Early identification of a “pre-arthritis” stage among athletes who have had knee injuries may facilitate simple modifications of activities that can reverse the risk of the disease and prevent the need for surgery.

Scott Dye, MD, says technetium bone scans can enable practitioners to detect a loss of osseous homeostasis in the knees of athletes who have had sports-related injuries that may increase their risk of developing arthritis in the knee. Dr. Dye says clinicians can make this early diagnosis with bone scans whereas traditional radiographs and MRI would come up normal.

“(With the use of the bone scan), knees that are ‘at risk’ of developing degenerative arthritis can be identified at the very earliest stage at a time when the osseous pathophysiologic process can be disrupted or aborted so arthritis can actually be prevented,” explains Dr. Dye, who is in practice at the California Pacific Medical Center and is a clinical faculty member at the University of California San Francisco.

One physician says technetium bone scans may help detect a loss of osseous homeostasis in the knees of athletes who have had sports-related injuries.

Dr. Dye says the role of osseous homeostasis is particularly important when it comes to preventive measures.
“Most of the arthritis research efforts are currently aimed at curing or preventing the structural damage of cartilage,” notes Dr. Dye. “In my view, the achievement of tissue homeostasis is more important than the achievement of structural normalcy.”

By recognizing this loss of osseous homeostasis years before the development of radiographically identifiable degenerative arthritis, Dr. Dye says clinicians can encourage patients to pursue simple modifications of activities that may help restore osseous homeostasis and reduce the risk of developing arthritis in the knee. He says the key is encouraging patients to load their knees more within their envelope of function or that range of loading which is compatible with the physiological normalcy of a joint.

“Even patients who have established degenerative changes in their knees can safely participate in activities such as swimming and bicycling while maintaining range of motion, muscle strengthening and even endorphin production without overloading the joint as a whole,” points out Dr. Dye.

When it comes to anterior knee pain, Dr. Dye says traditional theories in regard to the structural and biomechanical etiology of chondromalacia patellae and patellar misalignment “are clearly inadequate and, in fact, dangerous (as they encourage) aggressive surgical procedures that often make patients worse.”

Emphasizing Activity Modification When It Is Appropriate
Deborah Brown, APRN, BC, says Dr. Dye’s emphasis on early detection of osseous homeostasis loss and subsequent activity modification provides another example of the benefit in combining a low cost diagnostic study with patient education. Brown notes this can give clinicians important information about the potential for intraarticular healing after a sports-related injury.

“Not everyone needs reconstructive surgery after a sports-related injury,” maintains Brown, an Orthopaedic Nurse Practitioner at the Beth Israel Deaconess Medical Center in Boston. “Often, people who are not engaged in high-level, pivoting type of sports do very well with restructuring their workouts, which could include cycling and swimming.”

Jeff Temple, FNP, OPA-C, says there are other things to consider about Dr. Dye’s theory, such as additional related sports soft tissue injuries of the patient as well as the patient’s gender, age and body dynamics. These variables play an important role when evaluating a patient for the type of therapy that Dr. Dye is recommending, according to Temple.

Temple also questions if an anterior cruciate ligament (ACL) reconstruction can lead to arthritis in the athlete or if the disease would still develop without the surgical procedure.

“I believe both answers are a probable ‘yes’ because an injury to a ‘virgin’ joint increases the chance for any future problems or disability in general,” says Temple, a board certified family nurse practitioner and orthopaedic physician assistant at an orthopaedic clinic in Northern Minnesota.

If patients decide to pursue the aforementioned activity modifications, Brown says follow-up with an orthopaedic provider is still important in these types of situations. Temple says he would recommend these activity modifications to a patient with an ACL injury but only after he considers the current research, parental influence and the patient’s understanding of the options.

“I strongly believe that physical therapy is a definite must,” comments Temple.

FDA Approves Risedronate For Male Osteoporosis
Osteoporosis reportedly affects two million men in the United States and estimates suggest that six times that number are at risk for developing the condition. Now clinicians have another treatment option as risedronate (Actonel, Procter & Gamble Pharmaceuticals and Sanofi-Aventis) has garnered approval from the Food And Drug Administration (FDA) for the indication of male osteoporosis.

The approval was based upon the findings of a two-year, placebo-controlled, multicenter study of 284 male patients with osteoporosis. Researchers reported that a 35 mg/week dosage of risedronate facilitated statistically significant improvements in lumbar spine bone mineral density at six, 12 and 24 months. They were also able to achieve statistically significant reductions in bone turnover markers at three, six, 12 and 24 months.

The study researchers reported that side effects of risedronate included constipation, back pain, arthralgias, influenza and nasopharyngitis.

Actonel was recently approved by the FDA for the treatment of male osteoporosis.

Eugene Mochan, PhD, DO, says the new indication for risedronate is welcome. However, without a comparison study involving other medications, Dr. Mochan says it is hard to determine if risedronate is a better alternative for treating male osteoporosis than existing medications such as alendronate.

Accordingly, one may want to wait for more data to emerge before prescribing the medication, cautions Dr. Mochan, a Professor of Family Medicine and the Associate Dean for Primary Care/Continuing Education at the Philadelphia College of Osteopathic Medicine in Philadelphia.

