Osteoarthritis

ROME – Knee joint distraction – a method of relieving mechanical stress on the joint by temporarily pinning it – could help some patients with osteoarthritis avoid the need for a knee prosthesis, judging from preliminary findings from a randomized, controlled, comparative trial.

At 1-year follow-up, all subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Total KOOS score were significantly and progressively improved from baseline in patients who underwent knee distraction (P < .001). Overall the mean change in the Total KOOS score was not significantly different from that in the group of patients who underwent total knee replacement (TKR); although the KOOS subscale of quality of life did show greater improvement with the prosthesis than with distraction (P = .027), it was felt that this will “level out” when data on all 60 patients included in the trial are available. This research, performed at the UMC [University Medical Center] Utrecht and Sint Maartenskliniek in Woerden in the Netherlands, highlights how knee distraction may offer a valuable alternative to TKR, particularly in younger patients with OA, according to Simon Mastbergen, Ph.D., who studies tissue degeneration and regeneration in the department of rheumatology and clinical immunology at UMC Utrecht, and associates (Ann. Rheum. Dis. 2015;74:359-60).

“When you have a total knee prosthesis at a relatively young age, the outcome is not as successful as most people think,” Dr. Mastbergen said in an interview during a poster session at the European Congress of Rheumatology. Around 40% of TKRs are performed in people under the age of 65 years, he observed, and younger patients have a higher risk of revision failure because of mechanical failure as they tend to be more active than elderly patients with knee OA. Indeed, it’s been estimated that around 44% of younger patients who have TKR will need revision surgery at some point, and as secondary procedures are more difficult to perform and can be much more disabling “we need a joint-saving treatment.” Joint distraction is a surgical procedure that aims to gradually separate the two bony ends of a joint for a certain length of time. The method used by the Dutch team involved patients wearing an external frame bridging the knee that consisted of two long tubes with coiled springs inside with pins coming out that are inserted into the opposing soft tissue and bones and moved by about 5 mm each time. Patients wear the frame for 6-8 weeks and are encouraged to try to bear weight on the affected knee, with the aid of crutches if needed. The idea behind the method is that it will allow the joint to repair itself, and the team has already shown that cartilaginous tissue repair does indeed seem to occur (Cartilage 2013;21:1660-7).

Dr. Mastbergen noted that patients who underwent knee joint distraction in the study directly comparing it to TKR exhibited significant widening in the joint space, which is good because it indicates that cartilage has been regained. “We feel that knee joint distraction is an alternative for those [patients] who are ready for total knee prosthesis but are actually too young for [it],” he said.

Sara Freeman/Frontline Medical News

Other randomized controlled trial data from the team was presented during an oral abstract session at the meeting (Ann. Rheum. Dis. 2015;74:108) and showed that knee joint distraction is also as good as high tibial osteotomy, which is another method aimed at relieving mechanical stress on the knee joint. The senior author of the team Floris Lafeber, Ph.D., who presented data on behalf of colleague Dr. Jan Ton van der Woude, noted that there were several similarities between the two procedures in that they were both joint saving and could potentially postpone TKR and had been shown to improve bone turnover and cartilaginous tissue repair.

To compare the two methods, the researchers studied almost 70 patients aged 65 years or younger with medial compartment knee OA who were indicated for high tibial osteotomy. Patients were randomized 2:1 to the two procedures, with 45 undergoing osteotomy and 22 knee joint distraction. Significant improvements in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog pain, and quality of life (EQ-5D) scores were seen in both groups when compared with the preoperative values (P < .05). None of the parameters showed any statistically significant difference between the two procedures at 1-year follow-up. The data led to the conclusion that knee joint distraction had a clinical benefit that was comparable to osteotomy.

However, both the minimum and mean joint space width showed a steeper increase in patients randomized to the knee joint distraction group, suggesting that cartilaginous tissue repair might be better with the latter method.

Sara Freeman/Frontline Medical News

The potential clinical benefit of knee joint distraction was further highlighted in another poster from the team, presented by Dr. Natalia Kuchuk, which showed the effects of the procedure were maintained at 5-year follow-up. Importantly, 80% of the 20 patients studied in this open study still had their own knee joint. The mean age of patients at the time of distraction was 48.5 years. “In young patients, knee joint distraction effectively postpones total knee arthroplasty and is the only treatment which allows regeneration of cartilage,” she said in an interview.

Dr. Lafeber also commented in an interview on the practicalities of the procedure, which is still in its experimental phases. “It’s a rather an invasive procedure but if you compare it to a total knee replacement or high tibial osteotomy it’s less invasive,” he said.

“The surgical procedure takes about half an hour, we place a few pins through soft tissue and bone and the distraction tubes are placed mediolaterally to these pins, so in fact it’s less invasive than many of the other surgical techniques.” The distraction itself is not painful, he added, and actually alleviates OA pain but patients may need painkillers and perhaps antibiotics for short periods during the method.Next steps for the team are to follow up patients in the randomized trials for a longer period of time and refine the distraction device. “This is an off-the-shelf, ‘proof-of-concept’ device, and we are now developing a more patient-friendly, smaller, lighter frame device which is also easier to place by orthopedic surgeons,” Dr. Lafeber said. “Then we will do a comparison with the proof-of-concept device.”

Reumafonds (the Dutch Arthritis Foundation), ZonMw (The Netherlands Organization for Health Research and Development), UMC Utrecht, and Sint Maartinskliniek funded the research. Dr. Mastbergen, Dr. Lafeber, and Dr. Kuchuk had no disclosures to report.

ROME – Knee joint distraction – a method of relieving mechanical stress on the joint by temporarily pinning it – could help some patients with osteoarthritis avoid the need for a knee prosthesis, judging from preliminary findings from a randomized, controlled, comparative trial.

At 1-year follow-up, all subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Total KOOS score were significantly and progressively improved from baseline in patients who underwent knee distraction (P < .001). Overall the mean change in the Total KOOS score was not significantly different from that in the group of patients who underwent total knee replacement (TKR); although the KOOS subscale of quality of life did show greater improvement with the prosthesis than with distraction (P = .027), it was felt that this will “level out” when data on all 60 patients included in the trial are available. This research, performed at the UMC [University Medical Center] Utrecht and Sint Maartenskliniek in Woerden in the Netherlands, highlights how knee distraction may offer a valuable alternative to TKR, particularly in younger patients with OA, according to Simon Mastbergen, Ph.D., who studies tissue degeneration and regeneration in the department of rheumatology and clinical immunology at UMC Utrecht, and associates (Ann. Rheum. Dis. 2015;74:359-60).

“When you have a total knee prosthesis at a relatively young age, the outcome is not as successful as most people think,” Dr. Mastbergen said in an interview during a poster session at the European Congress of Rheumatology. Around 40% of TKRs are performed in people under the age of 65 years, he observed, and younger patients have a higher risk of revision failure because of mechanical failure as they tend to be more active than elderly patients with knee OA. Indeed, it’s been estimated that around 44% of younger patients who have TKR will need revision surgery at some point, and as secondary procedures are more difficult to perform and can be much more disabling “we need a joint-saving treatment.” Joint distraction is a surgical procedure that aims to gradually separate the two bony ends of a joint for a certain length of time. The method used by the Dutch team involved patients wearing an external frame bridging the knee that consisted of two long tubes with coiled springs inside with pins coming out that are inserted into the opposing soft tissue and bones and moved by about 5 mm each time. Patients wear the frame for 6-8 weeks and are encouraged to try to bear weight on the affected knee, with the aid of crutches if needed. The idea behind the method is that it will allow the joint to repair itself, and the team has already shown that cartilaginous tissue repair does indeed seem to occur (Cartilage 2013;21:1660-7).

Dr. Mastbergen noted that patients who underwent knee joint distraction in the study directly comparing it to TKR exhibited significant widening in the joint space, which is good because it indicates that cartilage has been regained. “We feel that knee joint distraction is an alternative for those [patients] who are ready for total knee prosthesis but are actually too young for [it],” he said.

Sara Freeman/Frontline Medical News

Other randomized controlled trial data from the team was presented during an oral abstract session at the meeting (Ann. Rheum. Dis. 2015;74:108) and showed that knee joint distraction is also as good as high tibial osteotomy, which is another method aimed at relieving mechanical stress on the knee joint. The senior author of the team Floris Lafeber, Ph.D., who presented data on behalf of colleague Dr. Jan Ton van der Woude, noted that there were several similarities between the two procedures in that they were both joint saving and could potentially postpone TKR and had been shown to improve bone turnover and cartilaginous tissue repair.

To compare the two methods, the researchers studied almost 70 patients aged 65 years or younger with medial compartment knee OA who were indicated for high tibial osteotomy. Patients were randomized 2:1 to the two procedures, with 45 undergoing osteotomy and 22 knee joint distraction. Significant improvements in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog pain, and quality of life (EQ-5D) scores were seen in both groups when compared with the preoperative values (P < .05). None of the parameters showed any statistically significant difference between the two procedures at 1-year follow-up. The data led to the conclusion that knee joint distraction had a clinical benefit that was comparable to osteotomy.

