Prognostic factors for the development of upper limb dysfunctions after breast cancer: the UPLIFT-BC prospective longitudinal cohort study protocol.

INTRODUCTION: Upper limb (UL) dysfunctions are highly prevalent in people after breast cancer and have a great impact on performing activities in daily living. To improve care, a more comprehensive understanding of the development and persistence of UL dysfunctions is needed. Therefore, the UPLIFT-BC study will primarily examine the prognostic value of different factors at the body functions and structures, environmental and personal level of the International Classification of Functioning, Disability and Health (ICF) framework at 1-month post-surgery for persisting UL dysfunctions at 6 months after finishing cancer treatment. METHODS AND ANALYSIS: A prospective longitudinal cohort study, running from 1-week pre-surgery to 6 months post-local cancer treatment, is performed in a cohort of 250 women diagnosed with primary breast cancer. Different potentially prognostic factors to UL dysfunctions, covering body functions and structures, environmental and personal factors of the ICF, are assessed pre-surgically and at different time points post-surgery. The primary aim is to investigate the prognostic value of these factors at 1-month post-surgery for subjective UL function (ie, QuickDASH) at 6 months post-cancer treatment, that is, 6 months post-radiotherapy or post-surgery (T3), depending on the individuals' cancer treatment trajectory. In this, factors with relevant prognostic value pre-surgery are considered as well. Similar analyses are performed with an objective measure for UL function (ie, accelerometry) and a composite score of the combination of subjective and objective UL function. Second, in the subgroup of participants who receive radiotherapy, the prognostic value of the same factors is explored at 1-month post-radiotherapy and 6 months post-surgery. A forward stepwise selection strategy is used to obtain these multivariable prognostic models. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of UZ/KU Leuven (reference number s66248). The results of this study will be published in peer-reviewed journals and will be presented at several research conferences. TRIAL REGISTRATION NUMBER: NCT05297591.

The bidirectional relationship between sleep problems and chronic musculoskeletal pain: a systematic review with meta-analysis.

ABSTRACT: Chronic musculoskeletal pain and sleep problems/disorders exhibit a recognized bidirectional relationship; yet, systematic investigations of this claim, particularly in a prospective context, are lacking. This systematic review with meta-analysis aimed to synthesize the literature on the prospective associations between sleep problems/disorders and chronic musculoskeletal pain. A comprehensive search across 6 databases identified prospective longitudinal cohort studies in adults examining the relationship between sleep problems/disorders and chronic musculoskeletal pain. Random-effects meta-analyses, using the Hartung-Knapp adjustment for 95% confidence intervals (CIs), were conducted, and all results were presented as odds ratios (ORs). Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Including 16 articles from 11 study populations (116,746 participants), meta-analyses indicated that sleep problems at baseline may heighten the risk of chronic musculoskeletal pain in both short term (OR 1.64, 95% CI 1.01-2.65) and long term (OR 1.39, 95% CI 1.21-1.59). The evidence for different sleep problem categories was very uncertain. Chronic musculoskeletal pain at baseline may increase the risk of short-term sleep problems (OR 1.56, 95% CI 1.02-2.38), but long-term evidence was very uncertain. The impact of only local or only widespread pain on short-term sleep problems was very uncertain, whereas widespread pain may elevate the risk of long-term sleep problems (OR 2.0, 95% CI 1.81-2.21). In conclusion, this systematic review with meta-analysis suggests that sleep problems are associated with an increased risk of chronic musculoskeletal pain, but the bidirectional nature of this relationship requires further investigation.

Integration of Cognitive Behavioral Therapy for Insomnia in Best-Practice Care for Patients With Knee Osteoarthritis and Insomnia: A Randomized Controlled Trial Protocol.

