Nasimah Maricar

Lateral Wedge Insoles as a Conservative Treatment for Pain in Patients With Medial Knee Osteoarthritis: A Meta-analysis

IMPORTANCE There is no consensus regarding the efficacy of lateral wedge insoles as a treatment for pain in medial knee osteoarthritis. OBJECTIVE To evaluate whether lateral wedge insoles reduce pain in patients with medial knee osteoarthritis compared with an appropriate control. DATA SOURCES Databases searched include the Cochrane Central Register of Controlled Trials, EMBASE, AMED, MEDLINE, CINAHL Plus, ScienceDirect, SCOPUS, Web of Science, and BIOSIS from inception to May 2013, with no limits on study date or language. The metaRegister of Controlled Trials and the NHS Evidence website were also searched. STUDY SELECTION Included were randomized trials comparing shoe-based treatments (lateral heel wedge insoles or shoes with variable stiffness soles) aimed at reducing medial knee load, with a neutral or no wedge control condition in patients with painful medial knee osteoarthritis. Studies must have included patient-reported pain as an outcome. DATA EXTRACTION AND SYNTHESIS Trial data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed using the Cochrane Risk of Bias tool by 2 observers. Eligible studies were pooled using a random-effects approach. MAIN OUTCOME AND MEASURES Change in self-reported knee pain at follow-up. RESULTS Twelve trials met inclusion criteria with a total of 885 participants of whom 502 received lateral wedge treatment. The pooled standardized mean difference (SMD) suggested a favorable association with lateral wedges compared with control (SMD, -0.47; 95% CI, -0.80 to -0.14); however, substantial heterogeneity was present (I2 = 82.7%). This effect size represents an effect of -2.12 points on the 20-point Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scale. Larger trials with a lower risk of bias suggested a null association. Meta-regression analyses showed that higher effect sizes (unstandardized β, 1.07 [95% CI, 0.28 to 1.87] for trials using a no treatment control) were seen in trials using a no wedge treatment control group (n = 4 trials; SMD, -1.20 [95% CI, -2.09 to -0.30]) and lower effect sizes (unstandardized β, 0.26 [95% CI, 0.002 to 0.52] for each bias category deemed low risk) when the study method was deemed at low risk of bias. Among trials in which the control treatment was a neutral insole (n = 7), lateral wedges showed no association (SMD, -0.03 [95% CI, -0.18 to 0.12] on WOMAC; this represents an effect of -0.12 points), and results showed little heterogeneity (I2 = 7.1%). CONCLUSIONS AND RELEVANCE Although meta-analytic pooling of all studies showed a statistically significant association between use of lateral wedges and lower pain in medial knee osteoarthritis, restriction of studies to those using a neutral insole comparator did not show a significant or clinically important association. These findings do not support the use of lateral wedges for this indication.

Predictors of response to intra-articular steroid injections in knee osteoarthritis—a systematic review

Objective. IA steroid injections (IASIs) have been shown to relieve pain in knee OA and are widely used in clinical practice. There is, however, evidence of some variation in response. Knowledge of predictors of response could aid in the selection of patients for this therapy. The aim of this systematic review was to determine factors associated with response to IASI in knee OA. Methods. Medline, Embase, AMED, CINAHL, Web of Science and Cochrane Central Registers for Controlled Trials up to January 2012 were searched with additional hand searches of relevant articles. Studies included were those that involved adults diagnosed with knee OA in whom IASIs were administered and factors that predicted treatment response were investigated. Results. Eleven publications meeting these criteria were reviewed and relevant information extracted. It was not possible to pool the results because of the different predictors studied, variable outcome measures, different criteria for symptom change and missing data. Given the relative paucity of data and small heterogeneously designed studies, it was difficult to identify predictors of response. Data from individual publications, although not consistent across studies, suggest that the presence of effusion, withdrawal of fluid from the knee, severity of disease, absence of synovitis, injection delivery under US guidance and greater symptoms at baseline may all improve the likelihood of response to IASI. Conclusion. Further larger-scale studies using standardized methods are required to characterize predictors of response and should focus on synovitis, effusion, pain and structural severity of disease. Such data would help in better targeting therapy to those most likely to benefit.

Synovial tissue volume: a treatment target in knee osteoarthritis (OA).