However, both the minimum and mean joint space width showed a steeper increase in patients randomized to the knee joint distraction group, suggesting that cartilaginous tissue repair might be better with the latter method.

Sara Freeman/Frontline Medical News

The potential clinical benefit of knee joint distraction was further highlighted in another poster from the team, presented by Dr. Natalia Kuchuk, which showed the effects of the procedure were maintained at 5-year follow-up. Importantly, 80% of the 20 patients studied in this open study still had their own knee joint. The mean age of patients at the time of distraction was 48.5 years. “In young patients, knee joint distraction effectively postpones total knee arthroplasty and is the only treatment which allows regeneration of cartilage,” she said in an interview.

Dr. Lafeber also commented in an interview on the practicalities of the procedure, which is still in its experimental phases. “It’s a rather an invasive procedure but if you compare it to a total knee replacement or high tibial osteotomy it’s less invasive,” he said.

“The surgical procedure takes about half an hour, we place a few pins through soft tissue and bone and the distraction tubes are placed mediolaterally to these pins, so in fact it’s less invasive than many of the other surgical techniques.” The distraction itself is not painful, he added, and actually alleviates OA pain but patients may need painkillers and perhaps antibiotics for short periods during the method.Next steps for the team are to follow up patients in the randomized trials for a longer period of time and refine the distraction device. “This is an off-the-shelf, ‘proof-of-concept’ device, and we are now developing a more patient-friendly, smaller, lighter frame device which is also easier to place by orthopedic surgeons,” Dr. Lafeber said. “Then we will do a comparison with the proof-of-concept device.”

Reumafonds (the Dutch Arthritis Foundation), ZonMw (The Netherlands Organization for Health Research and Development), UMC Utrecht, and Sint Maartinskliniek funded the research. Dr. Mastbergen, Dr. Lafeber, and Dr. Kuchuk had no disclosures to report.

ROME – Knee joint distraction – a method of relieving mechanical stress on the joint by temporarily pinning it – could help some patients with osteoarthritis avoid the need for a knee prosthesis, judging from preliminary findings from a randomized, controlled, comparative trial.

At 1-year follow-up, all subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Total KOOS score were significantly and progressively improved from baseline in patients who underwent knee distraction (P < .001). Overall the mean change in the Total KOOS score was not significantly different from that in the group of patients who underwent total knee replacement (TKR); although the KOOS subscale of quality of life did show greater improvement with the prosthesis than with distraction (P = .027), it was felt that this will “level out” when data on all 60 patients included in the trial are available. This research, performed at the UMC [University Medical Center] Utrecht and Sint Maartenskliniek in Woerden in the Netherlands, highlights how knee distraction may offer a valuable alternative to TKR, particularly in younger patients with OA, according to Simon Mastbergen, Ph.D., who studies tissue degeneration and regeneration in the department of rheumatology and clinical immunology at UMC Utrecht, and associates (Ann. Rheum. Dis. 2015;74:359-60).

“When you have a total knee prosthesis at a relatively young age, the outcome is not as successful as most people think,” Dr. Mastbergen said in an interview during a poster session at the European Congress of Rheumatology. Around 40% of TKRs are performed in people under the age of 65 years, he observed, and younger patients have a higher risk of revision failure because of mechanical failure as they tend to be more active than elderly patients with knee OA. Indeed, it’s been estimated that around 44% of younger patients who have TKR will need revision surgery at some point, and as secondary procedures are more difficult to perform and can be much more disabling “we need a joint-saving treatment.” Joint distraction is a surgical procedure that aims to gradually separate the two bony ends of a joint for a certain length of time. The method used by the Dutch team involved patients wearing an external frame bridging the knee that consisted of two long tubes with coiled springs inside with pins coming out that are inserted into the opposing soft tissue and bones and moved by about 5 mm each time. Patients wear the frame for 6-8 weeks and are encouraged to try to bear weight on the affected knee, with the aid of crutches if needed. The idea behind the method is that it will allow the joint to repair itself, and the team has already shown that cartilaginous tissue repair does indeed seem to occur (Cartilage 2013;21:1660-7).

Dr. Mastbergen noted that patients who underwent knee joint distraction in the study directly comparing it to TKR exhibited significant widening in the joint space, which is good because it indicates that cartilage has been regained. “We feel that knee joint distraction is an alternative for those [patients] who are ready for total knee prosthesis but are actually too young for [it],” he said.

Sara Freeman/Frontline Medical News

Other randomized controlled trial data from the team was presented during an oral abstract session at the meeting (Ann. Rheum. Dis. 2015;74:108) and showed that knee joint distraction is also as good as high tibial osteotomy, which is another method aimed at relieving mechanical stress on the knee joint. The senior author of the team Floris Lafeber, Ph.D., who presented data on behalf of colleague Dr. Jan Ton van der Woude, noted that there were several similarities between the two procedures in that they were both joint saving and could potentially postpone TKR and had been shown to improve bone turnover and cartilaginous tissue repair.

To compare the two methods, the researchers studied almost 70 patients aged 65 years or younger with medial compartment knee OA who were indicated for high tibial osteotomy. Patients were randomized 2:1 to the two procedures, with 45 undergoing osteotomy and 22 knee joint distraction. Significant improvements in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog pain, and quality of life (EQ-5D) scores were seen in both groups when compared with the preoperative values (P < .05). None of the parameters showed any statistically significant difference between the two procedures at 1-year follow-up. The data led to the conclusion that knee joint distraction had a clinical benefit that was comparable to osteotomy.

However, both the minimum and mean joint space width showed a steeper increase in patients randomized to the knee joint distraction group, suggesting that cartilaginous tissue repair might be better with the latter method.

Sara Freeman/Frontline Medical News

The potential clinical benefit of knee joint distraction was further highlighted in another poster from the team, presented by Dr. Natalia Kuchuk, which showed the effects of the procedure were maintained at 5-year follow-up. Importantly, 80% of the 20 patients studied in this open study still had their own knee joint. The mean age of patients at the time of distraction was 48.5 years. “In young patients, knee joint distraction effectively postpones total knee arthroplasty and is the only treatment which allows regeneration of cartilage,” she said in an interview.

Dr. Lafeber also commented in an interview on the practicalities of the procedure, which is still in its experimental phases. “It’s a rather an invasive procedure but if you compare it to a total knee replacement or high tibial osteotomy it’s less invasive,” he said.

“The surgical procedure takes about half an hour, we place a few pins through soft tissue and bone and the distraction tubes are placed mediolaterally to these pins, so in fact it’s less invasive than many of the other surgical techniques.” The distraction itself is not painful, he added, and actually alleviates OA pain but patients may need painkillers and perhaps antibiotics for short periods during the method.Next steps for the team are to follow up patients in the randomized trials for a longer period of time and refine the distraction device. “This is an off-the-shelf, ‘proof-of-concept’ device, and we are now developing a more patient-friendly, smaller, lighter frame device which is also easier to place by orthopedic surgeons,” Dr. Lafeber said. “Then we will do a comparison with the proof-of-concept device.”

Reumafonds (the Dutch Arthritis Foundation), ZonMw (The Netherlands Organization for Health Research and Development), UMC Utrecht, and Sint Maartinskliniek funded the research. Dr. Mastbergen, Dr. Lafeber, and Dr. Kuchuk had no disclosures to report.

SEATTLE – When it comes to managing osteoarthritis, clinicians can use their interactions with patients to tap into a powerful placebo effect, according to Dr. Paul Dieppe, a professor of health and well-being at the University of Exeter, England.

“I am particularly excited to have the opportunity to talk to you about a phenomenology that I think is amongst the most important within medicine and an area that those of us interested in osteoarthritis could really exploit,” he said at the World Congress on Osteoarthritis. “We don’t have a treatment that’s better than placebo, so let’s use placebo.”

In the clinical trial context, the placebo effect – the response seen from giving a sham or dummy treatment, or in essence, doing nothing – has an effect size of about 0.5 for alleviating pain and stiffness from osteoarthritis (Ann. Rheum. Dis. 2008;67:1716-23). “That’s an effect size which is quite a lot bigger than the effect size of most of the standard interventions that we use, be they drug therapy, physical therapy, whatever. It’s not as big as joint replacement, although there we don’t have the appropriate data. But it is bigger than pretty much everything else. So ‘nothing’ is efficacious,” Dr. Dieppe commented.

On the other hand, effectiveness in the real-world setting is unknown and would require large pragmatic trials or Big Data analyses using registries. “But I think the effectiveness of ‘nothing’ is much, much greater than its efficacy in the very artificial circumstance of a clinical trial,” he said, a viewpoint based on his experience both as a clinician and as a patient with knee osteoarthritis.

“I prefer to call [the placebo effect] a healing response, and I’m not trying to be provocative using that term because I think we do have innate healing abilities in our bodies. I think that’s an evolutionary demand, and good interactions can activate that,” Dr. Dieppe maintained.

