Do Clinical Correlates of Knee Osteoarthritis Predict Outcome to Intra-Articular Steroid Injections?

OBJECTIVE:To determine if clinical correlates of knee osteoarthritis(OA) affect likelihood of outcome to intra-articular steroid injections(IASI) in symptomatic knee OA. METHODS:Men and women aged≥40 years with painful knee OA who participated in an open label trial of IASI completed questionnaires and clinical examination. OMERACT-OARSI criteria were used to assess response to therapy in the short-term(within 2-weeks). Among those who initially responded, those whose pain had not returned to within 20% of the baseline KOOS-pain score at 6-months were characterised as longer-term responders. Log binomial regression was used to examine factors associated with outcome. RESULTS:199 participants were included, of whom 146(73.4%) were short-term and 40(20.1%) longer-term responders. Compared to short-term non-responders, participants with medial joint-line tenderness(RR=1.42;1.10-1.82), medial & lateral joint-line tenderness(RR=1.38;1.03-1.84), patellofemoral tenderness(RR=1.27;1.04-1.55), anserine tenderness(RR=1.27;1.06-1.52) and a belief that treatment would be effective(RR/unit increase, [range 0-10]=1.05;1.01-1.09), were more likely to be short-term responders. Aspiration of joint fluid(RR=0.79;0.66-0.95) and previous ligament/meniscus injury(RR=0.63;0.44-0.91) were associated with a reduced risk of being a short-term responder. Compared to initial non-responders and those whose pain recurred within 6-months, participants with higher number of pain sites(RR/unit increase, [range 0-10]=0.83;0.72-0.97), chronic widespread pain(RR=0.32;0.10-0.98), perceived chronicity of disease(RR/unit increase, [range 0-10]=0.86;0.78-0.94) and a higher depression score(RR/unit increase, [range 0-21]=0.89;0.81-0.99) were less likely to be longer-term responders. CONCLUSION:Among patients with symptomatic knee OA, tenderness around the knee was associated with better short-term outcome to IASI. However, clinical-related factors did not predict longer-term response while those with chronic widespread pain and depressive symptoms were less likely to obtain longer-term benefit

Barriers and enablers to engagement in exercise and physical activity in non-English speaking South Asian people with chronic musculoskeletal disease

Background Exercise and physical activity (EPA) are recommended for people with chronic musculoskeletal disease; however, lower levels of engagement with EPA has been consistently reported in people from the South Asian community across a range of diseases. As language can pose a significant barrier in healthcare, this study aimed to understand the enablers and barriers to the acceptance of EPA among non-English speaking South Asian people who attended rheumatology clinics. Methods 12 non-English speaking individuals from the South Asian community who had chronic musculoskeletal disease with significant pain scores were interviewed via telephone or face-to-face in their spoken languages. The audio recordings of the interviews were translated into English and transcribed verbatim. Data was analysed using thematic analysis implemented in the NVivo 12 Pro software program. Results The mean age was 52 years (9 women and 2 men). One main theme was identified: ‘Enablers and barriers to exercise and physical activity’. Enablers to EPA were having knowledge about the benefits of EPA, being given resources in a language that they understood, and supportive environments such as having access to community facilities for those who could not undertake EPA in their houses. Barriers included physical health such as pain and fatigue, lack of time, difficulties with transportation to exercise venues, dislike of group exercises and lack of understanding of what and how to do exercise and be physically active. Participants’ beliefs about EPA and whether they impacted their physical health seemed to influence whether they were undertaken or not. There was a perception that their culture shaped their compatriots’ beliefs about EPA, and it was not normal practice for people from their country of birth to engage in it. Conclusions This is the first qualitative study to explore the barriers and enablers to engagement in EPA in non-English speaking South Asian people with chronic musculoskeletal disease. Modifiable factors such as addressing the level of knowledge on the benefits of EPA in the management of chronic joint and muscle pain; aiding the development of the skills required to exercise safely and confidently despite chronic pain and providing information and services in the native language could promote the EPA engagement of non-English speaking South Asian individuals with chronic musculoskeletal disease. The findings may inform improvements within clinical services to promote the benefits, impact and self-efficacy of engagement with EPA as part of chronic musculoskeletal disease management. Ethics approval The West Midlands-Edgbaston Research Ethics Committee (reference:20/WM/0305)

