Osteoarthritis

DESTIN, FLA. – Facet joint osteoarthritis likely accounts for much of what is classified as "nonspecific" low back pain, according to Dr. Alfred C. Gellhorn.

"Amazingly – and I think sadly for us – the lumbar facet joints really have received very little attention in the literature," Dr. Gellhorn, who works in the department of rehabilitation medicine at the University of Washington, Seattle, said at the annual Congress of Clinical Rheumatology.

Eight of every ten American will experience low back pain at some point during their lifetime; low back pain is second only to the common cold in frequency, is the most common reason for time off work, and has a total social cost of more than $100 billion annually. Up to 85% of patients never receive a definitive diagnosis and are classified has having nonspecific pain, he said.

©Rocky89/thinkstockphotos.com

The facet joints may be responsible for a significant proportion of that pain.

Facet joint cartilage is aneural, but a number of nociceptors exist in the subchondral bone, the synovial folds, and the capsule. Once activated – by synovial inflammation or mechanical factors such as trabecular microfractures, capsular distention, pressure on the subchondral bone as joint load increases, or intramedullary hypertension, for example – the nociceptors may cause secondary reflex contraction of paraspinal muscles.

Patients will report this as spasms, and the contractions can be palpated, Dr. Gellhorn said, noting that prolonged inflammation in and around the facet joints can lead to central sensitization, neuronal plasticity, and development of chronic low back pain.

Facet joint osteoarthritis (OA) is distinct from disc degeneration, but the two conditions are interdependent. Radiographic hallmarks of disc degeneration include disc height loss, dehydration, and endplate sclerosis, whereas radiographic hallmarks of facet joint OA include narrowing of the facet joint space, osteophytosis of articular processes, hypertrophy of articular processes, sclerosis, subchondral erosion, and subchondral cysts.

Older studies that looked at facet joint OA by comparing findings on imaging and symptoms found either no association or only minimal association between facet joint OA and low back pain, but the threshold used in those studies was mild to moderate OA in young and middle-aged subjects.

"That’s the wrong criterion to use," Dr. Gellhorn said, noting that mild facet joint OA is "essentially ubiquitous" by middle age. Moderate to severe facet OA, however, is more symptomatic, and predominantly affects older adults – and should be the criterion used in studies of the condition.

In a recent study of 252 patients with a mean age of 67 years who were participants in the Framingham heart study, severe OA affecting the facet joint was significantly associated with frequent low back pain (odds ratio, 2.2). Disc height narrowing was not associated with low back pain in these patients (Osteoarthritis Cartilage 2013;21:1199-206).

The findings contrast with those from prior studies, likely because the cohort was older (mean age of 67 years vs. 30s to 50s), he said.

It may be that with age, back pain classified as "nonspecific" shifts from discogenic pain in younger adults to facetogenic pain in older adults, he suggested.

Findings with respect to disc pathology and low back pain in young and middle-aged adults seem to support this hypothesis, he noted.

For example, in a study of patients with a mean age of 49 years, low back pain was associated with a twofold increased likelihood of disc height loss and annular tears, and in a study of patients aged 18-50 years, moderate disc height loss was also associated with a twofold increased likelihood of low back pain. In another study of patients with a mean age of 50 years, advanced disc height loss was associated with a threefold increased likelihood of prevalent low back pain.

In another study, severe disc height narrowing was associated with a threefold increase in the odds of low back pain in those younger than age 60 years but not in those over age 60 years.

There are markers for symptomatic facet joint OA. Despite the known association between severe facet joint OA and low back pain, "the truth is there is still limited positive predictive value for that," he said.

"Many older adults with severe facet joint OA on imaging are relatively asymptomatic," he added.

There are some additional imaging makers, however. Symptomatic facet join OA is apparent on single-photon emission computed tomography/computed tomography (SPECT/CT) or fluid-sensitive, fat-suppressed MRI. Also, 64% of patients with suspected facet joint pain in one study had bone marrow lesions on short T1 inversion recovery (STIR) MRI, which were well correlated to the side of pain, he said.

There are no serum biomarkers for the condition at present, he noted.

In addition to older age and these findings on imaging, other risk factors and correlates for facet joint OA include sex (women are 1.5-1.9 times more likely than men to have facet joint OA), race (African Americans are about 60% less likely than white Americans to have facet joint OA), and high body mass index (those with BMI of 25-30 and 30-35 have a three- and fivefold increased risk of lumbar pain associated with facet joint OA, respectively, compared with those with BMI below 25).

Abdominal aortic calcifications and more sagittal orientation of the joints (vs. coronal orientation), also are associated with facet joint OA, Dr. Gellhorn said.

With additional research, these factors could be useful for "disambiguating nonspecific low back pain," he said.

"I think we’re getting closer. We’re not there yet, but we’re getting closer," he said.

Clinically, facet joint OA often presents as localized back or neck pain at C5-C6 with some radiation into the scapular region.

"It’s less clear in the lumbar spine, but almost always people will have pain in the lumbar region, and almost always they will have pain that radiates into the buttocks," he said, noting that pain radiating into the anterior or lateral thighs can be associated with facet joint OA, but pain that extends below the knees is more likely to be radicular.

There are no specific examination maneuvers that are pathognomonic – or even particularly helpful – for the condition, he added.

It is important to keep in mind that many patients will have associated conditions, including spondylolisthesis, disc degeneration, scoliosis, muscle atrophy, and spinal stenosis.

"It’s easy to get overwhelmed in the face of this, but I would urge you not to, and to still try to disentangle some of these concepts of low back pain without throwing up your hands," he said.

Although anesthetic blockade of the medial branches of the dorsal primary ramus (or "medial branch blocks,") are considered the gold standard for diagnosis, they are controversial, have an unacceptably high rate of false-positive results with a single block, and thus may require comparative blocks, which can result in numerous spinal injections.

This is problematic; there is no good way to make the diagnosis before doing more rational, conservative treatment, he said.

"I think that there are probably better things than doing 30 injections into someone’s spine to establish a diagnosis," he said.

In fact, treatment for facet joint OA generally involves physical activity.

"You don’t want to push these people to their limits, but certainly it is important to have them move and to have them keep the strength in their spine," he said.

In the absence of good studies evaluating noninterventional therapy for confirmed facet joint pain, treatment is generally based on findings in patients with chronic nonspecific low back pain and knee OA, and there is evidence in both of those settings that suggest exercise is helpful for increasing strength and decreasing pain and disability.

A Cochrane review showed that exercise therapy provides mild to moderate benefit. Additional studies have suggested that early referral to physical therapy results in modest improvement in function at 12 months in older adults, suggesting physical therapy provides longer-term results than many other interventions for low back pain, which tend to provide only short-term relief, he noted.

Furthermore, patients who have physical therapy tend to require fewer interventions. Dr. Gellhorn found in a recent study that physical therapy in a Medicare population with low back pain was associated with fewer lumbar injections, physician office visits, and lumbar surgeries.

"So it’s very reasonable to send your patients with facet joint OA to PT," he said.

Other treatments that may have some benefit if physical activity is inadequate include intra-articular steroid injections and radiofrequency denervation.

In studies that used SPECT for inclusion criteria, intra-articular injections were better than medial branch blocks at 3 months, and were more effective at 1 month and 3 months than were injections used in studies that did not use SPECT for inclusion, he said.

Injections were not useful in studies that used physical examination or diagnostic block for inclusion.

"So if you’re basing it on metabolic activity, you’re likely to have a good outcome from your injection," he said.

Radiofrequency denervation tends to work better in the cervical spine than in the lumbar spine, but it is difficult to justify in practice because it requires medial branch block, or double or even triple block to optimize success, and because it is associated with a number of potential complications, such as loss of innervation to the multifidus muscles.

In his practice he first screens for red flags in patients who present with low back pain. Next, he gets an X-ray to look for alignment issues, and he "heavily considers – if the clinical picture fits" – whether facet joint OA might be the cause of the pain.

"I’ll talk to them about it, and then almost always, I’ll send them for an empiric trial of physical therapy plus or minus some analgesics – Tylenol or NSAIDs," he said.

If patients experience improved function and a decrease in symptoms within 6-8 weeks, he recommends that they begin a more interesting (than their home physical therapy regimen) exercise program, such as yoga or Pilates to help them maintain those gains; if they remain symptomatic, he images them.

He starts with SPECT/CT rather than MRI if facet joint OA is high on his differential list for the patient, and if that’s positive, he will consider intra-articular steroid injections. If the injections are effective he recommends yoga and/or Pilates for maintaining the gains.

In rare cases a patient doesn’t respond to the injections, and then he will consider more aggressive treatment, such as medial branch block or radiofrequency denervation.

Understanding of facet joint OA has been slow to emerge, but progress is being made, Dr. Gellhorn said.

For example, the work with SPECT/CT and STIR MRI is very exciting, he said.

"I think this is going to give us a number of things to work with: first and foremost, it’s going to give us better criteria to diagnose patients and enroll them in treatment studies," he said.

Serum, urine, and genetic biomarkers, on the other hand, are interesting and on the horizon, "but we’re not really there yet," he added.

"But I think we will be able to at least use imaging studies to monitor some response to treatment," he said.

Additional study is also needed with respect to conservative treatments. Studies comparing different exercise programs, including studies comparing strength vs. flexibility and extension vs. flexion, are needed.

Regenerative treatments, such as platelet rich plasma and autologous stem cells are another area of interest, he said.

Dr. Gellhorn reported having no disclosures.

DESTIN, FLA. – Facet joint osteoarthritis likely accounts for much of what is classified as "nonspecific" low back pain, according to Dr. Alfred C. Gellhorn.

"Amazingly – and I think sadly for us – the lumbar facet joints really have received very little attention in the literature," Dr. Gellhorn, who works in the department of rehabilitation medicine at the University of Washington, Seattle, said at the annual Congress of Clinical Rheumatology.

Eight of every ten American will experience low back pain at some point during their lifetime; low back pain is second only to the common cold in frequency, is the most common reason for time off work, and has a total social cost of more than $100 billion annually. Up to 85% of patients never receive a definitive diagnosis and are classified has having nonspecific pain, he said.

©Rocky89/thinkstockphotos.com

The facet joints may be responsible for a significant proportion of that pain.

Facet joint cartilage is aneural, but a number of nociceptors exist in the subchondral bone, the synovial folds, and the capsule. Once activated – by synovial inflammation or mechanical factors such as trabecular microfractures, capsular distention, pressure on the subchondral bone as joint load increases, or intramedullary hypertension, for example – the nociceptors may cause secondary reflex contraction of paraspinal muscles.

Patients will report this as spasms, and the contractions can be palpated, Dr. Gellhorn said, noting that prolonged inflammation in and around the facet joints can lead to central sensitization, neuronal plasticity, and development of chronic low back pain.

Facet joint osteoarthritis (OA) is distinct from disc degeneration, but the two conditions are interdependent. Radiographic hallmarks of disc degeneration include disc height loss, dehydration, and endplate sclerosis, whereas radiographic hallmarks of facet joint OA include narrowing of the facet joint space, osteophytosis of articular processes, hypertrophy of articular processes, sclerosis, subchondral erosion, and subchondral cysts.

Older studies that looked at facet joint OA by comparing findings on imaging and symptoms found either no association or only minimal association between facet joint OA and low back pain, but the threshold used in those studies was mild to moderate OA in young and middle-aged subjects.

"That’s the wrong criterion to use," Dr. Gellhorn said, noting that mild facet joint OA is "essentially ubiquitous" by middle age. Moderate to severe facet OA, however, is more symptomatic, and predominantly affects older adults – and should be the criterion used in studies of the condition.

In a recent study of 252 patients with a mean age of 67 years who were participants in the Framingham heart study, severe OA affecting the facet joint was significantly associated with frequent low back pain (odds ratio, 2.2). Disc height narrowing was not associated with low back pain in these patients (Osteoarthritis Cartilage 2013;21:1199-206).

The findings contrast with those from prior studies, likely because the cohort was older (mean age of 67 years vs. 30s to 50s), he said.

It may be that with age, back pain classified as "nonspecific" shifts from discogenic pain in younger adults to facetogenic pain in older adults, he suggested.

Findings with respect to disc pathology and low back pain in young and middle-aged adults seem to support this hypothesis, he noted.

For example, in a study of patients with a mean age of 49 years, low back pain was associated with a twofold increased likelihood of disc height loss and annular tears, and in a study of patients aged 18-50 years, moderate disc height loss was also associated with a twofold increased likelihood of low back pain. In another study of patients with a mean age of 50 years, advanced disc height loss was associated with a threefold increased likelihood of prevalent low back pain.

In another study, severe disc height narrowing was associated with a threefold increase in the odds of low back pain in those younger than age 60 years but not in those over age 60 years.

There are markers for symptomatic facet joint OA. Despite the known association between severe facet joint OA and low back pain, "the truth is there is still limited positive predictive value for that," he said.

"Many older adults with severe facet joint OA on imaging are relatively asymptomatic," he added.

There are some additional imaging makers, however. Symptomatic facet join OA is apparent on single-photon emission computed tomography/computed tomography (SPECT/CT) or fluid-sensitive, fat-suppressed MRI. Also, 64% of patients with suspected facet joint pain in one study had bone marrow lesions on short T1 inversion recovery (STIR) MRI, which were well correlated to the side of pain, he said.

There are no serum biomarkers for the condition at present, he noted.

In addition to older age and these findings on imaging, other risk factors and correlates for facet joint OA include sex (women are 1.5-1.9 times more likely than men to have facet joint OA), race (African Americans are about 60% less likely than white Americans to have facet joint OA), and high body mass index (those with BMI of 25-30 and 30-35 have a three- and fivefold increased risk of lumbar pain associated with facet joint OA, respectively, compared with those with BMI below 25).

Abdominal aortic calcifications and more sagittal orientation of the joints (vs. coronal orientation), also are associated with facet joint OA, Dr. Gellhorn said.

With additional research, these factors could be useful for "disambiguating nonspecific low back pain," he said.

