Tuina Intervention in Sodium Monoiodoacetate Injection-Induced Rat Model of Knee Osteoarthritis.

Knee osteoarthritis (KOA), a common degenerative joint disorder, is characterized by chronic pain and disability, which can progress to irreparable structural damage of the joint. Investigations into the link between articular cartilage, muscles, synovium, and other tissues surrounding the knee joint in KOA are of great importance. Currently, managing KOA includes lifestyle modifications, exercise, medication, and surgical interventions; however, the elucidation of the intricate mechanisms underlying KOA-related pain is still lacking. Consequently, KOA pain remains a key clinical challenge and a therapeutic priority. Tuina has been found to have a regulatory effect on the motor, immune, and endocrine systems, prompting the exploration of whether Tuina could alleviate KOA symptoms, caused by the upregulation of inflammatory factors, and further, if the inflammatory factors in skeletal muscle can augment the progression of KOA. We randomized 32 male Sprague Dawley (SD) rats (180-220 g) into four groups of eight animals each: antiPD-L1+Tuina (group A), model (group B), Tuina (group C), and sham surgery (group D). For groups A, B, and C, we injected 25 µL of sodium monoiodoacetate (MIA) solution (4 mg MIA diluted in 25 µL of sterile saline solution) into the right knee joint cavity, and for group D, the same amount of sterile physiological saline was injected. All the groups were evaluated using the least to most stressful tests (paw mechanical withdrawal threshold, paw withdrawal thermal latency, swelling of the right knee joint, Lequesne MG score, skin temperature) before injection and 2, 9, and 16 days after injection.

Non-operative management of shoulder osteoarthritis: Current concepts.

Glenohumeral osteoarthritis (OA) is one of the most common causes of shoulder pain. Conservative treatment options include physical therapy, pharmacological therapy, and biological therapy. Patients with glenohumeral OA present shoulder pain and decreased shoulder range of motion (ROM). Abnormal scapular motion is also seen in patients as adaptation to the restricted glenohumeral motion. Physical therapy is performed to (1) decrease pain, (2) increase shoulder ROM, and (3) protect the glenohumeral joint. To decrease pain, it should be assessed whether the pain appears at rest or during shoulder motion. Physical therapy may be effective for motion pain rather than rest pain. To increase shoulder ROM, the soft tissues responsible for the ROM loss need to be identified and targeted for intervention. To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended. Administration of pharmacological agents is the major part next to physical therapy in the conservative treatment. The main aim of pharmacological treatment is the reduction of pain and diminution of inflammation in the joint. To achieve this aim, non-steroidal anti-inflammatory drugs are recommended as first-line therapy. Additionally, the supplementation of oral vitamin C and vitamin D can help to slow down cartilage degeneration. Depending on the individual comorbidities and contraindications, sufficient medication with good pain reduction is thus possible for each patient. This interrupts the chronic inflammatory state in the joint and, in turn, enables pain-free physical therapy. Biologics such as platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells have gathered increased attention. Good clinical outcomes have been reported, but we need to be aware that these options are helpful in decreasing shoulder pain but neither stopping the progression nor improving OA. Further evidence of biologics needs to be obtained to determine their effectiveness. In athletes, a combined approach of activity modification and physical therapy can be effective. Oral medications can provide patients with transient pain relief. Intra-articular corticosteroid injection, which provides longer-term effects, must be used cautiously in athletes. There is mixed evidence for the efficacy of hyaluronic acid injections. There is still limited evidence regarding the use of biologics.

Efficacy of combined ozone and platelet-rich-plasma treatment versus platelet-rich-plasma treatment alone in early stage knee osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic disease most often occurring in knee joints, leading to pain of varying severity and deterioration in daily living activities. OBJECTIVE: To compare efficacy of platelet-rich-plasma (PRP) versus PRP in combination with ozone gas injection in patients with early stage knee OA. METHODS: Retrospective data of patients who received PRP alone (n= 45) or combined treatment (PRP + ozone, n= 35) injection was analyzed. Patients were evaluated using the visual analogue scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. RESULTS: In both PRP alone and combined treatment groups, post-treatment VAS and WOMAC scores at month 1, month 3, and month 6 showed a significant reduction compared to pre-treatment scores (p< 0.001). Physical function and total WOMAC scores as well as VAS scores at post-treatment month 3 were significantly lower in the combined treatment group compared to the PRP alone group. Moreover, in the combined treatment group, VAS scores on Day 10 and hyper-inflammation at the injection site was significantly lower than the PRP alone group. CONCLUSION: In general, similar efficacy was observed between treatment with PRP alone and treatment with PRP in combination with ozone. However, patients receiving ozone treatment are less likely to experience post-injection pain and are more likely to recover faster when compared to patients receiving PRP treatment alone.

