Associations of pain sensitivity and conditioned pain modulation with physical activity: findings from the Multicenter Osteoarthritis Study (MOST).

OBJECTIVE: Individuals with chronic pain due to knee osteoarthritis (OA) are insufficiently physically active, and alterations of facilitatory and inhibitory nociceptive signaling are common in this population. Our objective was to examine the association of these alterations in nociceptive signaling with objective accelerometer-based measures of physical activity in a large observational cohort. DESIGN: We used data from the Multicenter Osteoarthritis Study. Measures of peripheral and central pain sensitivity included pressure pain threshold at the knee and mechanical temporal summation at the wrist, respectively. The presence of descending pain inhibition was assessed by conditioned pain modulation (CPM). Physical activity was quantitatively assessed over 7 days using a lower back-worn activity monitor. Summary metrics included steps/day, activity intensity, and sedentary time. Linear regression analyses were used to evaluate the association of pain sensitivity and the presence of descending pain inhibition with physical activity measures. RESULTS: Data from 1873 participants was analyzed (55.9% female, age = 62.8 ±â€¯10.0 years). People having greater peripheral and central sensitivity showed lower step counts. CPM was not significantly related to any of the physical activity measures, and none of the exposures were significantly related to sedentary time. CONCLUSIONS: In this cohort, greater peripheral and central sensitivity were associated with reduced levels of objectively-assessed daily step counts. Further research may investigate ways to modify or treat heightened pain sensitivity as a means to increase physical activity in older adults with knee OA.

Gait Alterations and Association With Worsening Knee Pain and Physical Function: A Machine Learning Approach With Wearable Sensors in the Multicenter Osteoarthritis Study.

OBJECTIVE: The objective of this study was to identify gait alterations related to worsening knee pain and worsening physical function, using machine learning approaches applied to wearable sensor-derived data from a large observational cohort. METHODS: Participants in the Multicenter Osteoarthritis Study (MOST) completed a 20-m walk test wearing inertial sensors on their lower back and ankles. Parameters describing spatiotemporal features of gait were extracted from these data. We used an ensemble machine learning technique ("super learning") to optimally discriminate between those with and without worsening physical function and, separately, those with and without worsening pain over two years. We then used log-binomial regression to evaluate associations of the top 10 influential variables selected with super learning with each outcome. We also assessed whether the relation of altered gait with worsening function was mediated by changes in pain. RESULTS: Of 2,324 participants, 29% and 24% had worsening knee pain and function over two years, respectively. From the super learner, several gait parameters were found to be influential for worsening pain and for worsening function. After adjusting for confounders, greater gait asymmetry, longer average step length, and lower dominant frequency were associated with worsening pain, and lower cadence was associated with worsening function. Worsening pain partially mediated the association of cadence with function. CONCLUSION: We identified gait alterations associated with worsening knee pain and those associated with worsening physical function. These alterations could be assessed with wearable sensors in clinical settings. Further research should determine whether they might be therapeutic targets to prevent worsening pain and worsening function.

Association of mechanical temporal summation of pain with muscle co-contraction during walking in people with knee osteoarthritis.

BACKGROUND: People with knee osteoarthritis walk with excessive muscle co-contraction that can accelerate disease progression. Central pain sensitization is common in people with knee osteoarthritis and may be related to walking patterns. The objective of this study was to examine the relation of central pain sensitization with muscle co-contraction during walking in people with knee osteoarthritis. METHODS: This study reports secondary analysis from baseline data of two clinical trials (n = 90 participants with knee osteoarthritis). The presence of central pain sensitization was measured by mechanical temporal summation at the patella and the wrist. Quadriceps and hamstrings activation was assessed using surface electromyography during walking at self-selected and fast paces. Muscle co-contraction indices for vastus medialis-medial hamstrings and vastus lateralis-lateral hamstrings muscle pairs were calculated during stance phases. Co-contraction outcomes were compared between people with and without mechanical temporal summation at each site, adjusting for age, sex, and body mass index. FINDINGS: People with mechanical temporal summation at the knee had greater vastus lateralis-lateral hamstrings co-contraction while walking at a fast pace (P = 0.04). None of the other differences was statistically significant, but the overall trends and effect sizes indicated greater co-contraction in people with temporal summation at the knee irrespective of gait phase, walking speed, or muscle pairs. INTERPRETATION: Central pain sensitization, assessed as mechanical temporal summation at the knee, is related to greater knee muscle co-contraction during fast walking in people with knee osteoarthritis. Thus, mitigating central sensitization may be an interventional target to reduce muscle co-contraction for people with knee osteoarthritis.