OBJECTIVE: Knee osteoarthritis (KOA) is a common musculoskeletal problem worldwide and its key symptom is pain. Guidelines recommend incorporating comorbidity-specific therapies into patient-centered care. Patients diagnosed with KOA frequently have insomnia, which is associated with higher-pain severity. For this reason, this study protocol outlines the methodology of a randomized controlled trial (RCT) investigating the effectiveness of cognitive behavioral therapy for insomnia (CBTi) combined with best-practice KOA care (BPC) compared to best-practice KOA care and lifestyle education. METHODS: A 2-arm RCT in patients with KOA and insomnia is conducted, in which a total of 128 patients are randomly allocated to an intervention or control group. The experimental intervention consists of 12 sessions of physical therapist-led BPC with an additional 6 sessions of CBTi. The control intervention also receives BPC, which is supplemented with 6 general lifestyle information sessions. The primary outcome is the between-group difference in change in pain severity at 6 months after intervention. Secondary outcomes are pain-related outcomes, sleep-related outcomes, symptoms of anxiety and depression, level of physical activity and function, perceived global improvement, biomarkers of inflammation, and health-related quality of life. Assessments are conducted at baseline, immediately after intervention, and 3, 6, and 12 months after intervention. Furthermore, a cost-utility analysis for the proposed intervention will be performed alongside the RCT. IMPACT: This is the first RCT investigating the clinical and cost-effectiveness of a physical therapist-led intervention integrating CBTi into BPC in patients with KOA and insomnia. The results of this trial will add to the growing body of evidence on the effectiveness of individualized and comorbidity-specific KOA care, which can inform clinical decision-making and assist policymakers and other relevant stakeholders in optimizing the care pathway for patients with KOA.

Assessing Upper Limb Function in Breast Cancer Survivors Using Wearable Sensors and Machine Learning in a Free-Living Environment.

(1) Background: Being able to objectively assess upper limb (UL) dysfunction in breast cancer survivors (BCS) is an emerging issue. This study aims to determine the accuracy of a pre-trained lab-based machine learning model (MLM) to distinguish functional from non-functional arm movements in a home situation in BCS. (2) Methods: Participants performed four daily life activities while wearing two wrist accelerometers and being video recorded. To define UL functioning, video data were annotated and accelerometer data were analyzed using a counts threshold method and an MLM. Prediction accuracy, recall, sensitivity, f1-score, 'total minutes functional activity' and 'percentage functionally active' were considered. (3) Results: Despite a good MLM accuracy (0.77-0.90), recall, and specificity, the f1-score was poor. An overestimation of the 'total minutes functional activity' and 'percentage functionally active' was found by the MLM. Between the video-annotated data and the functional activity determined by the MLM, the mean differences were 0.14% and 0.10% for the left and right side, respectively. For the video-annotated data versus the counts threshold method, the mean differences were 0.27% and 0.24%, respectively. (4) Conclusions: An MLM is a better alternative than the counts threshold method for distinguishing functional from non-functional arm movements. However, the abovementioned wrist accelerometer-based assessment methods overestimate UL functional activity.

The interplay between symptoms of insomnia and pain in people with osteoarthritis: A narrative review of the current evidence.

Osteoarthritis (OA) is a leading cause of disability worldwide and clinical pain is the major symptom of OA. This clinical OA-related pain is firmly associated with symptoms of insomnia, which are reported in up to 81% of people with OA. Since understanding the association between both symptoms is critical for their appropriate management, this narrative review synthesizes the existing evidence in people with OA on i) the mechanisms underlying the association between insomnia symptoms and clinical OA-related pain, and ii) the effectiveness of conservative non-pharmacological treatments on insomnia symptoms and clinical OA-related pain. The evidence available identifies depressive symptoms, pain catastrophizing and pain self-efficacy as mechanisms partially explaining the cross-sectional association between insomnia symptoms and pain in people with OA. Furthermore, in comparison to treatments without a specific insomnia intervention, the ones including an insomnia intervention appear more effective for improving insomnia symptoms, but not for reducing clinical OA-related pain. However, at a within-person level, treatment-related positive effects on insomnia symptoms are associated with a long-term pain reduction. Future longitudinal prospective studies offering fundamental insights into neurobiological and psychosocial mechanisms explaining the association between insomnia symptoms and clinical OA-related pain will enable the development of effective treatments targeting both symptoms.

