Aceclofenac vs paracetamol in the management of symptomatic osteoarthritis of the knee: a double-blind 6-week randomized controlled trial

OBJECTIVE: To evaluate the efficacy and tolerability of aceclofenac, 200 mg/day, and paracetamol, 3000 mg/day, in the treatment of osteoarthritis (OA) of the knee. METHODS: This was a double-blind, parallel-group, multicentre clinical trial involving patients with symptomatic OA of the knee, conducted in Spain. Patients were randomly allocated to aceclofenac 100 mg twice daily (n=82) or paracetamol 1000 mg three times daily (n=86). Patients were assessed at baseline and 6 weeks. Primary efficacy measures were severity of pain (visual analogue scale, VAS), Lequesne OA knee index, and patient's and physician's global assessment of disease activity. Severity of knee pain at rest or walking, stiffness, knee swelling and tenderness, and assessment of health-related quality of life (Health Assessment Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index, and Short Form 36) were included as secondary endpoints. RESULTS: Both treatment groups showed significant improvement compared with their baseline values in the four primary endpoints. Mean between-treatment differences favoured aceclofenac over paracetamol on pain (VAS, 7.64 mm [95% confidence interval (CI), 0.44-14.85 mm]), Lequesne OA index (1.41 [95% CI, 0.45-2.36]), and patient's (0.33 [95% CI, 0.06-0.61]) and physician's (0.23 [95% CI, 0.01-0.47]) global assessments. Adverse events were similar for both drugs (paracetamol, 29% patients vs aceclofenac, 32%; P=0.71). Four patients withdrew in each group due to adverse events. Patients tended to prefer aceclofenac to paracetamol (P=0.001), and more treated with paracetamol withdrew from the study due to lack of efficacy (n=8 vs n=1, P=0.035, for paracetamol and aceclofenac, respectively). CONCLUSION: At 6 weeks, patients with symptomatic OA of the knee showed a greater improvement in pain and functional capacity with aceclofenac than paracetamol with no difference in tolerability.     

A 3-month, randomized, double-blind, placebo-controlled study to evaluate the safety and efficacy of a highly optimized, capacitively coupled, pulsed electrical stimulator in patients with osteoarthritis of the knee

OBJECTIVE: To investigate the efficacy and safety of a capacitively coupled, pulsed electrical stimulation device in treating knee osteoarthritis (OA). DESIGN: Fifty-eight outpatients with moderate to severe OA of the knee entered a 3-month, double-blind, placebo-controlled trial, using either an active or placebo device at home for 6 to 14 h/day. Outcome measures included a patient global evaluation, a patient report of knee pain severity, and the Western Ontario and McMaster Universities (WOMAC) questionnaire. RESULTS: Active treatment provided superior outcomes between baseline and 3-month follow-up measurements: 50.6% greater improvement than placebo in patient global (P=0.03), 31.2% in patient pain (P=0.04), 25.1% in WOMAC stiffness (P=0.03), 29.5% in WOMAC function (P=0.01), 19.9% in WOMAC pain (P=0.11), and 27% in total WOMAC (P=0.01). The percent of patients who improved by more than 50% was 38.5 active vs 5.3 placebo in patient global (P=0.01), 43.6 vs 15.8 in patient pain (P=0.04), 38.5 vs 10.5 in WOMAC pain (P=0.03), 28.2 vs 5.3 in WOMAC stiffness (P=0.08), 23.1 vs 5.3 in WOMAC function (P=0.14), and 23.1 vs 5.3 in total WOMAC (P=0.14). Twenty-one percent of placebo and 18% of actively treated patients developed a transient rash at the electrode sites. No other adverse device effects were reported. CONCLUSION: A highly optimized, capacitively coupled, pulsed electrical stimulus device significantly improved symptoms and function in knee OA without causing any serious side effects.     

