Michelle C. Hall

Relative impact of radiographic osteoarthritis and pain on quadriceps strength, proprioception, static postural sway and lower limb function

Objective: To investigate the relative impact of radiographic osteoarthritis (ROA) and current knee pain on lower limb physical function, quadriceps strength, knee joint proprioception, and postural sway. Methods: Using a 2×2 factorial design, 142 community derived subjects aged over 45 were divided into four subgroups based on the presence or absence of ROA (Kellgren & Lawrence >grade 2) and knee pain (as assessed by NHANES questions and a 100 mm visual analogue scale). Maximum isometric contraction of the quadriceps, knee joint proprioceptive acuity, static postural sway, and WOMAC index (both whole and function subscale) were assessed in all subjects. Results: Compared with normal subjects, reported disability was greater for all other subgroups (p<0.01). Subjects with both ROA and knee pain reported the greatest disability, and those with knee pain only had greater disability than those with ROA only. Quadriceps weakness was observed in all groups compared with normal subjects (p<0.01), though they were no significant intergroup differences. Subjects with knee pain had a greater sway area than those without (p<0.05) but the presence of ROA was not associated with increased postural sway. No differences in proprioceptive acuity were observed between groups. Conclusions: The presence of knee pain has a negative association with quadriceps strength, postural sway, and disability compared with ROA. However, the presence of pain-free ROA has a significant negative influence on relative quadriceps strength and reported disability.

Synovial pathology detected on ultrasound correlates with the severity of radiographic knee osteoarthritis more than with symptoms

Summary Objective To [1] compare the frequency and severity of ultrasound (US) features in people with normal knees (controls), knee pain (KP), asymptomatic radiographic OA (ROA), and symptomatic OA (SROA), [2] examine relationships between US features, pain and radiographic severity, [3] explore the relationship between change in pain and US features over a 3-month period. Method Community participants were recruited into a multiple group case–control study. All underwent assessment for pain, knee radiographs and US examination for effusion, synovial hypertrophy, popliteal cysts and power Doppler (PD) signal within the synovium. A 3-month follow-up was undertaken in over half of control and SROA participants. Results 243 participants were recruited (90 controls; 59 KP; 32 ROA; 62 SROA). Effusion and synovial hypertrophy were more common in ROA and SROA participants. Severity of effusion and synovial hypertrophy were greater in SROA compared to ROA (P < 0.05). Severity of US effusion and synovial hypertrophy were correlated with radiographic severity (r = 0.6 and r = 0.7, P < 0.01) but the relationship between pain severity and US features was weak (r = 0.3, P < 0.01). In SROA participants, pain severity did not change in tandem with a change in synovial hypertrophy over time. Conclusion US abnormalities are common in OA. Effusion and synovial hypertrophy were moderately correlated with radiographic severity but the relationship with pain is less strong. The degree to which these features reflect “active inflammation” is questionable and they may be better considered as part of the total organ pathology in OA. Further studies are warranted to confirm these findings.

Special tests for assessing meniscal tears within the knee: a systematic review and meta-analysis

Background Musculoskeletal knee pain is a large and costly problem, and meniscal tears make up a large proportion of diagnoses. ‘Special tests’ to diagnose torn menisci are often used in the physical examination of the knee joint. A large number of publications within the literature have investigated the diagnostic accuracy of these tests, yet despite the wealth of research their diagnostic accuracy remains unclear. Aim To synthesise the most current literature on the diagnostic accuracy of special tests for meniscal tears of the knee in adults. Method An electronic search of MEDLINE, Cumulative Index to Nursing and Allies Health Literature (CINAHL), The Allied and Complementary Medicine Database (AMED) and SPORTDiscus databases was carried out from inception to December 2014. Two authors independently selected studies and independently extracted data. Methodological quality was evaluated using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) 2 tool. Results Nine studies were included (n=1234) and three special tests were included in the meta-analysis. The methodological quality of the included studies was generally poor. McMurrays had a sensitivity of 61% (95% CI 45% to 74%) and a specificity of 84% (95% CI 69% to 92%). Joint line tenderness had a sensitivity of 83% (95% CI 73% to 90%) and a specificity of 83% (95% CI 61% to 94%). Thessaly 20° had a sensitivity of 75% (95% CI 53% to 89%) and a specificity of 87% (95% CI 65% to 96%). Conclusions The accuracy of the special tests to diagnose meniscal tears remains poor. However, these results should be used with caution, due to the poor quality and low numbers of included studies and high levels of heterogeneity.