The effect of physical exercise on fatigue in systemic lupus erythematosus: a systematic review.

OBJECTIVE: Fatigue is a prominent and disabling manifestation that impairs the quality of life of Systemic Lupus Erythematosus (SLE) patients both physically and mentally. The majority of SLE patients reports fatigue as an unmet need. Physical exercise could help SLE patients to reduce fatigue and improve quality of life. METHODS: A systematic review was conducted to analyse the effectiveness of physical exercise interventions to reduce fatigue in SLE patients. PubMed, EMBASE, Web of Science: Core Collection, the Cochrane Library, CINAHL via EBSCO, and PEDro were searched (March 2021 to October 2021). Studies were included if they fulfilled prespecified criteria and were assessed for quality using the PEDro risk of bias tool. RESULTS: A total of 17 studies (11 RCTs, 3 non-RCTs, 2 one-group pretest-posttest designs, and 1 cross-sectional study) were included in this review. They compared exercise treatment with standard care, alternative treatment, or a different type of exercise. Most of the included studies reported significant improvement in fatigue after exercise therapy. However, study heterogeneity is an important methodological limitation. Exercise interventions did not cause disease flare-ups in patients with low to moderate disease activity. CONCLUSION: Studies are heterogeneous, precluding firm conclusions. In general, 10 out of 17 studies showed statistically significant but rarely clinically relevant improvement in fatigue after exercise treatment. However, results were not always consistent across different instruments used to assess fatigue. More multi-centred randomised controlled trials are needed to find the best type of physical activity that is both safe and effective for SLE patients.

Reduced knee extensor torque production at low to moderate velocities in postmenopausal women with knee osteoarthritis.

This study aimed to determine deficits in knee extensor muscle function through the torque-time and torque-velocity relationships and whether these deficits are associated with reduced functional performance in postmenopausal women with knee osteoarthritis (KOA). A clinical sample of postmenopausal women with established KOA (n = 18, ≥55 years) was compared to an age-matched healthy control sample (CON) (n = 26). The deficits in different parameters of the knee extensor torque-time (maximal isometric torque and rate of torque development) and torque-velocity relationship (maximum muscle power, maximal velocity and torque at 0-500°·s-1 ) were assessed through a protocol consisting of isometric, isotonic and isokinetic tests. Functional performance was evaluated with sit-to-stand and stair-climbing tasks using a sensor-based technology (ie, time- and power-based outcomes). Postmenopausal women with KOA showed reduced maximal isometric torque (Hedge's g effect size (g) = 1.05, p = 0.001) and rate of torque development (g = 0.77-1.17, all p ≤ 0.02), combined with impaired torque production at slow to moderate velocities (g = 0.92-1.70, p ≤ 0.004), but not at high or maximal velocities (g = 0.16, p > 0.05). KOA were slower (g = 0.81-0.92, p ≤ 0.011) and less powerful (g = 1.11-1.29, p ≤ 0.001) during functional tasks. Additionally, knee extensor deficits were moderately associated with power deficits in stair climbing (r = 0.492-0.659). To conclude, knee extensor muscle weakness was presented in postmenopausal women with KOA, not only as limited maximal and rapid torque development during isometric contractions, but also dynamically at low to moderate velocities. These deficits were related to impaired functional performance. The assessment of knee extensor muscle weakness through the torque-time and torque-velocity relationships might enable individual targets for tailored exercise interventions in KOA.

Physical therapy in adult inflammatory myopathy patients: a systematic review.