Interobserver and intraobserver reliability of clinical assessments in knee osteoarthritis

© 2016 The Journal of Rheumatology. All rights reserved. Objective. Clinical examination of the knee is subject to measurement error. The aim of this analysis was to determine interobserver and intraobserver reliability of commonly used clinical tests in patients with knee osteoarthritis (OA). Methods. We studied subjects with symptomatic knee OA who were participants in an open-label clinical trial of intraarticular steroid therapy. Following standardization of the clinical test procedures, 2 clinicians assessed 25 subjects independently at the same visit, and the same clinician assessed 88 subjects over an interval period of 2-10 weeks; in both cases prior to the steroid intervention. Clinical examination included assessment of bony enlargement, crepitus, quadriceps wasting, knee effusion, joint-line and anserine tenderness, and knee range of movement (ROM). Intraclass correlation coefficients (ICC), estimated kappa (k), weighted kappa (k?), and Bland-Altman plots were used to determine interobserver and intraobserver levels of agreement. Results. Using Landis and Koch criteria, interobserver k scores were moderate for patellofemoral joint (k = 0.53) and anserine tenderness (k = 0.48); good for bony enlargement (k = 0.66), quadriceps wasting (k = 0.78), crepitus (k = 0.78), medial tibiofemoral joint tenderness (k = 0.76), and effusion assessed by ballottement (k = 0.73) and bulge sign (k? = 0.78); and excellent for lateral tibiofemoral joint tenderness (k = 1.00), flexion (ICC = 0.97), and extension (ICC = 0.87) ROM. Intraobserver k scores were moderate for lateral tibiofemoral joint tenderness (k = 0.60); good for crepitus (k = 0.78), effusion assessed by ballottement test (k = 0.77), patellofemoral joint (k = 0.66), medial tibiofemoral joint (k = 0.64), and anserine tenderness (k = 0.73); and excellent for effusion assessed by bulge sign (k? = 0.83), bony enlargement (k = 0.98), quadriceps wasting (k = 0.83), flexion (ICC = 0.99), and extension (ICC = 0.96) ROM. Conclusion. Among individuals with symptomatic knee OA, the reliability of clinical examination of the knee was at least good for the majority of clinical signs of knee OA

Clinical assessment of effusion in knee osteoarthritis-A systematic review

© 2016 The Authors. Objective: The aim of this systematic review was to determine the validity and inter- and intra-observer reliability of the assessment of knee joint effusion in osteoarthritis (OA) of the knee. Methods: MEDLINE, Web of Knowledge, CINAHL, EMBASE, and AMED were searched from their inception to February 2015. Articles were included according to a priori defined criteria: samples containing participants with knee OA; prospective evaluation of clinical tests and assessments of knee effusion that included reliability, sensitivity, and specificity of these tests. Results: A total of 10 publications were reviewed. Eight of these considered reliability and four on validity of clinical assessments against ultrasound effusion. It was not possible to undertake a meta-analysis of reliability or validity because of differences in study designs and the clinical tests. Intra-observer kappa agreement for visible swelling ranged from 0.37 (suprapatellar) to 1.0 (prepatellar); for bulge sign 0.47 and balloon sign 0.37. Inter-observer kappa agreement for visible swelling ranged from -0.02 (prepatellar) to 0.65 (infrapatellar), the balloon sign -0.11 to 0.82, patellar tap -0.02 to 0.75 and bulge sign kappa -0.04 to 0.14 or reliability coefficient 0.97. Reliability and diagnostic accuracy tended to be better in experienced observers. Very few data looked at performance of individual clinical tests with sensitivity ranging 18.2-85.7% and specificity 35.3-93.3%, both higher with larger effusions. Conclusion: The majority of unstandardized clinical tests to assess joint effusion in knee OA had relatively low intra- and inter-observer reliability. There is some evidence experience improved reliability and diagnostic accuracy of tests. Currently there is insufficient evidence to recommend any particular test in clinical practice