"I think we’re getting closer. We’re not there yet, but we’re getting closer," he said.

Clinically, facet joint OA often presents as localized back or neck pain at C5-C6 with some radiation into the scapular region.

"It’s less clear in the lumbar spine, but almost always people will have pain in the lumbar region, and almost always they will have pain that radiates into the buttocks," he said, noting that pain radiating into the anterior or lateral thighs can be associated with facet joint OA, but pain that extends below the knees is more likely to be radicular.

There are no specific examination maneuvers that are pathognomonic – or even particularly helpful – for the condition, he added.

It is important to keep in mind that many patients will have associated conditions, including spondylolisthesis, disc degeneration, scoliosis, muscle atrophy, and spinal stenosis.

"It’s easy to get overwhelmed in the face of this, but I would urge you not to, and to still try to disentangle some of these concepts of low back pain without throwing up your hands," he said.

Although anesthetic blockade of the medial branches of the dorsal primary ramus (or "medial branch blocks,") are considered the gold standard for diagnosis, they are controversial, have an unacceptably high rate of false-positive results with a single block, and thus may require comparative blocks, which can result in numerous spinal injections.

This is problematic; there is no good way to make the diagnosis before doing more rational, conservative treatment, he said.

"I think that there are probably better things than doing 30 injections into someone’s spine to establish a diagnosis," he said.

In fact, treatment for facet joint OA generally involves physical activity.

"You don’t want to push these people to their limits, but certainly it is important to have them move and to have them keep the strength in their spine," he said.

In the absence of good studies evaluating noninterventional therapy for confirmed facet joint pain, treatment is generally based on findings in patients with chronic nonspecific low back pain and knee OA, and there is evidence in both of those settings that suggest exercise is helpful for increasing strength and decreasing pain and disability.

A Cochrane review showed that exercise therapy provides mild to moderate benefit. Additional studies have suggested that early referral to physical therapy results in modest improvement in function at 12 months in older adults, suggesting physical therapy provides longer-term results than many other interventions for low back pain, which tend to provide only short-term relief, he noted.

Furthermore, patients who have physical therapy tend to require fewer interventions. Dr. Gellhorn found in a recent study that physical therapy in a Medicare population with low back pain was associated with fewer lumbar injections, physician office visits, and lumbar surgeries.

"So it’s very reasonable to send your patients with facet joint OA to PT," he said.

Other treatments that may have some benefit if physical activity is inadequate include intra-articular steroid injections and radiofrequency denervation.

In studies that used SPECT for inclusion criteria, intra-articular injections were better than medial branch blocks at 3 months, and were more effective at 1 month and 3 months than were injections used in studies that did not use SPECT for inclusion, he said.

Injections were not useful in studies that used physical examination or diagnostic block for inclusion.

"So if you’re basing it on metabolic activity, you’re likely to have a good outcome from your injection," he said.

Radiofrequency denervation tends to work better in the cervical spine than in the lumbar spine, but it is difficult to justify in practice because it requires medial branch block, or double or even triple block to optimize success, and because it is associated with a number of potential complications, such as loss of innervation to the multifidus muscles.

In his practice he first screens for red flags in patients who present with low back pain. Next, he gets an X-ray to look for alignment issues, and he "heavily considers – if the clinical picture fits" – whether facet joint OA might be the cause of the pain.

"I’ll talk to them about it, and then almost always, I’ll send them for an empiric trial of physical therapy plus or minus some analgesics – Tylenol or NSAIDs," he said.

If patients experience improved function and a decrease in symptoms within 6-8 weeks, he recommends that they begin a more interesting (than their home physical therapy regimen) exercise program, such as yoga or Pilates to help them maintain those gains; if they remain symptomatic, he images them.

He starts with SPECT/CT rather than MRI if facet joint OA is high on his differential list for the patient, and if that’s positive, he will consider intra-articular steroid injections. If the injections are effective he recommends yoga and/or Pilates for maintaining the gains.

In rare cases a patient doesn’t respond to the injections, and then he will consider more aggressive treatment, such as medial branch block or radiofrequency denervation.

Understanding of facet joint OA has been slow to emerge, but progress is being made, Dr. Gellhorn said.

For example, the work with SPECT/CT and STIR MRI is very exciting, he said.

"I think this is going to give us a number of things to work with: first and foremost, it’s going to give us better criteria to diagnose patients and enroll them in treatment studies," he said.

Serum, urine, and genetic biomarkers, on the other hand, are interesting and on the horizon, "but we’re not really there yet," he added.

"But I think we will be able to at least use imaging studies to monitor some response to treatment," he said.

Additional study is also needed with respect to conservative treatments. Studies comparing different exercise programs, including studies comparing strength vs. flexibility and extension vs. flexion, are needed.

Regenerative treatments, such as platelet rich plasma and autologous stem cells are another area of interest, he said.

Dr. Gellhorn reported having no disclosures.

DESTIN, FLA. – Facet joint osteoarthritis likely accounts for much of what is classified as "nonspecific" low back pain, according to Dr. Alfred C. Gellhorn.

"Amazingly – and I think sadly for us – the lumbar facet joints really have received very little attention in the literature," Dr. Gellhorn, who works in the department of rehabilitation medicine at the University of Washington, Seattle, said at the annual Congress of Clinical Rheumatology.

Eight of every ten American will experience low back pain at some point during their lifetime; low back pain is second only to the common cold in frequency, is the most common reason for time off work, and has a total social cost of more than $100 billion annually. Up to 85% of patients never receive a definitive diagnosis and are classified has having nonspecific pain, he said.

©Rocky89/thinkstockphotos.com

The facet joints may be responsible for a significant proportion of that pain.

Facet joint cartilage is aneural, but a number of nociceptors exist in the subchondral bone, the synovial folds, and the capsule. Once activated – by synovial inflammation or mechanical factors such as trabecular microfractures, capsular distention, pressure on the subchondral bone as joint load increases, or intramedullary hypertension, for example – the nociceptors may cause secondary reflex contraction of paraspinal muscles.

Patients will report this as spasms, and the contractions can be palpated, Dr. Gellhorn said, noting that prolonged inflammation in and around the facet joints can lead to central sensitization, neuronal plasticity, and development of chronic low back pain.

Facet joint osteoarthritis (OA) is distinct from disc degeneration, but the two conditions are interdependent. Radiographic hallmarks of disc degeneration include disc height loss, dehydration, and endplate sclerosis, whereas radiographic hallmarks of facet joint OA include narrowing of the facet joint space, osteophytosis of articular processes, hypertrophy of articular processes, sclerosis, subchondral erosion, and subchondral cysts.

Older studies that looked at facet joint OA by comparing findings on imaging and symptoms found either no association or only minimal association between facet joint OA and low back pain, but the threshold used in those studies was mild to moderate OA in young and middle-aged subjects.

"That’s the wrong criterion to use," Dr. Gellhorn said, noting that mild facet joint OA is "essentially ubiquitous" by middle age. Moderate to severe facet OA, however, is more symptomatic, and predominantly affects older adults – and should be the criterion used in studies of the condition.

In a recent study of 252 patients with a mean age of 67 years who were participants in the Framingham heart study, severe OA affecting the facet joint was significantly associated with frequent low back pain (odds ratio, 2.2). Disc height narrowing was not associated with low back pain in these patients (Osteoarthritis Cartilage 2013;21:1199-206).

The findings contrast with those from prior studies, likely because the cohort was older (mean age of 67 years vs. 30s to 50s), he said.

It may be that with age, back pain classified as "nonspecific" shifts from discogenic pain in younger adults to facetogenic pain in older adults, he suggested.

Findings with respect to disc pathology and low back pain in young and middle-aged adults seem to support this hypothesis, he noted.

For example, in a study of patients with a mean age of 49 years, low back pain was associated with a twofold increased likelihood of disc height loss and annular tears, and in a study of patients aged 18-50 years, moderate disc height loss was also associated with a twofold increased likelihood of low back pain. In another study of patients with a mean age of 50 years, advanced disc height loss was associated with a threefold increased likelihood of prevalent low back pain.

In another study, severe disc height narrowing was associated with a threefold increase in the odds of low back pain in those younger than age 60 years but not in those over age 60 years.

There are markers for symptomatic facet joint OA. Despite the known association between severe facet joint OA and low back pain, "the truth is there is still limited positive predictive value for that," he said.

"Many older adults with severe facet joint OA on imaging are relatively asymptomatic," he added.

There are some additional imaging makers, however. Symptomatic facet join OA is apparent on single-photon emission computed tomography/computed tomography (SPECT/CT) or fluid-sensitive, fat-suppressed MRI. Also, 64% of patients with suspected facet joint pain in one study had bone marrow lesions on short T1 inversion recovery (STIR) MRI, which were well correlated to the side of pain, he said.

There are no serum biomarkers for the condition at present, he noted.

In addition to older age and these findings on imaging, other risk factors and correlates for facet joint OA include sex (women are 1.5-1.9 times more likely than men to have facet joint OA), race (African Americans are about 60% less likely than white Americans to have facet joint OA), and high body mass index (those with BMI of 25-30 and 30-35 have a three- and fivefold increased risk of lumbar pain associated with facet joint OA, respectively, compared with those with BMI below 25).

Abdominal aortic calcifications and more sagittal orientation of the joints (vs. coronal orientation), also are associated with facet joint OA, Dr. Gellhorn said.

With additional research, these factors could be useful for "disambiguating nonspecific low back pain," he said.

"I think we’re getting closer. We’re not there yet, but we’re getting closer," he said.

Clinically, facet joint OA often presents as localized back or neck pain at C5-C6 with some radiation into the scapular region.

"It’s less clear in the lumbar spine, but almost always people will have pain in the lumbar region, and almost always they will have pain that radiates into the buttocks," he said, noting that pain radiating into the anterior or lateral thighs can be associated with facet joint OA, but pain that extends below the knees is more likely to be radicular.

There are no specific examination maneuvers that are pathognomonic – or even particularly helpful – for the condition, he added.

It is important to keep in mind that many patients will have associated conditions, including spondylolisthesis, disc degeneration, scoliosis, muscle atrophy, and spinal stenosis.

"It’s easy to get overwhelmed in the face of this, but I would urge you not to, and to still try to disentangle some of these concepts of low back pain without throwing up your hands," he said.

Although anesthetic blockade of the medial branches of the dorsal primary ramus (or "medial branch blocks,") are considered the gold standard for diagnosis, they are controversial, have an unacceptably high rate of false-positive results with a single block, and thus may require comparative blocks, which can result in numerous spinal injections.

This is problematic; there is no good way to make the diagnosis before doing more rational, conservative treatment, he said.

"I think that there are probably better things than doing 30 injections into someone’s spine to establish a diagnosis," he said.

In fact, treatment for facet joint OA generally involves physical activity.

"You don’t want to push these people to their limits, but certainly it is important to have them move and to have them keep the strength in their spine," he said.

In the absence of good studies evaluating noninterventional therapy for confirmed facet joint pain, treatment is generally based on findings in patients with chronic nonspecific low back pain and knee OA, and there is evidence in both of those settings that suggest exercise is helpful for increasing strength and decreasing pain and disability.

A Cochrane review showed that exercise therapy provides mild to moderate benefit. Additional studies have suggested that early referral to physical therapy results in modest improvement in function at 12 months in older adults, suggesting physical therapy provides longer-term results than many other interventions for low back pain, which tend to provide only short-term relief, he noted.

Furthermore, patients who have physical therapy tend to require fewer interventions. Dr. Gellhorn found in a recent study that physical therapy in a Medicare population with low back pain was associated with fewer lumbar injections, physician office visits, and lumbar surgeries.

"So it’s very reasonable to send your patients with facet joint OA to PT," he said.

Other treatments that may have some benefit if physical activity is inadequate include intra-articular steroid injections and radiofrequency denervation.

In studies that used SPECT for inclusion criteria, intra-articular injections were better than medial branch blocks at 3 months, and were more effective at 1 month and 3 months than were injections used in studies that did not use SPECT for inclusion, he said.

Injections were not useful in studies that used physical examination or diagnostic block for inclusion.

"So if you’re basing it on metabolic activity, you’re likely to have a good outcome from your injection," he said.

Radiofrequency denervation tends to work better in the cervical spine than in the lumbar spine, but it is difficult to justify in practice because it requires medial branch block, or double or even triple block to optimize success, and because it is associated with a number of potential complications, such as loss of innervation to the multifidus muscles.

In his practice he first screens for red flags in patients who present with low back pain. Next, he gets an X-ray to look for alignment issues, and he "heavily considers – if the clinical picture fits" – whether facet joint OA might be the cause of the pain.

"I’ll talk to them about it, and then almost always, I’ll send them for an empiric trial of physical therapy plus or minus some analgesics – Tylenol or NSAIDs," he said.

If patients experience improved function and a decrease in symptoms within 6-8 weeks, he recommends that they begin a more interesting (than their home physical therapy regimen) exercise program, such as yoga or Pilates to help them maintain those gains; if they remain symptomatic, he images them.

He starts with SPECT/CT rather than MRI if facet joint OA is high on his differential list for the patient, and if that’s positive, he will consider intra-articular steroid injections. If the injections are effective he recommends yoga and/or Pilates for maintaining the gains.

In rare cases a patient doesn’t respond to the injections, and then he will consider more aggressive treatment, such as medial branch block or radiofrequency denervation.

Understanding of facet joint OA has been slow to emerge, but progress is being made, Dr. Gellhorn said.

For example, the work with SPECT/CT and STIR MRI is very exciting, he said.

"I think this is going to give us a number of things to work with: first and foremost, it’s going to give us better criteria to diagnose patients and enroll them in treatment studies," he said.

Serum, urine, and genetic biomarkers, on the other hand, are interesting and on the horizon, "but we’re not really there yet," he added.

"But I think we will be able to at least use imaging studies to monitor some response to treatment," he said.

Additional study is also needed with respect to conservative treatments. Studies comparing different exercise programs, including studies comparing strength vs. flexibility and extension vs. flexion, are needed.