Compelling evidence suggests that healing does indeed work (Explore [NY] 2015;11:11-23). “We think that it’s mediated by focused attention with good intention of sensitive people,” he said. “Maybe that’s what a lot of you as therapists are actually doing. Maybe that is the basis of much of what we call the placebo effect.”

Clinicians should also be aware of the nocebo effect, what Dr. Dieppe referred to as the placebo effect’s evil twin, as it can negatively influence outcomes and is stronger (Am. J. Med. 2015;128:126-9). “The fact is that doing nothing ... can and often does make our patients much worse. This is most likely to occur when one or both people in a consultation are feeling unsafe or anxious. ... A lot of what we do in modern health care seems designed to make people anxious and to make them worse,” he elaborated at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Many of the leading theories about the placebo and nocebo effects postulate that they relate to factors such as expectations or the release or blockage of natural endorphins. “These theories are basically saying that this is all about what’s going on in the brain of the patient,” Dr. Dieppe commented. “I think that’s wrong. ... It’s missing the point, completely, because the point is that this is about the quality of interactions between individuals. We are social beings, we are evolved as social beings, and our social interactions control a lot of what happens to us, not only psychologically but physiologically.”

He pointed to theories that instead focus on interactions, such as one pertaining to the concept of validation and invalidation (J. Clin. Psychol. 2006;62:459-80). “This theory goes beyond empathy and compassion, which are the usual sort of things evoked in this context, because you can be empathic and compassionate as much as you like, but if the patient in front of you doesn’t know you are being empathic or compassionate, then it’s no use at all. So validation, invalidation is more about have you successfully communicated that empathy and compassion to the other person or not. If you have, the person feels validated, they feel you genuinely do understand them, and you do genuinely care about them. If they are invalidated, they feel you haven’t understood them, and you don’t really care.” He added, “It depends very much on your behavior, as much as on what you say. Communication specialists tell us that 80% of communication to people is nonverbal.”

Another relevant theory here is the polyvagal theory of social interaction, which proposes that in addition to being hardwired for a fight or flight response, the autonomic nervous system is hardwired for a nurturing response (Cleve. Clin. J. Med. 2009;76 Suppl 2:S86-S90). Activation of this response has a calming physiologic effect and influences how messages are heard. “This nurturing response … is linked to communication strategies, so that you have to feel safe to be able to communicate well with another person,” Dr. Dieppe noted.

Taken together, these theories on interactions help explain “how we can make people better, how we can make people worse with ‘nothing,’ ” he maintained. “Of course, it’s not nothing – it’s the totality of our behavior with another person, and it’s crucial. And it can, in extreme cases, positively activate the innate healing response, or it can, as we often do sadly in clinical practice, activate an invalidation, fight-or-flight response, and make everything a lot worse.”

“There are colossal implications about how we behave when we are with patients,” Dr. Dieppe concluded. “I think basically, it’s just about our ability to be present for another human being in a nonjudgmental way. And that’s difficult, but that’s what we need to be able to do.”

SEATTLE – When it comes to managing osteoarthritis, clinicians can use their interactions with patients to tap into a powerful placebo effect, according to Dr. Paul Dieppe, a professor of health and well-being at the University of Exeter, England.

“I am particularly excited to have the opportunity to talk to you about a phenomenology that I think is amongst the most important within medicine and an area that those of us interested in osteoarthritis could really exploit,” he said at the World Congress on Osteoarthritis. “We don’t have a treatment that’s better than placebo, so let’s use placebo.”

In the clinical trial context, the placebo effect – the response seen from giving a sham or dummy treatment, or in essence, doing nothing – has an effect size of about 0.5 for alleviating pain and stiffness from osteoarthritis (Ann. Rheum. Dis. 2008;67:1716-23). “That’s an effect size which is quite a lot bigger than the effect size of most of the standard interventions that we use, be they drug therapy, physical therapy, whatever. It’s not as big as joint replacement, although there we don’t have the appropriate data. But it is bigger than pretty much everything else. So ‘nothing’ is efficacious,” Dr. Dieppe commented.

On the other hand, effectiveness in the real-world setting is unknown and would require large pragmatic trials or Big Data analyses using registries. “But I think the effectiveness of ‘nothing’ is much, much greater than its efficacy in the very artificial circumstance of a clinical trial,” he said, a viewpoint based on his experience both as a clinician and as a patient with knee osteoarthritis.

“I prefer to call [the placebo effect] a healing response, and I’m not trying to be provocative using that term because I think we do have innate healing abilities in our bodies. I think that’s an evolutionary demand, and good interactions can activate that,” Dr. Dieppe maintained.

Compelling evidence suggests that healing does indeed work (Explore [NY] 2015;11:11-23). “We think that it’s mediated by focused attention with good intention of sensitive people,” he said. “Maybe that’s what a lot of you as therapists are actually doing. Maybe that is the basis of much of what we call the placebo effect.”

Clinicians should also be aware of the nocebo effect, what Dr. Dieppe referred to as the placebo effect’s evil twin, as it can negatively influence outcomes and is stronger (Am. J. Med. 2015;128:126-9). “The fact is that doing nothing ... can and often does make our patients much worse. This is most likely to occur when one or both people in a consultation are feeling unsafe or anxious. ... A lot of what we do in modern health care seems designed to make people anxious and to make them worse,” he elaborated at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Many of the leading theories about the placebo and nocebo effects postulate that they relate to factors such as expectations or the release or blockage of natural endorphins. “These theories are basically saying that this is all about what’s going on in the brain of the patient,” Dr. Dieppe commented. “I think that’s wrong. ... It’s missing the point, completely, because the point is that this is about the quality of interactions between individuals. We are social beings, we are evolved as social beings, and our social interactions control a lot of what happens to us, not only psychologically but physiologically.”

He pointed to theories that instead focus on interactions, such as one pertaining to the concept of validation and invalidation (J. Clin. Psychol. 2006;62:459-80). “This theory goes beyond empathy and compassion, which are the usual sort of things evoked in this context, because you can be empathic and compassionate as much as you like, but if the patient in front of you doesn’t know you are being empathic or compassionate, then it’s no use at all. So validation, invalidation is more about have you successfully communicated that empathy and compassion to the other person or not. If you have, the person feels validated, they feel you genuinely do understand them, and you do genuinely care about them. If they are invalidated, they feel you haven’t understood them, and you don’t really care.” He added, “It depends very much on your behavior, as much as on what you say. Communication specialists tell us that 80% of communication to people is nonverbal.”

Another relevant theory here is the polyvagal theory of social interaction, which proposes that in addition to being hardwired for a fight or flight response, the autonomic nervous system is hardwired for a nurturing response (Cleve. Clin. J. Med. 2009;76 Suppl 2:S86-S90). Activation of this response has a calming physiologic effect and influences how messages are heard. “This nurturing response … is linked to communication strategies, so that you have to feel safe to be able to communicate well with another person,” Dr. Dieppe noted.

Taken together, these theories on interactions help explain “how we can make people better, how we can make people worse with ‘nothing,’ ” he maintained. “Of course, it’s not nothing – it’s the totality of our behavior with another person, and it’s crucial. And it can, in extreme cases, positively activate the innate healing response, or it can, as we often do sadly in clinical practice, activate an invalidation, fight-or-flight response, and make everything a lot worse.”

“There are colossal implications about how we behave when we are with patients,” Dr. Dieppe concluded. “I think basically, it’s just about our ability to be present for another human being in a nonjudgmental way. And that’s difficult, but that’s what we need to be able to do.”

SEATTLE – When it comes to managing osteoarthritis, clinicians can use their interactions with patients to tap into a powerful placebo effect, according to Dr. Paul Dieppe, a professor of health and well-being at the University of Exeter, England.

“I am particularly excited to have the opportunity to talk to you about a phenomenology that I think is amongst the most important within medicine and an area that those of us interested in osteoarthritis could really exploit,” he said at the World Congress on Osteoarthritis. “We don’t have a treatment that’s better than placebo, so let’s use placebo.”

In the clinical trial context, the placebo effect – the response seen from giving a sham or dummy treatment, or in essence, doing nothing – has an effect size of about 0.5 for alleviating pain and stiffness from osteoarthritis (Ann. Rheum. Dis. 2008;67:1716-23). “That’s an effect size which is quite a lot bigger than the effect size of most of the standard interventions that we use, be they drug therapy, physical therapy, whatever. It’s not as big as joint replacement, although there we don’t have the appropriate data. But it is bigger than pretty much everything else. So ‘nothing’ is efficacious,” Dr. Dieppe commented.

On the other hand, effectiveness in the real-world setting is unknown and would require large pragmatic trials or Big Data analyses using registries. “But I think the effectiveness of ‘nothing’ is much, much greater than its efficacy in the very artificial circumstance of a clinical trial,” he said, a viewpoint based on his experience both as a clinician and as a patient with knee osteoarthritis.

“I prefer to call [the placebo effect] a healing response, and I’m not trying to be provocative using that term because I think we do have innate healing abilities in our bodies. I think that’s an evolutionary demand, and good interactions can activate that,” Dr. Dieppe maintained.