Association of tibial acceleration during walking to pain and impact loading in adults with knee osteoarthritis.

BACKGROUND: Higher impact loading during walking is implicated in the pathogenesis of knee osteoarthritis. Accelerometry enables the measurement of peak tibial acceleration outside the laboratory. We characterized the relations of peak tibial acceleration to knee pain and impact loading during walking in adults with knee osteoarthritis. METHODS: Adults with knee osteoarthritis reported knee pain then walked at a self-selected speed on an instrumented treadmill for 3 min with an ankle-worn inertial measurement unit. Ground reaction forces and tibial acceleration data were sampled for 1 min. Vertical impact peaks, and average and peak instantaneous load rates were determined and averaged across 10 steps. Peak tibial acceleration was extracted for all steps and averaged. Pearson's correlations and multiple linear regression analyses assessed the relation of peak tibial acceleration to pain and impact loading metrics, independently and after controlling for gait speed and pain. FINDINGS: Higher peak tibial acceleration was associated with worse knee pain (r = 0.39; p = 0.01), and higher vertical average (r = 0.40; p = 0.01) and instantaneous (r = 0.46; p = 0.004) load rates. After adjusting for gait speed and pain, peak tibial acceleration was a significant predictor of vertical average (R2 = 0.33; p = 0.003) and instantaneous (R2 = 0.28; p = 0.02) load rates, but not strongly associated with vertical impact peak. INTERPRETATIONS: Peak tibial acceleration during walking is associated with knee pain and vertical load rates in those with knee osteoarthritis. Clinicians can easily access measures of peak tibial acceleration with wearable sensors equipped with accelerometers. Future work should determine the feasibility of improving patient outcomes by using peak tibial acceleration to inform clinical management.

Sitting may increase risk for radiographic incidence and progression of knee osteoarthritis over 2 years: Data from a large cohort study.

OBJECTIVES: To examine the association of leisure-time sitting with radiographic incidence and progression of knee osteoarthritis (OA) over 2 years, and to determine whether worktime sitting modifies this association. METHODS: We included adults with or at high risk for knee OA who enroled in the Osteoarthritis Initiative (OAI). Participants reported leisure-time sitting (≤4 vs. >4 h/day) and worktime sitting (frequent vs. infrequent) at enrolment, and had bilateral knee radiographs at enrolment and 2 years later. Our outcome, radiographic knee OA incidence/progression (yes/no), was defined as any increase in Kellgren-Lawrence grade over 2 years. We examined the association of leisure-time sitting (≤4 vs. >4 h/day) with risk of radiographic knee OA incidence/progression using binary linear regression, adjusting for potential confounders. We stratified by worktime sitting (frequent vs. infrequent) and repeated our analysis. RESULTS: We included 4254 adults (mean age 61 years; 58% women; mean body mass index 29 kg/m2 ) who contributed a total of 8127 knees. Adults with >4 h/day of leisure-time sitting had 25% higher risk (adjusted risk ratio [RR] 1.25, 95% confidence interval [95% CI] 1.08-1.50) for radiographic knee OA incidence/progression compared with adults with ≤4 h/day of leisure-time sitting (referent group). Importantly, this association was intensified (RR 1.60, 95% CI 1.19-2.33) among adults with frequent worktime sitting, but was attenuated (RR 1.11, 95% CI 0.89-1.39) among adults with infrequent worktime sitting. CONCLUSIONS: Higher leisure-time sitting (>4 h/day) may be associated with greater risk for radiographic knee OA incidence/progression over 2 years. Furthermore, this association was intensified among adults who also reported frequent worktime sitting.

Hip Abductor Weakness and Its Association With New or Worsened Knee Pain: Data From the Multicenter Osteoarthritis Study.