Background Synovitis occurring frequently in osteoarthritis (OA) may be a targeted outcome. There are no data examining whether synovitis changes following intra-articular intervention. Methods Persons aged 40 years and older with painful knee OA participated in an open label trial of intra-articular steroid therapy. At all time points they completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. They had a contrast-enhanced (CE) MRI immediately prior to an intra-articular steroid injection with a repeat scan within 20 days. Response status was assessed using the Osteoarthritis Research Society International (OARSI) response criteria. OARSI responders were followed until their pain relapsed either within 20% of baseline or 6 months, shortly after which a third MRI was performed. Synovial tissue volume (STV) was measured on postcontrast knee images. We looked at changes in the STV and in pain, and their association. Results 120 subjects with preinjection and postinjection CE MRI were followed. Their mean age was 62.3 years (SD=10.3) and 62 (52%) were women. The median time between injection and follow-up scan was 8 days (IQR 7–14 days). 85/120 (71%) were OARSI responders. Pain decreased (mean change in KOOS=+23.9; 95% CI 20.1 to 27.8, p<0.001) following steroid injection, as did mean STV (mean change=−1071 mm3; 95% CI −1839 mm3 to −303 mm3, p=0.01). Of the 80 who returned for a third MRI, pain relapsed in 57, and in the 48 of those with MRI data, STV increased between follow-up and final visit (+1220 mm3; 95% CI 25 mm3 to 2414 mm3, p=0.05). 23 were persistent responders at 6 months and, in these, STV did not increase (mean change=−202 mm3; 95% CI −2008 mm3 to 1604 mm3, p=0.83). Controlling for variation over time, there was a significant association between synovitis volume and KOOS pain (b coefficient—change in KOOS pain score per 1000 mm3 change in STV=−1.13; 95% CI −1.87 to −0.39, p=0.003), although STV accounted for only a small proportion of the variance in change in pain. Conclusions Synovial tissue volume in knee OA shrinks following steroid therapy, and rebounds in those whose pain relapses. It can be considered a treatment target in symptomatic knee OA. Trial registration number ISRCTN07329370.

Where and how to inject the knee—A systematic review ☆, ☆☆

Objectives The knee can be injected at different anatomic sites with or without image-guidance. We undertook a systematic review to determine the accuracy of intra-articular knee injection (IAKI) and whether this varied by site, use of image-guidance, and experience of injectors, and whether accuracy of injection, site, or use of image-guidance influenced outcomes following IAKIs. Methods Medline, Embase, AMED, CINAHL, Web of Knowledge, Cochrane Central Registers for Controlled Trials up to Dec 2012 were searched for studies that evaluated either accuracy of IAKIs or outcomes related to accuracy, knee injection sites, or use of image-guidance. Within-study and between-study analyses were performed. Results Data from 23 publications were included. Within-study analyses suggested IAKIs at the superomedial patellar, medial midpatellar (MMP), superolateral patellar (SLP) and lateral suprapatellar bursae sites were more accurate when using image-guidance than when blinded (ranges of pooled risk difference 0.09–0.19). Pooling data across studies suggested blinded IAKIs at the SLP site were most accurate (87%) while MMP (64%) and anterolateral joint line (ALJL) sites were (70%) least accurate. Overall about one in five blinded IAKIs were inaccurate. There was some evidence that experience of the injector was linked with improved accuracy for blinded though not image-guided injections. Based on a small number of studies, short but not longer-term outcomes for ultrasound-guided were found to be superior to blinded IAKIs. Conclusions Image-guided IAKIs are modestly more accurate than blinded IAKIs especially at the MMP and ALJL sites. Blinded injections at SLP site had good accuracy especially if performed by experienced injectors. Further studies are required to address the question whether accurate localization is linked with an improved response.

Synovial volume vs synovial measurements from dynamic contrast enhanced MRI as measures of response in osteoarthritis

Summary Objective Synovium is increasingly a target of osteoarthritis (OA) treatment, yet its optimal measurement is unclear. Using dynamic contrast enhanced (DCE) MRI in knee OA patients before and after intraarticular steroid injection, we compared the responsiveness of static synovial volume measures to measures of dynamic changes in synovial enhancement, changes that are strongly related to synovial vascularity. Methods Ninety three patients underwent DCE-MRI before and 1–2 weeks after intra-articular injection of 80 mg methylprednisolone. Synovium was segmented and volume, relative enhancement rate (RER), maximum relative enhancement (REmax), late relative enhancement (RElate) and pharmacokinetic parameters (Ktrans, ve) were calculated. KOOS (knee injury and osteoarthritis outcome score) pain score was recorded before and after injection. Standardized change scores were calculated for each parameter. Linear regression and Pearsons correlations were used to investigate the relationship between change in MRI parameters and change in pain. Results The change in standardized score for the measures of synovial enhancement, RElate and REmax were −0.58 (95% CI −0.79 to −0.37) and −0.62 (95% CI −0.83 to −0.41) respectively, whereas the score for synovial volume was −0.30 (−0.52 to −0.09). Further, change in knee pain correlated more strongly with changes in enhancement (for both REmax and RElate, r = −0.27 (95% CI −0.45 to −0.07)) than with changes in synovial volume −0.15 (−0.35 to 0.05). Conclusion This study suggests DCE-MRI derived measures of synovial enhancement may be more sensitive to the response to treatment and more strongly associated with changes in pain than synovial volume and may be better outcomes for assessment of structural effects of treatment in OA.