Compelling evidence suggests that healing does indeed work (Explore [NY] 2015;11:11-23). “We think that it’s mediated by focused attention with good intention of sensitive people,” he said. “Maybe that’s what a lot of you as therapists are actually doing. Maybe that is the basis of much of what we call the placebo effect.”

Clinicians should also be aware of the nocebo effect, what Dr. Dieppe referred to as the placebo effect’s evil twin, as it can negatively influence outcomes and is stronger (Am. J. Med. 2015;128:126-9). “The fact is that doing nothing ... can and often does make our patients much worse. This is most likely to occur when one or both people in a consultation are feeling unsafe or anxious. ... A lot of what we do in modern health care seems designed to make people anxious and to make them worse,” he elaborated at the meeting, which was sponsored by the Osteoarthritis Research Society International.

Many of the leading theories about the placebo and nocebo effects postulate that they relate to factors such as expectations or the release or blockage of natural endorphins. “These theories are basically saying that this is all about what’s going on in the brain of the patient,” Dr. Dieppe commented. “I think that’s wrong. ... It’s missing the point, completely, because the point is that this is about the quality of interactions between individuals. We are social beings, we are evolved as social beings, and our social interactions control a lot of what happens to us, not only psychologically but physiologically.”

He pointed to theories that instead focus on interactions, such as one pertaining to the concept of validation and invalidation (J. Clin. Psychol. 2006;62:459-80). “This theory goes beyond empathy and compassion, which are the usual sort of things evoked in this context, because you can be empathic and compassionate as much as you like, but if the patient in front of you doesn’t know you are being empathic or compassionate, then it’s no use at all. So validation, invalidation is more about have you successfully communicated that empathy and compassion to the other person or not. If you have, the person feels validated, they feel you genuinely do understand them, and you do genuinely care about them. If they are invalidated, they feel you haven’t understood them, and you don’t really care.” He added, “It depends very much on your behavior, as much as on what you say. Communication specialists tell us that 80% of communication to people is nonverbal.”

Another relevant theory here is the polyvagal theory of social interaction, which proposes that in addition to being hardwired for a fight or flight response, the autonomic nervous system is hardwired for a nurturing response (Cleve. Clin. J. Med. 2009;76 Suppl 2:S86-S90). Activation of this response has a calming physiologic effect and influences how messages are heard. “This nurturing response … is linked to communication strategies, so that you have to feel safe to be able to communicate well with another person,” Dr. Dieppe noted.

Taken together, these theories on interactions help explain “how we can make people better, how we can make people worse with ‘nothing,’ ” he maintained. “Of course, it’s not nothing – it’s the totality of our behavior with another person, and it’s crucial. And it can, in extreme cases, positively activate the innate healing response, or it can, as we often do sadly in clinical practice, activate an invalidation, fight-or-flight response, and make everything a lot worse.”

“There are colossal implications about how we behave when we are with patients,” Dr. Dieppe concluded. “I think basically, it’s just about our ability to be present for another human being in a nonjudgmental way. And that’s difficult, but that’s what we need to be able to do.”

Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.

The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.

However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.

© iStock / ThinkStockPhotos.com

“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).

The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.

Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.

The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.

However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.

© iStock / ThinkStockPhotos.com

“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).

The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.

Arthroscopic knee surgery in middle-aged or older patients with knee pain is associated with greater harm than good, according to a meta-analysis.

The analysis of nine randomized, controlled trials in 1,270 patients of arthroscopic surgery involving partial meniscectomy, debridement, or both showed a small but statistically significant benefit from the procedure – comparable to the pain-relieving effects of paracetamol – but which falls below significance after 12 months.

However, there were no significant improvements in knee function, and there were significant increases in the risk of deep vein thrombosis (4.13 events per 1,000 procedures) as well as infection, pulmonary embolism, and death, according to the paper published online June 16 in BMJ.

© iStock / ThinkStockPhotos.com

“Thus, middle-aged patients with knee pain and meniscal tears should be considered as having early-stage osteoarthritis and be treated according to clinical guidelines for knee osteoarthritis, starting with information, exercise, and often weight loss,” wrote Dr. Jonas B. Thorlund of the University of Southern Denmark, Odense, and coauthors (BMJ 2015, June 16 [doi:10.1136/bmj.h2747]).

The study was supported by the Swedish Research Council. One author declared personal fees from several pharmaceutical and medical companies and relevant journal editorship, while another declared fees from lectureships and books.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

ROME – Hydroxychloroquine should not be prescribed for patients with mild to moderate hand osteoarthritis (OA) according to data from a 24-week, randomized, multicenter, placebo-controlled trial.

The results of the Dutch study, presented at the European Congress of Rheumatology by Dr. Natalja M. Basoski of Maasstad Hospital, Rotterdam, the Netherlands, showed that hydroxychloroquine was no better than placebo at reducing patients’ pain and disability, or for improving their physical, social, or emotional well-being.

The primary outcome measure used was reduction in OA hand pain in the preceding 24 hours measured using a 100-mm visual analog scale (VAS) at the end of the study. The mean change in pain using the VAS over 24 weeks was a reduction of 1.3 mm in the hydroxychloroquine-treated patients versus a 0.10-mm rise in the patients who received placebo (P = .82).

There also was no change in the two secondary endpoints of change in total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and the Arthritis Impact Measurement Scale 2 SF (AIMS2-SF) by the end of the treatment period. Mean changes in AUSCAN total scores were –0.42 and –0.25 (P = .49) and mean reductions in total AIMS2-SF scores were –0.17 and –0.076 (P = .68), comparing hydroxychloroquine with placebo, respectively.

“Osteoarthritis of the hand is one of the most common types of osteoarthritis, leading to pain, stiffness, and loss of function,” Dr. Basoski explained during a clinical science session looking at manifestations of the disease beyond the knee. “Unfortunately, current pharmacological treatment options are limited,” she added.

The underlying pathophysiological mechanisms of OA that primarily affect the hand are not clear, although inflammation is known to have a role, as in knee OA. Hydroxychloroquine is an established disease-modifying antirheumatoid drug that has shown benefit in patients with mild rheumatoid arthritis, which has led many rheumatologists to prescribe off label for the treatment of hand OA as well, Dr. Basoski observed in an interview. Data to support this are lacking, however, so this trial aimed to look at the potential symptom-modifying effects of the drug specifically in OA.

Over a 3-year period starting in July 2010, 202 patients with symptoms of primary mild to moderate hand OA of at least 1 years’ duration were recruited at six hospitals in the Netherlands and randomized to hydroxychloroquine 400 mg/day or matching placebo for 24 weeks. Six patients were lost to follow-up early on in the study, leaving 98 patients in each study arm who could be included in the intent-to-treat analysis. Of these, 22 hydroxychloroquine-treated and nine placebo-treated patients discontinued treatment, 10 and 5 in each group, respectively, because of adverse effects.

Dr. Basoski noted that patient characteristics were similar at baseline. Mean age was 57 years, and about 86% of participants were women. Hand OA was defined via American College of Rheumatology criteria and 86% and 91% of hydroxychloroquine- and placebo-treated patients had at least one joint with radiographic evidence of joint disease defined as a Kellgren-Lawrence score of ≥2.

“This is one of the studies that does not support the use of hydroxychloroquine in patients with OA of the hands and mild complaints,” she said in an interview. “It means that you should not prescribe it anymore, at least based on the results of this study.”

Further research is needed to see if there are some patients who might benefit or if it applies to other OA phenotypes, such as erosive hand OA. “More studies should be done, although in our second analysis after the study we tried to differentiate between very low pain and high pain and we still didn’t really see a difference,” she observed.

Erosive hand OA could be a different case, and results of an ongoing UK study should provide insight on whether hydroxychloroquine could be beneficial in these patients.

Although a similar number of patients treated with hydroxychloroquine or placebo in the trial experienced adverse events (21 vs. 24, respectively), there was an increase in allergic reactions (3 vs. 0) and rash or itching (8 vs. 3) with the active treatment.

With hydroxychloroquine seemingly out of the picture, at least in mild to moderate cases, Dr. Basoski advised on how she might treat a patient with primary hand OA. “I would try to start with paracetamol [acetaminophen] at the dose that is currently recommended, like 4 g/day, then eventually try to use opioids, as NSAIDs are not such a good thing to use in the long term.”

Dr. Basoski did not have any conflicts of interest to disclose.

Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found. 

The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”

©pixologicstudio/thinkstockphotos.com

Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.

Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.

Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.

The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.

The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.

Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found. 

The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”

©pixologicstudio/thinkstockphotos.com

Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.

Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.

Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.

The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.

The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.

Patients with knee osteoarthritis and poor sleep habits suffered greater central sensitization to pain than other individuals, especially if they tended to ruminate about their pain, a case-control study found. 

The study is the largest to date to examine sleep, catastrophizing, and central sensitization in knee osteoarthritis, said Claudia Campbell, Ph.D., of Johns Hopkins University, Baltimore. “While we were underpowered to fully examine all possible data described, we hope that these data serve as a platform for future studies to adequately power themselves and explore potential differences.”