Regenerative treatments, such as platelet rich plasma and autologous stem cells are another area of interest, he said.

Dr. Gellhorn reported having no disclosures.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

Physical therapy incorporating manual therapy, exercise, patient education, and in some cases use of an assistive device for walking, failed to lessen pain or improve function in hip osteoarthritis beyond what was achieved with a sham therapy, according to a report published online May 20 in JAMA.

The multimodal active therapy, which was typical of those used in clinical practice, also was associated with significantly more adverse events than the sham treatment, including hip pain, hip stiffness, back pain, and pain in other bodily regions. "These results question the benefits of such a physical therapy program for this patient population," said Kim L. Bennell, Ph.D., foundation director and professor, centre for health, exercise and sports medicine, department of physiotherapy, Melbourne School of Health Sciences, the University of Melbourne, and her associates.

Very few clinical studies have assessed multimodal physical therapy (PT) for this indication, and those that have done so never compared it against a placebo. Studies that at least compared PT against usual care or no treatment have yielded conflicting results. Nevertheless, clinical guidelines recommend "conservative nonpharmacological physiotherapeutic treatments for hip osteoarthritis irrespective of disease severity, pain levels, and functional status," the investigators noted.

To test the efficacy of PT for hip OA, Dr. Bennell and her colleagues compared a 12-week course against 12 weeks of sham therapy in 102 patients aged 50 years and older who had moderate pain and moderate impairment of daily activities. Both interventions were delivered by experienced physical therapists at nine private clinics.

The PT included hip thrust manipulation, hip-lumbar spine mobilization, deep-tissue massage, and muscle stretches. Patients also were instructed to perform home exercises four times per week to strengthen the hip abductors and quadriceps, improve range of motion, and improve balance and gait, and they were given a walking stick if appropriate. The sham treatment comprised inactive ultrasound and the application of an inert gel to the hip region.

At 13- and 36-week follow-up, patients in both study groups reported lessening of pain and improvement in function. However, the changes were not significantly different between active and sham therapy on several instruments: a measure of hip pain intensity, the Hip Osteoarthritis Outcome Scale, a quality-of-life score, a global measure of body pain and function, the Arthritis Self-Efficacy Scale, the Pain Catastrophizing Scale, the Physical Activity Scale for the Elderly, a measure of hip range of motion, a measure of isometric strength of hip and thigh muscles, a stair-climbing test, a measure of walking velocity, and a balance test.

Nineteen of 46 patients (41%) who received active PT reported adverse events such as aggravated hip pain or back pain, compared with only 7 of 49 (14%) who received sham treatment, the investigators said (JAMA 2014 May 20 [doi:10.1001/jama.2014.4591]).

The "benefits" in both study groups, particularly in patient-reported pain and function, likely reflect the significant placebo effect that has been reported previously with hip OA. Both study groups participated in "10 individual sessions with an attentive therapist and treatment that involved skin stimulation and touch," which, together with patient confidence in their therapy, "are known to contribute to an effective placebo response," Dr. Bennell and her associates said.

This study was supported by Australia’s National Health and Medical Research Council. Dr. Bennell reported that she receives royalties for an educational DVD on knee OA and a commercially available shoe from Asics Oceania; no other investigator reported having potential conflicts of interest.

PARIS – Inflammatory ultrasound features in hand osteoarthritis may point clinicians toward patients at higher risk for radiographic progression, a longitudinal study suggests.

"We found inflammatory ultrasound features are independently associated with both progressive joint space narrowing and progression of osteophytes in hand osteoarthritis. This is especially true with persistent inflammation," Dr. Marion Kortekaas said at the World Congress on Osteoarthritis.

She presented data on 56 consecutive hand OA patients who underwent baseline and 2.3-year follow-up radiographic and ultrasound assessment of all first carpometacarpal, distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and first interphalangeal joints.

Radiographs were scored for osteophytes and joint space narrowing using the OARSI Atlas grading system (0-3 scale). Ultrasound synovial thickening, effusion, and power Doppler signal (PDS) were scored on a validated 3-point scale, with 3 being severe. Progression was defined as at least one grade increase of either joint space narrowing or osteophytes, explained Dr. Kortekaas, a rheumatologist at Leiden (the Netherlands) University Medical Center.

Most patients were female (86%) and their average age was 61 years. Patients with rheumatic diseases, trauma/operation, and corticosteroid use were excluded.

Of 1,680 joints at baseline, 141 (8.4%) had synovial thickening, 332 (19.8%) effusion, and 146 (8.7%) PDS.

At follow-up, progression of osteophytes and joint space narrowing was present in 120 and 96 joints, respectively, she said.

PDS, synovial thickening, and effusion were "persistent," defined as present at baseline and follow-up, in 40, 118, and 232 joints, and were "fluctuating," or present only at baseline or follow-up, in 243, 641, and 636 joints, respectively.

Using generalized estimating equations analyses, progression was independently associated with ultrasound synovial thickening (odds ratio, 2.6), effusion (OR, 3.5), and power Doppler signal (OR, 5.7) for grade 2-3 vs. grade 0, after adjustment for age, sex, body mass index, baseline osteophytes, and joint space narrowing scores, Dr. Kortekaas said.

Joint space narrowing was also independently associated with the ultrasound features of synovial thickening (OR, 3.4), effusion (OR, 3.3), and power Doppler signal (OR, 3.1), again after adjustment and comparing grade 2-3 vs. grade 0.

Persistent inflammation showed stronger associations with radiographic progression than did fluctuating inflammatory features in comparison with no inflammatory features at all, she said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, Dr. Kortekaas said inflammatory and synovial changes are loosely related to symptoms and pain, but that the group has yet to look at an association with C-reactive protein or inflammation in other joints.

Session comoderator Dr. Gillian Hawker, professor of medicine at the University of Toronto and physician in chief of medicine at Women’s College Hospital, Toronto, commented that until recently, ultrasound for hand OA has been far more common in clinical practice in Europe than in North America.

"I think that’s exactly where the radiology community is starting to go," she said in an interview. "Would we be doing a better job, picking things up earlier if we were ultrasounding? [There’s] definitely higher sensitivity. But, we haven’t quite gotten there yet. It’s going to cost money to get ultrasound machines into practices and train physicians."

Dr. Hawker observed that the American College of Radiology has added an ultrasound course and that residents at her institution are now going through ultrasound training as part of their residency.

Dr. Kortekaas and her coauthors reported no conflicting interests.

[email protected]

PARIS – Inflammatory ultrasound features in hand osteoarthritis may point clinicians toward patients at higher risk for radiographic progression, a longitudinal study suggests.

"We found inflammatory ultrasound features are independently associated with both progressive joint space narrowing and progression of osteophytes in hand osteoarthritis. This is especially true with persistent inflammation," Dr. Marion Kortekaas said at the World Congress on Osteoarthritis.

She presented data on 56 consecutive hand OA patients who underwent baseline and 2.3-year follow-up radiographic and ultrasound assessment of all first carpometacarpal, distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and first interphalangeal joints.

Radiographs were scored for osteophytes and joint space narrowing using the OARSI Atlas grading system (0-3 scale). Ultrasound synovial thickening, effusion, and power Doppler signal (PDS) were scored on a validated 3-point scale, with 3 being severe. Progression was defined as at least one grade increase of either joint space narrowing or osteophytes, explained Dr. Kortekaas, a rheumatologist at Leiden (the Netherlands) University Medical Center.

Most patients were female (86%) and their average age was 61 years. Patients with rheumatic diseases, trauma/operation, and corticosteroid use were excluded.

Of 1,680 joints at baseline, 141 (8.4%) had synovial thickening, 332 (19.8%) effusion, and 146 (8.7%) PDS.

At follow-up, progression of osteophytes and joint space narrowing was present in 120 and 96 joints, respectively, she said.

PDS, synovial thickening, and effusion were "persistent," defined as present at baseline and follow-up, in 40, 118, and 232 joints, and were "fluctuating," or present only at baseline or follow-up, in 243, 641, and 636 joints, respectively.

Using generalized estimating equations analyses, progression was independently associated with ultrasound synovial thickening (odds ratio, 2.6), effusion (OR, 3.5), and power Doppler signal (OR, 5.7) for grade 2-3 vs. grade 0, after adjustment for age, sex, body mass index, baseline osteophytes, and joint space narrowing scores, Dr. Kortekaas said.

Joint space narrowing was also independently associated with the ultrasound features of synovial thickening (OR, 3.4), effusion (OR, 3.3), and power Doppler signal (OR, 3.1), again after adjustment and comparing grade 2-3 vs. grade 0.

Persistent inflammation showed stronger associations with radiographic progression than did fluctuating inflammatory features in comparison with no inflammatory features at all, she said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, Dr. Kortekaas said inflammatory and synovial changes are loosely related to symptoms and pain, but that the group has yet to look at an association with C-reactive protein or inflammation in other joints.

Session comoderator Dr. Gillian Hawker, professor of medicine at the University of Toronto and physician in chief of medicine at Women’s College Hospital, Toronto, commented that until recently, ultrasound for hand OA has been far more common in clinical practice in Europe than in North America.

"I think that’s exactly where the radiology community is starting to go," she said in an interview. "Would we be doing a better job, picking things up earlier if we were ultrasounding? [There’s] definitely higher sensitivity. But, we haven’t quite gotten there yet. It’s going to cost money to get ultrasound machines into practices and train physicians."

Dr. Hawker observed that the American College of Radiology has added an ultrasound course and that residents at her institution are now going through ultrasound training as part of their residency.

Dr. Kortekaas and her coauthors reported no conflicting interests.

[email protected]

PARIS – Inflammatory ultrasound features in hand osteoarthritis may point clinicians toward patients at higher risk for radiographic progression, a longitudinal study suggests.

"We found inflammatory ultrasound features are independently associated with both progressive joint space narrowing and progression of osteophytes in hand osteoarthritis. This is especially true with persistent inflammation," Dr. Marion Kortekaas said at the World Congress on Osteoarthritis.

She presented data on 56 consecutive hand OA patients who underwent baseline and 2.3-year follow-up radiographic and ultrasound assessment of all first carpometacarpal, distal interphalangeal, proximal interphalangeal, metacarpophalangeal, and first interphalangeal joints.

Radiographs were scored for osteophytes and joint space narrowing using the OARSI Atlas grading system (0-3 scale). Ultrasound synovial thickening, effusion, and power Doppler signal (PDS) were scored on a validated 3-point scale, with 3 being severe. Progression was defined as at least one grade increase of either joint space narrowing or osteophytes, explained Dr. Kortekaas, a rheumatologist at Leiden (the Netherlands) University Medical Center.

Most patients were female (86%) and their average age was 61 years. Patients with rheumatic diseases, trauma/operation, and corticosteroid use were excluded.

Of 1,680 joints at baseline, 141 (8.4%) had synovial thickening, 332 (19.8%) effusion, and 146 (8.7%) PDS.

At follow-up, progression of osteophytes and joint space narrowing was present in 120 and 96 joints, respectively, she said.

PDS, synovial thickening, and effusion were "persistent," defined as present at baseline and follow-up, in 40, 118, and 232 joints, and were "fluctuating," or present only at baseline or follow-up, in 243, 641, and 636 joints, respectively.

Using generalized estimating equations analyses, progression was independently associated with ultrasound synovial thickening (odds ratio, 2.6), effusion (OR, 3.5), and power Doppler signal (OR, 5.7) for grade 2-3 vs. grade 0, after adjustment for age, sex, body mass index, baseline osteophytes, and joint space narrowing scores, Dr. Kortekaas said.

Joint space narrowing was also independently associated with the ultrasound features of synovial thickening (OR, 3.4), effusion (OR, 3.3), and power Doppler signal (OR, 3.1), again after adjustment and comparing grade 2-3 vs. grade 0.

Persistent inflammation showed stronger associations with radiographic progression than did fluctuating inflammatory features in comparison with no inflammatory features at all, she said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, Dr. Kortekaas said inflammatory and synovial changes are loosely related to symptoms and pain, but that the group has yet to look at an association with C-reactive protein or inflammation in other joints.

Session comoderator Dr. Gillian Hawker, professor of medicine at the University of Toronto and physician in chief of medicine at Women’s College Hospital, Toronto, commented that until recently, ultrasound for hand OA has been far more common in clinical practice in Europe than in North America.

"I think that’s exactly where the radiology community is starting to go," she said in an interview. "Would we be doing a better job, picking things up earlier if we were ultrasounding? [There’s] definitely higher sensitivity. But, we haven’t quite gotten there yet. It’s going to cost money to get ultrasound machines into practices and train physicians."

Dr. Hawker observed that the American College of Radiology has added an ultrasound course and that residents at her institution are now going through ultrasound training as part of their residency.

Dr. Kortekaas and her coauthors reported no conflicting interests.

[email protected]

PARIS – Weight loss of more than 5% produced clinically meaningful improvements in knee osteoarthritis, even when final body mass index remained high, a large, community-based study has shown.

For those patients who lost 10% body weight in the study, knee osteoarthritis symptoms improved by about 40%, consistent with the recent IDEA (Intensive Diet and Exercise for Arthritis) trial findings.

"There is a strong dose-response relationship between percentage weight loss and improvement in knee pain, function, symptoms, sport or recreation, and quality of life," Dr. Inoshi Atukorala said at the World Congress on Osteoarthritis.

Dr. Atukorala described the study as the first to examine the dose-response relationship between changes in body weight and knee osteoarthritis in a real-world, community setting.

The researchers evaluated 1,383 Australians who fulfilled the American College of Rheumatology criteria for knee osteoarthritis (OA) and were enrolled in the structured, remotely delivered "Healthy Weight for Life" knee and hip osteoarthritis management program. It integrates intensive weight loss as a component of tailored interventions, with the aim of achieving a 7%-10% body weight loss over 18 weeks, explained Dr. Atukorala, a consultant rheumatologist at the University of Colombo, Sri Lanka.