The safety and effect of physical therapy in adult patients with idiopathic inflammatory myopathies (IIMs) are currently unclear. Considering the muscle weakness resulting from disease activity as well as from the administered drugs, these patients could benefit from an evidence-based physical therapy program. To perform a systematic review to assess safety and effects of physical therapy on the functional outcome of patients with idiopathic inflammatory myopathies in both active and quiescent disease: Pubmed, Embase, and Cochrane. Patients with one of the following idiopathic inflammatory myopathies: polymyositis, dermatomyositis, immune-mediated necrotizing myopathy, and/or overlap myositis. The intervention included several types of rehabilitation programs, from strength and resistance training to endurance training, with a minimal duration of 1 month. Studies reporting intervention-related adverse events, disease activity, and functional outcomes were eligible. The risk of bias was assessed using the Cochrane guidelines. We included five randomized controlled and seven open-label non-randomized non-controlled trials. Data on statistical significance were extracted for all the trials. Included trials were of medium-quality evidence given the low number of patients and some risk of bias factors. Physical therapy does not have a negative effect on the disease activity of idiopathic inflammatory myopathies in quiescent disease and could improve functional outcome. The physical therapy program should minimally include endurance training. A combination with resistance training might be beneficial.

Educational outreach visits to improve knee osteoarthritis management in primary care.

BACKGROUND: Knee osteoarthritis is a common problem, but often underdiagnosed and undertreated in primary care as compared to evidence-based guidelines. Educational outreach visits are an effective strategy to improve guideline adherence, but its contribution to knee osteoarthritis management is largely unknown. The aim of this study was to evaluate the overall effectiveness of educational outreach visits on process quality indicators for knee osteoarthritis management, more specifically on the referral for physical therapy. METHODS: An educational intervention study, non-randomized and controlled, was designed for general practitioners (GPs) in Belgium. During four months, 426 GPs were visited by academic detailers and allocated to the intervention group. The control group was selected from GPs not visited by academic detailers during the study period. Six months post-intervention, both groups received a questionnaire with two case-vignettes to measure the effectiveness of the educational outreach. Outcomes were assessed with a Belgian set of quality indicators for knee osteoarthritis management and focused on the number of prescriptions for appropriate physical therapy (i.e. muscle strengthening, aerobic, functional or range of motion exercises) and the adherence to eight additional quality indicators related to knee osteoarthritis management. For the analysis, multivariable logistic regression models were used and Generalized Estimating Equations to handle the correlation between the multiple results per GP. RESULTS: The intervention group showed a tendency to prescribe more frequently at least one appropriate physical therapy for a case (43.8%), compared to the control group (31.3%, p = 0.057). Muscle strengthening exercises were the most frequently prescribed therapy with 37.0% in the intervention versus 26.9% in the control group. The adherence to the other quality indicators showed no significant difference between the intervention and control group and varied between 8.9 and 100% in the intervention group. CONCLUSIONS: This intervention did not alter significantly the adherence to quality indicators and in particular the probability of prescribing physical therapy. To change general practitioners' prescription behavior, more extensive or combined interventional approaches seem warranted.

Topographical Variation of Human Femoral Articular Cartilage Thickness, T1rho and T2 Relaxation Times Is Related to Local Loading during Walking.

OBJECTIVE: Early detection of degenerative changes in the cartilage matrix composition is essential for evaluating early interventions that slow down osteoarthritis (OA) initiation. T1rho and T2 relaxation times were found to be effective for detecting early changes in proteoglycan and collagen content. To use these magnetic resonance imaging (MRI) methods, it is important to document the topographical variation in cartilage thickness, T1rho and T2 relaxation times in a healthy population. As OA is partially mechanically driven, the relation between these MRI-based parameters and localized mechanical loading during walking was investigated. DESIGN: MR images were acquired in 14 healthy adults and cartilage thickness and T1rho and T2 relaxation times were determined. Experimental gait data was collected and processed using musculoskeletal modeling to identify weight-bearing zones and estimate the contact force impulse during gait. Variation of the cartilage properties (i.e., thickness, T1rho, and T2) over the femoral cartilage was analyzed and compared between the weight-bearing and non-weight-bearing zone of the medial and lateral condyle as well as the trochlea. RESULTS: Medial condyle cartilage thickness was correlated to the contact force impulse ( r = 0.78). Lower T1rho, indicating increased proteoglycan content, was found in the medial weight-bearing zone. T2 was higher in all weight-bearing zones compared with the non-weight-bearing zones, indicating lower relative collagen content. CONCLUSIONS: The current results suggest that medial condyle cartilage is adapted as a long-term protective response to localized loading during a frequently performed task and that the weight-bearing zone of the medial condyle has superior weight bearing capacities compared with the non-weight-bearing zones.