Intermittent treatment of knee osteoarthritis with oral chondroitin sulfate: a one-year, randomized, double-blind, multicenter study versus placebo

OBJECTIVE: To investigate the efficacy and tolerability of a 3-month duration, twice a-year, intermittent treatment with oral chondroitin sulfate (CS) in knee osteoarthritis (OA) patients. DESIGN: A total of 120 patients with symptomatic knee OA were randomized into two groups receiving either 800mg CS or placebo (PBO) per day for two periods of 3 months during 1 year. Primary efficacy outcome was Lequesne's algo-functional index (AFI); secondary outcome parameters included VAS, walking time, global judgment, and paracetamol consumption. Radiological progression was assessed by automatic measurement of medial femoro-tibial joint space width on weight-bearing X-rays of both knees. Clinical and biological tolerability was assessed. RESULTS: One hundred and ten of 120 patients were included in the ITT analysis. AFI decreased significantly by 36% in the CS group after 1 year as compared to 23% in the PBO group. Similar results were found for the secondary outcomes parameters. Radiological progression at month 12 showed significantly decreased joint space width in the PBO group with no change in the CS group. Tolerability was good with only minor adverse events identically observed in both groups. CONCLUSION: This study provides evidences that oral CS decreased pain and improved knee function. The 3-month intermittent administration of 800mg/day of oral CS twice a year does support the prolonged effect known with symptom-modifying agents for OA. The inhibitory effect of CS on the radiological progression of the medial femoro-tibial joint space narrowing could suggest further evidence of its structure-modifying properties in knee OA.     

The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults

OBJECTIVE: To estimate the contribution of selected non-articular conditions (NACs) to pain severity and functional limitation in community-dwelling older adults with knee pain. DESIGN: Population-based, cross-sectional study of 745 adults aged 50 years and over with knee pain. Self-complete questionnaires, clinical history and physical examination were used to identify the presence of selected NACs that could cause pain around the knee. Regression analyses were used to compare levels of knee pain severity (0-20) and functional limitation (0-68) (Western Ontario and McMaster Universities osteoarthritis index physical function subscale [WOMAC-PF]), between those with one or more NACs and those with none (NACs-absent). RESULTS: Two hundred and seventy-three (36.6%) participants had at least one NAC: widespread pain, n=159; low back pain with index leg referral, n=102; full-leg pain, n=88; hip arthritis, n=65; prepatellar, infrapatellar or pes anserine bursitis, n=35. The NACs group had significantly higher levels of pain severity and functional limitation than the NACs-absent group: 8.2(+/-4.6) vs 5.4(+/-3.8) and 27.9(+/-15.8) vs 16.8(+/-13.2), respectively. The groups did not differ with respect to severity of radiographic osteoarthritis (ROA). Having one or more NACs accounted for a significant proportion of the variance in WOMAC scores, above that which could be explained by age, gender, body mass index and severity of ROA. CONCLUSION: NACs appear to be common in older adults with knee pain. They make a significant contribution to knee pain severity and functional limitation and are likely to represent additional, rather than alternative, causes of knee pain/functional limitation to osteoarthritis (OA). These factors should be taken into account in epidemiological studies of knee pain and OA.     

Efficacy and safety of eltenac gel in the treatment of knee osteoarthritis

OBJECTIVE: A double-blind, placebo-controlled dose-finding study was performed in 237 patients with predominantly unilateral knee osteoarthritis (OA) evaluating efficacy and safety of a new topical NSAID. DESIGN: The patients applied 3 g tid eltenac gel 0.1%, 0.3%, 1% or placebo gel over a period of 4 weeks. The patients were supplied with paracetamol tablets as an escape analgesic. Primary efficacy end-point was mean global pain in the week preceding the examinatio ns, evaluated on a visual analog scale (VAS). Secondary criteria were Lequesne's score ISK, Jezek score, muscle strength and dolorimeter measurements, walking time, clinical examination results of the knee joint and patient's and investigator's overall efficacy estimates. RESULTS: The graphical depiction of VAS and ISK suggested a dose-related efficacy, but the pre-planned statistical analysis did not show significant differences between treatments.In the patient subgroup with a higher degree of baseline severity of knee OA the ISK showed significant and relevant advantages of eltenac gel 1% to placebo at different examination times. Two patients each of the eltenac gel 1% group and the placebo group showed local intolerance reactions which subsided spontaneously. CONCLUSION: This study did not provide confirmatory proof of an efficacy of topical eltenac in patients with knee OA. Methodological pitfalls and possible responder subgroups are described. Despite the difficulties, dose-finding studies seem to be feasible even with topical NSAIDs.     