Synovial changes detected by ultrasound in people with knee osteoarthritis - a meta-analysis of observational studies.

Summary Objectives To examine the prevalence of synovial effusion, synovial hypertrophy and positive Doppler signal (DS) detected by ultrasound (US) in people with knee osteoarthritis (OA) and/or knee pain compared to that in the general population. Method A systematic literature search was undertaken in Medline, EMBASE, Allied and Complementary Medicine, PubMed Web of Science, and SCOPUS databases in May 2015. Frequencies of US abnormalities in people with knee OA/pain, in the general population or asymptomatic controls were pooled using the random effects model. Publication bias and heterogeneity between studies were examined. Results Twenty four studies in people with knee pain/OA and five studies of the general population or asymptomatic controls met the inclusion criteria. The pooled prevalence of US effusion, synovial hypertrophy and positive DS in people with knee OA/pain were 51.5% (95% CI 40.2 to 62.8), 41.5% (26.3–57.5) and 32.7% (8.34–63.24), respectively, which were higher than those in the general population or asymptomatic controls (19.9% (95%CI 7.8–35.3%), 14.5% (0–58.81), and 15.8 (3.08–35.36), respectively). People with knee OA (ACR criteria or radiographic OA) had greater prevalence of US abnormalities than people with knee pain (P = 0.037, P = 0.010 and P = 0.009, respectively). Conclusions US detected effusion, synovial hypertrophy and DS are more common in people with knee OA/pain, compared to the general population. These abnormalities relate more to presence of OA structural changes than to pain.

Ultrasound detected synovial change and pain response following intra-articular injection of corticosteroid and a placebo in symptomatic osteoarthritic knees: a pilot study

Intra-articular injection (IAI) of steroid is a safe and effective treatment for painful knee osteoarthritis (OA).1 The mechanism of action is thought to be partly mediated by an anti-inflammatory effect on the synovium which may be detected by changes observed on ultrasound (US) examination.2 Placebo IAI of saline can also significantly reduce pain though the mechanisms are not generally thought to associate with a peripheral effect.3–5 This pilot study aimed to investigate whether improved knee pain correlated with improved US measures following IAI of a corticosteroid or a placebo in OA knees. Twenty-five participants with painful knee OA (Kellgren and Lawrence grade ≥2) were randomised to one of two treatment sequences (IAI of methylprednisolone (40 mg in 1 mL) followed by IAI of saline placebo (1 mL, 0.9%), or vice versa) to their most painful knee. Synovial fluid equal to volume injected …

A feasibility study for a pragmatic randomised controlled trial comparing cast immobilisation versus no immobilisation for patients following first-time patellar dislocation