Subjects with medial and lateral tibiofemoral articular cartilage defects do not alter compartmental loading during walking.

BACKGROUND: Healthy cartilage is essential for optimal joint function. Although, articular cartilage defects are highly prevalent in the active population and hamper joint function, the effect of articular cartilage defects on knee loading is not yet documented. Therefore, the present study compared knee contact forces and pressures between patients with tibiofemoral cartilage defects and healthy controls. Potentially this provides additional insights in movement adaptations and the role of altered loading in the progression from defect towards OA. METHODS: Experimental gait data collected in 15 patients with isolated cartilage defects (8 medial involvement, 7 lateral-involvement) and 19 healthy asymptomatic controls was processed using a musculoskeletal model to calculate contact forces and pressures. Differences between two patient groups and controls were evaluated using Kruskal-Wallis tests and individually compared using Mann-Whitney-U tests (alpha <0.05). FINDINGS: The patients with lateral involvement walked significantly slower compared to the healthy controls. No movement adaptations to decrease the loading on the injured condyle were observed. Additionally, the location of loading was not significantly affected. INTERPRETATION: The current results suggest that isolated cartilage defects do not induce significant changes in the knee joint loading distribution. Consequently, the involved condyle will capture a physiological loading magnitude that should however be distributed over the cartilage surrounding the defect. This may cause local degenerative changes in the cartilage and in combination with inflammatory responses, might play a key role in the progression from articular cartilage defect to a more severe OA phenotype.

Towards secondary prevention of early knee osteoarthritis.

Osteoarthritis (OA) of the knee is the most common arthritic disease, yet a convincing drug treatment is not available. The current narrative review focuses on integration of scientific evidence and professional experience to illustrate which management approaches can be taken for prototypical individual patient profiles with early knee OA. Animal models suggest that: (1) OA can progress even in the presence of fully recovered movement kinetics, kinematics and muscle activation patterns; (2) muscle weakness is an independent risk factor for the onset and possibly the rate of progression of knee OA; (3) onset and progression of OA are not related to body weight but appear to depend on the percentage of body fat. From studies in the human model, one could postulate that risk factors associated with progression of knee OA include genetic traits, preceding traumatic events, obesity, intensity of pain at baseline, static and dynamic joint malalignment and reduced muscle strength. Taken this into account, an individual can be identified as early knee OA at high risk for disease progression. A holistic patient-tailored management including education, supportive medication, weight loss, exercise therapy (aerobic, strengthening and neuromuscular) and behavioural approaches to improve self-management of early knee OA is discussed in individual prototypic patients. Secondary prevention of early knee OA provides a window of opportunity to slow down or even reverse the disease process. Yet, as the sheer number of patients early in the OA disease process is probably large, a more structured approach is needed to provide appropriate care depending on the patient's individual risk profile.

Knee Joint Loading in Healthy Adults During Functional Exercises: Implications for Rehabilitation Guidelines.

