Establishing outcome measures in early knee osteoarthritis

The classification and monitoring of individuals with early knee osteoarthritis (OA) are important considerations for the design and evaluation of therapeutic interventions and require the identification of appropriate outcome measures. Potential outcome domains to assess for early OA include patient-reported outcomes (such as pain, function and quality of life), features of clinical examination (such as joint line tenderness and crepitus), objective measures of physical function, levels of physical activity, features of imaging modalities (such as of magnetic resonance imaging) and biochemical markers in body fluid. Patient characteristics such as adiposity and biomechanics of the knee could also have relevance to the assessment of early OA. Importantly, research is needed to enable the selection of outcome measures that are feasible, reliable and validated in individuals at risk of knee OA or with early knee OA. In this Perspectives article, potential outcome measures for early symptomatic knee OA are discussed, including those measures that could be of use in clinical practice and/or the research setting

Identification of risk factors associated with the progression of knee -osteoarthritis: a prospective longitudinal study

Risk factors and prognostic factors of knee osteoarthritis: a prospective study with 2-4 years follow-up Osteoarthritis is a degenerative joint disease, where the knee is most frequently affected. The incidence of osteoarthritis of the knee increases with age, and it is more common in womenthan in men (Felson, 1987). Patients often complain of pain, muscle weakness, stiffness and instability, as well as limitations in physical activities. This could eventually lead to a loss of independence and a reduction in the quality of life. Osteoarthritis of the knee is therefore associated with high healthcare costs (1). In view ofthe aging of the population and the increasing proportion of people with obesity, it is expected that the incidence and / or progression of knee osteoarthritis will significantly increase in the coming decades (2). Prevention of knee osteoarthritis should therefore be oneof the key objectives in health care. Even more important, knowledge of risk factors in the progression of osteoarthritis is of paramountimportance as about 15 % of them are truly at risk to develop endstage disease within 10-15 years. In literature, various risk factors for progression of osteoarthritis have been described and consist of neuromuscular (eg muscle strength, muscle mass, muscle activation patterns), biomechanical (knee alignment, laxity, joint loading) and genetic (various gene polymorphisms) factors. The relationship between these factors and their relative importance remains unclear. Although research indicates that current treatment strategies for knee osteoarthritis in general have a positive effect on reducing pain and improving functionality, the effects appear to be only small to moderate (3). Thoroughinvestigation of the influence of potential risk factors in the initiation and progression of knee osteoarthritis might help to optimize the current treatment strategies.status: publishe

Attentional Demands of Walking in Athletes with and without Functional Ankle Instability

Objective: By mentioning this fact that the athletes have to be multi-tasking in the field in spite of injury, it seems vital to investigate the attentional demands of walking in these subjects. Materials & Methods: In this cross-sectional and case-control study, sixteen functionally unstable ankle athletes and sixteen healthy matched athletes were selected conveniently. The three factors mixed, dual task study was conducted using Motion Analysis System. Stride time and length, step time, length and width, stance and swing time and also cadence were measured while subjects experiencing 2 walking task difficulties (speed: 2.1 and 3.6 Km/h barefoot walking on a treadmill) and 2 cognitive loadings (with and without backward counting). Data were analyzed by statistical tests such as: Chi-Square, 3-way mixed ANOVA and Independent T-test. Results: 2×2×2 (2 groups, 2walking task difficulties and 2 cognitive loadings) mixed ANOVA showed significant group×condition interaction for stride length. Patients had significantly more increase in stride length without cognitive task than healthy subjects (P=0.03). Also the simple main effect of cadence was significant in the group with functional ankle instability (P=0.049). Conclusion: It seems that FAI is associated with increased attentional demands to dynamic postural control (Walking). Cognitive loading may be considered in any exercise program for FAI patients as an effective strategy

Towards classification criteria for early-stage knee osteoarthritis : A population-based study to enrich for progressors

