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1
Doherty, Michael. Osteoarthritis. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0266.
Full textAbstract:
Osteoarthritis (OA) is a disorder of synovial joints and is characterized by the combination of focal hyaline cartilage loss and accompanying subchondral bone remodelling and marginal new bone formation (osteophyte). It has genetic, constitutional, and environmental risk factors and presents a spectrum of clinical phenotypes and outcomes. OA commonly affects just one region (e.g. knee OA, hip OA). However, multiple hand interphalangeal joint OA, usually accompanied by posterolateral firm swellings (nodes), is a marker for a tendency towards polyarticular ‘generalized nodal OA’.
2
Dekker, Joost, Daniel Bossen, Jasmijn Holla, Mariëtte de Rooij, Cindy Veenhof, and Marike van der Leeden. Psychological strategies in osteoarthritis of the knee or hip. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0025.
Full textAbstract:
Characteristic clinical presentations of osteoarthritis (OA) include pain and activity limitations. These presentations are dependent on psychological processes. The literature reviewed in this chapter leads to the following conclusions: (1) symptoms of depression, anxiety, and fatigue are more prevalent among patients with OA than among the general population. Recently, a depressive mood phenotype has been identified in knee OA. (2) Symptoms of depression, anxiety, and fatigue, as well as other psychological variables are established risk factors for future worsening of pain and activity limitations. (3) Psychological interventions such as depression care and pain coping skills training have been demonstrated to improve pain and activity limitations, as well as psychological outcomes. Self-management may have beneficial effects, although there is clearly room for improvement. Interventions combining psychological interventions with exercise therapy have been shown to be effective; improved outcome over exercise therapy alone stills needs to be demonstrated. (4) Psychological interventions are effective in improving exercise adherence and promoting physical activity. Overall, it can be concluded that the psychological approach towards OA is fruitful: the psychological approach has resulted in substantial contributions to the understanding and management of clinical presentations of OA, including pain and activity limitations.
3
Jordan, Joanne M., Kelli D. Allen, and Leigh F. Callahan. Age, gender, race/ethnicity, and socioeconomic status in osteoarthritis and its outcomes. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0010.
Full textAbstract:
Osteoarthritis (OA) is the most common joint condition worldwide. It can impair mobility and result in significant disability, need for total joint replacement, and healthcare utilization. OA is unusual in those younger than 40 years, then commonly the result of an underlying metabolic disorder or a prior joint injury. Some geographic and racial/ethnic variation exists in the prevalence and incidence of OA for specific joints, likely due to variation in genetics, anatomy, and environmental exposures. Many OA outcomes vary by socioeconomic status and other social factors. This chapter describes demographic and social determinants of knee, hip, and hand OA, including how these factors impact radiographic and symptomatic OA, OA-related pain and function, and its treatment.
4
Hayashi, Daichi, Ali Guermazi, and Frank W. Roemer. Radiography and computed tomography imaging of osteoarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0016.
Full textAbstract:
Osteoarthritis (OA) is the most prevalent joint disorder in the elderly worldwide and there is still no effective treatment, other than joint arthroplasty for end-stage OA, despite ongoing research efforts. Imaging is essential for assessing structural joint damage and disease progression. Radiography is the most widely used first-line imaging modality for structural OA evaluation. Its inherent limitations should be noted including lack of ability to directly visualize most OA-related pathological features in and around the joint, lack of sensitivity to longitudinal change and missing specificity of joint space narrowing, and technical difficulties regarding reproducibility of positioning of the joints in longitudinal studies. Magnetic resonance imaging (MRI) is widely applied in epidemiological studies and clinical trials. Computed tomography (CT) is an important additional tool that offers insight into high-resolution bony anatomical details and allows three-dimensional post-processing of imaging data, which is of particular importance for orthopaedic surgery planning. However, its major disadvantage is limitations in the assessment of soft tissue structures compared to MRI. CT arthrography can be useful in evaluation of focal cartilage defects or meniscal tears; however, its applicability may be limited due to its invasive nature. This chapter describes the roles and limitations of both conventional radiography and CT, including CT arthrography, in clinical practice and OA research. The emphasis is on OA of the knee, but other joints are also mentioned where appropriate.
5
Bennell, Kim L., Ans Van Ginckel, Fiona Dobson, and Rana S. Hinman. Exercise for the person with osteoarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0022.