Study Design Controlled laboratory study. Background The inclusion of specific exercises in rehabilitation after knee injury is currently expert based, as a thorough description of the knee contact forces during different exercises is lacking. Objective To quantify knee loading during frequently used activities such as squats, lunges, single-leg hops, walking stairs, standing up, and gait, and to grade knee joint loading during these activities. Methods Three-dimensional motion-analysis data of 15 healthy adults were acquired during 9 standardized activities used in rehabilitation. Experimental motion data were processed using musculoskeletal modeling to calculate contact and shear forces on the different knee compartments (tibiofemoral and patellofemoral). Using repeated-measures analyses of variance, contact and shear forces were compared between compartments and exercises, whereas muscle and average maximum femoral forces were compared only between exercises. Results With the exception of squats, all therapeutic exercises imposed higher forces to the tibiofemoral joint compared to gait. Likewise, patellofemoral forces were greater during all exercises when compared to gait. Greater compartmental contact forces were accompanied by greater compartmental shear forces. Furthermore, force distribution over the medial and lateral compartments varied between exercises. With increased knee flexion, more force was imposed on the posterior portion of the condyles. Conclusion These results suggest that with careful selection of exercises, forces on an injured zone of the joint can be reduced, as the force distribution differs strongly between exercises. Based on the results, a graded exercise program for progressive knee joint loading during rehabilitation can be conceptualized. J Orthop Sports Phys Ther 2018;48(3):162-173. Epub 6 Jan 2018. doi:10.2519/jospt.2018.7459.

Knee Cartilage Thickness, T1ρ and T2 Relaxation Time Are Related to Articular Cartilage Loading in Healthy Adults.

Cartilage is responsive to the loading imposed during cyclic routine activities. However, the local relation between cartilage in terms of thickness distribution and biochemical composition and the local contact pressure during walking has not been established. The objective of this study was to evaluate the relation between cartilage thickness, proteoglycan and collagen concentration in the knee joint and knee loading in terms of contact forces and pressure during walking. 3D gait analysis and MRI (3D-FSE, T1ρ relaxation time and T2 relaxation time sequence) of fifteen healthy subjects were acquired. Experimental gait data was processed using musculoskeletal modeling to calculate the contact forces, impulses and pressure distribution in the tibiofemoral joint. Correlates to local cartilage thickness and mean T1ρ and T2 relaxation times of the weight-bearing area of the femoral condyles were examined. Local thickness was significantly correlated with local pressure: medial thickness was correlated with medial condyle contact pressure and contact force, and lateral condyle thickness was correlated with lateral condyle contact pressure and contact force during stance. Furthermore, average T1ρ and T2 relaxation time correlated significantly with the peak contact forces and impulses. Increased T1ρ relaxation time correlated with increased shear loading, decreased T1ρ and T2 relaxation time correlated with increased compressive forces and pressures. Thicker cartilage was correlated with higher condylar loading during walking, suggesting that cartilage thickness is increased in those areas experiencing higher loading during a cyclic activity such as gait. Furthermore, the proteoglycan and collagen concentration and orientation derived from T1ρ and T2 relaxation measures were related to loading.

Are physiotherapists adhering to quality indicators for the management of knee osteoarthritis? An observational study.

BACKGROUND: Osteoarthritis (OA) is a common musculoskeletal condition that often leads to pain, stiffness and disability. Physiotherapy plays an important role in the management of knee OA, however we hypothesize discordance between physiotherapists' practice and existing guideline recommendations. OBJECTIVES: This study aimed to measure physiotherapists' guideline adherence for knee OA. Additionally, determinants for guideline adherence at the professional and organizational level were explored, to find clues for improvement. METHOD: A survey was performed among Belgian physiotherapists. Guideline adherence was measured with a set of 9 quality indicators, developed for the Belgian primary healthcare system, applicable for physiotherapists and extracted from evidence-based guidelines. Treatment modalities that do not contribute to high quality care were also examined. RESULTS: 284 Physiotherapists responded to the survey. Compliance to the quality indicators varied between 27% and 98%. Quality indicator compliance above 80% was found for: education on the importance of exercise, delivering functional and strength exercise therapy, patient tailored exercise program, instruction of patients in appropriate exercises and referral for sports activities after therapy. Quality indicator compliance less than 50% was found for: education on the importance of weight loss, providing self-management strategies, spreading treatment session over longer periods and regular evaluations of the exercise therapy. For treatment modalities that do not contribute to high quality care, massage (49%) and cold application (24%) were most frequently applied. CONCLUSIONS: This study showed large variations in adherence to quality indicators in OA management by physiotherapists. Improvement strategies should focus on quality indicators related to long-term treatment options.