Efficacy and safety of a single intra-articular injection of non-animal stabilized hyaluronic acid (NASHA) in patients with osteoarthritis of the knee

OBJECTIVE: Non-animal stabilized hyaluronic acid (NASHA) is a novel hyaluronan (HA) preparation with a 4-week intra-articular half-life. This study compared the efficacy of a single injection of NASHA with placebo in patients with osteoarthritis (OA) of the knee. DESIGN: This was a 26-week randomized, double-blind, multicenter study of a single intra-articular knee injection with either NASHA or placebo (saline). Assessments included the Western Ontario McMasters Universities osteoarthritis index (WOMAC, Likert Scale) and patients' overall global disease status. A positive response was defined as a reduction in WOMAC pain score for the study knee of 40% from baseline with a minimum improvement of > or =5 points. RESULTS: A total of 346 (NASHA 172; placebo 174) patients were treated. WOMAC scores and quality of life were improved in both the NASHA and placebo groups. For the overall population, there were no statistically significant between-group differences in response rates for any efficacy parameters. In patients with OA confined to the knee (N=216), a greater response to NASHA than placebo was observed at week 6 (P=0.025). There were few treatment-related events. CONCLUSIONS: NASHA was not superior to placebo for the primary efficacy analysis. However, these data may be confounded by the inclusion of patients with OA at other sites, as significant benefits over placebo were found among patients with OA confined to the knee. Future trials of OA that examine a local therapy might need to consider restricting the study population to those patients having OA of only the signal joint.     

Response criteria for clinical trials on osteoarthritis of the knee and hip: a report of the Osteoarthritis Research Society International Standing Committee for Clinical Trials response criteria initiative

BACKGROUND: The domains of pain, function and patient's global assessment are identified as core variables and frequently measured in clinical trials of patients with osteoarthritis (OA) of the hip and knee. OBJECTIVE: To develop response criteria for OA of hip and knee based on the domains of pain, function and patient's global assessment. METHODS: A methodology was developed by an interaction of the Osteoarthritis Research Society International Standing Committee on Clinical Trials, biostatisticians, pharmaceutical company representatives and health agency representatives. Data from previously conducted placebo-controlled clinical trials were normalized and collated. Data were subset by location of OA (knee, hip), active agent used in the clinical trial (non-steroidal anti-inflammatory drug, other agent) and route of administration (oral, intra-articular). Statistical analysis identified response criteria which best discriminate active agent from placebo. RESULTS: Based on the analysis of data from 14 studies (totaling 1886 patients) and consensus opinion, the optimal responder criteria set differed for location of OA, active agent to be used, and route of administration. Because of nearly identical statistical results, two sets of responder criteria are proposed: (1) 'high' pain response or, alternatively, a 'moderate' response for at least two of three domains: pain, function and patient's global assessment; (2) 'high' response for either pain or function or, alternatively, a 'moderate' response for at least two of three domains: pain, function and patient's global assessment. The sensitivity (i.e., the percentage of responders in the active group) ranged from 52 to 96% and the specificity (i.e., the percentage of nonresponders in the control group) from 47 to 73%. CONCLUSION: Based on data from clinical trials, two sets of responder criteria have been developed that can categorize an individual's responses to treatment in a clinical trial. These responder criteria require validation in additional datasets.     

玻璃酸钠治疗膝骨关节炎的临床观察

目的: 探讨玻璃酸钠治疗膝骨关节炎的疗效。方法: 回顾性分析膝骨关节炎 179例, A组应用玻璃酸钠关节内注射, B组单纯进行膝关节镜手术, C组进行膝关节镜手术, 术后关节腔内注射玻璃酸钠。观察治疗前后病人的疼痛、膝关节活动情况。治疗后头半年每月随访 1次, 以后每半年随访 1次。结果: 116例患者获得随访, 随访时间 9~37个月, 平均 13. 3个月。采用林志雄评分标准评价疗效: 术后与术前相比, 差异有显著性。C组优 36例, 良 6例, 可 1例; A组优 18例, 良15例, 可 3例, 差 2例; B组优 14例, 良 14例, 可 6例, 差 1例; C组与A组、B组相比效果显著。治疗和随访过程中未发现玻璃酸钠明显的毒副作用。结论: 玻璃酸钠注射治疗膝骨关节炎疗效确切, 膝关节镜手术后关节腔内注射玻璃酸钠是治疗膝骨关节炎的理想方法。     

Celecoxib improves the efficiency of the locomotor mechanism in patients with knee osteoarthritis. A randomised, placebo, double-blind and cross-over trial

