Tx conservador oa medica sur 2015 final

Notas del editor

• #16: together these data indicate that, while synovitis could be affected in early oa, synovial inflammation can also be caused by the breakdown products of the extra cellular matrix produced by mechanical stress and tissuebreakdown enzymes (Figure 1). once cartilage degradation has begun, the synovial cells phagocytose the breakdown products released into the synovial fluid, resulting in the synovial membrane becoming hypertrophic and hyperplasic. these enzymes then activate synovial cells to cause the release of proinflammatory cytokines, collagenases and other hydrolytic enzymes. Consequently, a vicious positivefeedback loop involving cartilage breakdown and synovial inflammation occurs. to counteract this inflammatory response, the synovium and cartilage may produce antiinflammatory cytokines, including IL13 il4, il1ra and il10 (Figure 1). these cytokines have been shown to be spontaneously produced by the synovial membrane and are present in the synovial fluid of patients with oa.61 they decrease the release of PGe2, il1β, tnF and mmPs, and stimulate the production of il1ra and timP.104 additionally, il4 and il13 can inhibit the apoptosis of synoviocytes, thus contributing to sy novial hypertrophy.49 the synovium could—in addition to its effects on cartilage inflammation and breakdown in oa via mmPs and aDamts—be involved in bone matrix remodelling. synovial macrophages can differentiate to form functional osteoclasts capable of bone formation and resorption. Moreover, mature, activated osteoclasts have been found in rapidly destructive oa that are not found in common oa.106 these data show that the synovium has a major role in the osteoclastogenesis of subchondral bone in oa.
• #26: Pooled results of these 44 studies demonstrated statistically significant benefit, with an SMD of 0.49 (95% CI 0.39 to 0.59). This effect size would be considered moderate (Cohen 1977) and was equivalent to a reduction of 12 points (95% CI 10 to 15 points) on a 0 to 100-point VAS pain scale (0 means no pain). Between-study heterogeneity was moderate (I2 = 47%). No significant difference was noted between the SMD extrapolated from change scores and from end of treatment scores (P value 0.77) (I2 = 0%). After exclusion of two studies with extremely outlying results (Huang 2003; Huang 2005), six studies provided data on 1104 participants (Analysis 3.1). Pooled results demonstrated a non-sig- nificant effect (SMD 0.08, 95% CI -0.15 to 0.30). Between-study heterogeneity was moderate (I2 = 43%). No significant difference was noted between change scores and end of treatment scores (P value 0.73) (I2 = 0%).
• #27: Studies providing immediate post-treatment assessments for physical function were similarly classified Analysis 4.2: quadriceps strengthening only (10 studies, 726 participants), lower limb strengthening (13 studies, 1066 participants), combination strengthening and aerobic exercise (10 studies, 1231 participants), walking programmes (three studies, 317 participants) and ’other programmes’ (most Tai Chi or complex non-specific programmes) (10 studies, 915 participants). Each of the treatment content subgroups reported significantly improved physical function. No sig- nificant differences were noted between the various exercise programmes in mean pooled SMD which ranged from 0.27 for ’other programmes’ to 0.74 for quadriceps strengthening only - equiv- alent to improvements of 5 points (’other programmes’) to 15 points (quadriceps strengthening only) on a 0 to 100-point scale. Within-group between-study heterogeneity was considerable for many of the subgroups (quadriceps only I2 = 73%; lower limb strengthening I2 = 76%) and could not be reduced (by more than 25%) by exclusion of any one study.
