scoping methodology. We included qualitative or quantitative studies, and reviews that examined OA flare management, or that reported OA flare outcomes at timepoints ≤2 weeks post-intervention. Outcomes included any physical or psychological OA outcome treatable with a therapeutic intervention.ResultsWe included 9 studies, all of which examined the relationship between therapeutic exercise/ physical activity and OA flares. All studies reported pain outcomes at the knee. Two also included the hip. Only two studies examined specific management strategies for OA flares. Both favorably reported the benefits of undertaking an exercise program modified accordingly during an episode, but the quality of the evidence was low.DiscussionThis scoping review highlights the paucity of evidence available on non-pharmacological treatments of OA flare management that could influence clinical practice. At present, there is no robust evidence to support or reject any specific therapies for OA flare management in clinical practice. Future work is needed, particularly around outcomes beyond pain, trajectories of symptom improvement, and for joints other than the knee.     

A fatal muzzle/barrel injury by home-made firearm-an unusual mechanism

IntroductionTrap guns are a type of home-made firearms common to Sri Lanka. Prevalent in the rural regions of the country, their main purpose is to protect crops from wild animals. It consists of a long metal pipe with a basic firing mechanism which is activated by a trip wire. Although the firing range and capacity to injure are low, they have a high propensity for causing accidental injury to unintended targets.Case reportA 42- year-old female was brought to the emergency department with the metal pipe of a trap gun penetrating through her head. According to eyewitnesses, she had thrown the trap gun, which upon impact with the floor fired in the direction of the floor. The force of fire energized the body of the trap gun to rebound with massive force. It impacted the victim's forehead and penetrated through the skull. Shortly after admission, she was pronounced dead and an autopsy was conducted. Autopsy revealed entry and exit wounds at the left supra-orbital ridge and right parietal bone respectively, with significant laceration of the brain matter. The trajectory of the metal pipe was further confirmed by antemortem computed tomography (CT) imaging.ConclusionThis highlights the first reported case where accidental activation of a trap gun from direct force, caused the body of the trap gun to rebound and inflict fatal injuries on a distant, unintended individual.     

A Definition of “Flare” in Low Back Pain: A Multiphase Process Involving Perspectives of Individuals With Low Back Pain and Expert Consensus

Low back pain (LBP) varies over time. Consumers, clinicians, and researchers use various terms to describe LBP fluctuations, such as episodes, recurrences and flares. Although “flare” is use commonly, there is no consensus on how it is defined. This study aimed to obtain consensus for a LBP flare definition using a mixed-method approach. Step 1 involved the derivation of a preliminary candidate flare definition based on thematic analysis of views of 130 consumers in consultation with an expert consumer writer. In step 2, a workshop was conducted to incorporate perspectives of 19 LBP experts into the preliminary flare definition, which resulted in 2 alternative LBP flare definitions. Step 3 refined the definition using a 2-round Delphi consensus with 50 experts in musculoskeletal conditions. The definition favored by experts was further tested with 16 individuals with LBP in step 4, using the definition in three scenarios. This multiphase study produced a definition of LBP flare that distinguishes it from other LBP fluctuations, represents consumers’ views, involves expert consensus, and is understandable by consumers in clinical and research contexts: “A flare-up is a worsening of your condition that lasts from hours to weeks that is difficult to tolerate and generally impacts your usual activities and/or emotions.”Perspective: A multiphase process, incorporating consumers’ views and expert consensus, produced a definition of LBP flare that distinguishes it from other LBP fluctuations.     

Bioactive titanium calcium phosphate coating for disc arthroplasty: analysis of 58 vertebral end plates after 6- to 12-month implantation

Background contextFrom a biomechanical perspective, the successful outcome of total disc replacement is largely based on the mechanisms of acute fixation obtained at the index procedure and the extent of porous biological osseointegration at the prosthesis-bone interface, ensuring long-term device fixation.PurposeThe present retrospective investigation quantifies the extent of porous osseointegration in cervical and lumbar disc arthroplasty implants containing a bioactive titanium/calcium phosphate coating.Study designBased on radiographic analysis and quantitative histomorphometry, the study was designed to determine the extent of porous osseointegration and whether osseointegration was affected by arthroplasty implant position.Outcome measuresQuantitative histomorphometric analysis of trabecular apposition in metallic backed cervical and lumbar arthroplasty devices.MethodsTwenty-nine disc arthroplasty devices underwent radiographic and histomorphometric analysis after 6- to 12-month implantation. The specimens included 12 cervical porous-coated motion devices implanted in a caprine model, and 17 lumbar Charité devices implanted in a non-human primate baboon. The two prosthetic-bone surfaces (superior and inferior) of each implant were examined for a total of 58 vertebral end plates. The operative motion segments were processed using undecalcified histologic technique with production of high-resolution light photomicrographs and microradiographs used for histomorphometric quantification of trabecular bone area at the implant interface. Based on plain film radiographs and histologic microradiographs, the technical accuracy of implant placement was classified as Ideal, Suboptimal, or Poor, with alignment referenced to the sagittal and coronal planes.ResultsThe technical accuracy of implant placement in the cervical spine based on histologic microradiographs ranged from poor=8% (2 out of 24), suboptimal=17% (4 out of 24), to ideal=75% (18 out of 24), whereas accuracy of lumbar disc arthroplasty ranged from poor=20% (7 out of 34), suboptimal=52% (18 out of 34), and ideal=26% (9 out of 34). Based on histomorphometric analysis of the inferior and superior end plate surfaces, the trabecular apposition ranged from poor placement 21%±30% ingrowth, suboptimal 26%±33%, to ideal=44%±23% (p>.05). Similar findings were observed for the lumbar region; however, the suboptimal and ideal positions were closer in values with regard to trabecular apposition. Poor placement was 34%±29%, suboptimal 49%±19%, and ideal 51%±13%, but this was not statistically significant (p>.05).ConclusionsThe present study represents the largest analysis to date of any retrieved porous ingrowth disc replacement prostheses. A trend was observed of increase porous osseointegration with improved implant positioning; however, the small sample size and high standard deviations account for lack of statistical significance. Although osseointegration occurs despite nonideal intraoperative positioning, it remains imperative that surgeons strive for Ideal implant position.     