Predictors of Pain and Discomfort Associated with CT Arthrography of the Shoulder.

RATIONALE AND OBJECTIVES: The objective of this study was to investigate predictors of pain associated with computed tomographic arthrography of the shoulder. MATERIALS AND METHODS: Before shoulder arthrography, all participants were assessed with the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization Quality of Life Short Version Instrument (WHOQOL-BREF). The participants were nonrandomized into two groups: the anesthesia group, who underwent prior local infiltration anesthesia before shoulder arthrography, and the nonanesthesia group, who did not undergo prior local infiltration anesthesia. The pain levels at intraprocedure, at 1, 2, 6, and 12 hours, and at 1 and 2 days after injection were assessed by using a visual analog scale. Univariate and multivariate generalized linear model analyses were conducted. RESULTS: Sixty participants in the anesthesia group and 60 participants in the nonanesthesia group were included. The pain level at intraprocedure (3.37 ± 1.94 in the anesthesia group and 3.20 ± 1.34 in the nonanesthesia group) was the highest of the whole pain course. The psychological domain (P = .0013) of WHOQOL-BREF, gender (P = .042), body mass index (P = .0001), and the total number of reinsertion and redirection of needle (P< .0001) were independent predictors of arthrography-related pain. CONCLUSIONS: The pain associated with shoulder computed tomographic arthrography depends on the psychological domain of WHOQOL-BREF, gender, body mass index, and the total number of reinsertion and redirection of needle.

Mycobacterium chelonae hand infection after steroid injection in a patient with rheumatoid arthritis receiving long-term linezolid therapy.

A 66-year-old multimorbid man with rheumatoid arthritis developed an infection after a steroid injection in the hand. Mycobacterium chelonae was cultured 1-month after presentation. In the mean time, his third finger had been amputated. Further treatment was based on preliminary susceptibility testing and the American Thoracic Society guidelines. No regression of the infection was observed before the addition of linezolid (600 mg×1/day) to a combination antimicrobial therapy also consisting of clarithromycin (500 mg×2/day) and moxifloxacin (400 mg×1/day), even though two methods of susceptibility testing, the E-test and broth microdilution, had shown susceptibility to other antimicrobial drugs. The healing was complete 12 months after presentation. There were no serious side effects observed with the use of linezolid in reduced dosage of 600 mg×1/day for a duration of 9 months.

Septic arthritis of both knees following intra-articular injection of petrol.

A 70 years old man was referred to our center with bilateral knee arthritis following intra-articular petrol injection. Because of previous antibiotics use gram stain and culture were negative. Septic arthritis was diagnosed and antibiotics and drainage were started. After 2 years he improved eventually and was able to walk. But, some movement limitation remained.

An unusual cause of factitious arthritis.

Septic arthritis and toxic synovitis are clinical conditions that can develop in association with various causes and involve symptoms such as pain, swelling, redness, sensitivity and restricted movement in the joint. A 42-year-old male presented to the emergency department with severe joint pain and nausea after injecting a 1-cc mixture of turpentine oil, eucalyptus oil, mint oil and thyme oil, which he purchased from an alternative medicine store, into his right knee with a syringe because of chronic knee pain. Ballottement and sensitivity were present at physical examination. Knee puncture yielded 60 cc of cloudy fluid. There was no growth in the material obtained. Improvement was observed following subsequent arthroscopic washing of the joint space and IV antibiotherapy, and the patient was discharged on day 21 of hospitalization with oral antibiotic and analgesic therapy. Intra-articular injection of foreign bodies into the knee joint space for therapeutic purposes, as in this case report, is a very rare occurrence, but may lead to potentially complicated arthritis.

[Medical clowns--dream doctors as important team members in the treatment of young children with juvenile idiopathic arthritis].

Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. An intra-articular corticosteroid injection (IAS), one of the cornerstones of treatment for this disease, is usuaLLy associated with anxiety and pain. A major part of the success in reducing the pain is associated with the level of the child's anxiety even before starting the procedure. This is a case study of a 5 year old girl with JIA, who has been treated with an intra-articular corticosteroid injection to her knee joint. The case study is presented from the point of view of the medical clown, who is an important integral part of the team of the IAS procedure. In this article we will discuss the participation of medical clowns in the treatment of children in general, and in the IAS procedure in particular. The importance of the subject stems from the fact that it has been proven that the presence of medical clowns significantly alleviates the children's anxiety and pain. This study, as well as others on this subject, shows that we should encourage medical clowns as an integraL part of the treatment of children.

Hypertonic dextrose injections (prolotherapy) for knee osteoarthritis: results of a single-arm uncontrolled study with 1-year follow-up.

OBJECTIVE: The objective of this study was to determine whether prolotherapy, an injection-based complementary treatment for chronic musculoskeletal conditions, improves pain, stiffness, and function in adults with symptomatic knee osteoarthritis (KOA) compared to baseline status. DESIGN: This was a prospective, uncontrolled study with 1-year follow-up. SETTING: The study was conducted in an outpatient setting. PARTICIPANTS: Adults with at least 3 months of symptomatic KOA, recruited from clinical and community settings, participated in the study. INTERVENTIONS: Participants received extra-articular injections of 15% dextrose and intra-articular prolotherapy injections of 25% dextrose at 1, 5, and 9 weeks, with as-needed treatments at weeks 13 and 17. OUTCOME MEASURES: Primary outcome measure was the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC). Secondary outcome measure was the validated Knee Pain Scale (KPS). Tertiary outcome measure was procedure-related pain severity and participant satisfaction. RESULTS: Thirty-six (36) participants (60 ± 8.7 years old, 21 female) with moderate-to-severe KOA received an average of 4.3 ± 0.7 prolotherapy injection sessions over a 17-week treatment period and reported progressively improved scores during the 52-week study on WOMAC and KPS measures. Participants reported overall WOMAC score improvement 4 weeks after the first injection session (7.6 ± 2.4 points, 17.2%), and continued to improve through the 52-week follow-up (15.9 ± 2.5 points, p<0.001, 36.1%). KPS scores improved in both injected (p<0.001) and uninjected knees (p<0.05). Prescribed low-dose opioid analgesia effectively treated procedure-related pain. Satisfaction was high and there were no adverse events. Female gender, age 46-65 years old, and body-mass index of 25 kg/m(2) or less were associated with greater improvement on the WOMAC instrument. CONCLUSIONS: In adults with moderate to severe KOA, dextrose prolotherapy may result in safe, significant, sustained improvement of knee pain, function, and stiffness scores. Randomized multidisciplinary effectiveness trials including evaluation of potential disease modification are warranted to further assess the effects of prolotherapy for KOA.

Procedure-oriented sectional anatomy of the shoulder.

This is the first in a series of papers on procedure-oriented joint anatomy. This paper will review anatomy of the shoulder joint and focus on non-imaging-guided procedures. Needle procedures of the shoulder include glenohumeral, subacromial, and acromioclavicular joint injections; electromyography; trigger point and other intramuscular injections; bicipital tendon sheath injection; suprascapular nerve blocks; and botulinum toxin injections. The accuracy of these non-imaging-guided procedures is reviewed. Complications of these procedures include infection, damage to tendon, and local or systemic response to medication. This paper provides anatomically accurate schematics of the shoulder anatomy relevant to needle procedures. Cross-sectional schematics of the shoulder were drawn as they appear on axial and sagittal projections. Superficial and deep landmarks are highlighted and sources of potential complications. The schematics allow for safer and more accurate non-image-guided needle procedures in the shoulder region.

Effects of knee injection on skeletal muscle metabolism and contractile force in rats.