OBJECTIVE: To compare the effect of celecoxib vs placebo treatment on clinical and gait variables in knee osteoarthritis (OA) patients; focusing on the efficiency of the locomotor mechanism. METHODS: STUDY DESIGN: A prospective, randomised, double-blind placebo-controlled trial. PATIENTS: Eight adult patients with painful OA of the knee. OUTCOME MEASURES: Clinical assessment included knee pain assessed by the visual analogue scale, range of knee motion assessed by goniometer, and locomotor function status assessed by a Knee Score Scale. Gait was assessed by means of instrumented analysis including synchronous kinematic, dynamic, electromyographic, and energetic recordings. STATISTICAL ANALYSIS: The effect of treatment on the primary variable, the efficiency of the locomotor mechanism, and on secondary clinical and gait variables was assessed by the Hills and Armitage non-parametric approach. RESULTS: Celecoxib treatment improved the efficiency of the locomotor mechanism significantly. Among the secondary outcome measures assessed, celecoxib treatment improved walking cadence and reduced the knee pain significantly. CONCLUSION: This study shows that celecoxib is effective in improving locomotor function and pain in patients with knee OA.     

Effect of combined laser acupuncture on knee osteoarthritis: a pilot study

Our objective was to assess the efficacy and safety of combined 10.6 μm and 650 nm laser irradiation on patients with knee osteoarthritis (OA). Forty patients with OA were randomly allocated to an active laser group or to a placebo laser group (20 per group). They either received active or sham laser treatment at acupoint Dubi (ST 35) in a total of 12 sessions. There was significant difference between the two groups in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score change from baseline after 2 weeks of treatment (P = 0.047). The pain reduction of the active laser treatment group was 49%, whereas that of the placebo control group was only 13%. However, due to the high patient drop-out rate, the 4-week assessment could not be analyzed. Combined laser treatment seems beneficial to patients with knee OA. However, due to the small sample size and the high drop-out rate of patients in the placebo group, a large sample-size clinical trial is warranted to determine further the therapeutic efficacy of the device.     

Efficacy and safety of the COX-2 specific inhibitor valdecoxib in the management of osteoarthritis of the hip: a randomized, double-blind, placebo-controlled comparison with naproxen

OBJECTIVE: Non-steroidal antiinflammatory agents are commonly used to treat pain and inflammation associated with osteoarthritis (OA), but have poor gastrointestinal (GI) tolerability. This study compared the efficacy of the COX-2 specific inhibitor valdecoxib with naproxen and placebo, in treating symptomatic OA of the hip. DESIGN: This multicenter, randomized, double-blind 12-week study compared the efficacy and tolerability of single daily doses of valdecoxib 5 mg and 10 mg with placebo or naproxen 500 mg BID. Efficacy was assessed by Patient's and Physician's Global Assessment of Arthritis, and the WOMAC (Western Ontario and McMasters) OA Individual and Composite Indices. The incidence of adverse events was monitored throughout the study. RESULTS: Valdecoxib was clinically and statistically superior to placebo for Patient's and Physician's Global Assessment of Arthritis and for all WOMAC OA Indices over the 12 week study period (P相似文献   

Where does it hurt? Pain localization in osteoarthritis of the knee

OBJECTIVE: To identify the most common sites of pain in symptomatic knee osteoarthritis (OA) and to investigate clinical, radiographic and psychosocial associations of pain occurring in different locations. DESIGN: Sixty-eight outpatients with knee OA were interviewed in detail about their knee pain. Location of pain was recorded on a standard drawing of the knee. Validated instruments were used to measure pain severity, function, depression, anxiety, quality of life, fatigue, helplessness, self efficacy. Pain threshold was measured by dolorimetry and a knee examination performed. Radiographs (anterioposterior and lateral) were viewed if available. RESULTS: Most (85.3%) patients reported either 'generalized' (N = 35, 51.5%) or 'medial' (N = 23, 33.8%) knee pain. There were no differences between groups in pain severity, demographic or psychosocial variables, pain threshold or radiographic location or severity. However, function was significantly worse in the 'generalized' group (WOMAC function score 48.9 +/- 20.8 vs 34.2 +/- 22.3; P = 0.01): this remained significant after adjustment for potential confounding factors. The difference in function was most marked for activities involving knee bending. Early morning stiffness was also greater in the generalized group. CONCLUSIONS: Knee pain is not the same in all individuals with knee OA, confirming the heterogeneity of the condition. Location of pain is usually either generalized or medial. Patients with these patterns do not differ in demographic, radiographic or psychosocial variables but important differences in functional ability can be detected, suggesting differences in the underlying causes of pain and disability between the two groups.     