BACKGROUND The purpose of this feasibility study was to begin to determine the efficacy of cylinder cast immobilisation compared to no form of immobilisation for patients following first-time patellar dislocation (FTPD). MATERIALS AND METHODS Participants were patients who attended a National Health Service Accident and Emergency department following a FTPD. Patients were randomised to receive immobilisation for four weeks in a cylinder cast followed by rehabilitation, versus no immobilisation and early rehabilitation. All patients were followed-up over a three month period, assessed using the Visual analogue scale for pain, Short Form-36, the Lysholm knee score and the Modified Functional Index. RESULTS Forty-one patients were approached to participate. Eight satisfied the pre-defined eligibility criteria and were randomised between the two groups. Whilst the results indicated a trend for superior short-term functional outcomes for those patients not immobilised compared to those immobilised following a FTPD, the small sample and baseline imbalances between the groups may have had a substantial influence on the results. CONCLUSION This feasibility study has indicated that the outcome measurements adopted were appropriate to answer this research question, but the assessment of return to normal activity, recurrent instability and dislocation and cost-effectiveness over a longer follow-up period is recommended. Similarly, defining a more pragmatic eligibility criteria and recruiting from multiple centres would be recommended for the definitive trial requiring a sample of 348 patients to demonstrate a statistical significant treatment effect.

SAT0670 The prevalence of neuropathic pain-like symptoms and associated risk factors in the nottingham community: a cross-sectional study

Background Knee pain (KP) affects 1 in 4 adults over the age of 50. Aside from structural joint changes, person-specific factors influence the KP experience. Increased central sensitisation of neural pathways due to localised joint pain or ineffective descending inhibitory mechanisms can cause an enhanced pain response and neuropathic pain-like (NP) symptoms. Understanding these person-specific factors and how they modulate the pain experience might help profile different KP and NP phenotypes. Objectives a) To determine the prevalence of NP in a KP community population b) to identify significant risk factors associated with NP and those with both NP and non-NP KP. Methods 9,513 men and women, aged 40+ years, were recruited from the East Midlands region (United Kingdom) via postal questionnaire. The questionnaire included sections on KP severity (numerical rating scale) and type (NP versus nociceptive) using the modified PainDETECT Questionnaire (mPDQ); quality of KP using the intermittent and constant osteoarthritis pain (ICOAP) instrument) as well as other risk factors including age, body mass index (BMI), injury, pain catastrophizing scale (PCS) and mental wellness (Hospital Anxiety and Depression Scale). KP participants were those who reported “knee pain for most days of the past one month” while likely NP was mPDQ scores of ≥13 and definite NP, ≥19. Differences between groups were assessed using t-tests for continuous data and chi2 for categorical data. We used multinomial regression analysis to determine the odds ratios (ORs) of risk factors with 95% confidence intervals (CI) and significance set p<0.05. Results The prevalence of definite NP in the Nottingham Community was 366 (13.62%). There were more women (p=0.04) and higher BMI (p<0.001) in KP vs. non-KP responders but no age difference (p>0.05). When comparing the neuropathic-like KP to non-neuropathic KP responders, significant risk factors after adjustment for age, BMI, gender and pain severity included: anxiety (OR 3.17 (95% CI 2.38;4.23)); depression (OR 2.99 (95% CI 2.14;4.19)); PCS in highest tertile (OR 5.39 (95% CI 2.94;9.88)); fibromyalgia (OR 4.06 (95% CI 2.48;6.66)) and previous knee injury (OR 1.5 (95% CI 1.12;2.00)). When comparing neuropathic-like KP to non-KP responders, anxiety (1.74 (95% CI 1.31; 2.30), depression (2.05 (95% CI 1.40; 3.01), PCS 3.78 (95% CI 2.57; 5.56)), fibromyalgia (OR 1.94 (95% CI 1.10; 3.40)) and previous injury (OR 1.35 (95% CI 1.05; 1.73)) were significant risk factors after adjustment. Conclusions This is the first population based cross-sectional study in the UK to determine prevalence of NP in people with KP. The results suggest that both psychological factors (depression, anxiety, high catastrophising) and peripheral risk factors (injury) associate with NP reporting. These factors can augment pain sensitivity and produce an amplified response via central and peripheral pathways. Phenotypes based on these risk factor profiles may warrant specific management in KP populations. Acknowledgements Arthritis Research UK Grant Refs: 20777, 20194 Disclosure of Interest None declared

Relative efficacy of different types of exercise for treatment of knee and hip osteoarthritis: protocol for network meta-analysis of randomised controlled trials