©pixologicstudio/thinkstockphotos.com

Patients with osteoarthritis often report poor sleep, and studies show that many of these patients also have central sensitization, or hyperexcitability of nociceptive nerve pathways, a phenomenon that tends to amplify and prolong pain. Catastrophizing – a “persistently negative cognitive affective style” in which patients feel helpless, and magnify and ruminate about their pain – predicts worse pain outcomes in osteoarthritis and other painful conditions, the investigators noted (Arthritis Care Res. 2015 June 4 [doi: 10.1002/acr.22609]).Dr. Campbell and her colleagues categorized 208 adults into four groups: those with insomnia and knee osteoarthritis, those with one or the other of the disorders, and those with neither condition (healthy controls). More than 70% of participants were female, and individuals with knee osteoarthritis were significantly older than the rest. The investigators matched the groups with knee osteoarthritis based on radiographic severity.

Quantitative sensory testing showed that patients with knee osteoarthritis and insomnia had significantly greater central sensitization, compared with healthy controls, the researchers reported. Low sleep efficiency (a measure of self-perceived sleep quality) was linked to heightened central sensitization, but only when patients scored more 7.4 on the 13-item Pain Catastrophizing Scale, they added. In all 56% of the sample met that threshold, as did 77% of participants who had both insomnia and knee osteoarthritis.

Central sensitization also correlated positively with clinical pain. “Clinical implications of these findings suggest that treatment options for osteoarthritis patients could include sleep and/or intervention for catastrophizing, both modifiable risk factors, [which] may aid in reducing central sensitization and decrease clinical pain,” the researchers noted.

The study was the first part of a randomized trial that is examining cognitive behavioral therapy for insomnia in patients with osteoarthritis.

The National Institutes of Arthritis and Musculoskeletal and Skin Disease and the National Institutes of Health supported the study. The investigators reported having no relevant conflicts of interest.

SEATTLE – The pain of knee osteoarthritis is not exacerbated by regular exercise such as walking and may actually be relieved by it, according to several findings presented at the World Congress on Osteoarthritis.

“Physical activity is important for the reduction of knee pain and the prevention of functional limitation in knee osteoarthritis,” Daniel White, Sc.D., said.

“We should be recommending walking to people with painful knee osteoarthritis. Just as a preliminary goal, we can start with 3,000 steps per day and ultimately progress people to at least 6,000 steps per day,” he added.

National guidelines issued in 2008 for the general population call for at least 150 minutes per week of moderate to vigorous–intensity physical activity, according to Dr. White of the department of physical therapy at the University of Delaware in Newark. When that recommendation is applied to walking, which is the most common physical activity among older adults (Arthritis Care Res. 2014;66:139-46), it translates to a brisk pace that permits conversation but is exertional enough to cause sweating. Meeting the goal would mean approximately 100 steps per minute (Am. J. Prev. Med. 2009;36:410-5).

“The clinical hypothesis is that osteoarthritis pain is limiting your physical activity, but whether that has been empirically [established] has yet to be seen,” Dr. White said. For example, investigators for an Osteoarthritis Initiative study found that only 13% of men and 8% of women with knee osteoarthritis met the criteria for the national guideline (Arthritis Rheum. 2011;63:3372-82), but also noted that these values differed little from those of the general population. Data from the Multicenter Osteoarthritis Study found similarly low proportions, regardless of the presence of radiographic disease and the severity of knee pain (Arthritis Rheum. 2013;65:139-47). In a cohort that underwent total knee replacement, patients had more than 180% improvements in subjective pain and function at 6 months, yet their objectively measured time spent walking increased by only 5% (Clin. Orthop. Relat. Res. 2008;466:2201-8).

These findings suggest that osteoarthritis and pain may have a limited role in explaining physical inactivity, according to Dr. White. “An implication of this is that improvements in disease and pain may not lead to more physical activity; in other words, the pills you give to people to make them feel better or the exercises that they may do to improve their knee pain may not necessarily increase the amount of unstructured physical activity that people do on a day-to-day basis. Also, physical activity specifically may need to be targeted; you need to increase physical activity in a specific way rather than just expecting it to happen once the barriers of pain and disease are removed.”

Recommendations for physical activity must consider both potential risks and benefits, he noted. Data regarding its impact on structural changes in the knee are mixed. Conversely, there is substantial evidence that physical activity moderately reduces knee pain (Cochrane Database Syst Rev. 2015;1:CD004376) and lowers the likelihood of developing functional limitations in a dose-response manner (Arthritis Care Res. 2014;66:1328-36). And there are a variety of other health benefits, some of which may affect osteoarthritis, such as weight maintenance.

“In my mind, the benefits outweigh the risks for promoting physical activity in this patient population. And specifically, given that walking is the most common physical activity, from a clinical perspective, there is very strong evidence to recommend walking to this patient population,” Dr. White said at the meeting sponsored by the Osteoarthritis Research Society International.

He further endorsed use of a pedometer as a practical, objective way to measure this activity. “Regardless of what instrument or device you use, they all measure steps, and that is sort of the common denominator which is a very understandable outcome that patients can relate to, that clinicians understand,” he elaborated. Moreover, a meta-analysis has shown that interventions using pedometers achieve greater increases in walking (JAMA 2007;298:2296-304).

The above analysis of impact on functional limitations in people with knee osteoarthritis also helps to define target walking goals, according to Dr. White, who disclosed that he had no relevant conflicts of interest. The study showed that 95% of people who did not develop functional limitations walked at least 3,000 steps per day, and that 6,000 steps per day best discriminated between those who did and did not develop functional limitations.

Assuming that a moderate intensity of walking is 100 steps per minute, this step range translates to 30-60 minutes of walking per day, he said. As half of 60-year-olds in the general population already walk approximately 40-50 minutes daily as part of their usual activities (J. Gerontol. A Biol. Sci. Med. Sci. 2013;68:1426-32), they may need to add only 10 more minutes. And a recent report suggests that even people with severe knee osteoarthritis find this amount to be safe and feasible (Osteoarthritis Cartilage 2015 April 14 [doi:10.1016/j.joca.2015.04.001]).

SEATTLE – The pain of knee osteoarthritis is not exacerbated by regular exercise such as walking and may actually be relieved by it, according to several findings presented at the World Congress on Osteoarthritis.

“Physical activity is important for the reduction of knee pain and the prevention of functional limitation in knee osteoarthritis,” Daniel White, Sc.D., said.

“We should be recommending walking to people with painful knee osteoarthritis. Just as a preliminary goal, we can start with 3,000 steps per day and ultimately progress people to at least 6,000 steps per day,” he added.

National guidelines issued in 2008 for the general population call for at least 150 minutes per week of moderate to vigorous–intensity physical activity, according to Dr. White of the department of physical therapy at the University of Delaware in Newark. When that recommendation is applied to walking, which is the most common physical activity among older adults (Arthritis Care Res. 2014;66:139-46), it translates to a brisk pace that permits conversation but is exertional enough to cause sweating. Meeting the goal would mean approximately 100 steps per minute (Am. J. Prev. Med. 2009;36:410-5).

“The clinical hypothesis is that osteoarthritis pain is limiting your physical activity, but whether that has been empirically [established] has yet to be seen,” Dr. White said. For example, investigators for an Osteoarthritis Initiative study found that only 13% of men and 8% of women with knee osteoarthritis met the criteria for the national guideline (Arthritis Rheum. 2011;63:3372-82), but also noted that these values differed little from those of the general population. Data from the Multicenter Osteoarthritis Study found similarly low proportions, regardless of the presence of radiographic disease and the severity of knee pain (Arthritis Rheum. 2013;65:139-47). In a cohort that underwent total knee replacement, patients had more than 180% improvements in subjective pain and function at 6 months, yet their objectively measured time spent walking increased by only 5% (Clin. Orthop. Relat. Res. 2008;466:2201-8).

These findings suggest that osteoarthritis and pain may have a limited role in explaining physical inactivity, according to Dr. White. “An implication of this is that improvements in disease and pain may not lead to more physical activity; in other words, the pills you give to people to make them feel better or the exercises that they may do to improve their knee pain may not necessarily increase the amount of unstructured physical activity that people do on a day-to-day basis. Also, physical activity specifically may need to be targeted; you need to increase physical activity in a specific way rather than just expecting it to happen once the barriers of pain and disease are removed.”

Recommendations for physical activity must consider both potential risks and benefits, he noted. Data regarding its impact on structural changes in the knee are mixed. Conversely, there is substantial evidence that physical activity moderately reduces knee pain (Cochrane Database Syst Rev. 2015;1:CD004376) and lowers the likelihood of developing functional limitations in a dose-response manner (Arthritis Care Res. 2014;66:1328-36). And there are a variety of other health benefits, some of which may affect osteoarthritis, such as weight maintenance.

“In my mind, the benefits outweigh the risks for promoting physical activity in this patient population. And specifically, given that walking is the most common physical activity, from a clinical perspective, there is very strong evidence to recommend walking to this patient population,” Dr. White said at the meeting sponsored by the Osteoarthritis Research Society International.