Efficacy of different therapy regimes of low-power laser in painful osteoarthritis of the knee: a double-blind and randomized-controlled trial

BACKGROUND AND OBJECTIVES: A prospective, double-blind, randomized, and controlled trial was conducted in patients with knee osteoarthritis (OA) to evaluate the efficacy of infrared low-power Gallium-Arsenide (Ga-As) laser therapy (LPLT) and compared two different laser therapy regimes. STUDY DESIGN/MATERIALS AND METHODS: Ninety patients were randomly assigned to three treatment groups by one of the nontreating authors by drawing 1 of 90 envelopes labeled 'A' (Group I: actual LPLT consisted of 5 minutes, 3 J total dose + exercise; 30 patients), 'B' (Group II: actual LPLT consisted of 3 minutes, 2 J total dose + exercise; 30 patients), and 'C' (Group III: placebo laser group + exercise; 30 patients). All patients received a total of 10 treatments, and exercise therapy program was continued during study (14 weeks). Subjects, physician, and data analysts were unaware of the code for active or placebo laser until the data analysis was complete. All patients were evaluated with respect to pain, degree of active knee flexion, duration of morning stiffness, painless walking distance and duration, and the Western Ontario and Mc Master Universities Osteoarthritis Index (WOMAC) at week 0, 6, 10, and 14. RESULTS: Statistically significant improvements were indicated in respect to all parameters such as pain, function, and quality of life (QoL) measures in the post-therapy period compared to pre-therapy in both active laser groups (P < 0.01). Improvements in all parameters of the Group I and in parameters, such as pain and WOMAC of the Group II, were more statistically significant when compared with placebo laser group (P < 0.05). CONCLUSIONS: Our study demonstrated that applications of LPLT in different dose and duration have not affected results and both therapy regimes were a safe and effective method in treatment of knee OA.     

Prospective, multi-centre, randomised evaluation of the safety and efficacy of five dosing regimens of viscosupplementation with hylan G-F 20 in patients with symptomatic tibio-femoral osteoarthritis: a pilot study

Introduction  Viscosupplementation by repeated intra-articular injections of hyaluronic acid (HA) is used widely in the treatment of symptomatic knee osteoarthritis (OA). The number of injections required can limit the availability of treatment and affect patient compliance. The aim of this study was to assess different dosing regimens of hylan G-F 20, a high molecular-weight cross-linked derivative of HA, in the treatment of pain due to knee OA. Materials and methods  Pilot, prospective, multi-centre, open-label, randomised trial in 100 patients with unilateral, symptomatic, tibio-femoral OA (Kellgren–Lawrence grade II or III), aged ≥40 years. Patients were randomised to receive varying dosing regimens of hylan G-F 20 (1 × 6 mL, 1 × 4 mL, 2 × 4 mL 2 weeks apart, 3 × 4 mL 1 week apart, or 3 × 2 mL 1 week apart). Adverse events (AE’s) were monitored throughout the study. The primary efficacy endpoint was the change from baseline in the patient-rated knee OA pain assessment (100 mm visual analogue scale (VAS)) at 24 weeks. The secondary efficacy criteria included the WOMAC index, patient and physician global assessments using a 100 mm VAS, and knee OA pain assessment at all other visits. Concomitant use of permitted rescue medications (paracetamol) was also assessed. Results  The treatment was well tolerated overall. Patients in the 3 × 4 mL group reported the highest percentage of device-related local AE’s (30%) while patients in the 1 × 6 mL and 3 × 2 mL groups reported only 10%. There were no serious device-related AEs. There was a statistically significant improvement from baseline at week 24 in all efficacy endpoints for all treatment regimens. The 1 × 6 and 3 × 4 and 3 × 2 mL treatment groups showed the greatest mean improvements (−34.9, −32.6 and −36.7 mm respectively) in the patient-rated knee OA pain assessment VAS. Conclusion  This study suggests that a single 6 mL injection of hylan G-F 20 may be as efficacious, and as well tolerated, as 3 × 2 mL one week apart. A double-blind, controlled trial is needed to confirm these data.     