OBJECTIVE: Hip abductors, important for controlling pelvic and femoral orientation during gait, may affect knee pain. Our objective was to evaluate the relation of hip abductor strength to worsened or new-onset frequent knee pain. Given previously noted associations of knee extensor strength with osteoarthritis in women, we performed sex-specific analyses. METHODS: We used data from the Multicenter Osteoarthritis study. Hip abductor and knee extensor strength was measured. Knee pain was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire and a question about frequent knee pain at baseline (144-month visit), and 8, 16, and 24 months thereafter. Knee pain outcomes were worsened knee pain (2-point increase in WOMAC pain) and incident frequent knee pain (answering yes to the frequent knee pain question among those without frequent knee pain at baseline). Leg-specific analyses tested hip abductor strength as a risk factor for worsened and new frequent knee pain, adjusting for potential covariates. Additionally, we stratified by knee extensor strength (high versus low). RESULTS: Among women, compared to the highest quartile of hip abductor strength, the lowest quartile had 1.7 (95% confidence interval [95% CI] 1.1-2.6) times the odds of worsened knee pain; significant associations were limited to women with high knee extensor strength (odds ratio 2.0 [95% CI 1.1-3.5]). We found no relation of abductor strength to worsening knee pain in men or with incident frequent knee pain in men or women. CONCLUSION: Hip abductor weakness was associated with worsening knee pain in women with strong knee extensors, but not with incident frequent knee pain in men or women. Knee extensor strength may be necessary, but not sufficient, to prevent pain worsening.

Relation of Temporal Asymmetry During Walking to Two-Year Knee Pain Outcomes in Those With Mild-to-Moderate Unilateral Knee Pain: An Exploratory Analysis From the Multicenter Osteoarthritis Study.

OBJECTIVE: We aimed to explore the cross-sectional relation of unilateral knee pain severity and temporal asymmetry during walking and to determine relations of temporal asymmetry during walking to 2-year changes in ipsilateral and contralateral knee pain in those with mild-to-moderate unilateral knee pain. METHODS: The Multicenter Osteoarthritis Study is a prospective cohort study of adults with or at risk for knee osteoarthritis. The current study included participants with unilateral knee pain. Gait was assessed during self-selected and fast walking at baseline. Knee pain was assessed at baseline and 2 years. We calculated limb symmetry indices (LSIs; nonpainful limb/painful limb × 100) for stance, single-limb support time, and double-limb support time, then examined their relations to unilateral knee pain severity, incident contralateral knee pain, and persistent ipsilateral knee pain. RESULTS: Unilateral knee pain severity was not associated with temporal asymmetry during self-selected or fast walking. At 2 years, 17.1% of participants had incident contralateral knee pain and 51.4% had persistent ipsilateral knee pain. For self-selected walking, greater LSIs (i.e., longer time on the nonpainful limb) for stance and single-limb support time were associated with decreased odds of incident contralateral knee pain. Measures of temporal asymmetry were not associated with persistent ipsilateral knee pain, except for single-limb support time during fast walking. CONCLUSION: For those with unilateral knee pain, temporal asymmetry during walking is not associated with pain severity. However, select measures of stance and single-limb support time during self-selected and fast walking relate to longitudinal knee pain outcomes.

Magnetic Resonance Imaging-Defined Osteoarthritis Features and Anterior Knee Pain in Individuals With, or at Risk for, Knee Osteoarthritis: A Multicenter Study on Osteoarthritis.