The program uses a partial very-low-calorie diet, portion management tools and devices, written healthy eating advice, and lifestyle education together with targeted telephone, e-mail, and text-message motivation and support. All participants were given the same strength, balance, and mobility exercise tools, instruction, and support.

Patrice Wendling/Frontline Medical News

At baseline, 81.7% of participants were obese, the average body mass index (BMI) was 34.3 kg/m², and the mean Knee injury and Osteoarthritis Outcome Score (KOOS) pain and function subscale scores were 56.3 and 59.5. The cohort was 71% female and had an average age of 64 years.

At 18-weeks, there was a clear and significant incremental improvement in KOOS subscales across the weight-loss categories, with the greatest improvements in those losing at least 10% body weight, Dr. Atukorala said.

The weight-loss category cutoffs were chosen based on the IDEA trial (JAMA 2013;310:1263-73), as well as the weight-loss goal in the diet groups in the ADAPT study and the weight loss typically achieved in its exercise-only cohort of older adults with knee OA (Arthritis Rheum. 2004;50;1501-10), she explained.

Using repeated measures analysis of covariance, the investigators next examined the dose-response of weight loss, compared with differences in pain and function. For this analysis, the 2.5% or less weight-loss category was set as the reference.

The dose-relationship between weight loss and improvements in pain and function persisted, even after controlling for baseline age, gender, weight, height, and KOOS, Dr. Atukorala said at the meeting, sponsored by the Osteoarthritis Research Society International. The differences reached statistical significance on all KOOS subscales for the two highest weight-loss categories and on all but one subscale (KOOS sport) for those losing 5.1%-7.5% body weight.

"We are limited by the fact that the program did not assess the magnitude of exercise interventions in each weight-loss category, but it confirms the dose-response benefit of weight loss as a therapeutic intervention in knee osteoarthritis," Dr. Atukorala concluded. "And, it demonstrates the effectiveness of disseminating and implementing intensive weight-loss intervention in a community-based setting."

Dr. Atukorala reported no financial disclosures. One coauthor is the CEO and scientific director of Prima Health Solutions, and another is funded by the Australian Research Council future fellowships program.

[email protected]

PARIS – Weight loss of more than 5% produced clinically meaningful improvements in knee osteoarthritis, even when final body mass index remained high, a large, community-based study has shown.

For those patients who lost 10% body weight in the study, knee osteoarthritis symptoms improved by about 40%, consistent with the recent IDEA (Intensive Diet and Exercise for Arthritis) trial findings.

"There is a strong dose-response relationship between percentage weight loss and improvement in knee pain, function, symptoms, sport or recreation, and quality of life," Dr. Inoshi Atukorala said at the World Congress on Osteoarthritis.

Dr. Atukorala described the study as the first to examine the dose-response relationship between changes in body weight and knee osteoarthritis in a real-world, community setting.

The researchers evaluated 1,383 Australians who fulfilled the American College of Rheumatology criteria for knee osteoarthritis (OA) and were enrolled in the structured, remotely delivered "Healthy Weight for Life" knee and hip osteoarthritis management program. It integrates intensive weight loss as a component of tailored interventions, with the aim of achieving a 7%-10% body weight loss over 18 weeks, explained Dr. Atukorala, a consultant rheumatologist at the University of Colombo, Sri Lanka.

The program uses a partial very-low-calorie diet, portion management tools and devices, written healthy eating advice, and lifestyle education together with targeted telephone, e-mail, and text-message motivation and support. All participants were given the same strength, balance, and mobility exercise tools, instruction, and support.

Patrice Wendling/Frontline Medical News

At baseline, 81.7% of participants were obese, the average body mass index (BMI) was 34.3 kg/m², and the mean Knee injury and Osteoarthritis Outcome Score (KOOS) pain and function subscale scores were 56.3 and 59.5. The cohort was 71% female and had an average age of 64 years.

At 18-weeks, there was a clear and significant incremental improvement in KOOS subscales across the weight-loss categories, with the greatest improvements in those losing at least 10% body weight, Dr. Atukorala said.

The weight-loss category cutoffs were chosen based on the IDEA trial (JAMA 2013;310:1263-73), as well as the weight-loss goal in the diet groups in the ADAPT study and the weight loss typically achieved in its exercise-only cohort of older adults with knee OA (Arthritis Rheum. 2004;50;1501-10), she explained.

Using repeated measures analysis of covariance, the investigators next examined the dose-response of weight loss, compared with differences in pain and function. For this analysis, the 2.5% or less weight-loss category was set as the reference.

The dose-relationship between weight loss and improvements in pain and function persisted, even after controlling for baseline age, gender, weight, height, and KOOS, Dr. Atukorala said at the meeting, sponsored by the Osteoarthritis Research Society International. The differences reached statistical significance on all KOOS subscales for the two highest weight-loss categories and on all but one subscale (KOOS sport) for those losing 5.1%-7.5% body weight.

"We are limited by the fact that the program did not assess the magnitude of exercise interventions in each weight-loss category, but it confirms the dose-response benefit of weight loss as a therapeutic intervention in knee osteoarthritis," Dr. Atukorala concluded. "And, it demonstrates the effectiveness of disseminating and implementing intensive weight-loss intervention in a community-based setting."

Dr. Atukorala reported no financial disclosures. One coauthor is the CEO and scientific director of Prima Health Solutions, and another is funded by the Australian Research Council future fellowships program.

[email protected]

PARIS – Weight loss of more than 5% produced clinically meaningful improvements in knee osteoarthritis, even when final body mass index remained high, a large, community-based study has shown.

For those patients who lost 10% body weight in the study, knee osteoarthritis symptoms improved by about 40%, consistent with the recent IDEA (Intensive Diet and Exercise for Arthritis) trial findings.

"There is a strong dose-response relationship between percentage weight loss and improvement in knee pain, function, symptoms, sport or recreation, and quality of life," Dr. Inoshi Atukorala said at the World Congress on Osteoarthritis.

Dr. Atukorala described the study as the first to examine the dose-response relationship between changes in body weight and knee osteoarthritis in a real-world, community setting.

The researchers evaluated 1,383 Australians who fulfilled the American College of Rheumatology criteria for knee osteoarthritis (OA) and were enrolled in the structured, remotely delivered "Healthy Weight for Life" knee and hip osteoarthritis management program. It integrates intensive weight loss as a component of tailored interventions, with the aim of achieving a 7%-10% body weight loss over 18 weeks, explained Dr. Atukorala, a consultant rheumatologist at the University of Colombo, Sri Lanka.

The program uses a partial very-low-calorie diet, portion management tools and devices, written healthy eating advice, and lifestyle education together with targeted telephone, e-mail, and text-message motivation and support. All participants were given the same strength, balance, and mobility exercise tools, instruction, and support.

Patrice Wendling/Frontline Medical News

At baseline, 81.7% of participants were obese, the average body mass index (BMI) was 34.3 kg/m², and the mean Knee injury and Osteoarthritis Outcome Score (KOOS) pain and function subscale scores were 56.3 and 59.5. The cohort was 71% female and had an average age of 64 years.

At 18-weeks, there was a clear and significant incremental improvement in KOOS subscales across the weight-loss categories, with the greatest improvements in those losing at least 10% body weight, Dr. Atukorala said.

The weight-loss category cutoffs were chosen based on the IDEA trial (JAMA 2013;310:1263-73), as well as the weight-loss goal in the diet groups in the ADAPT study and the weight loss typically achieved in its exercise-only cohort of older adults with knee OA (Arthritis Rheum. 2004;50;1501-10), she explained.

Using repeated measures analysis of covariance, the investigators next examined the dose-response of weight loss, compared with differences in pain and function. For this analysis, the 2.5% or less weight-loss category was set as the reference.

The dose-relationship between weight loss and improvements in pain and function persisted, even after controlling for baseline age, gender, weight, height, and KOOS, Dr. Atukorala said at the meeting, sponsored by the Osteoarthritis Research Society International. The differences reached statistical significance on all KOOS subscales for the two highest weight-loss categories and on all but one subscale (KOOS sport) for those losing 5.1%-7.5% body weight.

"We are limited by the fact that the program did not assess the magnitude of exercise interventions in each weight-loss category, but it confirms the dose-response benefit of weight loss as a therapeutic intervention in knee osteoarthritis," Dr. Atukorala concluded. "And, it demonstrates the effectiveness of disseminating and implementing intensive weight-loss intervention in a community-based setting."

Dr. Atukorala reported no financial disclosures. One coauthor is the CEO and scientific director of Prima Health Solutions, and another is funded by the Australian Research Council future fellowships program.

[email protected]

PARIS – Impaired vibratory sense and muscle strength may be important risk factors for knee instability in persons with or at risk for symptomatic knee osteoarthritis, according to an analysis of a large, longitudinal cohort.

"Buckling is commonly been thought of as a mechanical phenomenon, but no one really knows the risk factors," Dr. Najia Shakoor said in an interview at the World Congress on Osteoarthritis. "For many, sensory input may be important. If you have greater sensory input, in this case, greater vibratory sense, perhaps you can protect yourself from buckling."

Knee instability is common in persons with knee osteoarthritis (OA) and has been found in studies to be associated with muscle weakness. None have examined whether weakness predicts onset or worsening of knee instability, she said.

Patrice Wendling/Frontline Medical News

It is also unknown whether decreased vibratory sense, often seen in older adults with knee OA, may distort one’s sense of knee position and increase the risk of instability.

For the current analysis, unilateral knee extensor strength and bilateral vibratory perception thresholds (VPT) were evaluated in 2,212 participants with or at risk for knee OA in the Multicenter Osteoarthritis Study (MOST). VPT was measured using a biothesiometer, with the tip placed on the tibial tuberosity and the voltage increased by 1 volt/sec from 0 until the participant acknowledged sensation.

The mean age of study participants was 68 years, mean body mass index (BMI) was 31 kg/m², and 60% were women.

At the 60-month visit, 17% of participants reported knee buckling in the past 3 months, 29% reported slipping or "shifting, slipping, or going to give way, but didn’t actually do so," and 37% reported instability (buckling and/or slipping), said Dr. Shakoor, a rheumatologist with Rush University Medical Center, Chicago.

During follow-up, 32% of patients developed incident instability, 20% incident buckling, 11% worsening instability, and 21% worsening buckling.

In Poisson regression person-based analyses, the risk of incident knee instability was significantly less in those with greater quadriceps strength (relative risk, 0.60; P = .003) as well as in those with better vibratory sense (P value for linear trend of .024), after adjustment for age, sex, BMI, race, clinic site, Kellgren-Lawrence OA grade, Western Ontario and McMaster Osteoarthritis Index knee pain, and both predictors.

Better vibratory sense also protected against worsening of both knee instability (RR, 0.42; P = .021) and buckling (RR, 0.67; P = .020), Dr. Shakoor reported in the poster presentation at the meeting, sponsored by the Osteoarthritis Research Society International.

Although it’s not known whether vibratory sense can be improved, muscle strength can be. "So these are potentially modifiable risk factors for a common problem," she said.

Prior work by the group has found that vibratory sense is impaired in hip as well as knee OA, compared with healthy controls.

The study was supported by the National Institutes of Health. Dr. Shakoor reported no conflicting interests.

[email protected]

PARIS – Impaired vibratory sense and muscle strength may be important risk factors for knee instability in persons with or at risk for symptomatic knee osteoarthritis, according to an analysis of a large, longitudinal cohort.

"Buckling is commonly been thought of as a mechanical phenomenon, but no one really knows the risk factors," Dr. Najia Shakoor said in an interview at the World Congress on Osteoarthritis. "For many, sensory input may be important. If you have greater sensory input, in this case, greater vibratory sense, perhaps you can protect yourself from buckling."

Knee instability is common in persons with knee osteoarthritis (OA) and has been found in studies to be associated with muscle weakness. None have examined whether weakness predicts onset or worsening of knee instability, she said.

Patrice Wendling/Frontline Medical News

It is also unknown whether decreased vibratory sense, often seen in older adults with knee OA, may distort one’s sense of knee position and increase the risk of instability.

For the current analysis, unilateral knee extensor strength and bilateral vibratory perception thresholds (VPT) were evaluated in 2,212 participants with or at risk for knee OA in the Multicenter Osteoarthritis Study (MOST). VPT was measured using a biothesiometer, with the tip placed on the tibial tuberosity and the voltage increased by 1 volt/sec from 0 until the participant acknowledged sensation.

The mean age of study participants was 68 years, mean body mass index (BMI) was 31 kg/m², and 60% were women.

At the 60-month visit, 17% of participants reported knee buckling in the past 3 months, 29% reported slipping or "shifting, slipping, or going to give way, but didn’t actually do so," and 37% reported instability (buckling and/or slipping), said Dr. Shakoor, a rheumatologist with Rush University Medical Center, Chicago.

During follow-up, 32% of patients developed incident instability, 20% incident buckling, 11% worsening instability, and 21% worsening buckling.

In Poisson regression person-based analyses, the risk of incident knee instability was significantly less in those with greater quadriceps strength (relative risk, 0.60; P = .003) as well as in those with better vibratory sense (P value for linear trend of .024), after adjustment for age, sex, BMI, race, clinic site, Kellgren-Lawrence OA grade, Western Ontario and McMaster Osteoarthritis Index knee pain, and both predictors.

Better vibratory sense also protected against worsening of both knee instability (RR, 0.42; P = .021) and buckling (RR, 0.67; P = .020), Dr. Shakoor reported in the poster presentation at the meeting, sponsored by the Osteoarthritis Research Society International.

Although it’s not known whether vibratory sense can be improved, muscle strength can be. "So these are potentially modifiable risk factors for a common problem," she said.

Prior work by the group has found that vibratory sense is impaired in hip as well as knee OA, compared with healthy controls.

The study was supported by the National Institutes of Health. Dr. Shakoor reported no conflicting interests.

[email protected]

PARIS – Impaired vibratory sense and muscle strength may be important risk factors for knee instability in persons with or at risk for symptomatic knee osteoarthritis, according to an analysis of a large, longitudinal cohort.