Barriers for guideline adherence in knee osteoarthritis care: A qualitative study from the patients' perspective.

RATIONALE, AIMS AND OBJECTIVES: Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and facilitators in current care were investigated. METHODS: Eleven patients with knee OA were extensively interviewed using a semistructured script based on quality indicators. Directed content analysis, within the framework of Grol and Wensing, was performed to describe barriers and facilitators in 6 domains: guideline, health care professional, patient, social environment, organization, and financial context. Data were analyzed using NVIVO 10 software. RESULTS: In total, 38 barriers, at all 6 domains, were identified. The most frequently mentioned barriers were in the domains of the patient and the health care professional, namely, patients' disagreement with guidelines recommendations, negative experience with drugs, patients' limited comprehension of the disease process, and poor communication by the health care professional. The patients' disagreement with recommendations is further explained by the following barriers: "insistence on medical imaging," "fear that physiotherapy aggravates pain," and "perception that knee OA is not a priority health issue". Patients also reported 20 facilitators, all of which are listed as opposing barriers. CONCLUSIONS: Patients indicate that both personal factors and factors related to health care professionals play an important role in nonadherence. An interview script, based on quality indicators, was a significant aid to structurally formulate barriers and facilitators in the perceived knee OA care. Future guideline implementation strategies should take the identified barriers and facilitators into account.

Non-surgical treatments for the management of early osteoarthritis.

Non-surgical treatments are usually the first choice for the management of knee degeneration, especially in the early osteoarthritis (OA) phase when no clear lesions or combined abnormalities need to be addressed surgically. Early OA may be addressed by a wide range of non-surgical approaches, from non-pharmacological modalities to dietary supplements and pharmacological therapies, as well as physical therapies and novel biological minimally invasive procedures involving injections of various substances to obtain a clinical improvement and possibly a disease-modifying effect. Numerous pharmaceutical agents are able to provide clinical benefit, but no one has shown all the characteristic of an ideal treatment, and side effects have been reported at both systemic and local level. Patients and physicians should have realistic outcome goals in pharmacological treatment, which should be considered together with other conservative measures. Among these, exercise is an effective conservative approach, while physical therapies lack literature support. Even though a combination of these therapeutic options might be the most suitable strategy, there is a paucity of studies focusing on combining treatments, which is the most common clinical scenario. Further studies are needed to increase the limited evidence on non-surgical treatments and their combination, to optimize indications, application modalities, and results with particular focus on early OA. In fact, most of the available evidence regards established OA. Increased knowledge about degeneration mechanisms will help to better target the available treatments and develop new biological options, where preliminary results are promising, especially concerning early disease phases. Specific treatments aimed at improving joint homoeostasis, or even counteracting tissue damage by inducing regenerative processes, might be successful in early OA, where tissue loss and anatomical changes are still at very initial stages.

Characterized chondrocyte implantation in the patellofemoral joint: an up to 4-year follow-up of a prospective cohort of 38 patients.

BACKGROUND: Autologous chondrocyte implantation (ACI) is an accepted treatment option for selected condylar cartilage defects in the knee. Results for patellofemoral chondral defects have been less favorable. HYPOTHESIS: Autologous chondrocyte implantation with characterized chondrocytes will result in clinically relevant improvement in patellofemoral lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with symptomatic patellofemoral full-thickness cartilage lesions were treated with ACI using characterized chondrocytes (ChondroCelect) covered with a collagen type I membrane. Clinical outcome was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and a visual analog scale (VAS) for pain. Responders were defined using 5 categories (≥10 points and ≥20%, 30%, 50%, 70%) based on the KOOS and VAS. Treatment failure was defined as partial loosening of more than 20% of the graft with subsequent procedures to the subchondral bone. RESULTS: Thirty-eight patients, with a mean defect size of 4.89 cm(2) (range, 1.5-11 cm(2)), were treated for a patellar defect (n = 28), trochlear defect (n = 7), or a kissing lesion (trochlea and patella; n = 3). The minimum follow-up period was 24 months (mean, 37 months; range, 24-72 months). Treated patients showed statistically significant improvements in the KOOS (at 12, 18, 24, 36, and 48 months) and VAS (at the same time points) compared with pretreatment for each time point. Responder analysis identified approximately 84% of patients with a clinically relevant improvement greater than 10 points at 3 years. Treatment failure was observed in 5 patients. The most commonly reported adverse events were joint crepitation (n = 18) and arthrofibrosis (n = 7). No relationship could be found between clinical outcome and anatomic characteristics of the patellofemoral joint, lesion size and site, time since onset, or age. Nine patients required additional surgery: 6 because of persistent symptoms and 3 for hardware removal. CONCLUSION: Characterized chondrocyte implantation resulted in statistically significant and clinically relevant improvement over time. These results add to the evidence demonstrating that ACI is a valuable cartilage repair technique for patellofemoral lesions.