Clinical experience with the effectiveness and tolerability of hylan G-F 20 in 1047 patients with osteoarthritis of the knee

This retrospective review evaluates the effectiveness and tolerability of hylan G-F 20 for relief of pain due to knee osteoarthritis in a large orthopedic practice over a 5-year period. Prospectively collected data from patients who initiated intra-articular hylan G-F 20 (3 weekly injections) for osteoarthritis knee pain treatment were analyzed. Efficacy variables included physician visual analogue scale (VAS: 100 mm), and patient rating of pain, mobility, and amount of pain medication taken after treatment. Patients (n=1047; 1489 knees) were an average age of 65.3 years, 60% female, and 71% had radiologic osteoarthritis grade IV. Mean VAS scores significantly improved with hylan G-F 20 compared to baseline at all time points (P<.0001). Most knees (62%-89%) responded positively with hylan G-F 20. Pain and mobility improved and less pain medication was needed after therapy. The incidences of local adverse events were 5.2% per patient and 1.2% per injection; most local adverse events were mild or moderate, with severe local events in 0.3% of injections. Our clinical experience shows that hylan G-F 20 effectively relieves osteoarthritis knee pain (as indicated) and reduces pain medication needed for up to 6 months with a low incidence of local adverse events.     

Symptomatic efficacy of avocado-soybean unsaponifiables (ASU) in osteoarthritis (OA) patients: a meta-analysis of randomized controlled trials

OBJECTIVE: To evaluate the efficacy of preparations with avocado-soybean unsaponifiables (ASUs) in osteoarthritis (OA) patients using meta-analysis on randomized controlled trials (RCTs). METHOD: RCTs from systematic searches were included if they explicitly stated that hip and/or knee OA patients were randomized to either ASU or placebo. The co-primary outcome was reduction in pain and Lequesne index, leading to effect size (ES), calculated as the standardized mean difference. As secondary analysis, the number of responders to therapy was analyzed as odds ratios (ORs). Restricted maximum likelihood methods were applied for the meta-analyses, using mixed effects models. RESULTS: Four trials--all supported by the manufacturer--were included, with 664 OA patients with either hip (41.4%) or knee (58.6%) OA allocated to either 300 mg ASU (336) or placebo (328). Average trial duration was 6 months (range: 3-12 months). Though based on heterogeneous results, the combined pain reduction favored ASU (I(2) = 83.5%, ES = 0.39 [95% confidence intervals: 0.01-0.76], P=0.04). Applying the Lequesne index also favored ASU (I(2) = 61.0%, ES = 0.45 [0.21-0.70], P = 0.0003). Secondarily, the number of responders following ASU compared to placebo (OR = 2.19, P = 0.007) corresponded to a number needed to treat of six (4-21) patients. CONCLUSIONS: Based on the available evidence, patients may be recommended to give ASU a chance for e.g., 3 months. Meta-analysis data support better chances of success in patients with knee OA than in those with hip OA.     

Knee osteoarthritis in community-dwelling older adults: are there characteristic patterns of pain location?

OBJECTIVE: To determine whether there are characteristic patterns of pain location associated with knee osteoarthritis (OA) among community-dwelling older adults. DESIGN: Population-based, cross-sectional survey of 697 adults aged 50 years and over reporting knee pain within the past 6 months. Pain at 13 individual sites at or around the knee was coded. Pain locations in participants with and without "symptomatic knee OA" (defined as symptoms on most days in the past month, at least a definite osteophyte on plain X-ray, and current pain intensity of at least 2 out of 10) were compared. Participants were then grouped by pattern of knee pain location, and their clinical and radiographic characteristics compared. RESULTS: Generalised knee pain (n=313) and medial knee pain (either in isolation or with peripatellar or lateral knee pain: n=175) were the most common patterns. Medial knee pain and distally radiating pain were significantly more likely in those with symptomatic knee OA. Individuals with generalised knee pain with radiation had more persistent, severe pain, and a relatively high proportion had moderate or severe radiographic disease. CONCLUSION: No single pattern of pain location is pathognomonic for knee OA. Attention towards the role of peripheral nociception and central sensitisation in producing medial knee pain and distally radiating knee pain is warranted.     