Full textAbstract:
Because of its beneficial effects on pain and physical dysfunction commonly reported by afflicted individuals, all clinical guidelines of osteoarthritis (OA) advocate exercise therapy as a vital component of conservative management strategies. Although the optimal exercise modalities in terms of dosage, exercise type, or delivery mode are not yet known, clinical benefits can be achieved with a wide range of exercise types. While treatment effect sizes may be considered small to moderate, they are similar to those of common analgesic drugs or oral non-steroidal anti-inflammatories but seem to elicit fewer side effects. To achieve optimal treatment outcomes, programme parameters should be individualized to the patient’s clinical characteristics and preferences. Where validated instruments could assist the clinician in monitoring the progress of an exercise intervention programme, adherence to exercise in the longer term is a prerequisite to maintain symptom relief over time. Whereas the current body of evidence mainly comprises clinical trials in people with knee OA, future studies should continue to address efficacy and safety of exercise therapy in individuals suffering from hand or hip OA and should further determine its ability to postpone the need for costly arthroplasty surgery.
6
Thorlund, Jonas Bloch, and L. Stefan Lohmander. Other surgical approaches in the management of osteoarthritis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0034.
Full textAbstract:
Joint replacement is often considered the surgical treatment for patients with osteoarthritis (OA). However, several other surgical treatments, of which some are more frequently performed, have been advocated for patients with OA in order to relieve symptoms, stall progression, and avoid or postpone joint replacement. This chapter briefly describes the most common procedures such as knee and hip arthroscopy and knee and hip osteotomy. It also reviews the evidence for the efficacy of these treatments compared with non-surgical alternatives, which is frequently insufficient due to lack of controlled low-risk-of-bias studies. The risk of adverse events is also reported when data is available. Some of the more recent surgical techniques such as implantation of chondrocytes or stem cells are also described and discussed but their utility for treating osteoarthritis remains uncertain. There is a great need for continued innovation and development of surgical techniques for managing in particular the earlier stages of osteoarthritis. To reduce the risk of future costly failures, a stepwise introduction of new surgical procedures and devices must be encouraged.
7
McDougall, Jason J., and Joel A. Vilensky. The innervation of the joint and its role in osteoarthritis pain. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0007.
Full textAbstract:
Diarthrodial joints possess an extensive network of sensory and sympathetic nerve fibres whose physiological functions are varied and complex. Nerves are primarily located in the synovium but also innervate the subchondral bone, the outer third of menisci, and the superficial surface of tendons and ligaments. Large-diameter, myelinated neurons are involved in joint position sense while small-diameter neurons with thin or no myelin typically sense pain. The small-diameter nerves in conjunction with sympathetic fibres control synovial blood flow and maintain joint homeostasis. In patients with osteoarthritis (OA), the sensory nerves become sensitized and increase their firing rate in response to normal movement. This peripheral sensitization is mediated by numerous algogenic agents released into the OA knee including neuropeptides, eicosanoids, and proteinases. A portion of joint afferents fire in the absence of mechanical stimuli and encode pain at rest. Interestingly, the firing rate of joint afferents does not correlate with OA severity, indicating that pain is a poor predictor of joint pathology. Evidence is accumulating to suggest that a subpopulation of OA patients who are unresponsive to classical non-steroidal anti-inflammatory drugs may be suffering from neuropathic pain in which there is damage to the joint nerves themselves. Better understanding of the biology of joint nerves could help in the development of patient-targeted therapies to alleviate OA pain and inflammation.
8
Abhishek, Abhishek, and Michael Doherty. Epidemiology and risk factors for calcium pyrophosphate deposition. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0048.
Full textAbstract:
Calcium pyrophosphate crystal deposition (CPPD) is rare in younger adults but becomes increasingly common over the age of 55 years, especially at the knee. Ageing and osteoarthritis (OA) are the main attributable risk factors. Hyperparathyroidism, hypomagnesaemia, haemochromatosis, and hypophosphatasia are other less common risk factors. Rare families with familial CPPD have been reported from many different parts of the world, and mainly present as young-onset polyarticular CPPD. Recent studies suggest that CPPD occurs as the result of a generalized constitutional predisposition and may also associate with low cortical bone mineral density. Previous meniscectomy, joint injury, and constitutional knee malalignment are local biomechanical risk factors specifically for knee chondrocalcinosis. Although associated with OA, current evidence suggests that CPPD does not associate with development or progression of OA.
9
Nguyen, Christelle, and François Rannou. Addressing adverse mechanical factors. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0024.
Full textAbstract:
Non-pharmacological approaches are widely and consistently recommended for the management of osteoarthritis (OA). This recommendation is based on biomechanical observations and emphasizes the therapeutic interest of biomechanical interventions able to modulate adverse mechanical factors affecting the symptomatic OA joint. Therapeutic approaches include braces, orthoses, insoles, joint protection, joint-preserving surgical procedures, walking sticks, and other aids. Overall, biomechanical interventions aim to modulate joint biomechanics, in order to improve joint mechanosensitivity, decrease mechanical joint loading, and eventually reduce pain. These interventions must be adjusted to the biomechanical specificities of each joint, and of the individual patient. This chapter uses an evidence-based approach, including the most recent European League Against Rheumatism, Osteoarthritis Research Society International, and American College of Rheumatology recommendations, to describe and to review non-pharmacological strategies available in daily clinical practice, designed to modulate mechanical joint loading, with a focus on the management of hand, hip, and knee OA. The interest of weight loss, specific and non-specific exercises, patient education, and self-care programmes is discussed elsewhere in this book.
