Efficacy of Periosteal Stimulation for Chronic Pain Associated With Advanced Knee Osteoarthritis: A Randomized,Controlled Clinical Trial

Background

Because of morbidity associated with painful knee osteoarthritis (OA) and commonly prescribed analgesics, patients often pursue complementary and alternative modalities (eg, acupuncture). Clinical trials have demonstrated modest therapeutic efficacy of traditional Chinese acupuncture for knee OA pain, and patients with advanced disease have largely been excluded. We have previously demonstrated preliminary short-term tolerability and efficacy of periosteal stimulation therapy (PST) (ie, electrical stimulation of the periosteum facilitated by acupuncture needles) for older adults with advanced knee OA.

Objective

This study evaluated the sustained efficacy of PST and boosters for treating chronic pain with advanced knee OA.

Methods

One hundred ninety participants age >50 years with Kellgren-Lawrence grade 3 or 4 knee OA and chronic pain were randomized to (1) PST (once a week for 10 weeks) followed by PST boosters for 6 months (once every 2 weeks 2 times, then once a month), (2) control PST (ie, periosteal needles and brief electrical stimulation of control points) once a week for 10 weeks, or (3) PST for 10 weeks followed by control PST boosters for 6 months. Change in the Western Ontario and McMaster Universities Osteoarthritis Index pain score immediately after the 10-week intervention and at 6-month follow-up (9 months after baseline) was the primary outcome. OMERACT-OARSI (Outcome Measures in Rheumatology Clinical Trials–Osteoarthritis Research Society International) criteria also were evaluated. Secondary measures of outcome included (1) physical performance (Short Physical Performance Battery, gait speed, Timed Up and Go, and timed stair climb); (2) psychological factors (depressive symptoms measured with the Center for Epidemiologic Studies–Depression scale, coping measured with the catastrophizing subscale of the Coping Strategies Questionnaire, and self-efficacy measured with the Arthritis Self-Efficacy Scale); (3) health-related quality of life measured with the Medical Outcomes Study 36-Item Short-Form Health Survey; (4) rescue pain medication use tracked with diaries; and (5) health care utilization and interim physical activity were monitored via monthly telephone calls.

Results

After adjustment for pain at baseline, the PST and control booster did not differ from controls at 10 weeks (difference, 1.3; 95% CI, −0.10 to 2.8; P = 0.0683) or 9 months (difference, 1.1; 95% CI, −0.32 to 2.6; P = 0.13). The PST and PST booster group had similar improvement compared with controls at 10 weeks (baseline adjusted difference, 1.1; 95% CI, −0.34 to 2.5; P = 0.1369) but significantly more improvement at 9 months (baseline adjusted difference, 1.5; 95% CI, 0.069 to 3.0; P = 0.0401). Baseline depressive symptoms, low self-efficacy, higher difficulty performing daily activities, and greater knee stiffness predicted a lower likelihood of response.

Conclusion

PST plus PST boosters in patients age >50 with advanced knee OA were well-tolerated and modestly reduced pain. ClinicalTrials.gov identifier: NCT00865046.     

老年膝骨关节炎患者运动锻炼自我管理行为及影响因素调查

目的了解老年膝骨关节炎(KOA)患者运动锻炼自我管理行为的现状,并分析影响因素。方法采用一般情况调查表和自我管理行为量表,对唐山市296 例老年KOA患者进行调查。结果体能锻炼自我管理得分为(24.22±36.18) min/周,主要影响因素为家庭住址和体质量指数(BMI);耐力锻炼得分为(136.27±83.21) min/周,主要影响因素为家庭住址、受教育程度及BMI。结论老年KOA患者运动锻炼自我管理欠佳,应针对不同的影响因素,采取相应的干预措施。     

The Effect of Preoperative Intra-Articular Methylprednisolone on Pain After TKA: A Randomized Double-Blinded Placebo Controlled Trial in Patients With High-Pain Knee Osteoarthritis and Sensitization

In a randomized, double-blind, placebo controlled trial, we investigated the postoperative analgesic effect of a single intra-articular injection of 40?mg methylprednisolone acetate (MP) administered 1 week before total knee arthroplasty (TKA). Forty-eight patients with high pain osteoarthritis (≥5 on a numeric rating scale during walk) and sensitization (pressure pain threshold?<250?kPa), aged 50 to 80 years and scheduled for primary unilateral TKA under spinal anaesthesia were included. The primary outcome was the proportion of patients with moderate/severe pain during a 5-m walk test 24 hours postoperatively. Secondary outcomes included pain at 48 hours, during the first 14 days, sensitization (quantitative sensory testing with pressure pain threshold and wind-up from temporal summation), and inflammatory changes (systemic C-reactive protein, intra-articular interleukin [IL]-6). No difference in the proportion of patients with moderate/severe pain was found between MP/placebo groups at 24 hours (67% and 74%, χ²?=?.2, P?=?.63, odds ratio = .7, 95% confidence interval = .2–2.8) or at 48 hours (57% and 68%, χ²?=?.5, P?=?.46, odds ratio = .6, 95% confidence interval = .2–2.3), and no difference between groups in postoperative sensitization was found (P?>?.4) despite reduced preoperative intra-articular inflammation (IL-6) in the MP group versus placebo (median change in IL-6 = ?70?pg/mL, interquartile range = ?466 to 0 vs. 32?pg/mL, interquartile range = ?26 to 75, P = .029). Alternative central or peripheral analgesic interventions in this high-risk group are required.