• #34: This systematic review establishes that there is emerging high-quality evidence to support that certain rehabilitation interventions provide benefits to specific treatment goals in individuals with hand OA. A summary of the higher-quality evidence is provided to assist with clinical decision making based on current evidence. In this review, the evidence suggests the following: (a) longterm use of a night splint offers significant benefits to improve pain, hand function, strength, and ROM for patients with OA; (b) programs of joint protection, advice, and home exercises are effective at improving grip strength and hand function; (c) low-level laser therapy is effective at improving ROM; and (d) no rehabilitation interventions were found to improve stiffness. Though recommended for OA, exercise programs have not yet been shown to reduce pain in this patient group. We concur with previous systematic reviews suggesting that further high-quality research is urgently needed concerning the effects of rehabilitation interventions on specific patient goals for individuals with hand OA. Specifically, the future agenda should include (a) the use of a common set of outcome measures that adequately capture the dimensions of impairments and function; (b) the use of higher-quality, well-powered studies that adhere to the CONSORT (Consolidated Standards of Reporting Trials) guidelines for nonpharmacological treatments [59]; and (c) the role of exercise on specific patient goals for individuals with hand OA with consideration of the optimal frequency and intensity of training
• #40: Globalmente, el tratamiento de la artrosis tiene como objetivo aliviar la sintomatología fundamentalmente dolorosa y mejorar la capacidad funcional del individuo. En ultimo termino, otro objetivo a conseguir seria el control de la progresión de la enfermedad y sus consecuencias Para ello debemos implantar tanto medidas no farmacológicas (educación, modificación de los estilos de vida, ejercicio físico, etc.) como medidas farmacológicas e incluso técnicas invasivas (infiltraciones intraarticulares, lavados articulares, artroplastias, etc.) si fuera necesario Entre los tratamientos farmacológicos figuran el paracetamol, los AINE, los opioides, tanto menores como mayores, los fármacos de acción sintomática lenta (SYSADOA), los tratamientos tópicos, capsaicina y AINE, y los tratamientos intraarticulares, corticoides y ácido hialurónico. La decisión clínica de tratar con uno u otro fármaco debe fundamentarse en la evidencia científica existente, la articulación afectada, la intensidad del dolor, los factores de riesgo individuales de cada paciente, tanto locales como generales, el grado de discapacidad, la comorbilidad, las posibles interacciones farmacológicas y la posible existencia de signos inflamatorios evidentes
• #57: Es un grupo pero su eficacia está avalada por la propia Agencia Europea del Medicamento (EMEA), la AEMPS y por numerosas instituciones médicas nacionales e internacionales
• #64: A funnel plot is a simple scatter plot of the intervention effect estimates from individual studies against some measure of each study’s size or precision. In common with forest plots, it is most common to plot the effect estimates on the horizontal scale, and thus the measure of study size on the vertical axis. This is the opposite of conventional graphical displays for scatter plots, in which the outcome (e.g. intervention effect) is plotted on the vertical axis and the covariate (e.g. study size) is plotted on the horizontal axis.
• #68: Effect sizes for pain were small to non- existent [e.g., 0.01 (95% CI: 0.07e0.13)] in stratified analyses of large-scale, high-quality trials. Quality assessment:Level of evidence: SR and meta-analysis of RCTs. Quality of evidence: Good. Estimated Effect Size for Pain (SMD): Ranges from 0.13 (0.00e 0.27)45 to 0.75 (0.50e0.99)46.Estimated Effect Size for reduction in rate of decline of minimum joint-space width (SMD): Ranges from 0.26 (0.14e0.38)47 to 0.30 (0.00e0.59)48.
• #69: Estimated Effect Size for Pain (SMD): Ranges from 0.17 (0.05, 0.28)45 to 0.47 (0.23e0.72)52.Estimated Effect Size for reduction in rate of decline of Pain (SMD): Ranges from 0.37 (0.28e0.46)56 to 0.46 (0.28e0.65)55. Physical function: 0.33 (0.22e0.43)56 to 0.31 (0.11e0.51)55. minimum joint-space width (SMD): 0.08 (0.12e0.27)
• #82: Relation between the effect sizes of improvement scores from baseline and the molecular weight of HA preparations (A), the amount of HA administered (B), the total number of injections (C), and the injection volume per dose (D). The size of the circle indicates the weighting of each study in the meta-regression. The gray shaded area represents the 95% CI.
• #84: A recent SR demonstrated small but significant efficacy of intra-articular hyaluronic acid for knee OA pain by week 4 with a peak at week 8 (reaching moderate clinical significance) and residual benefit until 24 weeks55. Another review found mod- erate benefits of IAHA for pain and physical function in knee OA, though sensitivity analyses including larger trials or trials with adequate blinding found only small effect size for pain56. A third review comparing IAHA with intra-articular corticosteroids (IACS) found that while IACS provided greater benefit for pain 2 weeks after injection, IAHA provided greater benefit at 12 and 26 weeks43. Inconsistent conclusions among the meta-analyses and conflicting results regarding IAHA’s safety influenced panel votes. Pain (SMD): Ranges from 0.37 (0.28e0.46)56 to 0.46 (0.28e0.65)55. Physical function: 0.33 (0.22e0.43)56 to 0.31 (0.11e0.51)
• #86: The 16 included studies had a total enrollment of 1543 patients,
• #87: Forest plot of the ES of functional changes from baseline at (A) 2 months, (B) 6 months, and (C) 12 months after PRP injections. Abbreviation: ES, effect sizes
• #89: Forest plot of the ES of functional changes from baseline after HA injections. Abbreviation: ES, effect sizes