OBJECTIVE: The lack of strong association between knee osteoarthritis (OA) structural features and pain continues to perplex researchers and clinicians. Evaluating the patellofemoral joint in addition to the tibiofemoral joint alone has contributed to explaining this structure-pain discordance, hence justifying a more comprehensive evaluation of whole-knee OA and pain. The present study, therefore, was undertaken to evaluate the association between patellofemoral and tibiofemoral OA features with localized anterior knee pain (AKP) using 2 study designs. METHODS: Using cross-sectional data from the Multicenter Osteoarthritis Study, our first approach was a within-person, knee-matched design in which we identified participants with unilateral AKP. We then assessed magnetic resonance imaging (MRI)-derived OA features (cartilage damage, bone marrow lesions [BMLs], osteophytes, and inflammation) in both knees and evaluated the association of patellofemoral and tibiofemoral OA features to unilateral AKP. In our second approach, MRIs from 1 knee per person were scored, and we evaluated the association of OA features to AKP in participants with AKP and participants with no frequent knee pain. RESULTS: Using the first approach (n = 71, 66% women, mean ± SD age 69 ± 8 years), lateral patellofemoral osteophytes (odds ratio [OR] 5.0 [95% confidence interval (95% CI) 1.7-14.6]), whole-knee joint effusion-synovitis (OR 4.7 [95% CI 1.3-16.2]), and infrapatellar synovitis (OR 2.8 [95% CI 1.0-7.8]) were associated with AKP. Using the second approach (n = 882, 59% women, mean ± SD age 69 ± 7 years), lateral and medial patellofemoral cartilage damage (prevalence ratio [PR] 2.3 [95% CI 1.3-4.0] and PR 1.9 [95% CI 1.1-3.3], respectively) and lateral patellofemoral BMLs (PR 2.6 [95% CI 1.5-4.7]) were associated with AKP. CONCLUSION: Patellofemoral but not tibiofemoral joint OA features and inflammation were associated with AKP.

Relationship of Patellofemoral Osteoarthritis to Changes in Performance-based Physical Function Over 7 Years: The Multicenter Osteoarthritis Study.

OBJECTIVE: To determine the relationship of patellofemoral osteoarthritis (PFOA) to changes in performance-based function over 7 years. METHODS: There were 2666 participants (62.2 ± 8.0 yrs, BMI 30.6 ± 5.9 kg/m2, 60% female) from the Multicenter Osteoarthritis Study with knee radiographs at baseline who completed repeated chair stands and a 20-meter walk test (20MWT) at baseline, 2.5, 5, and 7 years. Generalized linear models assessed the relation of radiographic PFOA and radiographic PFOA with frequent knee pain to longitudinal changes in performance-based function. Analyses were adjusted for age, sex, BMI, tibiofemoral OA, and injury/surgery. RESULTS: Linear models demonstrated a significant group-by-time interaction for the repeated chair stands (P = 0.04) and the 20MWT (P < 0.0001). Those with radiographic PFOA took 1.01 seconds longer on the repeated chair stands (P = 0.02) and 1.69 seconds longer on the 20MWT (P < 0.0001) at 7 years compared with baseline. When examining the relation of radiographic PFOA with frequent knee pain to performance-based function, there was a significant group-by-time interaction for repeated chair stands (P = 0.05) and the 20MWT (P < 0.0001). Those with radiographic PFOA with frequent knee pain increased their time on the repeated chair stands by 1.12 seconds (P = 0.04) and on the 20MWT by 1.91 seconds (P < 0.0001) over 7 years. CONCLUSION: Individuals with radiographic PFOA and those with radiographic PFOA with frequent knee pain have worsening of performance-based function over time. This knowledge may present opportunities to plan for early treatment strategies for PFOA to limit functional decline over time.

The Branching and Innervation Pattern of the Radial Nerve in the Forearm: Clarifying the Literature and Understanding Variations and Their Clinical Implications.

BACKGROUND: This study attempted to clarify the innervation pattern of the muscles of the distal arm and posterior forearm through cadaveric dissection. METHODS: Thirty-five cadavers were dissected to expose the radial nerve in the forearm. Each muscular branch of the nerve was identified and their length and distance along the nerve were recorded. These values were used to determine the typical branching and motor entry orders. RESULTS: The typical branching order was brachialis, brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, supinator, extensor digitorum, extensor carpi ulnaris, abductor pollicis longus, extensor digiti minimi, extensor pollicis brevis, extensor pollicis longus and extensor indicis. Notably, the radial nerve often innervated brachialis (60%), and its superficial branch often innervated extensor carpi radialis brevis (25.7%). CONCLUSIONS: The radial nerve exhibits significant variability in the posterior forearm. However, there is enough consistency to identify an archetypal pattern and order of innervation. These findings may also need to be considered when planning surgical approaches to the distal arm, elbow and proximal forearm to prevent an undue loss of motor function. The review of the literature yielded multiple studies employing inconsistent metrics and terminology to define order or innervation.