膝骨关节炎生物力学参数的研究进展

膝骨关节炎是老年人常见的慢性退行性疾病,其发生与发展与生物力学因素密切相关。膝关节受力受到关节形态、下肢力线、肌肉的主动收缩、外部负荷、软组织牵拉等不同因素的影响。由于体内测量限制,基于运动分析技术的生物力学参数被广泛应用于临床研究。目前应用较多的生物力学参数包括膝关节内收力矩、膝关节内收冲量、膝关节屈曲力矩、内翻延伸等。充分研究膝骨关节炎发生发展过程中膝关节生物力学参数的变化,对疾病的病因探究、诊断、干预及治疗均有重要意义。     

膝骨关节炎患者膝屈伸肌群等速肌力及其与功能的相关性

目的观察膝关节骨关节炎(KOA)患者膝屈伸肌群等速肌力变化及其与膝关节功能的关系。方法23 例双侧KOA患者及14 名正常人进行膝屈伸肌等速肌力检查、五次坐-起试验(FTSST)、静态平衡测试、步态分析。KOA组还完成疼痛视觉模拟评分(VAS)及WOMAC骨关节炎指数评定。结果KOA组伸肌及屈肌峰力矩、峰力矩均值、平均功率、单次最佳做功及总功主患侧均小于对侧(P<0.05);峰力矩屈肌/伸肌(H/Q)百分比主患侧大于对侧(P<0.05)。组间比较,伸肌所有观察指标、屈肌平均功率KOA组均小于正常对照组(P<0.05);峰力矩H/Q 百分比KOA组大于正常对照组(P<0.05)。KOA组伸肌等速肌力峰力矩与FTSST、步行速度、步行距离、跌倒指数、VAS 评分、WOMAC-疼痛评分之间存在相关性(P<0.05),屈肌等速肌力峰力矩与FTSST、步态参数、跌倒指数、VAS评分、WOMAC评分之间无明显相关性(P>0.05)。结论KOA患者伸肌及屈肌等速肌力主患侧较对侧减弱,伸肌等速肌力较正常人减弱,膝伸屈肌肌力变化不同步。KOA患者伸肌等速肌力峰力矩与膝关节疼痛、功能之间存在相关性。     

老年单、双膝痛骨关节炎患者的平衡功能及其跌倒风险对比分析

目的比较单膝痛和双膝痛骨关节炎老年患者的平衡功能特点及其跌倒风险。方法对30例老年无膝痛骨关节炎患者、30例老年单膝痛骨关节炎患者和32例老年双膝痛骨关节炎患者进行计时起立-行走测试(TUG)、静态姿势稳定性测试(PS)、动态姿势稳定极限性测试(LOS)以及动态跌倒风险测试(DFI)。结果单膝痛组TUG时间长于无膝痛组(P<0.05),双膝痛组明显长于无膝痛组(P<0.01),单、双膝痛组之间无显著性差异(P>0.05)。双膝痛组PS得分高于无膝痛组与单膝痛组(P<0.05),无膝痛组与单膝痛组之间无显著性差异(P>0.05)。双膝痛组的LOS完成时间明显长于无膝痛组和单膝痛组(P<0.01),无膝痛组与单膝痛组之间无显著性差异(P>0.05)。单、双膝痛组的DFI得分高于无膝痛组(P<0.05),双膝痛组高于单膝痛组(P<0.05)。结论老年单膝痛骨关节炎患者动态平衡功能的下降,存在高跌倒风险;老年双膝痛骨关节炎患者静态和动态平衡功能均下降,跌倒风险更高。     

Holistic/Integrative Interventions Relieve Knee Osteoarthritis Pain in Older Adults

Older adults have often used multiple treatment strategies for knee osteoarthritis (OA). Furthermore, older adults may have limited treatment options available because of issues such as morbidity, polypharmacy, and adverse drug reactions. Holistic/integrative interventions may be a viable option to decrease knee OA pain. Guidelines and literature are used to assist primary care providers in determining optimal holistic/integrative interventions for older adults with knee OA.     

Depression and Pain in Asian and White Americans With Knee Osteoarthritis

Few studies have examined the underlying psychosocial mechanisms of pain in Asian Americans. Using the biopsychosocial model, we sought to determine whether variations in depression contribute to racial group differences in symptomatic knee osteoarthritis pain between Asian Americans and non-Hispanic white Americans. The sample consisted of 100 participants, including 50 Asian Americans (28 Korean Americans, 9 Chinese Americans, 7 Japanese Americans, 5 Filipino Americans, and 1 Indian American) and 50 age- and sex-matched non-Hispanic white Americans with symptomatic knee osteoarthritis pain. The Centers for Epidemiologic Studies Depression Scale was used to assess symptoms of depression, and the Western Ontario and McMaster Universities Osteoarthritis Index and the Graded Chronic Pain Scale were used to measure clinical pain. In addition, quantitative sensory testing was used to measure experimental sensitivity to heat- and mechanically-induced pain. The results indicated that higher levels of depression in Asian Americans may contribute to greater clinical pain and experimental pain sensitivity. These findings add to the growing literature regarding ethnic and racial differences in pain and its associated psychological conditions, and additional research is warranted to strengthen these findings.

