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Varying skills take on different types of knee osteoarthritis

Published on 01 October 2009
Source: Arthritis Today

Manchester research team

A new research programme into osteoarthritis led by world expert Professor David Felson is now underway in Manchester. Arthritis Today takes a closer look.

If there’s an effective treatment just around the corner for the six million people in the UK currently suffering from osteoarthritis of the knee it is not likely to be in the form of an exciting new “magic bullet” type drug. Nor is it probable that it will be a “one size fits all” solution either, now it is becoming increasing accepted that osteoarthritis is not one disease but a heterogeneous disorder involving not just cartilage but bone, gait (the way we walk) and inflammation.

Researchers in Manchester, led by Boston-based world osteoarthritis expert Professor David Felson, are confident that their four-and-a-half year £1.8m Arthritis Research UK-funded programme of work will ultimately result in real benefits for patients with this disabling condition.

As reported in Arthritis Today 144, the multi-disciplinary team is testing the effectiveness of different treatments (known in the medical profession as interventions) on groups of local patients with knee osteoarthritis. These treatments include steroid injections, special shoes and insoles, and knee braces.

While this research may be perceived to lack wow factor, nevertheless, for people with osteoarthritis who for so long have had such little effective treatment or hope of any, the Manchester team believe their approach could offer a real step forward.

What makes the research novel and of particular significance is that the groups of patients trying out these types of treatment have been specifically targeted as having three distinctly different types of osteoarthritis. Rather than being classified as having, if you like, generic osteoarthritis of the knee, they are grouped into three categories: those who have patellofemoral osteoarthritis (affecting the knee cap), those with medial osteoarthritis (inside the knee) and those with so-called effusions of the knee, which causes the knee to swell up.

Pinpoint accurate imaging techniques

The other thing that marks out this programme as different to other UK-based osteoarthritis research is rather than using cartilage degeneration as a measure of disease severity or progression, the Manchester team is using pinpoint-accurate imaging techniques to establish if pain correlates with other important elements in osteoarthritis including bone marrow lesions (areas of bone damage which show up on scans as white blotches) and swelling or fluid on the knee, known as synovitis. “The focus of our research is shifting away from cartilage, towards other targets for treatment studies which have shown to be linked to pain,” explains Dr Terry O’Neill, rheumatologist and epidemiologist at the University of Manchester and one of the leaders of the team.

"We hope to show that structural changes within the knee in response to a treatment correlate with changes in a patient’s pain.”

Treatments being tested offer attractive options to GPs

Colleague Dr Michael Callaghan, physiotherapist and research associate in rehabilitation sciences at the university, accepts that insoles and special shoes, knee braces and steroid injections are hardly groundbreaking, but believes that they will be attractive options to GPs, who often have little practical advice to offer osteoarthritis patients other than weight losspainkillers and exercise.

“We’re not looking at exciting new treatments, but existing treatments, and finding out how they work. General practitioners are happy to use these interventions,” he adds.

All three studies will take advantage of the latest in imaging technologies, using magnetic resonance imaging (MRI) which provides much clearer images of the joint than standard images.

Dr O’Neill is enthusiastic about the prospects for the osteoarthritis programme. “Our group is multidisciplinary, with experts in biomechanics and engineering, radiology, clinical epidemiology, rheumatology and physiotherapy. With this assembled expertise we have a real chance of making an important contribution. This was a project almost waiting to happen, and David Felson was the catalyst who brought the group together.”

Colin Sydney, a 64-year-old osteoarthritis sufferer from Stockport, is a willing guinea pig for the knee brace study, and will be one of the first patients recruited. A former electrician, he attributes his knee osteoarthritis to a lifetime of kneeling and physical work, so that kneeling, going up and down the stairs and walking all now cause him pain.

“I’m very pleased to be taking part in something new and experimental, and if it helps me or others in the same boat then that’s the main thing,” Colin says. “I’m hoping the knee brace will make a big difference to me. Otherwise it’s back to the orthopaedic surgeon.”

The trials

Reflective markers on limbsIn total over 300 men and women will be recruited from the Manchester and Salford areas for participation in the research. They will be recruited from both local hospital clinics and from primary care.

Patients with osteoarthritis of the knee affecting the knee cap (patellofemoral) typically experience pain that is made worse by going up and down stairs, kneeling, squatting and prolonged sitting. The intervention being tested on these patients is a lightweight knee brace which is fitted around the knee cap to give support as the patient walks. The device will be worn by patients for a minimum of three hours a day for 12 weeks. “The theory is that as the brace gives a degree of support to the knee cap, it might also reduce pain and improve function,” says Dr Callaghan.

Patients with medial knee osteoarthritis, the most common type, which affects the inside of the knee joint, between the femur and the tibia, will be asked to wear various insoles/shoes to see if they help their pain. They will be asked also to walk on a pressure platform that measures the pressure on their knees.

“Because of the way we walk we have constant loading on the inside of the knee joint, and this is linked with the progression of disease,” says Dr Rich Jones, senior lecturer in clinical biomechanics at Salford University, who is leading the study. “We’re looking at how the knee moves and why it moves in a particular way, using 3D gait analysis to look at the hip, ankle and foot, as well as the knee.”

A significant proportion of patients with knee osteoarthritis have inflammation (known as synovitis). In the third study patients with inflammation in their knees will have intraarticular steroid injections performed. The study will provide information about how steroids work in osteoarthritis and also the factors that predict a good outcome – in other words who will do best from steroid injections.

A key component of the research programme is the plan to study in detail the images obtained from the participants. Experts in the University of Manchester who are collaborating with the osteoarthritis team have developed computer-based tools which can examine images in detail and allow accurate and precise measurements of the component structures – the application of these tools will allow much more information to be gleaned than by simple visualisation of the images.

Reflective markers placed on the individual limb allow infrared cameras to track them as the individual moves in the gait laboratory.

A new era for osteoarthritis treatment

Rubbing hands

Arthritis Research UK launches its fourth national centre of excellence this month. The team behind the new tissue engineering centre predict that within five years, using keyhole surgery they will be able to treat people with osteoarthritis with adult stem cells to regenerate damaged joints, delaying the need for joint replacement.

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