Background‘Exercise’ is universally recommended as a core treatment for knee and hip osteoarthritis (OA). However, there are very few head-to-head comparative trials to determine the relative efficacy between different types of exercise. The aim of this study is to benchmark different types of exercises against each other through the use of a common comparator in a network meta-analysis of randomised controlled trials (RCTs).MethodsThis study will include only RCTs published in peer-reviewed journals. A systematic search will be conducted in several electronic databases and other relevant online resources. No limitations are imposed on language or publication date. Participants must be explicitly identified by authors as having OA. Interventions that involved exercise or comparators in any form will be included. Pain is the primary outcome of interest; secondary outcomes will include function and quality of life measures. Quality assessment of studies will be based on the modified Cochrane’s risk of bias assessment tool. At least two investigators will be involved throughout all stages of screening and data acquisition. Conflicts will be resolved through discussion. Conventional meta-analysis will be performed based on random effects model and network meta-analysis on a Bayesian model. Subgroup analysis will also be conducted based on study, patient and disease characteristics.DiscussionThis study will provide for the first time comprehensive research evidence for the relative efficacy of different exercise regimens for treatment of OA. We will use network meta-analysis of existing RCT data to answer this question.Systematic review registrationPROSPERO CRD42016033865

OP0315 Ultrasound Features of Inflammation in the Knee Joint and its Relationship to Pain and Radiographic Osteoarthritis

Background Ultrasound (US) is a useful imaging modality that allows the evaluation of features suggestive of inflammation in osteoarthritis (OA). US features are more common in those with painful knee OA but the association between them remains inconclusive. Objectives To determine: [1] whether the frequency of ultrasound (US) features of inflammation differs between people with (a) normal asymptomatic knees (controls); (b) knee pain (KP) with no radiographic osteoarthritis (ROA); (c) asymptomatic ROA; and (d) symptomatic ROA (SROA); [2] whether US features associate with knee pain, OA change on x-ray, or symptoms and signs of inflammation; and [3] whether US features change in parallel with temporal change in knee pain. Methods A multiple group case-control study design was used. Community participants were recruited and divided into 4 groups based on presence or absence of (1) knee pain and (2) ROA. Standardised knee radiographs and assessments for pain, stiffness and function were carried out. All underwent US examination for effusion, synovial hypertrophy, popliteal cysts and power Doppler signal (PD) within the synovium. Features were dichotomised as present/absent, and grey-scale features were measured directly in mm. Follow-up US and pain assessments were collected in some OA and non-OA participants after 3 months. Comparisons between groups were examined using Χ2 tests, one-way ANOVA and post-hoc Bonferroni tests. Logistic regression was used to examine association between US features, knee pain and ROA adjusting for age, sex and BMI. Results 243 participants were recruited: 90 controls, 59 with KP, 32 with ROA and 62 with SROA. Greyscale US features of inflammation were more common in SROA (effusion 92%, synovial hypertrophy 82% and popliteal cysts 39%) than control and KP participants (p<0.05). US effusion, synovial hypertrophy and popliteal cysts were strongly associated with ROA (aOR(95%CI) =13.39 (6.14, 29.02); 14.39 (6.28, 32.94); 3.19 (1.42, 7.17) respectively) but only synovial hypertrophy was independently associated with pain (aOR=6.56 (2.85, 15.11)). No independent associations were found between PD signal, and pain or ROA. Follow-up of 65 non-OA and 51 OA participants found no relationship between change in pain severity and change in US features. Conclusions US features of inflammation are most strongly associated with ROA but the relationship with symptoms is less clear. This supports synovial changes as predominantly a secondary rather than primary feature of OA. Further studies are warranted to confirm these findings. Acknowledgements We are grateful to Arthritis Research UK for funding this work (AHP Training Fellowship Grant no.18861). Disclosure of Interest None Declared