Sagittal balance influences range of motion: an in vivo study with the ProDisc-C

Background contextCervical arthroplasty is designed to maintain cervical motion of the functional spinal unit after cervical discectomy. The impact of the ProDisc-C (Synthes Spine, Paoli, PA) on in vivo kinematics and sagittal alignment requires further assessment.PurposeThe purpose of this study is to test the hypothesis that the ProDisc-C increases range of motion (ROM) in flexion and extension at the surgical level, and assess its impact on cervical alignment.Study designClinical study.Patient sampleFifteen patients with a mean age of 49 years were included in this study. Each patient had a single-level arthroplasty. Patients with multilevel arthroplasty, previous cervical spine surgery, and length of follow-up less than 6 months were excluded from this study.Outcome measureLateral dynamic radiographs of the cervical spine were analyzed using quantitative measurement analysis (QMA) preoperatively and postoperatively. QMA software was also used to determine the ROM and sagittal translation at the surgical level.MethodsFlexion/extension lateral radiographs of the cervical spine were prospectively collected and reviewed in 15 patients preoperatively and at early (1–3 months) and late (6–14 months) follow-up after placement of the ProDisc-C. Shell angle (SA) and C2–C7 Cobb angles were measured. Sagittal translation and ROM were calculated at each time point. Preoperative values were compared with early and late follow-up values using paired Student t tests and Pearson's correlation.ResultsThe C2–C7 Cobb angle did not change significantly after surgery. Segmental ROM increased significantly from neutral to flexion (p=.02) and neutral to extension (p=.002) at late follow-up. SA correlated significantly with ROM from neutral to extension (Pearson's r=?0.55; p=.02) and translation from neutral to extension (Pearson's r=?0.58; p=.02).ConclusionsThe ProDisc-C increased overall segmental ROM. A lordotic SA may be associated with restricted segmental ROM and translation in extension. This study did not detect any change in overall cervical spinal alignment after insertion of the device.     

Results after Morton's neuroma resection via plantar approach

PurposeThe purpose of the study is to present the results after resection of Morton's neuroma via the plantar approach.Materials and methodsIn total 415 consecutive patients were operated on Morton's neuroma. The average follow-up was 39 months (range: 9–94). The mean age at the time of surgery was 56 years (range: 28–86). In 217 cases the neuroma was located in 2nd–3rd and 256 cases in the 3rd–4th interdigital space. A 174 neuromas were seen at the left and 170 at the right foot; 64 cases were bilateral. A 356 patients could be followed-up with a VAS and modified Kitaoka-score. All patients were operated via a plantar approach.ResultsA 328 of the 356 patients were subjectively satisfied with the results. The most significant improvement was documented for pain relief during daily activity. The average Kitaoka-score at the follow-up was 72 points (range: 35–75). In 6 cases postoperatively superficial wound healing problems occurred which were treated conservatively. A 10 patients complained about the plantar scar, in 32 patients a shoe conflict was observed for less than 6 months.ConclusionSurgical resection of a Morton's neuroma via the plantar approach lead to good and reproducible results.     

A New Conceptual Model of Neck Pain

European Spine Journal - Iterative discussion and consensus by a multidisciplinary task force scientific secretariat reviewing scientific evidence on neck pain and its associated disorders. To...     

Medial Prefrontal High-Definition Transcranial Direct Current Stimulation to Improve Pain Modulation in Chronic Low Back Pain: A Pilot Randomized Double-blinded Placebo-Controlled Crossover Trial

Chronic low back pain (CLBP) is highly disabling, but often without identifiable source. Focus has been on impaired anti-nociceptive mechanisms contributing to pain maintenance, though methods of targeting this impairment remain limited. This randomised-controlled cross-over pilot trial used active versus sham medial prefrontal cortex (mPFC) high-definition transcranial direct current stimulation (HD-tDCS) for 3-consecutive days to improve descending pain inhibitory function. Twelve CLBP patients were included with an average visual analogue scale (VAS) pain intensity of 3.0 ± 1.5 and pain duration of 5.3 ± 2.6 years. Pressure pain thresholds (PPTs), conditioned pain modulation (CPM), and temporal summation of pain (TSP) assessed by cuff algometry, as well as pain symptomatology (intensity, unpleasantness, quality, disability) and related psychological features (pain catastrophizing, anxiety, affect), were assessed on Day1 before 3 consecutive days of HD-tDCS sessions (each 20 minutes), at 24-hours (Day 4) and 2-weeks (Day 21) following final HD-tDCS. Blinding was successful. No significant differences in psychophysical (PPT, CPM, TSP), symptomatology or psychological outcomes were observed between active and sham HD-tDCS on Day4 and Day21. CPM-effects at Day 1 negatively correlated with change in CPM-effect at Day4 following active HD-tDCS (P = .002). Lack of efficacy was attributed to several factors, not least that patients did not display impaired CPM at baseline.Trial registration: ClinicalTrials.gov (NCT03864822).PerspectiveMedial prefrontal HD-tDCS did not alter pain, psychological nor psychophysical outcomes, though correlational analysis suggested response may depend on baseline pain inhibitory efficacy, with best potential effects in patients with severe impairments in descending pain inhibitory mechanisms. Future work should focus on appropriate patient selection and optimising stimulation targeting.