Are personal characteristics associated with exercise participation in patients with rheumatoid arthritis? A cross-sectional explorative survey.

BACKGROUND: Organized exercise programs for patients with rheumatoid arthritis (RA) are useful to enhance physical activity and fitness. However, participation and adherence rates of these programs are low. This study aimed to identify demographic, personal and disease-related factors interfering with implementing an exercise program for RA. METHODS: A random sample of ambulatory RA patients from a single centre was divided into two groups, depending on their willingness to participate in an exercise program. Subsequently, demographic data (gender, age, disease duration and educational level) and disease-related and personal factors were obtained (Disease Activity Score; Short Form 36 [SF-36]; Health Assessment Questionnaire; Global Disease Activity; and also the Utrecht Coping List [UCL], Illness Cognition Questionnaire; TAMPA scale and modified Baecke questionnaire). RESULTS: Of the 154 people completing the survey, 113 (73%) indicated that they were willing to participate in an exercise program. These positive responders (PR) were more often female (p<0.05), and had a higher educational level (p<0.05). In the negative responders (NR), higher scores were found in the general health perception (54.7; [SD 18.3] versus 47.4; [SD 20.8]) and vitality (61.6 [SD 19.8] versus 53.7 [SD 20.1] sections of the SF-36, and a lower score was found on the reassuring thoughts subscale of the UCL (11.9 [SD 2.7] versus 12.9 [SD 2.7]) compared with the PR (all p<0.05). CONCLUSIONS: Although few differences were found between the groups, some insights regarding pitfalls in implementing an exercise program were highlighted. Further insights into external and personal motivators for patients are needed.

Autologous chondrocyte implantation versus microfracture for knee cartilage injury: a prospective randomized trial, with 2-year follow-up.

The objective was to evaluate the functional performance over a 2-year period following autologous chondrocyte implantation (ACI) in an open knee procedure compared to microfracture. Objective functional outcome was studied as secondary analysis in a subgroup of patients, in a randomized clinical trial, with concealed allocation and independent evaluators. Sixty-seven patients with local cartilage defect, with a mean size of 2.4 cm(2) (SD 1.5) of the femoral condyle of the knee were included. Thirty-three patients underwent the microfracture and 34 the ACI procedure. An identical rehabilitation protocol was implemented for both groups. Active knee flexion and extension range, anterior laxity, knee extension strength (concentric at 60 degrees/s) and single leg hop performance (single hop, crossover triple hop and 6 m timed hop test) were evaluated pre-surgery and at 6, 9,12 and 24 months post-surgery. We calculated the symmetry index for individual and four performance tests pooled. Mixed linear model analyses were used with confidence interval set at 95%. The change over 2 years for the pooled performance-based tests was comparable between the two treatment arms. At 2 years, 70% (38/54) of all patients returned to >85% symmetry in overall functional performance. A decrease in functional performance at 6 months following ACI resulted in slower recovery at 9 and 12 months compared to microfracture. Rehabilitation following both cartilage repair procedures is a lengthy process. At 2 years after surgery, ACI patients have similar overall functional outcome compared to microfracture patients.