He further endorsed use of a pedometer as a practical, objective way to measure this activity. “Regardless of what instrument or device you use, they all measure steps, and that is sort of the common denominator which is a very understandable outcome that patients can relate to, that clinicians understand,” he elaborated. Moreover, a meta-analysis has shown that interventions using pedometers achieve greater increases in walking (JAMA 2007;298:2296-304).

The above analysis of impact on functional limitations in people with knee osteoarthritis also helps to define target walking goals, according to Dr. White, who disclosed that he had no relevant conflicts of interest. The study showed that 95% of people who did not develop functional limitations walked at least 3,000 steps per day, and that 6,000 steps per day best discriminated between those who did and did not develop functional limitations.

Assuming that a moderate intensity of walking is 100 steps per minute, this step range translates to 30-60 minutes of walking per day, he said. As half of 60-year-olds in the general population already walk approximately 40-50 minutes daily as part of their usual activities (J. Gerontol. A Biol. Sci. Med. Sci. 2013;68:1426-32), they may need to add only 10 more minutes. And a recent report suggests that even people with severe knee osteoarthritis find this amount to be safe and feasible (Osteoarthritis Cartilage 2015 April 14 [doi:10.1016/j.joca.2015.04.001]).

SEATTLE – The pain of knee osteoarthritis is not exacerbated by regular exercise such as walking and may actually be relieved by it, according to several findings presented at the World Congress on Osteoarthritis.

“Physical activity is important for the reduction of knee pain and the prevention of functional limitation in knee osteoarthritis,” Daniel White, Sc.D., said.

“We should be recommending walking to people with painful knee osteoarthritis. Just as a preliminary goal, we can start with 3,000 steps per day and ultimately progress people to at least 6,000 steps per day,” he added.

National guidelines issued in 2008 for the general population call for at least 150 minutes per week of moderate to vigorous–intensity physical activity, according to Dr. White of the department of physical therapy at the University of Delaware in Newark. When that recommendation is applied to walking, which is the most common physical activity among older adults (Arthritis Care Res. 2014;66:139-46), it translates to a brisk pace that permits conversation but is exertional enough to cause sweating. Meeting the goal would mean approximately 100 steps per minute (Am. J. Prev. Med. 2009;36:410-5).

“The clinical hypothesis is that osteoarthritis pain is limiting your physical activity, but whether that has been empirically [established] has yet to be seen,” Dr. White said. For example, investigators for an Osteoarthritis Initiative study found that only 13% of men and 8% of women with knee osteoarthritis met the criteria for the national guideline (Arthritis Rheum. 2011;63:3372-82), but also noted that these values differed little from those of the general population. Data from the Multicenter Osteoarthritis Study found similarly low proportions, regardless of the presence of radiographic disease and the severity of knee pain (Arthritis Rheum. 2013;65:139-47). In a cohort that underwent total knee replacement, patients had more than 180% improvements in subjective pain and function at 6 months, yet their objectively measured time spent walking increased by only 5% (Clin. Orthop. Relat. Res. 2008;466:2201-8).

These findings suggest that osteoarthritis and pain may have a limited role in explaining physical inactivity, according to Dr. White. “An implication of this is that improvements in disease and pain may not lead to more physical activity; in other words, the pills you give to people to make them feel better or the exercises that they may do to improve their knee pain may not necessarily increase the amount of unstructured physical activity that people do on a day-to-day basis. Also, physical activity specifically may need to be targeted; you need to increase physical activity in a specific way rather than just expecting it to happen once the barriers of pain and disease are removed.”

Recommendations for physical activity must consider both potential risks and benefits, he noted. Data regarding its impact on structural changes in the knee are mixed. Conversely, there is substantial evidence that physical activity moderately reduces knee pain (Cochrane Database Syst Rev. 2015;1:CD004376) and lowers the likelihood of developing functional limitations in a dose-response manner (Arthritis Care Res. 2014;66:1328-36). And there are a variety of other health benefits, some of which may affect osteoarthritis, such as weight maintenance.

“In my mind, the benefits outweigh the risks for promoting physical activity in this patient population. And specifically, given that walking is the most common physical activity, from a clinical perspective, there is very strong evidence to recommend walking to this patient population,” Dr. White said at the meeting sponsored by the Osteoarthritis Research Society International.

He further endorsed use of a pedometer as a practical, objective way to measure this activity. “Regardless of what instrument or device you use, they all measure steps, and that is sort of the common denominator which is a very understandable outcome that patients can relate to, that clinicians understand,” he elaborated. Moreover, a meta-analysis has shown that interventions using pedometers achieve greater increases in walking (JAMA 2007;298:2296-304).

The above analysis of impact on functional limitations in people with knee osteoarthritis also helps to define target walking goals, according to Dr. White, who disclosed that he had no relevant conflicts of interest. The study showed that 95% of people who did not develop functional limitations walked at least 3,000 steps per day, and that 6,000 steps per day best discriminated between those who did and did not develop functional limitations.

Assuming that a moderate intensity of walking is 100 steps per minute, this step range translates to 30-60 minutes of walking per day, he said. As half of 60-year-olds in the general population already walk approximately 40-50 minutes daily as part of their usual activities (J. Gerontol. A Biol. Sci. Med. Sci. 2013;68:1426-32), they may need to add only 10 more minutes. And a recent report suggests that even people with severe knee osteoarthritis find this amount to be safe and feasible (Osteoarthritis Cartilage 2015 April 14 [doi:10.1016/j.joca.2015.04.001]).

SEATTLE – C-reactive protein is associated with the presence and progression of bone marrow lesions in patients with osteoarthritis of the knee, according to data from a cohort study of 192 patients that were reported at the World Congress on Osteoarthritis.

“Osteoarthritis has predominantly been viewed as a degenerative joint disease driven by continued and irreversible deterioration of joints,” said lead investigator Zhaohua (Alex) Zhu, a PhD candidate at the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia. “However, current studies suggest a different way of understanding this disease, showing that the development of osteoarthritis may be in great part driven by a low-grade inflammatory process.”

He and his colleagues analyzed data from the randomized phase III VIDEO trial (Vitamin D Effect on Osteoarthritis), which enrolled patients aged 50-79 years who had symptomatic knee osteoarthritis and vitamin D deficiency. Analyses were based on 192 patients who had measurement of high-sensitivity C-reactive protein (CRP) and resistin (a proinflammatory cytokine secreted by adipose tissue) at baseline and again 2 years later.

Bone marrow lesions also were assessed at both time points with a modified version of the whole-organ magnetic resonance imaging score (WORMS). “Bone marrow lesions may represent areas of edema, inflammation, and remodeling,” Mr. Zhu explained. “Plenty of studies have shown that bone marrow lesions are linked to knee pain, cartilage volumes, and cartilage defect changes, so it’s a very important subchondral feature in knee osteoarthritis. But so far, the cause of bone marrow lesions remains unclear.”

Multivariate analyses showed that, as patients’ baseline CRP quartile increased, so did their odds of having total knee bone marrow lesions at that time (odds ratio, 1.45) and worsening of these lesions during follow-up (odds ratio, 1.56), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Additionally, the absolute change in CRP level during follow-up was positively associated with a worsening of lesions.

Associations for resistin were generally weaker or absent, with the only significant one seen between baseline quartile of that marker and bone marrow lesions at that time, reported Dr. Zhu.

In an interview, Dr. Timothy McAlindon, one of the session’s comoderators and professor of medicine at Tufts University in Boston, said that the study helps elucidate a possible role for adipose tissue, overweight, and adipocytokines in one subphenotype of osteoarthritis. “They found some associations, and I think those associations are probably the basis for further study and hopefully more understanding of what they mean,” he commented.

Dr. Rik Lories, the other session comoderator and professor at the University of Leuven (Belgium), noted that research on this topic is complicated. “You can ask questions about the chicken and the egg in this case because, if you are obese, you have a higher fat mass, so you are more likely to produce proinflammatory mediators, which can then induce your CRP. The fact that you have more inflammatory mediators could also contribute to the fact that you get these bone marrow lesions,” he elaborated. “But on the other hand, if you put more weight on your knees, the impact may also play a role. So it remains a very, very difficult thing to study and to come up with clear answers.”

Dr. Zhu disclosed no relevant conflicts of interest.

SEATTLE – C-reactive protein is associated with the presence and progression of bone marrow lesions in patients with osteoarthritis of the knee, according to data from a cohort study of 192 patients that were reported at the World Congress on Osteoarthritis.

“Osteoarthritis has predominantly been viewed as a degenerative joint disease driven by continued and irreversible deterioration of joints,” said lead investigator Zhaohua (Alex) Zhu, a PhD candidate at the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia. “However, current studies suggest a different way of understanding this disease, showing that the development of osteoarthritis may be in great part driven by a low-grade inflammatory process.”