Psychological and Pain Sensitization Characteristics Are Associated With Patellofemoral Osteoarthritis Symptoms: The Multicenter Osteoarthritis Study.

OBJECTIVE: Determine the relation of symptomatic and structural features of patellofemoral osteoarthritis (PFOA) to psychological characteristics and measures of pain sensitization, in older adults with or at risk of knee osteoarthritis (OA). METHODS: This study included 1112 participants from the Multicenter Osteoarthritis Study (713 females, mean age 66.8 ± SD 7.6 yrs, body mass index 29.5 ± 4.8 kg/m2). Participants were grouped based on the presence of PFOA symptoms (anterior knee pain and pain on stairs) and magnetic resonance imaging (MRI) PFOA (full-thickness cartilage lesion with bone marrow lesion): (1) patellofemoral (PF) symptoms with MRI PFOA; (2) PF symptoms without MRI PFOA; (3) MRI PFOA without PF symptoms; and (4) no PF symptoms or MRI PFOA (no PFOA). Relation of PFOA classification to depressive symptoms, catastrophizing, temporal summation (TS) and pressure pain thresholds (PPT) was evaluated using logistic (categorical variables) and linear regression (continuous variables). RESULTS: Compared with no PFOA, those with PF symptoms with or without MRI PFOA had significantly greater odds of depressive symptoms, catastrophizing, and patellar TS (OR range 1.5-2.01), and those with PF symptoms without MRI PFOA had significantly greater odds of wrist TS (OR 1.66). Males with PF symptoms without MRI PFOA had significantly lower pressure PPT at the patella compared with no PFOA and those with MRI PFOA only (no symptoms). There were no significant differences at the wrist for males, or the patella or wrist for females. CONCLUSION: Persons with PFOA symptoms, regardless of MRI PFOA status, are more likely to demonstrate depressive symptoms, catastrophizing, and TS. Males with PFOA symptoms without MRI PFOA demonstrate local hyperalgesia.

Reducing knee pain and loading with a gait retraining program for individuals with knee osteoarthritis: Protocol for a randomized feasibility trial.

Objective: This study aims to 1) determine the feasibility of conducting a full-scale randomized controlled trial (RCT) evaluating the efficacy of a gait retraining program on decreasing knee pain and impact loading in people with knee osteoarthritis, and 2) provide an estimate of treatment effects for a gait retraining program compared to a traditional walking program. Methods: Forty individuals with knee osteoarthritis will be enrolled in this randomized, double-blind, feasibility trial with two parallel groups. Participants will be randomly allocated to a gait retraining program aimed to decrease peak axial acceleration of the lower leg (i.e., tibia) by 20% or a traditional walking program. Both programs involve 8 sessions of walking on a treadmill. Feasibility will be assessed with recruitment, enrollment, and retention rates, and number of adverse events and unanticipated problems. Treatment effects will be estimated with measures of knee pain and impact loading collected at baseline, follow-up (<1 week post-intervention), and retention (≥1 month post-intervention) visits. Knee pain will be evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index and impact loading will be measured during walking with three-dimensional motion analysis. Conclusion: Findings of this study will inform the feasibility of a full-scale RCT investigating the efficacy of a gait retraining program for people with knee osteoarthritis. Trial registration: (NCT04148807).

Mediating Role of Bone Marrow Lesions, Synovitis, Pain Sensitization, and Depressive Symptoms on Knee Pain Improvement Following Substantial Weight Loss.