OBJECTIVE: We tested the hypothesis that intrusion of the knee joint capsule alters quadriceps muscle metabolism and function independently from the damage induced to knee cartilage. METHODS: Adult rats were separated into four groups: intraarticular injections of saline (SAL; n=9); intraarticular injections of papain, a model for osteoarthritis (PIA; n=7); sham injections (SHAM; n=8); and controls (CTL; n=5). 31P magnetic resonance spectroscopy (31P-MRS) was performed after 2 weeks. Spectra were obtained from the left quadriceps: two at baseline, eight during electrical stimulation with simultaneous measurement of contractile force, and 15 during recovery. 31P-MRS data were presented as the ratio of inorganic phosphate (Pi) to phosphocreatine (PCr), concentrations of PCr [PCr], intramuscular pH, and the rates and time constants of PCr breakdown during stimulation and PCr recovery. Intramuscular cytokine concentrations were measured within the quadriceps. Histologic slides of the knees were scored for severity of cartilage damage. RESULTS: The interventional groups produced values of Pi/PCr ratio, [PCr], contractile force and pH that were significantly different from CTL. These changes in muscle function were accompanied by higher concentrations of interleukin-1 observed with PIA and SAL. We did not observe any effect of cartilage damage on muscle function or metabolism. CONCLUSIONS: Knee joint intrusion alters quadriceps muscle metabolism with accelerated depletion of energy stores and fatigue during stimulation. This study demonstrates that needle intrusion into the knee joint results in muscle dysfunction, independently from the extent of cartilage damage.

Supplements and injections for joint disease.

Dietary supplements and single joint treatments are gaining increasing popularity, with evidence of efficacy in randomized controlled trials compared with placebo, and minimal side-effects compared with some more traditional therapies. This article clarifies some of the newer approaches and the science behind them.

The response of rabbit patellar tendons after autologous blood injection.

PURPOSE: Blood is a rich source of growth factors that can stimulate fibrocyte migration and help induce neovascular ingrowth. These properties may be able to stimulate a healing response in chronic degeneration of a tendon (tendonosis). The purpose of this study was to assess the biomechanical and histological effects of autologous blood injection on animal tendons. METHODS: New Zealand white rabbit left side patellar tendons were injected with 0.15 cc of autologous blood. We then compared the mechanical properties and histology to the normal right patellar tendon at 6 and 12 wk. RESULTS: At 6 and 12 wk after the injection, there were no differences in the histology compared with normal tendon tissue, and there were no significant changes in tendon stiffness. Biomechanically, the tendons were not damaged at 6 wk after the injection. By 12 wk, tendons that were injected with blood were significantly (P < 0.014) stronger. CONCLUSION: We found that injecting blood directly into normal tendons appears safe. Further evaluation of this technique would appear indicated.

Articular cartilage is more susceptible to blood induced damage at young than at old age.

OBJECTIVE: It has been shown that cartilage is damaged upon intraarticular hemorrhage. We investigated differences in the susceptibility of cartilage from young adult and old animals to blood induced joint damage in a canine in vivo model. METHODS: Right knees of 6 young adult beagles (aged 2.2 +/- 0.1 yrs) and 6 old beagles (7.4 +/- 0.3 yrs) were intraarticularly injected twice in 4 days with autologous blood. Dogs were killed 4 or 16 days after the first injection and cartilage matrix proteoglycan content and synthesis and collagen damage were determined. RESULTS: Shortly after blood injection (Day 4), proteoglycan synthesis was inhibited and the proteoglycan content of the cartilage was decreased in both groups. However, the degree of the inhibition of proteoglycan synthesis was significantly greater in young adult animals than in old animals. On Day 16 proteoglycan synthesis was increased in both young adult and old cartilage, but more elevated in old cartilage. The proteoglycan content remained decreased in both young adult and old cartilage, but significantly more so in young adult cartilage than in old cartilage. CONCLUSION: Results suggest that intraarticular bleeding influences cartilage metabolism and repair, and that the cartilage of young adult animals is more susceptible to these influences than cartilage of old animals. Differences in the aging of chondrocytes and age related changes in matrix integrity may be involved. Prevention and appropriate treatment of joint bleeding is indicated and this is especially relevant for young adult cartilage.

Septic arthritis caused by treatment resistant Pseudomonas cepacia.

A case of septic arthritis of the knee caused by Pseudomonas cepacia following an intraarticular corticosteroid injection in a patient with a history of osteoarthritis is presented. This is the second report of this agent causing infection in a diarthrodial joint, which proved difficult to eradicate despite in vitro antibiotic sensitivity.