膝骨关节炎患者伸肌肌力与疼痛和功能状况的关系

目的调查膝骨关节炎患者患肢肌力与其疼痛和功能状况之间的关系。方法对25例经放射影像学确诊且有临床症状的膝关节骨关节炎患者进行西安大略和麦克马斯特大学（WOMAC）骨关节炎指数评分和等速肌力测试。结果膝骨关节炎患者患肢伸肌肌力与WOMAC疼痛得分、WOMAC日常活动能力得分、WOMAC总分之间存在相关性（P<0.05）。结论膝骨关节炎患者的疼痛和功能状况与患肢的伸肌肌力之间存在密切关系。     

Narrative: Review of Anterior Knee Pain Differential Diagnosis (Other than Patellofemoral Pain)

Purpose of ReviewThis review presents a framework for constructing a differential diagnosis for chronic anterior knee pain associated with overuse other than patellofemoral pain. Traumatic, systemic, and pediatric injuries will not be covered.Recent FindingsFrom superficial to deep, the anterior knee can be conceptually organized into four layers: (1) soft tissue, (2) extensor mechanism, (3) intracapsular/extrasynovial, and (4) intra-articular.SummaryFrom superficial to deep, diagnoses to consider include bursitis, patellar and quadriceps tendinosis, fat pad impingement, and plica syndromes.     

脑卒中患者膝关节骨关节炎的康复治疗

目的探讨脑卒中患者膝关节骨关节炎（KOA）的有效康复治疗方法。方法将伴发KOA的24例脑卒中患者随机分为治疗组和对照组各12例，均接受以易化技术为主的康复治疗，治疗组加用包括电针、理疗及运动疗法的综合康复治疗。采用视觉模拟评分法（VAS）及Fugl—Meyer下肢功能评分（FMMS）在治疗前和治疗1个疗程后对患者进行评定。结果治疗组患者的VAS及FMMS评分均优于对照组（P〈0.01）。结论电针、理疗加运动疗法的综合康复治疗对脑卒中患者的KOA有较好疗效。     

不同综合疗法对老年性重度膝骨关节炎的临床观察

目的比较关节腔注射玻璃酸钠和复方倍他米松复合口服草乌甲素片或双氯芬酸钠治疗老年性重度膝骨关节炎(KOA)的疗效。方法从580例KOA患者中选择程度为重度关节炎的患者60例,分为草乌甲素组和双氯芬酸钠组,每组各30例。两组均采用膝关节内注射玻璃酸钠和复方倍他米松,每周1次,5次为1个疗程。另外,草乌甲素组还口服草乌甲素片;双氯芬酸钠组还口服双氯芬酸钠片。根据Tegner的膝关节功能评价标准进行综合评价疗效,并比较两组副作用。结果两组患者膝关节功能综合评分较治疗前显著提高,治疗后显效率达80％以上,疼痛明显缓解(P<0.01);两组间疗效无显著性差异;但是草乌甲素组患者胃肠道反应的发生率明显低于双氯芬酸钠组(P＜0.01)。结论关节腔注射玻璃酸钠和复方倍他米松复合口服草乌甲素片的综合治疗方法对老年性重度关节炎的疗效确切,副作用少、安全性高。     

Behavioral Pain Indicators in People With Intellectual Disabilities: A Systematic Review

People with intellectual disabilities (IDs) have a higher risk of painful medical conditions. Partly because of the impaired ability to communicate about it, pain is often undertreated. To strengthen pain assessment in this population, we conducted a systematic review to identify behavioral pain indicators in people with IDs by using Embase, PubMed, PsycINFO, CINAHL, and Cochrane. Inclusion criteria were 1) scientific papers; 2) published in the last 20 years, that is, 1992 to 2012; 3) written in English, 4) using human subjects, 5) intellectual disabilities, 6) pain, 7) behavior, and 8) an association between observable behavior and pain experience. From 527 publications, 27 studies were included. Pain was acute in 14 studies, chronic in 2 studies, both acute and chronic in 2 studies, and unspecified in 9 studies. Methodological quality was assessed with the Mixed Methods Appraisal Tool. Of the 14 categories with behavioral pain indicators, motor activity, facial activity, social-emotional indicators, and nonverbal vocal expression were the most frequently reported. Most of the behavioral pain indicators are reported in more than 1 study and form a possible clinical relevant set of indicators for pain in people with IDs. Determination of a behavioral pattern specific for pain, however, remains a challenge for future research.PerspectiveThis review focuses on categories of behavior indicators related to pain in people with IDs. The quality of evidence is critically discussed per category. This set of indicators could potentially help clinicians to recognize pain in this population, especially when unique individual pain responses are also identified.