OBJECTIVE: Massive weight loss leads to marked knee pain reduction in individuals with knee pain, but the reason for the reduction in pain is unknown. This study was undertaken to quantify the contribution of magnetic resonance imaging (MRI)-evidenced changes in pain-sensitive structures, bone marrow lesions (BMLs), and synovitis, and changes in pain sensitization or depressive symptoms, to knee pain improvement after substantial weight loss. METHODS: Morbidly obese patients with knee pain on most days were evaluated before bariatric surgery or medical weight management and at 1-year follow-up for BMLs and synovitis seen on MRI, the pressure pain threshold (PPT) at the patella and the right wrist, depressive symptoms (using the Center for Epidemiologic Studies Depression scale [CES-D]), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain survey. Natural-effects models were used to quantify the extent that achieving a minimum clinically important difference (MCID) of ≥18% on the WOMAC pain scale could be mediated by weight loss-induced changes in BMLs, synovitis, PPT, and depressive symptoms. RESULTS: Of 75 participants, 53.3% lost ≥20% of weight by 1 year. Of these, 75% attained the MCID for pain improvement, compared with 34.3% in those who had <20% weight loss. Mediation analyses suggested that, in those with at least 20% weight loss, the odds of pain improvement increased by 62%, 15%, and 22% through changes in patella PPT, wrist PPT, and CES-D, respectively, but pain improvement was not mediated by MRI changes in BMLs or synovitis. CONCLUSION: Weight loss-induced knee pain improvement is partially mediated by changes in pain sensitization and depressive symptoms but is independent of MRI changes in BMLs and synovitis.

Patient-Reported Outcomes One to Five Years After Anterior Cruciate Ligament Reconstruction: The Effect of Combined Injury and Associations With Osteoarthritis Features Defined on Magnetic Resonance Imaging.

OBJECTIVE: Persistent symptoms and poor quality of life (QoL) are common following anterior cruciate ligament reconstruction (ACLR). We aimed to determine the influence of a combined ACL injury (i.e., concomitant meniscectomy and/or arthroscopic chondral defect at the time of ACLR and/or secondary injury/surgery to ACLR knee) and cartilage defects defined on magnetic resonance imaging (MRI), bone marrow lesions (BMLs), and meniscal lesions on patient-reported outcomes 1 to 5 years after ACLR. METHODS: A total of 80 participants (50 men; mean ± SD age 32 ± 14 years) completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the International Knee Documentation Committee (IKDC) questionnaires as well as a 3T MRI assessment at 1 and 5 years after ACLR. Median patient-reported outcome scores were compared between isolated and combined ACL injuries and with published normative values. Using multivariate regression, we evaluated the association between compartment-specific MRI cartilage, BMLs, and meniscal lesions and patient-reported outcomes at 1 and 5 years. RESULTS: Individuals with a combined injury had significantly worse scores in the KOOS subscale of function in sport and recreation (KOOS sport/rec) and in the IKDC questionnaire at 1 year, and worse scores in the KOOS subscales of pain (KOOS pain), symptoms (KOOS symptoms), and QoL (KOOS QoL) and in the IKDC questionnaire at 5 years compared to those with an isolated injury. Although no feature on MRI was associated with patient-reported outcomes cross-sectionally at 1 year, patellofemoral cartilage defects at 1 year were significantly associated with worse 5-year KOOS symptoms (ß = -9.79, 95% confidence interval [95% CI] -16.67, -2.91), KOOS sport/rec (ß = -7.94, 95% CI -15.27, -0.61), KOOS QoL (ß = -8.29, 95% CI -15.28, -1.29), and IKDC (ß = -4.79, 95% CI -9.34, -0.24) scores. Patellofemoral cartilage defects at 5 years were also significantly associated with worse 5-year KOOS symptoms (ß = -6.86, 95% CI -13.49, -0.24) and KOOS QoL (ß = -11.71, 95% CI -19.08, -4.33) scores. CONCLUSION: Combined injury and patellofemoral cartilage defects shown on MRI are associated with poorer long-term outcomes. Clinicians should be vigilant and aware of individuals with these injuries, as such individuals may benefit from targeted interventions to improve QoL and optimize symptoms.

The Spectrum of Learning and Teaching: The Impact of a Fourth-Year Anatomy Course on Medical Student Knowledge and Confidence.