"Buckling is commonly been thought of as a mechanical phenomenon, but no one really knows the risk factors," Dr. Najia Shakoor said in an interview at the World Congress on Osteoarthritis. "For many, sensory input may be important. If you have greater sensory input, in this case, greater vibratory sense, perhaps you can protect yourself from buckling."

Knee instability is common in persons with knee osteoarthritis (OA) and has been found in studies to be associated with muscle weakness. None have examined whether weakness predicts onset or worsening of knee instability, she said.

Patrice Wendling/Frontline Medical News

It is also unknown whether decreased vibratory sense, often seen in older adults with knee OA, may distort one’s sense of knee position and increase the risk of instability.

For the current analysis, unilateral knee extensor strength and bilateral vibratory perception thresholds (VPT) were evaluated in 2,212 participants with or at risk for knee OA in the Multicenter Osteoarthritis Study (MOST). VPT was measured using a biothesiometer, with the tip placed on the tibial tuberosity and the voltage increased by 1 volt/sec from 0 until the participant acknowledged sensation.

The mean age of study participants was 68 years, mean body mass index (BMI) was 31 kg/m², and 60% were women.

At the 60-month visit, 17% of participants reported knee buckling in the past 3 months, 29% reported slipping or "shifting, slipping, or going to give way, but didn’t actually do so," and 37% reported instability (buckling and/or slipping), said Dr. Shakoor, a rheumatologist with Rush University Medical Center, Chicago.

During follow-up, 32% of patients developed incident instability, 20% incident buckling, 11% worsening instability, and 21% worsening buckling.

In Poisson regression person-based analyses, the risk of incident knee instability was significantly less in those with greater quadriceps strength (relative risk, 0.60; P = .003) as well as in those with better vibratory sense (P value for linear trend of .024), after adjustment for age, sex, BMI, race, clinic site, Kellgren-Lawrence OA grade, Western Ontario and McMaster Osteoarthritis Index knee pain, and both predictors.

Better vibratory sense also protected against worsening of both knee instability (RR, 0.42; P = .021) and buckling (RR, 0.67; P = .020), Dr. Shakoor reported in the poster presentation at the meeting, sponsored by the Osteoarthritis Research Society International.

Although it’s not known whether vibratory sense can be improved, muscle strength can be. "So these are potentially modifiable risk factors for a common problem," she said.

Prior work by the group has found that vibratory sense is impaired in hip as well as knee OA, compared with healthy controls.

The study was supported by the National Institutes of Health. Dr. Shakoor reported no conflicting interests.

[email protected]

PARIS – Vigorous, but not moderate, physical exercise was associated with a significantly greater risk of knee osteoarthritis progression over 1 year in a longitudinal analysis of 99 patients.

Engaging in vigorous activity was associated with a 1.38-times increased risk for progression (95% confidence intervals, 1.04-1.83; P = .025), defined as an increase in either cartilage or meniscus defect scores at 1 year.

© Stockbyte/Thinkstock

The odds ratios were not significantly increased for moderate activity (OR, 0.78; 95% CI, 0.47-1.28; P = .322) but were close to significance for walking activity (OR, 1.50; 95% CI, 1-2.25; P = .052), lead author Deepak Kumar, Ph.D., said at the World Congress on Osteoarthritis.

The analyses adjusted for age, body mass index, sex, pain, Kellgren-Lawrence (KL) score, and modified Whole Organ Magnetic Resonance Scores for cartilage and meniscus in the first block, and International Physical Activity Questionnaire (IPAQ) scores in the second block.

"We did not see that moderate activity was associated with progression, and this indicates that we need to further investigate the optimal dosage of physical activity for someone with knee osteoarthritis," said Dr. Kumar, a postdoctoral scholar, radiology department, University of California, San Francisco.

Although greater physical activity has been shown to reduce pain and improve function, the results support more recent work suggesting that certain types of activity may be associated with disease progression. Walking 10,000 steps or more per day was found to increase the risk of meniscus and cartilage lesions on MRI in people with knee OA (Ann. Rheum. Dis. 2013;72:1170-5), while high and very low levels of self-reported activity were associated with greater cartilage relaxation times on 2T MRI at 4 years in data from the Osteoarthritis Initiative (Osteoarthritis Cartilage 2013;12:1558-66).

For the current analysis, 99 participants in the ongoing, longitudinal Cartilage Loading and Unloading (CLOC) knee OA study underwent 3T MRI of the knee using a sagittal, high-resolution 3D fast spin-echo Cube sequence at baseline, which was repeated 1 year later. Cartilage and meniscus defects were graded by experienced radiologists. Participants with OA had a baseline radiographic KL score of more than 1 and were symptomatic; controls had a KL of 0 or 1 and no knee symptoms.

By 1 year, 35 participants showed progression (14 with OA and 21 controls) and 64 did not. Surprisingly, there was greater progression in the lateral compartment (11 lateral menisci, 12 lateral tibiae) and, more expectedly, in the patella in 12 persons, Dr. Kumar said at the meeting, sponsored by the Osteoarthritis Research Society International.

No significant baseline differences existed between nonprogressors and progressors with respect to age (53.2 years vs. 50.8 years), body mass index (24.4 kg/m² vs. 24.5 kg/m²), and sex (62.5% vs. 48.5% female), he said.

Knee injury and Osteoarthritis Outcome Score subscale scores were also similar for pain (85.7 vs. 82.4) and symptoms (84.5 vs. 83.4).

Progressors had engaged, however, in significantly more metabolic equivalent-minutes per week of vigorous exercise than did nonprogressors (2,410.6 vs. 1,413.1; P = .046), Dr. Kumar said. Metabolic equivalent-minutes per week were similar for moderate activity (1,094.1 vs. 858.7; P = .396) and walking (1,646.2 vs. 1,245.1; P = .151).

During the discussion following the formal presentation, an attendee said the study is potentially very valuable because it suggests that something all clinicians want to do is "dangerous" but questioned whether some of the MRI data were "overread" given the almost 40% rate of progression in a relatively fit cohort. A Danish attendee also remarked that her group has experienced so many problems with patients filling out the IPAQ questionnaire that they no longer trust the data.

Dr. Kumar responded that the MRI readings were performed by expert radiologists and were reliable, and that more stringent definitions of progression are being explored. His group is also working on a new questionnaire to better define physical activity levels.

Data are also being analyzed from the rest of the cohort (160 participants) and over a longer, 3-year follow-up, he said in an interview.

"We are also identifying quantitative MRI and biomechanical metrics that may be more sensitive to disease progression in knee OA. These will help us understand the factors that are related to worsening of knee OA and develop therapies."

The National Institutes of Health–National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the work. Dr. Kumar and his coauthors reported no conflicting interests.

[email protected]

PARIS – Vigorous, but not moderate, physical exercise was associated with a significantly greater risk of knee osteoarthritis progression over 1 year in a longitudinal analysis of 99 patients.

Engaging in vigorous activity was associated with a 1.38-times increased risk for progression (95% confidence intervals, 1.04-1.83; P = .025), defined as an increase in either cartilage or meniscus defect scores at 1 year.

© Stockbyte/Thinkstock

The odds ratios were not significantly increased for moderate activity (OR, 0.78; 95% CI, 0.47-1.28; P = .322) but were close to significance for walking activity (OR, 1.50; 95% CI, 1-2.25; P = .052), lead author Deepak Kumar, Ph.D., said at the World Congress on Osteoarthritis.

The analyses adjusted for age, body mass index, sex, pain, Kellgren-Lawrence (KL) score, and modified Whole Organ Magnetic Resonance Scores for cartilage and meniscus in the first block, and International Physical Activity Questionnaire (IPAQ) scores in the second block.

"We did not see that moderate activity was associated with progression, and this indicates that we need to further investigate the optimal dosage of physical activity for someone with knee osteoarthritis," said Dr. Kumar, a postdoctoral scholar, radiology department, University of California, San Francisco.

Although greater physical activity has been shown to reduce pain and improve function, the results support more recent work suggesting that certain types of activity may be associated with disease progression. Walking 10,000 steps or more per day was found to increase the risk of meniscus and cartilage lesions on MRI in people with knee OA (Ann. Rheum. Dis. 2013;72:1170-5), while high and very low levels of self-reported activity were associated with greater cartilage relaxation times on 2T MRI at 4 years in data from the Osteoarthritis Initiative (Osteoarthritis Cartilage 2013;12:1558-66).

For the current analysis, 99 participants in the ongoing, longitudinal Cartilage Loading and Unloading (CLOC) knee OA study underwent 3T MRI of the knee using a sagittal, high-resolution 3D fast spin-echo Cube sequence at baseline, which was repeated 1 year later. Cartilage and meniscus defects were graded by experienced radiologists. Participants with OA had a baseline radiographic KL score of more than 1 and were symptomatic; controls had a KL of 0 or 1 and no knee symptoms.

By 1 year, 35 participants showed progression (14 with OA and 21 controls) and 64 did not. Surprisingly, there was greater progression in the lateral compartment (11 lateral menisci, 12 lateral tibiae) and, more expectedly, in the patella in 12 persons, Dr. Kumar said at the meeting, sponsored by the Osteoarthritis Research Society International.

No significant baseline differences existed between nonprogressors and progressors with respect to age (53.2 years vs. 50.8 years), body mass index (24.4 kg/m² vs. 24.5 kg/m²), and sex (62.5% vs. 48.5% female), he said.

Knee injury and Osteoarthritis Outcome Score subscale scores were also similar for pain (85.7 vs. 82.4) and symptoms (84.5 vs. 83.4).

Progressors had engaged, however, in significantly more metabolic equivalent-minutes per week of vigorous exercise than did nonprogressors (2,410.6 vs. 1,413.1; P = .046), Dr. Kumar said. Metabolic equivalent-minutes per week were similar for moderate activity (1,094.1 vs. 858.7; P = .396) and walking (1,646.2 vs. 1,245.1; P = .151).

During the discussion following the formal presentation, an attendee said the study is potentially very valuable because it suggests that something all clinicians want to do is "dangerous" but questioned whether some of the MRI data were "overread" given the almost 40% rate of progression in a relatively fit cohort. A Danish attendee also remarked that her group has experienced so many problems with patients filling out the IPAQ questionnaire that they no longer trust the data.

Dr. Kumar responded that the MRI readings were performed by expert radiologists and were reliable, and that more stringent definitions of progression are being explored. His group is also working on a new questionnaire to better define physical activity levels.

Data are also being analyzed from the rest of the cohort (160 participants) and over a longer, 3-year follow-up, he said in an interview.

"We are also identifying quantitative MRI and biomechanical metrics that may be more sensitive to disease progression in knee OA. These will help us understand the factors that are related to worsening of knee OA and develop therapies."

The National Institutes of Health–National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the work. Dr. Kumar and his coauthors reported no conflicting interests.

[email protected]

PARIS – Vigorous, but not moderate, physical exercise was associated with a significantly greater risk of knee osteoarthritis progression over 1 year in a longitudinal analysis of 99 patients.

Engaging in vigorous activity was associated with a 1.38-times increased risk for progression (95% confidence intervals, 1.04-1.83; P = .025), defined as an increase in either cartilage or meniscus defect scores at 1 year.

© Stockbyte/Thinkstock

The odds ratios were not significantly increased for moderate activity (OR, 0.78; 95% CI, 0.47-1.28; P = .322) but were close to significance for walking activity (OR, 1.50; 95% CI, 1-2.25; P = .052), lead author Deepak Kumar, Ph.D., said at the World Congress on Osteoarthritis.

The analyses adjusted for age, body mass index, sex, pain, Kellgren-Lawrence (KL) score, and modified Whole Organ Magnetic Resonance Scores for cartilage and meniscus in the first block, and International Physical Activity Questionnaire (IPAQ) scores in the second block.

"We did not see that moderate activity was associated with progression, and this indicates that we need to further investigate the optimal dosage of physical activity for someone with knee osteoarthritis," said Dr. Kumar, a postdoctoral scholar, radiology department, University of California, San Francisco.

Although greater physical activity has been shown to reduce pain and improve function, the results support more recent work suggesting that certain types of activity may be associated with disease progression. Walking 10,000 steps or more per day was found to increase the risk of meniscus and cartilage lesions on MRI in people with knee OA (Ann. Rheum. Dis. 2013;72:1170-5), while high and very low levels of self-reported activity were associated with greater cartilage relaxation times on 2T MRI at 4 years in data from the Osteoarthritis Initiative (Osteoarthritis Cartilage 2013;12:1558-66).

For the current analysis, 99 participants in the ongoing, longitudinal Cartilage Loading and Unloading (CLOC) knee OA study underwent 3T MRI of the knee using a sagittal, high-resolution 3D fast spin-echo Cube sequence at baseline, which was repeated 1 year later. Cartilage and meniscus defects were graded by experienced radiologists. Participants with OA had a baseline radiographic KL score of more than 1 and were symptomatic; controls had a KL of 0 or 1 and no knee symptoms.

By 1 year, 35 participants showed progression (14 with OA and 21 controls) and 64 did not. Surprisingly, there was greater progression in the lateral compartment (11 lateral menisci, 12 lateral tibiae) and, more expectedly, in the patella in 12 persons, Dr. Kumar said at the meeting, sponsored by the Osteoarthritis Research Society International.

No significant baseline differences existed between nonprogressors and progressors with respect to age (53.2 years vs. 50.8 years), body mass index (24.4 kg/m² vs. 24.5 kg/m²), and sex (62.5% vs. 48.5% female), he said.

Knee injury and Osteoarthritis Outcome Score subscale scores were also similar for pain (85.7 vs. 82.4) and symptoms (84.5 vs. 83.4).

Progressors had engaged, however, in significantly more metabolic equivalent-minutes per week of vigorous exercise than did nonprogressors (2,410.6 vs. 1,413.1; P = .046), Dr. Kumar said. Metabolic equivalent-minutes per week were similar for moderate activity (1,094.1 vs. 858.7; P = .396) and walking (1,646.2 vs. 1,245.1; P = .151).