Objective: To facilitate a greater likelihood of favorable response to new disease-modifying therapies, recruitment of patients at an earlier stage of their disease into clinical trials may be an attractive strategy. Hence, there is a need to develop widely accepted classification criteria for early-stage knee osteoarthritis (OA). We have proposed a set of classification criteria for early-stage knee OA (2018 classification criteria) now being further refined. Here, we test the draft criteria for enrichment for clinical and structural progression. Design: Performance of the 2018 classification criteria for early stage knee OA was tested using data from the Osteoarthritis Initiative (OAI). The OAI comprises data of 4796 men and women aged 45–79 years with or at risk for knee OA at baseline. Based on the 2018 classification criteria, a knee with Kellgren & Lawrence (K&L) grade of 0-I, two out of four Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales equal or less than 85, and presence of at least one of joint line tenderness or crepitus, was considered as early-stage knee OA. Knees with K&L grade 0-I that did not fulfill the 2018 criteria, were considered as controls. Logistic regression analysis was used to evaluate the predictive performance of the criteria set for structural as well as clinical progression. We further explored the discriminatory capability of criteria by including the average KOOS4 score, and relevant clinical examination findings such as the presence of effusion and/or Heberden's nodes. Results: We identified 1315 (27%) knees from OAI fulfilling the 2018 early-stage knee OA classification criteria. The female to male ratio was higher in the early knee OA group compared to controls. The early-stage knee OA group were on average slightly younger and had higher body mass index vs controls (mean [SD] age: 59.2 [8.9] years vs. 60.2 [9.1] and mean [SD] BMI 28.3 [7.0] vs. 26.8 [6.0]). By applying the 2018 criteria, there was a substantial enrichment compared to controls at 48 and 96 months for both structural (OR=1.1–1.4, and AUC=0.72–0.74) and clinical progressors (OR=2.1–2.5, 95% and AUC=0.66). Expanding the clinical examination findings by including joint effusion and/or Heberden's nodes improved the enrichment for both structural and clinical progressors (OR=4.2, 95% confidence interval=3.2–5.5 and OR=3.3, 95% confidence interval=2.8–3.5, respectively). Replacing scoring of the 4 separate KOOS domains by a KOOS4 score performed comparably. Conclusions: The proposed 2018 early-stage knee OA classification criteria showed encouraging performance characteristics with regard to an enrichment for structural and clinical progression using longitudinal OAI data. Our results indicate that the addition of clinical findings improves the performance of previous criteria to define early-stage disease and risk for progression

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.status: publishe

Early-stage symptomatic osteoarthritis of the knee — time for action

Osteoarthritis (OA) remains the most challenging arthritic disorder, with a high burden of disease and no available disease-modifying treatments. Symptomatic early-stage OA of the knee (the focus of this Review) urgently needs to be identified and defined, as efficient early-stage case finding and diagnosis in primary care would enable health-care providers to proactively and substantially reduce the burden of disease through proper management including structured education, exercise and weight management (when needed) and addressing lifestyle-related risk factors for disease progression. Efforts to define patient populations with symptomatic early-stage knee OA on the basis of validated classification criteria are ongoing. Such criteria, as well as the identification of molecular and imaging biomarkers of disease risk and/or progression, would enable well-designed clinical studies, facilitate interventional trials, and aid the discovery and validation of cellular and molecular targets for novel therapies. Treatment strategies, relevant outcomes and ethical issues also need to be considered in the context of the cost-effective management of symptomatic early-stage knee OA. To move forwards, a multidisciplinary and sustained international effort involving all major stakeholders is required

Do Psychosocial Factors Predict Muscle Strength, Pain, or Physical Performance in Patients With Knee Osteoarthritis?

OBJECTIVE: The aim of this study was to examine the relationship of psychosocial factors, namely, pain catastrophizing, kinesiophobia, and maladaptive coping strategies, with muscle strength, pain, and physical performance in patients with knee osteoarthritis (OA)-related symptoms. METHODS: A total of 109 women (64 with knee OA-related symptoms) with a mean age of 65.4 years (49-81 years) were recruited for this study. Psychosocial factors were quantified by the Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Pain Coping Inventory. Clinical features were assessed using isometric and isokinetic knee muscle strength measurements, visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index, and functional tests. Associations were examined using correlation and regression analysis. RESULTS: In knee OA patients, pain catastrophizing, kinesiophobia, and coping strategy explained a significant proportion of the variability in isometric knee extension and flexion strength (6.3%-9.2%), accounting for more overall variability than some demographic and medical status variables combined. Psychosocial factors were not significant independent predictors of isokinetic strength, knee pain, or physical performance. CONCLUSIONS: In understanding clinical features related to knee OA, such as muscle weakness, pain catastrophizing, kinesiophobia, and coping strategy might offer something additional beyond what might be explained by traditional factors, underscoring the importance of a biopsychosocial approach in knee OA management. Further research on individual patient characteristics that mediate the effects of psychosocial factors is, however, required in order to create opportunities for more targeted, personalized treatment for knee OA.status: publishe