He and his colleagues analyzed data from the randomized phase III VIDEO trial (Vitamin D Effect on Osteoarthritis), which enrolled patients aged 50-79 years who had symptomatic knee osteoarthritis and vitamin D deficiency. Analyses were based on 192 patients who had measurement of high-sensitivity C-reactive protein (CRP) and resistin (a proinflammatory cytokine secreted by adipose tissue) at baseline and again 2 years later.

Bone marrow lesions also were assessed at both time points with a modified version of the whole-organ magnetic resonance imaging score (WORMS). “Bone marrow lesions may represent areas of edema, inflammation, and remodeling,” Mr. Zhu explained. “Plenty of studies have shown that bone marrow lesions are linked to knee pain, cartilage volumes, and cartilage defect changes, so it’s a very important subchondral feature in knee osteoarthritis. But so far, the cause of bone marrow lesions remains unclear.”

Multivariate analyses showed that, as patients’ baseline CRP quartile increased, so did their odds of having total knee bone marrow lesions at that time (odds ratio, 1.45) and worsening of these lesions during follow-up (odds ratio, 1.56), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Additionally, the absolute change in CRP level during follow-up was positively associated with a worsening of lesions.

Associations for resistin were generally weaker or absent, with the only significant one seen between baseline quartile of that marker and bone marrow lesions at that time, reported Dr. Zhu.

In an interview, Dr. Timothy McAlindon, one of the session’s comoderators and professor of medicine at Tufts University in Boston, said that the study helps elucidate a possible role for adipose tissue, overweight, and adipocytokines in one subphenotype of osteoarthritis. “They found some associations, and I think those associations are probably the basis for further study and hopefully more understanding of what they mean,” he commented.

Dr. Rik Lories, the other session comoderator and professor at the University of Leuven (Belgium), noted that research on this topic is complicated. “You can ask questions about the chicken and the egg in this case because, if you are obese, you have a higher fat mass, so you are more likely to produce proinflammatory mediators, which can then induce your CRP. The fact that you have more inflammatory mediators could also contribute to the fact that you get these bone marrow lesions,” he elaborated. “But on the other hand, if you put more weight on your knees, the impact may also play a role. So it remains a very, very difficult thing to study and to come up with clear answers.”

Dr. Zhu disclosed no relevant conflicts of interest.

SEATTLE – C-reactive protein is associated with the presence and progression of bone marrow lesions in patients with osteoarthritis of the knee, according to data from a cohort study of 192 patients that were reported at the World Congress on Osteoarthritis.

“Osteoarthritis has predominantly been viewed as a degenerative joint disease driven by continued and irreversible deterioration of joints,” said lead investigator Zhaohua (Alex) Zhu, a PhD candidate at the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia. “However, current studies suggest a different way of understanding this disease, showing that the development of osteoarthritis may be in great part driven by a low-grade inflammatory process.”

He and his colleagues analyzed data from the randomized phase III VIDEO trial (Vitamin D Effect on Osteoarthritis), which enrolled patients aged 50-79 years who had symptomatic knee osteoarthritis and vitamin D deficiency. Analyses were based on 192 patients who had measurement of high-sensitivity C-reactive protein (CRP) and resistin (a proinflammatory cytokine secreted by adipose tissue) at baseline and again 2 years later.

Bone marrow lesions also were assessed at both time points with a modified version of the whole-organ magnetic resonance imaging score (WORMS). “Bone marrow lesions may represent areas of edema, inflammation, and remodeling,” Mr. Zhu explained. “Plenty of studies have shown that bone marrow lesions are linked to knee pain, cartilage volumes, and cartilage defect changes, so it’s a very important subchondral feature in knee osteoarthritis. But so far, the cause of bone marrow lesions remains unclear.”

Multivariate analyses showed that, as patients’ baseline CRP quartile increased, so did their odds of having total knee bone marrow lesions at that time (odds ratio, 1.45) and worsening of these lesions during follow-up (odds ratio, 1.56), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Additionally, the absolute change in CRP level during follow-up was positively associated with a worsening of lesions.

Associations for resistin were generally weaker or absent, with the only significant one seen between baseline quartile of that marker and bone marrow lesions at that time, reported Dr. Zhu.

In an interview, Dr. Timothy McAlindon, one of the session’s comoderators and professor of medicine at Tufts University in Boston, said that the study helps elucidate a possible role for adipose tissue, overweight, and adipocytokines in one subphenotype of osteoarthritis. “They found some associations, and I think those associations are probably the basis for further study and hopefully more understanding of what they mean,” he commented.

Dr. Rik Lories, the other session comoderator and professor at the University of Leuven (Belgium), noted that research on this topic is complicated. “You can ask questions about the chicken and the egg in this case because, if you are obese, you have a higher fat mass, so you are more likely to produce proinflammatory mediators, which can then induce your CRP. The fact that you have more inflammatory mediators could also contribute to the fact that you get these bone marrow lesions,” he elaborated. “But on the other hand, if you put more weight on your knees, the impact may also play a role. So it remains a very, very difficult thing to study and to come up with clear answers.”

Dr. Zhu disclosed no relevant conflicts of interest.

SEATTLE – A new study using an analytic framework grounded in behavior change theory shows several modifiable ways to help patients with knee and/or hip osteoarthritis to exercise, the most influential being beliefs about exercise, medical advice, gym referral, supervision, and encouragement, according to a report at the World Congress on Osteoarthritis.

“Our study provides a comprehensive synthesis of the many barriers and facilitators faced by those with osteoarthritis regarding intentional exercise,” commented lead investigator Philippa Nicolson, a research scientist at the Centre for Health, Exercise & Sports Medicine, University of Melbourne.

“Importantly, exercise adherence is not a problem that patients can solve on their own. Clinicians must take an active and leading role in identifying and considering barriers and facilitators to exercise, and engage with patients to create a patient-centered exercise plan that suits each individual’s needs and circumstances,” she recommended. “Clinicians must also help patients to gain the knowledge and skills that they need in order to adhere to exercise in the long term.”

In an interview, Stephen P. Messier, Ph.D., session comoderator and professor and director of both the J.B. Snow Biomechanics Laboratory and the Wake Forest University Runners’ Clinic in Winston-Salem, N. C., said, “A lot of this is not new information, I would say, but it really is important that [clinicians] understand that people who have been sedentary all their lives need help. They can’t do it on their own.”

Critical issues are how to stay in contact with patients and give them ongoing support in the long term, he noted, adding that, with social media and other methods, physicians can give patients personal help in the beginning and then wean them off of that help but still stay in contact in some way so patients feel like they have someone to talk to and someone that cares.

The physician plays a key role in the process, all the way from prescribing exercise to identifying suitable facilities to monitoring progress. “When your doctor cares about it, then older folks are going to do it because they really pay attention to what the physician says,” Dr. Messier said.

Introducing the study, Ms. Nicolson commented, “Exercise is a core component of osteoarthritis management and is now recommended in all clinical guidelines. High-quality evidence for the benefits of exercise in improving pain and function for those with lower-limb osteoarthritis are well established. However, exercise is globally underutilized, and among those for whom exercise is prescribed, adherence is found to be poor, particularly in the long term.”

“Understanding the barriers and facilitators to exercise will allow clinicians to change their practice to better facilitate adherence and allow researchers to develop and evaluate behavioral interventions targeting improved adherence,” she explained. “Given that initiating and adhering to exercise often requires significant behavior change, the use of behavior change theory is essential. In order to facilitate people with osteoarthritis to exercise, we need to analyze the behaviors influencing exercise participation. Interventions based on behavior change theory have been found to be significantly more successful than those that are not.”

The investigators conducted a scoping review to identify exercise barriers and facilitators in this population. They identified 23 relevant articles on intentional exercise (supervised or not and prescribed or self-initiated) among a total of 4,633 patients aged 45 years or older with hip and/or knee osteoarthritis.

Most of the more than 200 barriers and facilitators extracted from the articles were modifiable, according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The investigators mapped these modifiable factors onto domains of the Theoretical Domains Framework, which integrates multiple behavior change theories into a single framework and is aimed at helping researchers identify processes that do and do not work (Implement. Sci. 2012;7:37). They found that the barriers and facilitators mapped onto all 14 domains.

Among highlights, the many barriers mapping onto the framework’s Environmental Context and Resources domain included having to descend hills or stairs during a walking program, inability to find a suitable exercise, and rigidity of the program. Facilitators mapping onto this domain included use of a pedometer, physical therapist guidance, and receipt of a gym referral from the doctor.

Barriers mapping onto the Beliefs About Consequences domain included a belief that exercise has limited benefit, fear about damaging the joint further, and concern about precipitating pain.

Facilitators mapping onto the Reinforcement domain included medical advice to exercise, telephone reinforcement, and getting physician encouragement.

“Our findings have a number of clinical implications,” commented Ms. Nicolson.

“Given the many barriers that we identified linking to a person’s environment and resources, this highlights the need for individualized exercise tailored to each person’s situation,” she said. “Many barriers also relate to a person’s beliefs about their ability and consequences of exercise … This highlights the need for thorough and accurate education to each and every patient about their capabilities and the likely benefits of exercise.”