During the discussion following the formal presentation, an attendee said the study is potentially very valuable because it suggests that something all clinicians want to do is "dangerous" but questioned whether some of the MRI data were "overread" given the almost 40% rate of progression in a relatively fit cohort. A Danish attendee also remarked that her group has experienced so many problems with patients filling out the IPAQ questionnaire that they no longer trust the data.

Dr. Kumar responded that the MRI readings were performed by expert radiologists and were reliable, and that more stringent definitions of progression are being explored. His group is also working on a new questionnaire to better define physical activity levels.

Data are also being analyzed from the rest of the cohort (160 participants) and over a longer, 3-year follow-up, he said in an interview.

"We are also identifying quantitative MRI and biomechanical metrics that may be more sensitive to disease progression in knee OA. These will help us understand the factors that are related to worsening of knee OA and develop therapies."

The National Institutes of Health–National Institute of Arthritis and Musculoskeletal and Skin Diseases funded the work. Dr. Kumar and his coauthors reported no conflicting interests.

[email protected]

PARIS – Recent knee injuries are strongly associated with accelerated knee osteoarthritis, according to an analysis from the prospective, multicenter Osteoarthritis Initiative.

"Certain injuries may initiate or coincide with an accelerated cascade towards joint failure in as little as 12 months," Jeffrey Driban, Ph.D., said at the World Congress on Osteoarthritis. "In fact, 76% of individuals with an injury and accelerated knee osteoarthritis experienced their injury in the 12 months prior to the study outcome."

The study defined accelerated knee OA as progression from a Kellgren-Lawrence grade 0 or 1 on baseline bilateral radiographs to end-stage KL grade 3 or 4 within 48 months.

Although knee OA typically has been a slowly progressive disorder, 5%-17% of patients now experience accelerated forms of OA.

"If we can better characterize this phenomenon and its potential risk factors, we can provide more insights into the nature of progression in hopes of identifying an at-risk subset," said Dr. Driban of the division of rheumatology at Tufts Medical Center, Boston.

The study by Dr. Driban and his colleagues was published in Arthritis Care & Research (2014 April 29 [doi:10.1002/acr.22359]).

A total of 1,930 participants in the Osteoarthritis Initiative, all with a KL grade of 0 or 1 on baseline bilateral radiographs, were asked at baseline and at each annual visit whether they had ever been "injured enough to limit ability to walk for at least 2 days."

On follow-up, 1,325 had no knee OA, 54 had accelerated knee OA, and 187 had typical knee OA, defined as at least one knee increased in radiographic scoring within 48 months (excluding accelerated OA).

After exclusion of 12 patients with missing data, 30% of the accelerated OA group, 28% in the typical OA group, and 35% in the no OA group had a history of knee injury before baseline. A new knee injury was reported by 32%, 13%, and 11%, respectively, with data missing from 59 persons.

In univariate analyses, participants with accelerated knee OA were significantly older than were those with typical OA or no OA (61.8 years vs. 58 years vs. 59.2 years; P = .023) and had a greater body mass index (28.9 kg/m² vs. 27.9 kg/m² vs. 27.1 kg/m²; P = .002), Dr. Driban said.

In multinomial logistic regression analyses that adjusted for age, sex, BMI, presence of static knee malalignment, and systolic blood pressure, there was no association between prior knee injury and accelerated OA (odds ratio, 0.84) or typical OA (OR, 0.76).

However, when the investigators looked further, participants with accelerated OA were almost 3.5 times more likely to report a recent knee injury during the observation period (OR, 3.37; 95% confidence interval, 1.82-6.25) than were those with typical OA (OR, 0.99) or no OA (reference), he said.

Moreover, if a participant experienced a knee injury 1 year before the study outcome, the risk of accelerated OA increased ninefold (OR, 9.22; CI, 4.50-18.90) versus threefold for typical OA (OR, 3.04; CI, 1.66-5.58).

Despite the focus on injuries leading to accelerated OA, the analyses can’t rule out that accelerated OA may also cause an injury or that there could be a "vicious cycle," in which an injury can cause accelerated OA, associated with joint space loss, increased symptoms, and increased risk for subsequent injury, Dr. Driban said.

This line of thought helps explain why prior injury was not associated with accelerated knee OA, but recent injury was. As patients were free of radiographic OA at baseline, those with a history of a prior injury that could cause accelerated knee OA would already have been eliminated from the study, he explained in an interview.

Secondly, if accelerated knee OA can increase the risk of injury, knee injuries from years ago would not be related to accelerated knee OA because the disorder did not exist at the time of the injury.

Finally, there also could be a recall bias, as patients often have a hard time recalling injuries that may have happened years ago.

Despite the limitations of self-reported injuries and insufficient data regarding the type, severity, status of the meniscus, mechanism, or subsequent treatment of the knee injury, the findings represent an important "starting point" in understanding the association between injuries and accelerated osteoarthritis, Dr. Driban said.

"We need to monitor older adults who report an injury, as this may initiate accelerated OA or indicate an individual experiencing accelerated OA, and we need to determine which injuries may be related to accelerated osteoarthritis," he said at the meeting, sponsored by the Osteoarthritis Research Society International.

During the discussion following the formal presentation, Dr. David Felson, professor of medicine and epidemiology at Boston University, said, "I think what you are saying is exactly right," but suggested that the investigators exclude patients with spontaneous osteonecrosis of the knee and osteochondritis dissecans, as both conditions are more common than anticipated and can drive very rapid development of OA. Conversely, inclusion of patients with osteophyte-only knee OA would increase the number likely identified with accelerated OA, he said.

Dr. Driban reported no conflicting interests.

[email protected]

PARIS – Recent knee injuries are strongly associated with accelerated knee osteoarthritis, according to an analysis from the prospective, multicenter Osteoarthritis Initiative.

"Certain injuries may initiate or coincide with an accelerated cascade towards joint failure in as little as 12 months," Jeffrey Driban, Ph.D., said at the World Congress on Osteoarthritis. "In fact, 76% of individuals with an injury and accelerated knee osteoarthritis experienced their injury in the 12 months prior to the study outcome."

The study defined accelerated knee OA as progression from a Kellgren-Lawrence grade 0 or 1 on baseline bilateral radiographs to end-stage KL grade 3 or 4 within 48 months.

Although knee OA typically has been a slowly progressive disorder, 5%-17% of patients now experience accelerated forms of OA.

"If we can better characterize this phenomenon and its potential risk factors, we can provide more insights into the nature of progression in hopes of identifying an at-risk subset," said Dr. Driban of the division of rheumatology at Tufts Medical Center, Boston.

The study by Dr. Driban and his colleagues was published in Arthritis Care & Research (2014 April 29 [doi:10.1002/acr.22359]).

A total of 1,930 participants in the Osteoarthritis Initiative, all with a KL grade of 0 or 1 on baseline bilateral radiographs, were asked at baseline and at each annual visit whether they had ever been "injured enough to limit ability to walk for at least 2 days."

On follow-up, 1,325 had no knee OA, 54 had accelerated knee OA, and 187 had typical knee OA, defined as at least one knee increased in radiographic scoring within 48 months (excluding accelerated OA).

After exclusion of 12 patients with missing data, 30% of the accelerated OA group, 28% in the typical OA group, and 35% in the no OA group had a history of knee injury before baseline. A new knee injury was reported by 32%, 13%, and 11%, respectively, with data missing from 59 persons.

In univariate analyses, participants with accelerated knee OA were significantly older than were those with typical OA or no OA (61.8 years vs. 58 years vs. 59.2 years; P = .023) and had a greater body mass index (28.9 kg/m² vs. 27.9 kg/m² vs. 27.1 kg/m²; P = .002), Dr. Driban said.

In multinomial logistic regression analyses that adjusted for age, sex, BMI, presence of static knee malalignment, and systolic blood pressure, there was no association between prior knee injury and accelerated OA (odds ratio, 0.84) or typical OA (OR, 0.76).

However, when the investigators looked further, participants with accelerated OA were almost 3.5 times more likely to report a recent knee injury during the observation period (OR, 3.37; 95% confidence interval, 1.82-6.25) than were those with typical OA (OR, 0.99) or no OA (reference), he said.

Moreover, if a participant experienced a knee injury 1 year before the study outcome, the risk of accelerated OA increased ninefold (OR, 9.22; CI, 4.50-18.90) versus threefold for typical OA (OR, 3.04; CI, 1.66-5.58).

Despite the focus on injuries leading to accelerated OA, the analyses can’t rule out that accelerated OA may also cause an injury or that there could be a "vicious cycle," in which an injury can cause accelerated OA, associated with joint space loss, increased symptoms, and increased risk for subsequent injury, Dr. Driban said.

This line of thought helps explain why prior injury was not associated with accelerated knee OA, but recent injury was. As patients were free of radiographic OA at baseline, those with a history of a prior injury that could cause accelerated knee OA would already have been eliminated from the study, he explained in an interview.

Secondly, if accelerated knee OA can increase the risk of injury, knee injuries from years ago would not be related to accelerated knee OA because the disorder did not exist at the time of the injury.

Finally, there also could be a recall bias, as patients often have a hard time recalling injuries that may have happened years ago.

Despite the limitations of self-reported injuries and insufficient data regarding the type, severity, status of the meniscus, mechanism, or subsequent treatment of the knee injury, the findings represent an important "starting point" in understanding the association between injuries and accelerated osteoarthritis, Dr. Driban said.

"We need to monitor older adults who report an injury, as this may initiate accelerated OA or indicate an individual experiencing accelerated OA, and we need to determine which injuries may be related to accelerated osteoarthritis," he said at the meeting, sponsored by the Osteoarthritis Research Society International.

During the discussion following the formal presentation, Dr. David Felson, professor of medicine and epidemiology at Boston University, said, "I think what you are saying is exactly right," but suggested that the investigators exclude patients with spontaneous osteonecrosis of the knee and osteochondritis dissecans, as both conditions are more common than anticipated and can drive very rapid development of OA. Conversely, inclusion of patients with osteophyte-only knee OA would increase the number likely identified with accelerated OA, he said.

Dr. Driban reported no conflicting interests.

[email protected]

PARIS – Recent knee injuries are strongly associated with accelerated knee osteoarthritis, according to an analysis from the prospective, multicenter Osteoarthritis Initiative.

"Certain injuries may initiate or coincide with an accelerated cascade towards joint failure in as little as 12 months," Jeffrey Driban, Ph.D., said at the World Congress on Osteoarthritis. "In fact, 76% of individuals with an injury and accelerated knee osteoarthritis experienced their injury in the 12 months prior to the study outcome."

The study defined accelerated knee OA as progression from a Kellgren-Lawrence grade 0 or 1 on baseline bilateral radiographs to end-stage KL grade 3 or 4 within 48 months.

Although knee OA typically has been a slowly progressive disorder, 5%-17% of patients now experience accelerated forms of OA.

"If we can better characterize this phenomenon and its potential risk factors, we can provide more insights into the nature of progression in hopes of identifying an at-risk subset," said Dr. Driban of the division of rheumatology at Tufts Medical Center, Boston.

The study by Dr. Driban and his colleagues was published in Arthritis Care & Research (2014 April 29 [doi:10.1002/acr.22359]).

A total of 1,930 participants in the Osteoarthritis Initiative, all with a KL grade of 0 or 1 on baseline bilateral radiographs, were asked at baseline and at each annual visit whether they had ever been "injured enough to limit ability to walk for at least 2 days."

On follow-up, 1,325 had no knee OA, 54 had accelerated knee OA, and 187 had typical knee OA, defined as at least one knee increased in radiographic scoring within 48 months (excluding accelerated OA).

After exclusion of 12 patients with missing data, 30% of the accelerated OA group, 28% in the typical OA group, and 35% in the no OA group had a history of knee injury before baseline. A new knee injury was reported by 32%, 13%, and 11%, respectively, with data missing from 59 persons.

In univariate analyses, participants with accelerated knee OA were significantly older than were those with typical OA or no OA (61.8 years vs. 58 years vs. 59.2 years; P = .023) and had a greater body mass index (28.9 kg/m² vs. 27.9 kg/m² vs. 27.1 kg/m²; P = .002), Dr. Driban said.

In multinomial logistic regression analyses that adjusted for age, sex, BMI, presence of static knee malalignment, and systolic blood pressure, there was no association between prior knee injury and accelerated OA (odds ratio, 0.84) or typical OA (OR, 0.76).

However, when the investigators looked further, participants with accelerated OA were almost 3.5 times more likely to report a recent knee injury during the observation period (OR, 3.37; 95% confidence interval, 1.82-6.25) than were those with typical OA (OR, 0.99) or no OA (reference), he said.

Moreover, if a participant experienced a knee injury 1 year before the study outcome, the risk of accelerated OA increased ninefold (OR, 9.22; CI, 4.50-18.90) versus threefold for typical OA (OR, 3.04; CI, 1.66-5.58).

Despite the focus on injuries leading to accelerated OA, the analyses can’t rule out that accelerated OA may also cause an injury or that there could be a "vicious cycle," in which an injury can cause accelerated OA, associated with joint space loss, increased symptoms, and increased risk for subsequent injury, Dr. Driban said.

This line of thought helps explain why prior injury was not associated with accelerated knee OA, but recent injury was. As patients were free of radiographic OA at baseline, those with a history of a prior injury that could cause accelerated knee OA would already have been eliminated from the study, he explained in an interview.

Secondly, if accelerated knee OA can increase the risk of injury, knee injuries from years ago would not be related to accelerated knee OA because the disorder did not exist at the time of the injury.

Finally, there also could be a recall bias, as patients often have a hard time recalling injuries that may have happened years ago.

Despite the limitations of self-reported injuries and insufficient data regarding the type, severity, status of the meniscus, mechanism, or subsequent treatment of the knee injury, the findings represent an important "starting point" in understanding the association between injuries and accelerated osteoarthritis, Dr. Driban said.

"We need to monitor older adults who report an injury, as this may initiate accelerated OA or indicate an individual experiencing accelerated OA, and we need to determine which injuries may be related to accelerated osteoarthritis," he said at the meeting, sponsored by the Osteoarthritis Research Society International.