A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol

ABSTRACT: BACKGROUND: Knee osteoarthritis (OA) is a prevalent chronic musculoskeletal condition with no cure. Pain is the primary symptom and results from a complex interaction between structural changes, physical impairments and psychological factors. Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population. There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training (PCST) in improving pain and psychological impairments particularly in other chronic pain conditions. Though typically provided separately, there are resource and personnel advantages of exercise and PCST being delivered together by a single healthcare professional. Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognizant of the need for a biopsychosocial approach to management. No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population. The aim of this randomised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA. METHODS: This will be an assessor-blinded, 3-arm randomised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice. Participants with symptomatic and radiographic knee OA will be recruited. Participants will be randomised into one of three groups: exercise alone, PCST alone, or integrated PCST and exercise. Primary outcomes will be pain measured by a Visual Analogue Scale (VAS) and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Measurements will be taken at baseline and immediately following the intervention (12 weeks) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects. Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42. The study will be conducted at two sites, Melbourne and Brisbane, Australia to facilitate generalizabilty of the results and to ensure timely recruitment. CONCLUSION: The findings from this randomised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA. The trial design will conform to CONSORT requirements for non-pharmacological treatment. Trial Registration: Australian New Zealand Clinical Trials Registry reference number: ACTRN12610000533099.     

Pain threshold correlates with functional scores in osteoarthritis patients

Background and purpose — Pain sensitization may be one of the reasons for persistent pain after technically successful joint replacement. We analyzed how pain sensitization, as measured by quantitative sensory testing, relates preoperatively to joint function in patients with osteoarthritis (OA) scheduled for joint replacement.

Patients and methods — We included 50 patients with knee OA and 49 with hip OA who were scheduled for joint replacement, and 15 control participants. Hip/knee scores, thermal and pressure detection, and pain thresholds were examined.

Results — Median pressure pain thresholds were lower in patients than in control subjects: 4.0 (range: 0–10) vs. 7.8 (4–10) (p = 0.003) for the affected knee; 4.5 (2–10) vs. 6.8 (4–10) (p = 0.03) for the affected hip. Lower pressure pain threshold values were found at the affected joint in 26 of the 50 patients with knee OA and in 17 of the 49 patients with hip OA. The American Knee Society score 1 and 2, the Oxford knee score, and functional questionnaire of Hannover for osteoarthritis score correlated with the pressure pain thresholds in patients with knee OA. Also, Harris hip score and the functional questionnaire of Hannover for osteoarthritis score correlated with the cold detection threshold in patients with hip OA.

Interpretation — Quantitative sensory testing appeared to identify patients with sensory changes indicative of mechanisms of central sensitization. These patients may require additional pain treatment in order to profit fully from surgery. There were correlations between the clinical scores and the level of sensitization.     

Treatment of knee osteoarthritis with pulsed electromagnetic fields: a randomized, double-blind, placebo-controlled study

OBJECTIVE: The investigation aimed at determining the effectiveness of pulsed electromagnetic fields (PEMF) in the treatment of osteoarthritis (OA) of the knee by conducting a randomized, double-blind, placebo-controlled clinical trial. DESIGN: The trial consisted of 2h daily treatment 5 days per week for 6 weeks in 83 patients with knee OA. Patient evaluations were done at baseline and after 2 and 6 weeks of treatment. A follow-up evaluation was done 6 weeks after treatment. Activities of daily living (ADL), pain and stiffness were evaluated using the Western Ontario and McMaster Universities (WOMAC) questionnaire. RESULTS: Within group analysis revealed a significant improvement in ADL, stiffness and pain in the PEMF-treated group at all evaluations. In the control group there was no effect on ADL after 2 weeks and a weak significance was seen after 6 and 12 weeks. Significant effects were seen on pain at all evaluations and on stiffness after 6 and 12 weeks. Between group analysis did not reveal significant improvements over time. Analysis of ADL score for the PEMF-treated group revealed a significant correlation between less improvement and increasing age. Analysis of patients <65 years using between group analysis revealed a significant improvement for stiffness on treated knee after 2 weeks, but this effect was not observed for ADL and pain. CONCLUSIONS: Applying between group analysis we were unable to demonstrate a beneficial symptomatic effect of PEMF in the treatment of knee OA in all patients. However, in patients <65 years of age there is significant and beneficial effect of treatment related to stiffness.