There is growing demand from accrediting agencies for improved basic science integration into fourth-year medical curricula and inculcation of medical students with teaching skills. The objective of this study was to determine the effectiveness of a fourth-year medical school elective course focused on teaching gross anatomy on anatomical knowledge and teaching confidence. Fourth-year medical student "teacher" participants' gross anatomy knowledge was assessed before and after the course. Students rated their overall perceived anatomy knowledge and teaching skills on a scale from 0 (worst) to 10 (best), and responded to specific knowledge and teaching confidence items using a similar scale. First-year students were surveyed to evaluate the effectiveness of the fourth-year student teaching on their learning. Thirty-two students completed the course. The mean anatomy knowledge pretest score and posttest scores were 43.2 (±22.1) and 74.1 (±18.4), respectively (P < 0.001). The mean perceived anatomy knowledge ratings before and after the course were 6.19 (±1.84) and 7.84 (±1.30), respectively (P < 0.0001) and mean perceived teaching skills ratings before and after the course were 7.94 (±1.24) and 8.53 (±0.95), respectively (P = 0.002). Student feedback highlighted five themes which impacted fourth-year teaching assistant effectiveness, including social/cognitive congruence and improved access to learning opportunities. Together these results suggest that integrating fourth-year medical students in anatomy teaching increases their anatomical knowledge and improves measures of perceived confidence in both teaching and anatomy knowledge. The thematic analysis revealed that this initiative has positive benefits for first-year students.

Step Rate and Worsening of Patellofemoral and Tibiofemoral Joint Osteoarthritis in Women and Men: The Multicenter Osteoarthritis Study.

OBJECTIVE: To determine the association of self-selected walking step rate with worsening of cartilage damage in the patellofemoral (PF) joint and tibiofemoral (TF) joint compartments at a 2-year follow-up visit. METHODS: The Multicenter Osteoarthritis Study (MOST) is a prospective cohort of men and women with or at risk of knee osteoarthritis. Self-selected step rate was measured using an instrumented GAITRite walkway (CIR Systems) at the 60-month visit. Cartilage damage was semiquantitatively graded on magnetic resonance images at the 60- and 84-month visits in the medial and lateral PF and TF compartments. Step rate was divided into quartiles, and logistic regression was used to determine the association of step rate with the risk of worsening cartilage damage in men and women separately. Analyses were adjusted for age, body mass index, and knee injury/surgery. RESULTS: A total of 1,089 participants were included. Mean ± SD age was 66.9 ± 7.5 years, mean ± SD body mass index was 29.6 ± 4.7 kg/m2 , and 62.3% of the participants were women. Women with the lowest step rate had increased risk of lateral PF (risk ratio [RR] 2.1 [95% confidence interval (95% CI) 1.1-3.8]) and TF (RR 1.8 [95% CI 1.1-2.9]) cartilage damage worsening 2 years later compared to those with the highest step rate. Men with the lowest step rate had increased risk of medial TF cartilage damage worsening 2 years later (RR 2.1 [95% CI 1.1-3.9]). CONCLUSION: Lower step rate was associated with increased risk of cartilage damage worsening in the lateral PF and TF compartments in women and worsening medial TF joint damage in men. Future research is necessary to understand the influence of step rate manipulation on joint biomechanics in women and men.

Relation of Patellofemoral Joint Alignment, Morphology, and Radiographic Osteoarthritis to Frequent Anterior Knee Pain: Data from the Multicenter Osteoarthritis Study.

OBJECTIVE: Patellofemoral (PF) alignment and trochlear morphology are associated with PF osteoarthritis (OA) and knee pain, but whether they are associated with localized anterior knee pain is unknown, which is believed to be a symptom specific to PF joint pathology. We therefore aimed to evaluate the relation of PF alignment and morphology, as well as PFOA and tibiofemoral OA, to anterior knee pain. METHODS: The Multicenter Osteoarthritis Study is a cohort study of individuals with, or at risk for, knee OA. We evaluated cross-sectional associations of PF alignment, trochlear morphology, and PF and tibiofemoral radiographic OA, with localized anterior knee pain (defined with a pain map). We used 2 approaches: a within-person knee-matched evaluation of participants with unilateral anterior knee pain (conditional logistic regression), and a cohort approach comparing those with anterior knee pain to those without (binomial regression). RESULTS: With the within-person knee-matched approach (n = 110; 64% women, mean age 70 years, body mass index [BMI] 30.9), PF alignment, morphology, and tibiofemoral OA were not associated with unilateral anterior knee pain. Radiographic PFOA was associated with pain, odds ratio 5.3 (95% confidence interval [95% CI] 1.6-18.3). Using the cohort approach (n = 1,818; 7% of knees with anterior knee pain, 59% women, mean age 68 years, BMI 30.4), results were similar: only PFOA was associated with pain, with a prevalence ratio of 2.2 (95% CI 1.4-3.4). CONCLUSION: PF alignment and trochlear morphology were not associated with anterior knee pain in individuals with, or at risk for, knee OA. Radiographic PFOA, however, was associated with pain, suggesting that features of OA, more so than mechanical features, may contribute to localized symptoms.