During the discussion following the formal presentation, Dr. David Felson, professor of medicine and epidemiology at Boston University, said, "I think what you are saying is exactly right," but suggested that the investigators exclude patients with spontaneous osteonecrosis of the knee and osteochondritis dissecans, as both conditions are more common than anticipated and can drive very rapid development of OA. Conversely, inclusion of patients with osteophyte-only knee OA would increase the number likely identified with accelerated OA, he said.

Dr. Driban reported no conflicting interests.

[email protected]

PARIS – Knee trauma from a childhood sports injury can have serious consequences in young adults, judging from preliminary results from a historical cohort.

When assessed 3-10 years after the sports injury, at an average age of 22 years, young adults appear to be at higher risk of abnormalities visible on MRI that are consistent with future arthropathy and have poorer knee-related quality of life and more knee symptoms.

They are at higher risk of having structural asymmetry of the vastus medialis muscle and being categorized as being overweight or obese.

There also appears to be some trends for increased percent body fat and reduced participation in physical activity, Jackie L. Whittaker, Ph.D., said at the World Congress on Osteoarthritis.

She stressed that these are preliminary findings and that the group hopes to quadruple the size of the cohort this year in order to better understand the relationships they’ve identified.

"With that being said, if we are seeing what we think we’re seeing, there may be some clinical, structural, physiologic, and behavioral markers that can be used to identify individuals who are at risk and target them with secondary prevention strategies at an earlier age," said Dr. Whittaker, a postdoctoral fellow and physiotherapist, University of Calgary Sport Injury Prevention Research Centre, Alberta, Canada.

The historical cohort study involved 25 patients recruited from previous sports injury epidemiology studies who had an intra-articular knee injury in ice hockey (male and female), soccer, basketball, or other sports that required medical attention and time off play, and 25 uninjured controls matched on age, sex, and sport. The median age at injury was 15 years (range 9-18 years). Eight patients in the injured group had contralateral knee surgeries, in addition to surgery on the primary knee. The median age in both groups was 22 years.

Using the Knee injury and Osteoarthritis Outcome Scores (KOOS) outcome, injured participants scored significantly lower, indicating worse function, on all five, 100-point subscales: pain (mean 93 vs. 97), symptoms (mean 82.9 vs. 92.4), activities of daily living (mean 96.3 vs. 99.3), sport/recreation (mean 90.6 vs. 97.4), and knee-related quality of life (mean 89.7 vs. 97.7), Dr. Whittaker said.

Further, in a subsample of 10 matched pairs, injured participants were three times more likely to have an MRI Osteoarthritis Score (MOAKS) of one than were matched controls, according to the study, led by her colleague Carolyn Emery, Ph.D.

Although there was no difference in quadriceps strength between groups, injured participants were 3.8 times more likely to have a difference in the cross-sectional area of the vastus medialis muscle greater than 15%.

"We think that this may be clinically relevant, as there has been some recent prospective work (Arthritis Rheum. 2012;64:3917-25) that has shown a temporal relationship between a decrease in size of the vastus medialis muscle and progression or loss of tibial joint cartilage," she said.

Within 3-10 years after their knee trauma, injured participants have a significantly higher mean body mass index (BMI) than do uninjured participants (25.4 kg/m² vs. 23.2 kg/m²) and a trend for more body fat (20.8% vs. 18.7%).

Not surprisingly, these troubling findings were coupled with a trend for injured participants to spend less time each week participating in moderate to strenuous activity (97.8 minutes vs. 101.4 minutes) and also fewer participated in sports in the previous year (4% vs. 16%).

"If we dichotomize BMI, what we see is that those individuals in the injured group are two times more likely to have a BMI that is [classified as] overweight or obese," Dr. Whittaker said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, the suggestion was made to stratify future data by age at injury, as puberty has an influence on response to injury.

Dr. Whittaker reported funding from the Alberta Children’s Hospital Foundation, Alberta Innovates Health Solutions Alberta Team Osteoarthritis, Canadian Institutes of Health Research, and the University of Calgary Sport Injury Prevention Research Centre.

[email protected]

PARIS – Knee trauma from a childhood sports injury can have serious consequences in young adults, judging from preliminary results from a historical cohort.

When assessed 3-10 years after the sports injury, at an average age of 22 years, young adults appear to be at higher risk of abnormalities visible on MRI that are consistent with future arthropathy and have poorer knee-related quality of life and more knee symptoms.

They are at higher risk of having structural asymmetry of the vastus medialis muscle and being categorized as being overweight or obese.

There also appears to be some trends for increased percent body fat and reduced participation in physical activity, Jackie L. Whittaker, Ph.D., said at the World Congress on Osteoarthritis.

She stressed that these are preliminary findings and that the group hopes to quadruple the size of the cohort this year in order to better understand the relationships they’ve identified.

"With that being said, if we are seeing what we think we’re seeing, there may be some clinical, structural, physiologic, and behavioral markers that can be used to identify individuals who are at risk and target them with secondary prevention strategies at an earlier age," said Dr. Whittaker, a postdoctoral fellow and physiotherapist, University of Calgary Sport Injury Prevention Research Centre, Alberta, Canada.

The historical cohort study involved 25 patients recruited from previous sports injury epidemiology studies who had an intra-articular knee injury in ice hockey (male and female), soccer, basketball, or other sports that required medical attention and time off play, and 25 uninjured controls matched on age, sex, and sport. The median age at injury was 15 years (range 9-18 years). Eight patients in the injured group had contralateral knee surgeries, in addition to surgery on the primary knee. The median age in both groups was 22 years.

Using the Knee injury and Osteoarthritis Outcome Scores (KOOS) outcome, injured participants scored significantly lower, indicating worse function, on all five, 100-point subscales: pain (mean 93 vs. 97), symptoms (mean 82.9 vs. 92.4), activities of daily living (mean 96.3 vs. 99.3), sport/recreation (mean 90.6 vs. 97.4), and knee-related quality of life (mean 89.7 vs. 97.7), Dr. Whittaker said.

Further, in a subsample of 10 matched pairs, injured participants were three times more likely to have an MRI Osteoarthritis Score (MOAKS) of one than were matched controls, according to the study, led by her colleague Carolyn Emery, Ph.D.

Although there was no difference in quadriceps strength between groups, injured participants were 3.8 times more likely to have a difference in the cross-sectional area of the vastus medialis muscle greater than 15%.

"We think that this may be clinically relevant, as there has been some recent prospective work (Arthritis Rheum. 2012;64:3917-25) that has shown a temporal relationship between a decrease in size of the vastus medialis muscle and progression or loss of tibial joint cartilage," she said.

Within 3-10 years after their knee trauma, injured participants have a significantly higher mean body mass index (BMI) than do uninjured participants (25.4 kg/m² vs. 23.2 kg/m²) and a trend for more body fat (20.8% vs. 18.7%).

Not surprisingly, these troubling findings were coupled with a trend for injured participants to spend less time each week participating in moderate to strenuous activity (97.8 minutes vs. 101.4 minutes) and also fewer participated in sports in the previous year (4% vs. 16%).

"If we dichotomize BMI, what we see is that those individuals in the injured group are two times more likely to have a BMI that is [classified as] overweight or obese," Dr. Whittaker said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, the suggestion was made to stratify future data by age at injury, as puberty has an influence on response to injury.

Dr. Whittaker reported funding from the Alberta Children’s Hospital Foundation, Alberta Innovates Health Solutions Alberta Team Osteoarthritis, Canadian Institutes of Health Research, and the University of Calgary Sport Injury Prevention Research Centre.

[email protected]

PARIS – Knee trauma from a childhood sports injury can have serious consequences in young adults, judging from preliminary results from a historical cohort.

When assessed 3-10 years after the sports injury, at an average age of 22 years, young adults appear to be at higher risk of abnormalities visible on MRI that are consistent with future arthropathy and have poorer knee-related quality of life and more knee symptoms.

They are at higher risk of having structural asymmetry of the vastus medialis muscle and being categorized as being overweight or obese.

There also appears to be some trends for increased percent body fat and reduced participation in physical activity, Jackie L. Whittaker, Ph.D., said at the World Congress on Osteoarthritis.

She stressed that these are preliminary findings and that the group hopes to quadruple the size of the cohort this year in order to better understand the relationships they’ve identified.

"With that being said, if we are seeing what we think we’re seeing, there may be some clinical, structural, physiologic, and behavioral markers that can be used to identify individuals who are at risk and target them with secondary prevention strategies at an earlier age," said Dr. Whittaker, a postdoctoral fellow and physiotherapist, University of Calgary Sport Injury Prevention Research Centre, Alberta, Canada.

The historical cohort study involved 25 patients recruited from previous sports injury epidemiology studies who had an intra-articular knee injury in ice hockey (male and female), soccer, basketball, or other sports that required medical attention and time off play, and 25 uninjured controls matched on age, sex, and sport. The median age at injury was 15 years (range 9-18 years). Eight patients in the injured group had contralateral knee surgeries, in addition to surgery on the primary knee. The median age in both groups was 22 years.

Using the Knee injury and Osteoarthritis Outcome Scores (KOOS) outcome, injured participants scored significantly lower, indicating worse function, on all five, 100-point subscales: pain (mean 93 vs. 97), symptoms (mean 82.9 vs. 92.4), activities of daily living (mean 96.3 vs. 99.3), sport/recreation (mean 90.6 vs. 97.4), and knee-related quality of life (mean 89.7 vs. 97.7), Dr. Whittaker said.

Further, in a subsample of 10 matched pairs, injured participants were three times more likely to have an MRI Osteoarthritis Score (MOAKS) of one than were matched controls, according to the study, led by her colleague Carolyn Emery, Ph.D.

Although there was no difference in quadriceps strength between groups, injured participants were 3.8 times more likely to have a difference in the cross-sectional area of the vastus medialis muscle greater than 15%.

"We think that this may be clinically relevant, as there has been some recent prospective work (Arthritis Rheum. 2012;64:3917-25) that has shown a temporal relationship between a decrease in size of the vastus medialis muscle and progression or loss of tibial joint cartilage," she said.

Within 3-10 years after their knee trauma, injured participants have a significantly higher mean body mass index (BMI) than do uninjured participants (25.4 kg/m² vs. 23.2 kg/m²) and a trend for more body fat (20.8% vs. 18.7%).

Not surprisingly, these troubling findings were coupled with a trend for injured participants to spend less time each week participating in moderate to strenuous activity (97.8 minutes vs. 101.4 minutes) and also fewer participated in sports in the previous year (4% vs. 16%).

"If we dichotomize BMI, what we see is that those individuals in the injured group are two times more likely to have a BMI that is [classified as] overweight or obese," Dr. Whittaker said at the meeting, sponsored by the Osteoarthritis Research Society International.

During a discussion of the results, the suggestion was made to stratify future data by age at injury, as puberty has an influence on response to injury.

Dr. Whittaker reported funding from the Alberta Children’s Hospital Foundation, Alberta Innovates Health Solutions Alberta Team Osteoarthritis, Canadian Institutes of Health Research, and the University of Calgary Sport Injury Prevention Research Centre.

[email protected]

PARIS – Use of conservative, nonpharmacologic osteoarthritis therapies was relatively low and varied considerably across 10 primary care clinics within the same U.S. health care system.

In seven of the clinics, for example, less than half of patients had ever received physical therapy for knee osteoarthritis, with a range of 24%-61%.

Physical therapy for hip OA was even less common, ranging from 0%-71%, Kelli D. Allen, Ph.D., reported at the World Congress on Osteoarthritis.

In contrast, 70%-88% of patients were currently using pain medications such as opioids or NSAIDs to treat their symptomatic hip and/or knee OA, according to the cross-sectional analysis.

Patients received care at 1 of 10 family and internal medicine Duke Primary Care clinics in North Carolina. All were overweight and not meeting physical activity recommendations. Patients had OA symptoms for an average of 10 years, their average WOMAC (Western Ontario and McMaster Osteoarthritis Index) score was 39, and average age was 63 years.

Four of the clinics were in a rural setting (population less than 20,000), one in a medium-size town (20,000-99,999), four in small cities (100,000-250,000), and one in a large city (more than 250,000). The clinics had an average of 6.4 physicians and one nurse practitioner or physician’s assistant.

Knee brace use of any type ranged from 40%-64% across clinics, Dr. Allen reported. Use of knee braces with metal supports was even lower at 0%-18%.

The relatively low use of PT and knee braces with metal supports "may signal a need for more specific treatment recommendations or guidance for consistent application," suggested Dr. Allen, a health services researcher and exercise physiologist, Duke University Medical Center and Durham VA Medical Center, both in Durham, N.C.

Knee injections were reported by 43%-70% of patients.

Intraclass correlation coefficients (ICCs) were calculated to measure between-clinic variation in treatment use, with an ICC of more than .01 indicating considerable variation.

ICCs were 0.01 for the proportion using any pain medications, 0 for opioids, NSAIDS, knee injections and knee braces, 0.02 for metal knee braces, 0.07 for knee PT, and 0.08 for hip PT, according to Dr. Allen.

Rural clinics were typically below the median for nonpharmacologic use, possibly because of fewer resources in these areas, according to the poster presentation.

Clinics with fewer patients reporting "fair" or "poor" general health, however, tended to have higher use across treatment categories.

"These OA therapies may be more highly utilized when patients have fewer competing health problems," she suggested at the meeting, sponsored by the Osteoarthritis Research Society International.

Overall, 20% of patients in the study reported having fair or poor health, but rates ranged from a low of 10% to a high of 35%.

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Allen reported no conflicts of interest.

[email protected]

PARIS – Use of conservative, nonpharmacologic osteoarthritis therapies was relatively low and varied considerably across 10 primary care clinics within the same U.S. health care system.

In seven of the clinics, for example, less than half of patients had ever received physical therapy for knee osteoarthritis, with a range of 24%-61%.