10
Aspden, Richard, and Jenny Gregory. Morphology. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0011.
Full textAbstract:
The study of joint morphology can help us to understand the risk factors for osteoarthritis (OA), how it progresses, and aids in developing imaging biomarkers for study of the disease. OA results in gross structural changes in affected joints. Growth of osteophytes, deformation of joint components, and loss of joint space where cartilage has broken down are all characteristics of the disorder. Certain bone shapes as well as malalignment predispose people to future OA, or may be a marker for early OA. Geometrical measures, such as the alpha angle or Wiberg’s CE angle, used to be the primary tool for investigating morphology. In recent years, however, statistical shape modelling (SSM) has become increasingly popular. SSM can be used with any imaging modality and has been successfully applied to a number of musculoskeletal conditions. It uses sets of landmark points denoting the anatomy of one or more bones to generate new variables (modes) that describe and quantify the shape variation in a set of images via principal components analysis. With the aid of automated search algorithms for point placement, the use of SSMs is expanding and provides a valuable and versatile tool for exploration of bone and joint morphometry. Whilst the majority of research has focused on hip and knee OA, this chapter provides an overview of joint morphology through the whole skeleton and how it has helped our ability to understand and quantify the risk and progression of osteoarthritis.
11
Bannwarth, Bernard, and Francis Berenbaum. Systemic analgesics (including paracetamol and opioids). Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0029.
Full textAbstract:
Apart from non-steroidal anti-inflammatory drugs (NSAIDs), there are only two categories of systemic analgesics, namely paracetamol (acetaminophen) and opioids, that are currently available worldwide for clinical use. Paracetamol is poorly effective in relieving pain and improving function in patients with symptomatic osteoarthritis (OA). Furthermore, its safety profile is less favourable than classically thought. In fact, there is evidence paracetamol acts as a weak inhibitor of the cyclooxygenase enzymes. Given that paracetamol poses a lower risk of severe adverse events than NSAIDs while being better tolerated than opioids, it is usually considered as the first-line systemic analgesic for OA. Commonly prescribed opioids are primarily agonists of the mu receptors, thereby producing similar desirable (analgesia) and untoward effects. Meta-analyses of short-term clinical trials showed that, on average, the modest clinical benefits of opioids did not outweigh the side effects in patients with knee or hip OA. Accordingly, most current guidelines support the use of opioids for selected OA patients only (e.g. patients who have not had an adequate response to other treatment modalities and are not candidates for total joint arthroplasty). In view of the limited efficacy and/or potential harms of available analgesics, particular attention was paid to novel painkillers, especially nerve growth factor (NGF) antagonists. Although these agents provided clinically meaningful improvements in pain and physical function in patients with hip or knee OA, they lead to severe side effects, including rapidly destructive arthropathies and neuropathies. Thus, if approved for marketing, NGF antagonists would be reserved for selected and well-defined patients with OA.
12
Arden, Nigel, and Terence O’Neill. Intra-articular injection therapy. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0032.
Full textAbstract:
Intra-articular injection therapy is widely used in the management of osteoarthritis (OA). It has advantages over oral therapy in that it can provide targeted therapy to individual joint sites and at higher dose than could be achieved through oral administration and with fewer adverse effects. Intra-articular steroid therapy, the most widely used intra-articular therapy, is safe and effective in the short term particularly at the knee; though more studies are needed to better characterize the longer-term benefit. The role of intra-articular hyaluronic acid in clinical management of OA is less clear though it may have a role in selected patients in whom other therapies are contraindicated. Currently there are no factors which have been identified as being predictors of response to therapy with intra-articular therapy. Many other intra-articular agents have been used in the management of OA, however, because of the limited evidence base relating to efficacy and safety they cannot currently be recommended for use in routine clinical practice.
13
Holden, Melanie A., Martin J. Thomas, and Krysia S. Dziedzic. Miscellaneous physical therapies. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0026.