Using Cumulative Load to Explain How Body Mass Index and Daily Walking Relate to Worsening Knee Cartilage Damage Over Two Years: The MOST Study.

OBJECTIVE: Knee cartilage damage is often linked to mechanical overloading. However, cartilage requires mechanical load to remain healthy, suggesting that underloading may be detrimental. This study was undertaken to examine knee overloading and underloading by defining cumulative load as the joint effects of body mass index (BMI) and daily walking, and examine the relationship between cumulative load and worsening cartilage damage over 2 years. METHODS: We used data from the Multicenter Osteoarthritis Study. Steps/day, measured by accelerometry, and BMI were calculated at the 60-month visit. Cartilage damage on magnetic resonance imaging was semiquantitatively scored using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) at the 60-month and 84-month visits; worsening damage was defined as increased WORMS between visits. Risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated using binomial regression, with adjustment for potential confounders. RESULTS: Our study included 964 participants, 62% of whom were female, with a mean ± SD age of 66.9 ± 7.5 years. Participants had a mean ± SD BMI of 29.7 ± 4.8 kg/m2 and walked a mean ± SD of 7,153 ± 2,591 steps/day. Participants who walked a moderate number of steps/day (6,000-7,900) or a high number of steps/day (>7,900) and had a high BMI (>31 kg/m2 ) had a greater risk of worsening medial tibiofemoral (TF) damage (RR 2.83 [95% CI 1.46-5.48] and RR 2.61 [95% CI 1.50-4.54], respectively) compared with those who walked similar steps/day and had a low BMI (18-27 kg/m2 ). Participants with a low number of steps/day (<6,000) and a low BMI had a greater risk of worsening medial TF and lateral patellofemoral (PF) damage (RR 2.03 [95% CI 1.06-3.92] and RR 2.28 [95% CI 1.06-4.85], respectively) compared with those who walked a high number of steps/day and had a low BMI. Effect estimates for other compartments of the knee did not reach statistical significance. CONCLUSION: This study provides preliminary evidence that both overloading and underloading may be detrimental to medial TF cartilage, and underloading may be detrimental to lateral PF cartilage.

Slower Walking Speed Is Related to Early Femoral Trochlear Cartilage Degradation After ACL Reconstruction.

Post-traumatic patellofemoral osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR) and early cartilage degradation may be especially common in the femoral trochlear cartilage. Determining the presence of and factors associated with early femoral trochlear cartilage degradation, a precursor to OA, is a critical preliminary step in identifying those at risk for patellofemoral OA development and designing interventions to combat the disease. Early cartilage degradation can be detected using quantitative magnetic resonance imaging measures, such as tissue T2 relaxation time. The purposes of this study were to (i) compare involved (ACLR) versus uninvolved (contralateral) femoral trochlear cartilage T2 relaxation times 6 months after ACLR, and (ii) determine the relationship between walking speed and walking mechanics 3 months after ACLR and femoral trochlear cartilage T2 relaxation times 6 months after ACLR. Twenty-six individuals (age 23 ± 7 years) after primary, unilateral ACLR participated in detailed motion analyses 3.3 ± 0.6 months after ACLR and quantitative magnetic resonance imaging 6.3 ± 0.5 months after ACLR. There were no limb differences in femoral trochlear cartilage T2 relaxation times. Slower walking speed was related to higher (worse) femoral trochlear cartilage T2 relaxation times in the involved limb (Pearson's r: -0.583, p = 0.002) and greater interlimb differences in trochlear T2 relaxation times (Pearson's r: -0.349, p = 0.080). Walking mechanics were weakly related to trochlear T2 relaxation times. Statement of clinical significance: Slower walking speed was by far the strongest predictor of worse femoral trochlear cartilage health, suggesting slow walking speed may be an early clinical indicator of future patellofemoral OA after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:645-652, 2020.