Structural predictors of response to intra-articular steroid injection in symptomatic knee osteoarthritis

© 2017 The Author(s). Background: The aim was to examine if structural factors could affect response to intra-articular steroid injections (IASI) in knee osteoarthritis (OA). Method: Persons with painful knee OA participated in an open-label trial of IASI where radiographic joint space narrowing (JSN) and Kellgren-Lawrence (KL) grade, whole-organ magnetic resonance imaging (MRI) scores (WORMS) and quantitative assessment of synovial tissue volume (STV) were assessed on baseline images. Participants completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and a question about knee pain with a visual analogue scale for pain during nominated activity (VAS NA ), and Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess responder status within 2 weeks (short term) and 6 months (longer term). Regression models were used to examine predictors of short and longer term response to IASI. Results: Subjects (n = 207) attended and had IASI. Information on responder status was available on 199 participants. Of these, 188 subjects, mean age 63.2 years (standard deviation (SD) 10.3), 97 (51.6%) female, had x-rays and 120 had MRI scans available. Based on the OMERACT-OARSI criteria, 146 (73.4%) participants responded to therapy and 40 (20.1%) were longer term responders. A few factors were associated with a reduced KOOS-pain and VAS NA response though none were associated with OMERACT-OARSI responder status in the short term. Higher MRI meniscal damage (odds ratio (OR) = 0.74; 95% CI 0.55 to 0.98), increasing KL maximal grade (OR = 0.43; 95% CI 0.23 to 0.82) and joint space narrowing (JSN) maximal score (OR = 0.60; 95% CI 0.36 to 0.99) were each associated with a lower odds of longer term responder status. Baseline synovitis was not associated with treatment response. The predicted probability of longer term response decreased from 38% to 12% as baseline maximal JSN increased from grade 0 to 3. Conclusion: Compared with those who have mild structural damage, persons with more severe knee damage on either MRI or x-ray are less likely to respond to knee IASI. Trial registration: ISRCTN.com, ISRCTN07329370. Registered 21 May 2010. Retrospectively registere

Where and how to inject the knee-A systematic review

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

Barriers and enablers to engagement in exercise and physical activity in non-English speaking South Asian people with chronic musculoskeletal disease

Background: Exercise and physical activity (EPA) are recommended for people with chronic musculoskeletal disease; however, lower levels of engagement with EPA has been consistently reported in people from the South Asian community across a range of diseases. As language can pose a significant barrier in healthcare, this study aimed to understand the enablers and barriers to the acceptance of EPA among non-English speaking South Asian people who attended rheumatology clinics. Methods: 12 non-English speaking individuals from the South Asian community who had chronic musculoskeletal disease with significant pain scores were interviewed via telephone or face-to-face in their spoken languages. The audio recordings of the interviews were translated into English and transcribed verbatim. Data was analysed using thematic analysis implemented in the NVivo 12 Pro software program. Results: The mean age was 52 years (9 women and 2 men). One main theme was identified: ‘Enablers and barriers to exercise and physical activity’. Enablers to EPA were having knowledge about the benefits of EPA, being given resources in a language that they understood, and supportive environments such as having access to community facilities for those who could not undertake EPA in their houses. Barriers included physical health such as pain and fatigue, lack of time, difficulties with transportation to exercise venues, dislike of group exercises and lack of understanding of what and how to do exercise and be physically active. Participants' beliefs about EPA and whether they impacted their physical health seemed to influence whether they were undertaken or not. There was a perception that their culture shaped their compatriots’ beliefs about EPA, and it was not normal practice for people from their country of birth to engage in it. Conclusions: This is the first qualitative study to explore the barriers and enablers to engagement in EPA in non-English speaking South Asian people with chronic musculoskeletal disease. Modifiable factors such as addressing the level of knowledge on the benefits of EPA in the management of chronic joint and muscle pain; aiding the development of the skills required to exercise safely and confidently despite chronic pain and providing information and services in the native language could promote the EPA engagement of non-English speaking South Asian individuals with chronic musculoskeletal disease. The findings may inform improvements within clinical services to promote the benefits, impact and self-efficacy of engagement with EPA as part of chronic musculoskeletal disease management.<br/