Full textAbstract:
Miscellaneous physical therapies, such as assistive devices, thermotherapy, manual therapy, and electrotherapy are commonly used to treat patients with osteoarthritis (OA) in addition to written information and exercise. However, the evidence underpinning specific miscellaneous physical therapies is often limited, with small study sizes, heterogeneous populations, and differing study designs making it difficult to draw firm conclusions about their effectiveness. One or more miscellaneous physical therapies feature within 15 current clinical guidelines for OA. The specific types of physical therapies addressed are variable, as are their recommendations. There is most agreement for miscellaneous physical therapies in hand OA, with multiple guidelines addressing and consistently recommending joint protection, splinting, and thermotherapy in addition to core treatment. However these recommendations are predominantly based on a small number of randomized controlled trials (RCTs). Use of walking aids and footwear is commonly addressed and recommended for patients with hip and knee OA, although recommendations are predominantly based on expert opinion. Other physical therapies recommended for hip and knee OA range from orthoses to less conventional leech therapy. When a recommendation for a miscellaneous physical therapy is not made, it is commonly due to limited clinical evidence, rather than evidence of harm. Due to limited evidence and lack of consensus between clinical guidelines, for some therapies, use of specific miscellaneous physical therapies in clinical practice should be based upon the best available evidence, a holistic, individualized clinical assessment and shared decision-making with the patient. Further large-scale, high-quality RCTs would be useful to inform future guideline recommendations and clinical practice.
14
Abhishek, Abhishek, Adrian Jones, and Michael Doherty. Topical pharmacological treatments. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0028.
Full textAbstract:
Topical pharmacological agents such as non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin are widely recommended as first-line analgesics in the treatment of osteoarthritis (OA) of the knee, hand, and potentially other peripheral joints in view of their safety and efficacy. Although initial studies were short in duration (2–4 weeks), recent randomized controlled trials have confirmed the efficacy of topical NSAIDs over longer (12-week) study periods. Systematic reviews demonstrate that their efficacy can be equivalent to oral NSAIDs for OA pain, but they have a significantly better systemic toxicity profile than the corresponding oral formulations. Topical capsaicin is less well studied than topical NSAIDs but has been demonstrated to be effective in several placebo-controlled clinical trials. Local warming and an uncomfortable burning sensation is a common problem with initial applications, but this subsides with continued treatment and can be minimized by using a low-strength preparation (e.g. 0.025%) initially. Several other topical treatments such as drug-free transfersome gel and local lignocaine patches have been shown to be effective in controlling pain due to OA. However, they have been studied in relatively few studies and currently are not recommended for general use.
15
Abhishek, Abhishek, and Michael Doherty. Clinical features of calcium pyrophosphate crystal deposition. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0050.
Full textAbstract:
Calcium pyrophosphate deposition (CPPD) occurs in the elderly, and is commonly asymptomatic. However, it can cause acute calcium pyrophosphate (CPP) crystal arthritis, chronic CPP crystal inflammatory arthritis, and is frequently present in joints with osteoarthritis (OA). Acute CPP crystal arthritis presents with rapid onset of acute synovitis, which frequently affects the knees, wrists, shoulders, and elbows. It can mimic sepsis in the elderly, and may require hospital admission. Patients with CPPD plus OA may have more inflammatory signs and symptoms (e.g. joint swelling, stiffness) than those with OA alone. Additionally, patients with CPPD plus OA may also have intermittent attacks of acute CPP crystal arthritis. Some patients with CPPD may have more chronic inflammatory joint involvement and are classified as chronic CPP crystal inflammatory arthritis. This chapter describes the clinical features and differential diagnosis of common clinical manifestations of CPPD and outlines some of its rarer manifestations.
16
Wyatt, Laura A., and Michael Doherty. Morphological aspects of pathology. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199668847.003.0003.
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Osteoarthritis (OA) is the commonest condition to affect synovial joints, but although any synovial joint can be affected, most studies of pathology relate to large joints (knees and hips). OA involves the whole joint and pathological alterations typically occur in all joint tissues. Established OA is characterized by a mixture of tissue loss and new tissue production resulting in focal loss of articular hyaline cartilage together with bone remodelling and osteophyte formation. Articular cartilage may show increased thickness in the earliest stages of OA with increased numbers of hypertrophic chondrocytes, followed by progressive decline in matrix components, thickness, and chondrocyte number. Surface fibrillation and vertical clefts become evident in mid- to end-stage OA and eventual complete loss of cartilage can occur, predominantly in maximum load-bearing regions, with subsequent eburnation and furrowing of bone. Bone remodelling may lead to alteration of bone shape and variable trabecular thickness in subchondral bone, whilst subchondral microfractures may result in localized osteonecrosis, fibrosis, and ‘cysts’. Endochondral ossification of new fibrocartilage produced predominantly at the joint margin produces characteristic bony osteophytes. The synovium shows areas of hyperplasia with varying amounts of lymphocyte aggregates and inclusion of osteochondral ‘loose’ bodies, and the outer fibrous capsule thickens to help stabilize the compromised joint. Synovial fluid increases in volume but decreases in viscosity. Periarticular changes include type II muscle atrophy and enthesophytes.