Treatment of Sports and Injury-Related Patients

 A report on how people suffering with symptomatic Osteoarthritis (OA) of the knee may still be able to remain active in sport was published in the Clinical Journal of Sport Medicine: Clinical Journal of Sport Medicine: January 2016 - Volume 26 - Issue 1 - p 1–11 doi: 10.1097/JSM.0000000000000274 

The authors – who are all members of AMSSM, an organisation which represents over 2100 nonsurgical sports medicine physicians - carried out a detailed meta-analysis (a process where the results of many different studies are pooled and then subjected to sensitive statistical testing) of all relevant clinical investigations relating to the use of Viscosupplementation published between 1960 and 2014.  

Viscosupplementation is an internationally recognised treatment modality for Osteoarthritis of the knee. The process involves injecting Hyaluronic Acid (HA) or Sodium Hyaluronate as it is often referred to, directly into the affected joint. HA is a viscous fluid which closely resembles the natural synovial fluid found in all healthy articular joints.

Osteoarthritis is a disabling disease that produces severe morbidity, and the most commonly reported symptoms of pain and restricted motion within the joint result in reduced physical activity. As OA develops, the normal consistency of the synovial fluid is degraded, and the lubricating and shock absorbing properties that this fluid provides within the joint is lost. By re-introducing a synthetic substitute such as HA, the normal environment within the joint is restored, and symptoms such as pain are reduced, along with functional improvement and a return to a more normal range of motion.
Although there have been quite a number of meta-analytic studies examining the benefits of Viscosupplementation for treating Knee OA published previously - with varying conclusions as to whether the intervention has any merit - this recently published work utilised more clinically relevant methodology. In many studies seeking to determine how effective Viscosupplementation is for treating OA, participating patients are allocated to discrete treatment groups – depending on whether they receive the study intervention or a “control” intervention or in some cases a placebo – and the before and after measurements are analysed on a between groups basis, whereby the average change between groups is subjected to statistical testing to determine if there is any “statistically significant” difference between interventions. 

The study by AMSSM members, however, based its conclusions on the evaluation of treatment effect by examining the number of subjects within a treatment arm that met the Outcome Measures in Rheumatoid Arthritis Clinical Trials – Osteoarthritis Research Society International (OMERACT-OARSI) criteria. Using this model, each patient’s response to the treatment they received, be it study intervention, or a control intervention, or a placebo, was measured against pre-determined criteria which are validated to demonstrate if a treatment delivers meaningful change in a patient’s condition. The authors conclude:

“In light of the aforementioned results of our NMA [Network Meta-analysis], the AMSSM recommends the use of HA for the appropriate patients with knee OA. ...  We RECOMMEND viscosupplementation injections for K-L [Kellgren-Lawrence] grade II-III [mild to moderate] knee osteoarthritis in those patients above the age of 60 years based on HIGH quality evidence demonstrating benefit using OMERACT-OARSI Responder Rating. … We SUGGEST viscosupplementation injections for knee osteoarthritis for those under the age of 60 years based on MODERATE quality evidence due to response of treatment in those over 60 years of age.”