Physical therapy as effective as surgery for meniscal tear

Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows.

In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain.

This finding, presented here at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides "considerable reassurance regarding an initial nonoperative strategy," the investigators report.

Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms," principal investigator Jeffrey Katz, MD, from Brigham and Women's Hospital in Boston, Massachusetts, told Medscape Medical News.

"These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear," Dr. Katz explained. "We hope physicians will use these data to help patients understand their choices."

In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that "these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial."

These results should change practice.

The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity.

In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone.

The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group.

Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups.

At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. The mean between-group difference of 2.4 points was not statistically significant after analysis of covariance. There was also no significant difference between groups in pain improvement or frequency of adverse events.

There was 1 death in each group, and 8 patients in the nonsurgery group and 13 in the surgery group withdrew in the first 6 months of the study.

Patients in the nonsurgery group were allowed to cross over to the surgical group at any time. Within 6 months, 30% of patients did so.

"They were not doing very well," Dr. Katz said. His team is still analyzing the reasons these patients did not benefit from intensive physical therapy.

The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar.

Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don't choose physical therapy. "In the real world, most people want a quick fix" and choose surgery, he noted.

Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises.

He added that "most insurance plans have limits on the number of physical therapy sessions they allow."

Source: http://www.medscape.com/viewarticle/781102?nlid=29464_1301&src=wnl_edit_dail

Green lipped mussels better than fish oil for joint health

Extracts from the New Zealand green lipped mussels may benefit joint mobility and reduce pain more than fish oil supplements, report researchers from Poland.

According to findings published in Rheumatologia, the official journal of the Institute of Rheumatology and the Polish Rheumatological Society, a daily dose of 1.2 grams of a green lipped mussel (Perna canaliculus) produced 'significantly less pain, greater joint mobility and no side effects' in all 25 people taking the supplements for 12 weeks. 

In comparison, a daily dose of 1.2 grams of fish oil, containing 18% EPA and 12% DHA, produced 'pain relief or increased joint mobility', report researchers from the Academic Clinical Hospital in Wroclaw, Poland. This study used the commercial green lipped mussel extract Lyprinol from Pharmalink International, and the study was partly financed by the company.

"Given the potential side effects, large dosages needed and long duration required for fish oil, practitioners could consider stabilised Perna canaliculus oil as a safer and faster acting first-line medication for patients who suffer from osteoarthritis," wrote the researchers.

Eco-mussel

The NZ green lipped mussel, ranked among the top 'eco-friendly seafoods' according to the US environmental agency Blue Ocean Institute's list, is already used as a source of nutraceuticals. The extract, a rich source of iron, betain, and glycoaminoglycans (including chondroitin sulphate) has gained a reputation amongst consumers as a natural product with anti-inflammatory properties - an effect that has been attributed to a body of science to its lipid factions. The majority of green-lipped mussel extracts reportedly retain, to a greater or lesser degree of standardisation, the mussels' natural nutrient profile.

The study

The Polish researchers divided 50 people into two equal groups. One received eight capsules per day of Lyprinol (150 milligrams per capsule) or eight fish oil capsules per day (150 milligrams per capsule) for 12 weeks. The authors of the study reported that all 25 of the subjects who used the mussel oil extract reported significantly less pain, greater joint mobility and no side effects.

The half of the group who were treated with fish oil reported no pain relief or increased joint mobility and 36% reported unpleasant side effects. “In the present study, we observed a surprisingly rapid reduction of clinical symptoms associated with osteoarthritis notable within four weeks and continuous improvement over the 12 weeks of the study,” wrote the researchers.

Source: Rheumatologia Volume 49, Issue 4, Pages 244-252 “Measurement of pain relief resulting from the administration of Perna canaliculus lipid complex PCSO-524 as compared to fish oil for treating patients who suffer from osteoarthritis of knee and/or hip joints”Authors: J. Szechinski, M. Zawadzki