Effect of Maitland mobilization and exercises for the treatment of shoulder adhesive capsulitis: A single-case design

The purpose of this single-case design (ABCBC) was to investigate the response of shoulder motions, pain, and function to two commonly used physiotherapy management approaches. An individual with stage three shoulder adhesive capsulitis was treated with exercise (phase B) and exercise plus mobilization (phase C). Initially, a “baseline” phase (phase A) when treatment had not started was established for comparison. Two types of Maitland “accessory” glenohumeral mobilization techniques, anteroposterior mobilization in shoulder flexion and longitudinal caudad in shoulder abduction, were evaluated during phase C. The Shoulder Pain and Disability Index (SPADI) was used to monitor pain and functional disability, and four shoulder movements (flexion, abduction, internal, and external rotations) were measured. The results were evaluated by using single-case design analysis method of Split Middle Technique and visual observation. The SPADI scores deteriorated in phase A but improved in phase B1, C1, and B2. All four shoulder movements improved under both management approaches, although more gain in motion was observed when mobilizations were added to an exercise program. The exercise plus mobilization intervention shows promise as a cost-effective management. The deterioration in shoulder motion, pain, and function observed in phase A may suggest benefit of an earlier physiotherapy intervention.

Clinical assessment of effusion in knee osteoarthritis—A systematic review

Objective The aim of this systematic review was to determine the validity and inter- and intra-observer reliability of the assessment of knee joint effusion in osteoarthritis (OA) of the knee. Methods MEDLINE, Web of Knowledge, CINAHL, EMBASE, and AMED were searched from their inception to February 2015. Articles were included according to a priori defined criteria: samples containing participants with knee OA; prospective evaluation of clinical tests and assessments of knee effusion that included reliability, sensitivity, and specificity of these tests. Results A total of 10 publications were reviewed. Eight of these considered reliability and four on validity of clinical assessments against ultrasound effusion. It was not possible to undertake a meta-analysis of reliability or validity because of differences in study designs and the clinical tests. Intra-observer kappa agreement for visible swelling ranged from 0.37 (suprapatellar) to 1.0 (prepatellar); for bulge sign 0.47 and balloon sign 0.37. Inter-observer kappa agreement for visible swelling ranged from −0.02 (prepatellar) to 0.65 (infrapatellar), the balloon sign −0.11 to 0.82, patellar tap −0.02 to 0.75 and bulge sign kappa −0.04 to 0.14 or reliability coefficient 0.97. Reliability and diagnostic accuracy tended to be better in experienced observers. Very few data looked at performance of individual clinical tests with sensitivity ranging 18.2–85.7% and specificity 35.3–93.3%, both higher with larger effusions. Conclusion The majority of unstandardized clinical tests to assess joint effusion in knee OA had relatively low intra- and inter-observer reliability. There is some evidence experience improved reliability and diagnostic accuracy of tests. Currently there is insufficient evidence to recommend any particular test in clinical practice.

Interobserver and Intraobserver Reliability of Clinical Assessments in Knee Osteoarthritis

Objective. Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). Methods. We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2–10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coefficients (ICC), estimated kappa (κ), weighted kappa (κω), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. Results. Using Landis and Koch criteria, interobserver κ scores were moderate for patellofemoral joint (κ = 0.53) and anserine tenderness (κ = 0.48); good for bony enlargement (κ = 0.66), quadriceps wasting (κ = 0.78), crepitus (κ = 0.78), medial tibiofemoral joint tenderness (κ = 0.76), and effusion assessed by ballottement (κ = 0.73) and bulge sign (κω = 0.78); and excellent for lateral tibiofemoral joint tenderness (κ = 1.00), flexion (ICC = 0.97), and extension (ICC = 0.87) ROM. Intraobserver κ scores were moderate for lateral tibiofemoral joint tenderness (κ = 0.60); good for crepitus (κ = 0.78), effusion assessed by ballottement test (κ = 0.77), patellofemoral joint (κ = 0.66), medial tibiofemoral joint (κ = 0.64), and anserine tenderness (κ = 0.73); and excellent for effusion assessed by bulge sign (κω = 0.83), bony enlargement (κ = 0.98), quadriceps wasting (κ = 0.83), flexion (ICC = 0.99), and extension (ICC = 0.96) ROM. Conclusion. Among individuals with symptomatic knee OA, the reliability of clinical examination of the knee was at least good for the majority of clinical signs of knee OA.

Brief report : synovial fluid white blood cell count in knee osteoarthritis : association with structural findings and treatment response

Osteoarthritis (OA) is a disease with a significant inflammatory component. The aim of this analysis was to determine the relationship between synovial fluid (SF) white blood cell (WBC) count and 2 parameters: disease severity and the reduction in knee pain after intraarticular (IA) steroid injection.

Synovial Fluid White Cell Count in Knee Osteoarthritis: Association with Structural Findings and Treatment Response

Osteoarthritis (OA) is a disease with a significant inflammatory component. The aim of this analysis was to determine the relationship between synovial fluid (SF) white blood cell (WBC) count and 2 parameters: disease severity and the reduction in knee pain after intraarticular (IA) steroid injection.