Andreas Grauer, MD, PhD, a Medical Director with Procter and Gamble Pharmaceuticals, says the FDA approval of the drug will raise awareness that male osteoporosis poses “a substantial clinical and economic burden,” and hopefully facilitate timely diagnosis and treatment.

Dr. Grauer, who planned and approved the aforementioned study, expressed confidence in risedronate’s “proven vertebral and non-vertebral fracture protection, and its rapid onset of action.”
— A.L.

Study Assesses Link Between Type 2 Diabetes And Bone Turnover
Aprospective study of more than 1,600 patients found that higher levels of glycemia and decreased PTH levels contribute to lower bone turnover in female nursing home patients with type 2 diabetes.

The study, which was conducted in Austria and recently published in The Journal of Clinical Endocrinology and Metabolism, looked at 583 elderly females with type 2 DM and 1,081 nursing home residents without diabetes. The study authors performed quantitative bone ultrasound measurements as well as measurements of quadriceps strength and biochemical parameters of mineral metabolism and bone turnover. They assessed for possible hip and other nonvertebral fractures over a two-year timeframe.

While the study confirms some previous findings from other studies, Kathleen Satterfield, DPM, says it does raise some intriguing questions as well. For example, Dr. Satterfield notes that serum calcium levels were higher in those patients with diabetes. While she says there were hints of biochemical reasons for this, Dr. Satterfield says the study data “points to a form of hypoparathyroidism in patients with diabetes” and she posits that may be the true reason for the higher serum calcium levels.

“Further investigation is definitely in order,” urges Dr. Satterfield, a Clinical Associate Professor at the University of Texas Health Science Center at San Antonio.

While patients with type 2 diabetes tend to have higher body mass index (BMI) than those without the disease, excess weight tends to be the cause of the onset of diabetes, notes Dr. Satterfield.

“(In regard to the study), diabetes is actually a positive factor. Excess weight puts extra demands on our skeletal structures and tends to strengthen them,” she says. “Osteoporosis is delayed or denied.”
Dr. Satterfield does see patients who have both type 2 diabetes and osteoporosis. While osteoporosis can manifest in the feet and ankles, Dr. Satterfield says it is more debilitating in the hip joints.
— A.L.

Weight Training May Slow OA Progression
A new study shows patients who participated in regular strength training exercises had a slower development of osteoarthritis (OA) in comparison to patients who were involved with a range-of-motion workout regimen.

The study, which was recently published in Arthritis Care And Research, was compromised of 221 patients who were divided up into the following four groups: those with OA and pain, those with OA and no pain, those with pain and no OA, and those with no pain or OA. The patients were subsequently randomized into a strength training program or a program that emphasized range-of-motion (ROM) exercises for a 30-month period.

Researchers showed that both exercise groups lost lower-extremity strength over the study period but the rate of loss was lower in the strength training group. Progression of joint space narrowing occurred less often in the strength training group and this group also exhibited improved function during the last six months of the study, according to study researchers.

A new study suggests that weight training may be beneficial in slowing the development of OA.

Charlene Morris, PA-C, says one type of exercise is not a cure-all for OA but feels a well-monitored program would benefit a patient with the disease. While weight training is a good form of exercise, OA patients need to be diverse in their workout regiment and seek out other exercise programs they are capable of doing, advises Morris.

“As a former marathoner with severe OA myself, I can personally attest to swimming as a ‘perfect’ sport for a person with painful joints. Beyond that, yoga, T’ai Chi and cycling are gentle, tolerated endeavors that benefit patients,” emphasizes Morris, the Past President of the Association for Family Practice Physicians.
— A.L.

Can Topical NSAIDS Provide Long-Term Relief From Knee Pain?
In a quest to evaluate the long-term efficacy of topical nonsteroidal antiinflammatory drug (NSAID) therapies for OA knee pain, researchers performed a meta-analysis study on this subject. Unfortunately, out of 172 citations, researchers noted that only four studies involved randomized, controlled clinical trials of four weeks or longer in duration.

While the four studies showed that topical NSAIDs have superior pain relief compared to placebo treatments, Nathan Wei, MD, FACP, FACR, says he was stunned by the lack of studies that met the researchers’ criteria.
“I was surprised that out of 172 citations, only four studies fulfilled all the specified criteria. Most topical NSAID trials are not properly designed and need more standardization,” says Dr. Wei, the Clinical Director of the Arthritis and Osteoporosis Center in Frederick, Md.

In regard to a meta-analysis study of this nature, Dr. Wei says it is difficult to take into account all the statistical techniques and variables of each of the studies.

However, this does not mean that Dr. Wei disregards topical NSAIDs, noting that he uses them extensively for his patients with OA. Yet he says the response is difficult to measure due to different perceptions of pain, underlying conditions and other factors of patient variability.

For mild cases of OA, Dr. Wei says one may utilize topical agents by themselves. For more severe OA, he recommends combining them with other forms of medication, like orals or injectables. He says clinicians should also pay heed to patient variability, possible allergic reactions, whether a patient is using anticoagulation therapy, skin conditions and the existence of any open wounds.
— A.L.

In Brief
The University of Arizona’s Program in Integrative Medicine has two new scholarships for its 2008 Fellowship class. For more information, go to www.integrativemedicine.arizona.edu.