Physical therapy for hip OA was even less common, ranging from 0%-71%, Kelli D. Allen, Ph.D., reported at the World Congress on Osteoarthritis.

In contrast, 70%-88% of patients were currently using pain medications such as opioids or NSAIDs to treat their symptomatic hip and/or knee OA, according to the cross-sectional analysis.

Patients received care at 1 of 10 family and internal medicine Duke Primary Care clinics in North Carolina. All were overweight and not meeting physical activity recommendations. Patients had OA symptoms for an average of 10 years, their average WOMAC (Western Ontario and McMaster Osteoarthritis Index) score was 39, and average age was 63 years.

Four of the clinics were in a rural setting (population less than 20,000), one in a medium-size town (20,000-99,999), four in small cities (100,000-250,000), and one in a large city (more than 250,000). The clinics had an average of 6.4 physicians and one nurse practitioner or physician’s assistant.

Knee brace use of any type ranged from 40%-64% across clinics, Dr. Allen reported. Use of knee braces with metal supports was even lower at 0%-18%.

The relatively low use of PT and knee braces with metal supports "may signal a need for more specific treatment recommendations or guidance for consistent application," suggested Dr. Allen, a health services researcher and exercise physiologist, Duke University Medical Center and Durham VA Medical Center, both in Durham, N.C.

Knee injections were reported by 43%-70% of patients.

Intraclass correlation coefficients (ICCs) were calculated to measure between-clinic variation in treatment use, with an ICC of more than .01 indicating considerable variation.

ICCs were 0.01 for the proportion using any pain medications, 0 for opioids, NSAIDS, knee injections and knee braces, 0.02 for metal knee braces, 0.07 for knee PT, and 0.08 for hip PT, according to Dr. Allen.

Rural clinics were typically below the median for nonpharmacologic use, possibly because of fewer resources in these areas, according to the poster presentation.

Clinics with fewer patients reporting "fair" or "poor" general health, however, tended to have higher use across treatment categories.

"These OA therapies may be more highly utilized when patients have fewer competing health problems," she suggested at the meeting, sponsored by the Osteoarthritis Research Society International.

Overall, 20% of patients in the study reported having fair or poor health, but rates ranged from a low of 10% to a high of 35%.

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Allen reported no conflicts of interest.

[email protected]

PARIS – Use of conservative, nonpharmacologic osteoarthritis therapies was relatively low and varied considerably across 10 primary care clinics within the same U.S. health care system.

In seven of the clinics, for example, less than half of patients had ever received physical therapy for knee osteoarthritis, with a range of 24%-61%.

Physical therapy for hip OA was even less common, ranging from 0%-71%, Kelli D. Allen, Ph.D., reported at the World Congress on Osteoarthritis.

In contrast, 70%-88% of patients were currently using pain medications such as opioids or NSAIDs to treat their symptomatic hip and/or knee OA, according to the cross-sectional analysis.

Patients received care at 1 of 10 family and internal medicine Duke Primary Care clinics in North Carolina. All were overweight and not meeting physical activity recommendations. Patients had OA symptoms for an average of 10 years, their average WOMAC (Western Ontario and McMaster Osteoarthritis Index) score was 39, and average age was 63 years.

Four of the clinics were in a rural setting (population less than 20,000), one in a medium-size town (20,000-99,999), four in small cities (100,000-250,000), and one in a large city (more than 250,000). The clinics had an average of 6.4 physicians and one nurse practitioner or physician’s assistant.

Knee brace use of any type ranged from 40%-64% across clinics, Dr. Allen reported. Use of knee braces with metal supports was even lower at 0%-18%.

The relatively low use of PT and knee braces with metal supports "may signal a need for more specific treatment recommendations or guidance for consistent application," suggested Dr. Allen, a health services researcher and exercise physiologist, Duke University Medical Center and Durham VA Medical Center, both in Durham, N.C.

Knee injections were reported by 43%-70% of patients.

Intraclass correlation coefficients (ICCs) were calculated to measure between-clinic variation in treatment use, with an ICC of more than .01 indicating considerable variation.

ICCs were 0.01 for the proportion using any pain medications, 0 for opioids, NSAIDS, knee injections and knee braces, 0.02 for metal knee braces, 0.07 for knee PT, and 0.08 for hip PT, according to Dr. Allen.

Rural clinics were typically below the median for nonpharmacologic use, possibly because of fewer resources in these areas, according to the poster presentation.

Clinics with fewer patients reporting "fair" or "poor" general health, however, tended to have higher use across treatment categories.

"These OA therapies may be more highly utilized when patients have fewer competing health problems," she suggested at the meeting, sponsored by the Osteoarthritis Research Society International.

Overall, 20% of patients in the study reported having fair or poor health, but rates ranged from a low of 10% to a high of 35%.

The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Allen reported no conflicts of interest.

[email protected]

PARIS – Patients with knee osteoarthritis are significantly more likely to experience a flare if they report a higher negative mood in the previous 10 days.

Passive coping strategies such as "I restrict my social activities" or "I focus on the location and intensity of pain" were also significantly associated with an increased risk of flares, while more active coping strategies were protective in a Web-based, case-crossover study.

"We really need to elaborate on this, replicate it, and elucidate this connection because psychosocial factors of mood and pain coping are modifiable and ultimately may improve our patients experience of this disease, osteoarthritis," Dr. David J. Hunter said at the World Congress on Osteoarthritis.

The investigators recruited 298 patients with symptomatic knee osteoarthritis (OA) and asked them to log on to the study website if they experienced a knee pain exacerbation over 3 months of follow-up.

Daily mood (negative/positive) in the previous 10 days was assessed using the Profile of Mood States (POMS) questionnaire. The Pain Coping Inventory (PCI) was used to assess daily pain coping in the previous 30 days.

Pain exacerbation during follow-up was defined as a 2-unit increase in the patient’s visual analog knee pain score (10-point scale) from his or her mildest pain score reported at the baseline visit, said Dr. Hunter, the Florance and Cope Chair of Rheumatology, Northern Clinical School, University of Sydney, Australia.

Most of the patients were female (61%) and white (92%), and their average body mass index was 29.4 kg/m². Their average baseline Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms subscale score was 44.5 and KOOS pain subscale score 55.6.

The average POMS positive mood score was 33.9 and average negative mood (for example, distressed, irritable, nervous) score 16.5, both on a 50-point scale. The average PCI passive coping score was 8.1 on a 24-point scale, and average PCI active coping score 12.2 on a 20-point scale.

In conditional logistic regression analyses, increasing negative affect scores were significantly associated with having a pain exacerbation (P less than .001) such that patients with a score of 13-17 were nearly three times more likely to experience a flare (odds ratio, 2.77) and those with a score of 18 or more were 6.5 times more likely to do so (OR, 6.5), Dr. Hunter said.

Patients with higher PCI passive coping scores were also significantly more likely to have a pain exacerbation (OR, 1.26; P = .01), while those with more active coping strategies such as "I stay busy or active," or "I clear my mind of bothersome thoughts" were less likely to have a pain flare (OR, 0.81; P = .03).

During a discussion of the results, Dr. Hunter said they have yet to look at trajectories to see whether patients returned to their prior pain level.

Session comoderator Aileen Davis, Ph.D., senior scientist with the Toronto Western Research Institute, said the general literature recognizes there is a psychosocial component to OA pain, but that this is the first study to make the direct link with OA pain flares.

If the results can be replicated, "It means there’s a lot more we can do in terms of coping strategies and in recognizing this a lot more often," she said in an interview at the meeting, sponsored by the Osteoarthritis Research Society International.

Since many OA patients are cared for by primary care physicians, Dr. Davis suggested they may want to have a psychosocial profile of their OA patients and push management strategies or referrals to psychologists or social workers skilled in coping strategies to patients who are "fluctuators," so they can "proactively change how they’re doing things."

Dr. Hunter reported support from the Australian National Health and Medical Research Council.

[email protected]

PARIS – Patients with knee osteoarthritis are significantly more likely to experience a flare if they report a higher negative mood in the previous 10 days.

Passive coping strategies such as "I restrict my social activities" or "I focus on the location and intensity of pain" were also significantly associated with an increased risk of flares, while more active coping strategies were protective in a Web-based, case-crossover study.

"We really need to elaborate on this, replicate it, and elucidate this connection because psychosocial factors of mood and pain coping are modifiable and ultimately may improve our patients experience of this disease, osteoarthritis," Dr. David J. Hunter said at the World Congress on Osteoarthritis.

The investigators recruited 298 patients with symptomatic knee osteoarthritis (OA) and asked them to log on to the study website if they experienced a knee pain exacerbation over 3 months of follow-up.

Daily mood (negative/positive) in the previous 10 days was assessed using the Profile of Mood States (POMS) questionnaire. The Pain Coping Inventory (PCI) was used to assess daily pain coping in the previous 30 days.

Pain exacerbation during follow-up was defined as a 2-unit increase in the patient’s visual analog knee pain score (10-point scale) from his or her mildest pain score reported at the baseline visit, said Dr. Hunter, the Florance and Cope Chair of Rheumatology, Northern Clinical School, University of Sydney, Australia.

Most of the patients were female (61%) and white (92%), and their average body mass index was 29.4 kg/m². Their average baseline Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms subscale score was 44.5 and KOOS pain subscale score 55.6.

The average POMS positive mood score was 33.9 and average negative mood (for example, distressed, irritable, nervous) score 16.5, both on a 50-point scale. The average PCI passive coping score was 8.1 on a 24-point scale, and average PCI active coping score 12.2 on a 20-point scale.

In conditional logistic regression analyses, increasing negative affect scores were significantly associated with having a pain exacerbation (P less than .001) such that patients with a score of 13-17 were nearly three times more likely to experience a flare (odds ratio, 2.77) and those with a score of 18 or more were 6.5 times more likely to do so (OR, 6.5), Dr. Hunter said.

Patients with higher PCI passive coping scores were also significantly more likely to have a pain exacerbation (OR, 1.26; P = .01), while those with more active coping strategies such as "I stay busy or active," or "I clear my mind of bothersome thoughts" were less likely to have a pain flare (OR, 0.81; P = .03).

During a discussion of the results, Dr. Hunter said they have yet to look at trajectories to see whether patients returned to their prior pain level.

Session comoderator Aileen Davis, Ph.D., senior scientist with the Toronto Western Research Institute, said the general literature recognizes there is a psychosocial component to OA pain, but that this is the first study to make the direct link with OA pain flares.

If the results can be replicated, "It means there’s a lot more we can do in terms of coping strategies and in recognizing this a lot more often," she said in an interview at the meeting, sponsored by the Osteoarthritis Research Society International.

Since many OA patients are cared for by primary care physicians, Dr. Davis suggested they may want to have a psychosocial profile of their OA patients and push management strategies or referrals to psychologists or social workers skilled in coping strategies to patients who are "fluctuators," so they can "proactively change how they’re doing things."

Dr. Hunter reported support from the Australian National Health and Medical Research Council.

[email protected]

PARIS – Patients with knee osteoarthritis are significantly more likely to experience a flare if they report a higher negative mood in the previous 10 days.

Passive coping strategies such as "I restrict my social activities" or "I focus on the location and intensity of pain" were also significantly associated with an increased risk of flares, while more active coping strategies were protective in a Web-based, case-crossover study.

"We really need to elaborate on this, replicate it, and elucidate this connection because psychosocial factors of mood and pain coping are modifiable and ultimately may improve our patients experience of this disease, osteoarthritis," Dr. David J. Hunter said at the World Congress on Osteoarthritis.

The investigators recruited 298 patients with symptomatic knee osteoarthritis (OA) and asked them to log on to the study website if they experienced a knee pain exacerbation over 3 months of follow-up.

Daily mood (negative/positive) in the previous 10 days was assessed using the Profile of Mood States (POMS) questionnaire. The Pain Coping Inventory (PCI) was used to assess daily pain coping in the previous 30 days.

Pain exacerbation during follow-up was defined as a 2-unit increase in the patient’s visual analog knee pain score (10-point scale) from his or her mildest pain score reported at the baseline visit, said Dr. Hunter, the Florance and Cope Chair of Rheumatology, Northern Clinical School, University of Sydney, Australia.

Most of the patients were female (61%) and white (92%), and their average body mass index was 29.4 kg/m². Their average baseline Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms subscale score was 44.5 and KOOS pain subscale score 55.6.

The average POMS positive mood score was 33.9 and average negative mood (for example, distressed, irritable, nervous) score 16.5, both on a 50-point scale. The average PCI passive coping score was 8.1 on a 24-point scale, and average PCI active coping score 12.2 on a 20-point scale.

In conditional logistic regression analyses, increasing negative affect scores were significantly associated with having a pain exacerbation (P less than .001) such that patients with a score of 13-17 were nearly three times more likely to experience a flare (odds ratio, 2.77) and those with a score of 18 or more were 6.5 times more likely to do so (OR, 6.5), Dr. Hunter said.

Patients with higher PCI passive coping scores were also significantly more likely to have a pain exacerbation (OR, 1.26; P = .01), while those with more active coping strategies such as "I stay busy or active," or "I clear my mind of bothersome thoughts" were less likely to have a pain flare (OR, 0.81; P = .03).

During a discussion of the results, Dr. Hunter said they have yet to look at trajectories to see whether patients returned to their prior pain level.

Session comoderator Aileen Davis, Ph.D., senior scientist with the Toronto Western Research Institute, said the general literature recognizes there is a psychosocial component to OA pain, but that this is the first study to make the direct link with OA pain flares.

If the results can be replicated, "It means there’s a lot more we can do in terms of coping strategies and in recognizing this a lot more often," she said in an interview at the meeting, sponsored by the Osteoarthritis Research Society International.

Since many OA patients are cared for by primary care physicians, Dr. Davis suggested they may want to have a psychosocial profile of their OA patients and push management strategies or referrals to psychologists or social workers skilled in coping strategies to patients who are "fluctuators," so they can "proactively change how they’re doing things."

Dr. Hunter reported support from the Australian National Health and Medical Research Council.

[email protected]