“Reinforcement, both internal and external, was frequently identified as a facilitator to exercise. The use of such things as logbooks, diaries, ongoing encouragement, and clinician advice to exercise can utilize these facilitators,” she concluded.

Ms. Nicolson disclosed no relevant conflicts of interest.

SEATTLE – A new study using an analytic framework grounded in behavior change theory shows several modifiable ways to help patients with knee and/or hip osteoarthritis to exercise, the most influential being beliefs about exercise, medical advice, gym referral, supervision, and encouragement, according to a report at the World Congress on Osteoarthritis.

“Our study provides a comprehensive synthesis of the many barriers and facilitators faced by those with osteoarthritis regarding intentional exercise,” commented lead investigator Philippa Nicolson, a research scientist at the Centre for Health, Exercise & Sports Medicine, University of Melbourne.

“Importantly, exercise adherence is not a problem that patients can solve on their own. Clinicians must take an active and leading role in identifying and considering barriers and facilitators to exercise, and engage with patients to create a patient-centered exercise plan that suits each individual’s needs and circumstances,” she recommended. “Clinicians must also help patients to gain the knowledge and skills that they need in order to adhere to exercise in the long term.”

In an interview, Stephen P. Messier, Ph.D., session comoderator and professor and director of both the J.B. Snow Biomechanics Laboratory and the Wake Forest University Runners’ Clinic in Winston-Salem, N. C., said, “A lot of this is not new information, I would say, but it really is important that [clinicians] understand that people who have been sedentary all their lives need help. They can’t do it on their own.”

Critical issues are how to stay in contact with patients and give them ongoing support in the long term, he noted, adding that, with social media and other methods, physicians can give patients personal help in the beginning and then wean them off of that help but still stay in contact in some way so patients feel like they have someone to talk to and someone that cares.

The physician plays a key role in the process, all the way from prescribing exercise to identifying suitable facilities to monitoring progress. “When your doctor cares about it, then older folks are going to do it because they really pay attention to what the physician says,” Dr. Messier said.

Introducing the study, Ms. Nicolson commented, “Exercise is a core component of osteoarthritis management and is now recommended in all clinical guidelines. High-quality evidence for the benefits of exercise in improving pain and function for those with lower-limb osteoarthritis are well established. However, exercise is globally underutilized, and among those for whom exercise is prescribed, adherence is found to be poor, particularly in the long term.”

“Understanding the barriers and facilitators to exercise will allow clinicians to change their practice to better facilitate adherence and allow researchers to develop and evaluate behavioral interventions targeting improved adherence,” she explained. “Given that initiating and adhering to exercise often requires significant behavior change, the use of behavior change theory is essential. In order to facilitate people with osteoarthritis to exercise, we need to analyze the behaviors influencing exercise participation. Interventions based on behavior change theory have been found to be significantly more successful than those that are not.”

The investigators conducted a scoping review to identify exercise barriers and facilitators in this population. They identified 23 relevant articles on intentional exercise (supervised or not and prescribed or self-initiated) among a total of 4,633 patients aged 45 years or older with hip and/or knee osteoarthritis.

Most of the more than 200 barriers and facilitators extracted from the articles were modifiable, according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The investigators mapped these modifiable factors onto domains of the Theoretical Domains Framework, which integrates multiple behavior change theories into a single framework and is aimed at helping researchers identify processes that do and do not work (Implement. Sci. 2012;7:37). They found that the barriers and facilitators mapped onto all 14 domains.

Among highlights, the many barriers mapping onto the framework’s Environmental Context and Resources domain included having to descend hills or stairs during a walking program, inability to find a suitable exercise, and rigidity of the program. Facilitators mapping onto this domain included use of a pedometer, physical therapist guidance, and receipt of a gym referral from the doctor.

Barriers mapping onto the Beliefs About Consequences domain included a belief that exercise has limited benefit, fear about damaging the joint further, and concern about precipitating pain.

Facilitators mapping onto the Reinforcement domain included medical advice to exercise, telephone reinforcement, and getting physician encouragement.

“Our findings have a number of clinical implications,” commented Ms. Nicolson.

“Given the many barriers that we identified linking to a person’s environment and resources, this highlights the need for individualized exercise tailored to each person’s situation,” she said. “Many barriers also relate to a person’s beliefs about their ability and consequences of exercise … This highlights the need for thorough and accurate education to each and every patient about their capabilities and the likely benefits of exercise.”

“Reinforcement, both internal and external, was frequently identified as a facilitator to exercise. The use of such things as logbooks, diaries, ongoing encouragement, and clinician advice to exercise can utilize these facilitators,” she concluded.

Ms. Nicolson disclosed no relevant conflicts of interest.

SEATTLE – A new study using an analytic framework grounded in behavior change theory shows several modifiable ways to help patients with knee and/or hip osteoarthritis to exercise, the most influential being beliefs about exercise, medical advice, gym referral, supervision, and encouragement, according to a report at the World Congress on Osteoarthritis.

“Our study provides a comprehensive synthesis of the many barriers and facilitators faced by those with osteoarthritis regarding intentional exercise,” commented lead investigator Philippa Nicolson, a research scientist at the Centre for Health, Exercise & Sports Medicine, University of Melbourne.

“Importantly, exercise adherence is not a problem that patients can solve on their own. Clinicians must take an active and leading role in identifying and considering barriers and facilitators to exercise, and engage with patients to create a patient-centered exercise plan that suits each individual’s needs and circumstances,” she recommended. “Clinicians must also help patients to gain the knowledge and skills that they need in order to adhere to exercise in the long term.”

In an interview, Stephen P. Messier, Ph.D., session comoderator and professor and director of both the J.B. Snow Biomechanics Laboratory and the Wake Forest University Runners’ Clinic in Winston-Salem, N. C., said, “A lot of this is not new information, I would say, but it really is important that [clinicians] understand that people who have been sedentary all their lives need help. They can’t do it on their own.”

Critical issues are how to stay in contact with patients and give them ongoing support in the long term, he noted, adding that, with social media and other methods, physicians can give patients personal help in the beginning and then wean them off of that help but still stay in contact in some way so patients feel like they have someone to talk to and someone that cares.

The physician plays a key role in the process, all the way from prescribing exercise to identifying suitable facilities to monitoring progress. “When your doctor cares about it, then older folks are going to do it because they really pay attention to what the physician says,” Dr. Messier said.

Introducing the study, Ms. Nicolson commented, “Exercise is a core component of osteoarthritis management and is now recommended in all clinical guidelines. High-quality evidence for the benefits of exercise in improving pain and function for those with lower-limb osteoarthritis are well established. However, exercise is globally underutilized, and among those for whom exercise is prescribed, adherence is found to be poor, particularly in the long term.”

“Understanding the barriers and facilitators to exercise will allow clinicians to change their practice to better facilitate adherence and allow researchers to develop and evaluate behavioral interventions targeting improved adherence,” she explained. “Given that initiating and adhering to exercise often requires significant behavior change, the use of behavior change theory is essential. In order to facilitate people with osteoarthritis to exercise, we need to analyze the behaviors influencing exercise participation. Interventions based on behavior change theory have been found to be significantly more successful than those that are not.”

The investigators conducted a scoping review to identify exercise barriers and facilitators in this population. They identified 23 relevant articles on intentional exercise (supervised or not and prescribed or self-initiated) among a total of 4,633 patients aged 45 years or older with hip and/or knee osteoarthritis.

Most of the more than 200 barriers and facilitators extracted from the articles were modifiable, according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International.

The investigators mapped these modifiable factors onto domains of the Theoretical Domains Framework, which integrates multiple behavior change theories into a single framework and is aimed at helping researchers identify processes that do and do not work (Implement. Sci. 2012;7:37). They found that the barriers and facilitators mapped onto all 14 domains.

Among highlights, the many barriers mapping onto the framework’s Environmental Context and Resources domain included having to descend hills or stairs during a walking program, inability to find a suitable exercise, and rigidity of the program. Facilitators mapping onto this domain included use of a pedometer, physical therapist guidance, and receipt of a gym referral from the doctor.

Barriers mapping onto the Beliefs About Consequences domain included a belief that exercise has limited benefit, fear about damaging the joint further, and concern about precipitating pain.

Facilitators mapping onto the Reinforcement domain included medical advice to exercise, telephone reinforcement, and getting physician encouragement.

“Our findings have a number of clinical implications,” commented Ms. Nicolson.

“Given the many barriers that we identified linking to a person’s environment and resources, this highlights the need for individualized exercise tailored to each person’s situation,” she said. “Many barriers also relate to a person’s beliefs about their ability and consequences of exercise … This highlights the need for thorough and accurate education to each and every patient about their capabilities and the likely benefits of exercise.”

“Reinforcement, both internal and external, was frequently identified as a facilitator to exercise. The use of such things as logbooks, diaries, ongoing encouragement, and clinician advice to exercise can utilize these facilitators,” she concluded.

Ms. Nicolson disclosed no relevant conflicts of interest.

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.