INTERNATIONAL CRITERIA EKG INTERPRETATION COMPARISON STUDY

BACKGROUND: There has been an evolution of athlete specific Electrocardiogram (EKG) criteria over the years, resulting in improved specificity and lower false positive rates, starting with the European Society of Cardiology 2005 guidelines and most recently with the current 2017 International Recommendations. The consistency of EKG interpretation with the 2017 International Criteria have been compared between various groups, including local and specialized center physicians. Whether novice EKG interpreters (undergraduate/graduate students) can be taught to accurately interpret athletes’ EKGs with the 2017 International Criteria has not been extensively studied. This study seeks to assess the accuracy and variability of novice EKG interpreters, compared to cardiologist interpretations and expert readers. METHODS: Two novice EKG interpreters (undergraduate exercise science students) were trained in interpreting EKGs of athletes with the 2017 International Criteria during one semester under the instruction of an expert reader. During an annual high school, sports screening day 1350 EKGs were collected and assigned a corresponding number. The on-site cardiologists evaluated the EKGs in real-time and classified as “normal” or “abnormal” according to the International Criteria. Following the sports physical day, two novice EKG interpreters (students), a cardiologist and an Exercise Physiology Professor (expert reader) were asked separately to classify the same EKGs as normal or “abnormal” according to the International Criteria. All readers were blinded to the initial classifications made by the cardiologist during the sports physical event. Information regarding the athlete\u27s age, gender, race/ethnicity, and sport was provided on the EKGs. We assessed the agreement between the cardiologist, expert reader and students in interpreting EKGs using Fleiss\u27 kappa analysis. RESULTS: 1350 athlete EKGs (males = 879; females = 471, age (mean + SD) 15.09+1.3y) including 37 (2.7%) abnormal cases were reviewed. The inter-rater agreement between novice readers, expert reader, and physicians in classifying an EKG as abnormal was good (k = 0.7, p \u3c .001). CONCLUSION: This study demonstrated that novice EKG readers could correctly classify EKGs based on the International Criteria as “normal and abnormal” to identify athletes at high risk of acute cardiovascular events

Do psychosocial factors predict muscle strength, pain, or physical performance in patients with knee osteoarthritis?

Objective: The aim of this study was to examine the relationship of psychosocial factors, namely, pain catastrophizing, kinesiophobia, andmaladaptive coping strategies, withmuscle strength, pain, and physical performance in patients with knee osteoarthritis (OA)-related symptoms. Methods: A total of 109 women (64 with knee OA-related symptoms) with a mean age of 65.4 years (49-81 years) were recruited for this study. Psychosocial factors were quantified by the Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Pain Coping Inventory. Clinical features were assessed using isometric and isokinetic kneemuscle strength measurements, visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index, and functional tests. Associations were examined using correlation and regression analysis. Results: In knee OA patients, pain catastrophizing, kinesiophobia, and coping strategy explained a significant proportion of the variability in isometric knee extension and flexion strength (6.3%-9.2%), accounting for more overall variability than some demographic and medical status variables combined. Psychosocial factors were not significant independent predictors of isokinetic strength, knee pain, or physical performance. Conclusions: In understanding clinical features related to knee OA, such as muscle weakness, pain catastrophizing, kinesiophobia, and coping strategy might offer something additional beyond whatmight be explained by traditional factors, underscoring the importance of a biopsychosocial approach in knee OA management. Further research on individual patient characteristics that mediate the effects of psychosocial factors is, however, required in order to create opportunities for more targeted, personalized treatment for knee OA

Weak associations between structural changes on MRI and symptoms, function and muscle strength in relation to knee osteoarthritis

PURPOSE: To explore associations between MRI-defined structural abnormalities and clinical features related to knee osteoarthritis (OA). METHODS: Structural and clinical knee OA features were assessed in 87 women (45 with knee OA symptoms). Structural features were quantified by the Kellgren and Lawrence grade on radiography and by the Boston-Leeds Osteoarthritis Knee Score on MRI. Clinical features were assessed using the Knee Injury and Osteoarthritis Outcome Score, functional tests and muscle strength measurements. Associations were examined using regression analyses. RESULTS: Limited significant associations between structural and clinical features were found. An increased meniscal signal was associated with more pain/symptoms (P < 0.027). An anterior cruciate ligament tear was associated with poorer stair climbing test performance (P = 0.045). In a stepwise linear regression model, patellofemoral cartilage integrity and pain explained 28 % of the isometric quadriceps strength variability. The amount of cartilage lesions, loose bodies and pain explained 38 % of the isokinetic quadriceps strength variability. Synovitis/effusion and patellofemoral cartilage integrity combined with pain explained 34 % of the isometric hamstring strength variability. CONCLUSION: Although MRI-detected cartilage lesions, synovitis/effusion and loose bodies did explain part of the muscle strength variability, results suggest that MRI does not improve the link between joint degeneration and the clinical expression of knee OA. MRI contributes less than expected to the understanding of pain and function in knee OA and possibly offers little opportunity to develop structure-modifying treatments in knee OA that could influence the patient's pain and function. LEVEL OF EVIDENCE: Case series with no comparison groups, Level IV.status: publishe