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Yoga and healing therapies for osteoarthritis
Abstracts / Osteoarthritis and Cartilage 24 (2016) S1eS7
approaches, we also discovered that endothelial hypoxia-inducible factor 1a promotes angiogenesis in the postnatal skeletal system and thereby bone formation. The sum of these findings establish a molecular framework coupling angiogenesis, angiocrine signals and osteogenesis through endothelial Notch and HIF signaling, which may prove significant for the development of future therapeutic applications. Acknowledgement: This study has been supported by the Max Planck Society, the University of Muenster, the European Research Council, and the German Research Foundation. I-18 STRATEGIES FOR PREVENTING OA AFTER ACUTE ACL INJURY: BIOLOGICAL VS SURGICAL? E.M. Roos. Sports Sci. and Clinical Biomechanics, Odense M, Denmark ACL injuries occur during sport and physical activity and are often disrupting athletic careers. Current treatment practice includes surgical reconstruction to mechanically stabilize the knee, with or without varying degree of concurrent rehabilitation. Rehabilitation strategies vary but have the overall aim to improve dynamic stability and knee function. A primary goal of ACL injury treatment is return to pre-injury sport, with about half reaching that goal. Actually, in many patients an ACL injury is the starting point for a new career as a patient with frequent visits and procedures by surgeons, physicians and therapists, sometimes for decades to come. Multiple surgical procedures are common, and knee replacement is performed at younger ages in those with a prior knee injury. About half have radiographic signs of OA already in their thirties. An alternative treatment pathway following ACL injury is starting with focused supervised rehabilitation alone, and later reconstruction for those needing it. The only high-quality randomized study available found that 50% of surgical reconstructions could be avoided, with no difference in outcomes as 2 and 5 years. This presentation will give the rationale and evidence for this alternative treatment strategy for ACL injury of the knee. I-19 PLENARY DEBATE: STRATEGIES FOR PREVENTING POSTTRAUMATIC OA AFTER ACUTE ACL INJURIES: BIOLOGICAL VS. SURGICAL K.P. Spindler. Vanderbilt Univ. Med. Ctr., Nashville, TN, USA High quality evidence establishes that an acute ACL tear substantially increases the risk of posttraumatic OA after injury regardless of rehabilitation alone or ACL reconstruction. What is also clear is that a strategy of rehabilitation only or ACL reconstruction for everyone will not prevent posttraumatic OA for the following reasons. First meniscus injury and “loss” partial menisectomy results in more radiographic OA. Second after initial injury and hemarthrosis in the first several weeks a global loss of proteoglycans in the articular cartilages surfaces throughout the knee that is not recovered. Third in assessing radiographic OA on specialized standing radiographs, joint space changes occur less with meniscus repair then partial meniscetomy. Fourth the outstanding KANON RCT clearly demonstrates that >50% will elect ACL reconstruction failing rehabilitation alone. Fifth that a structured rehabilitation strategy preoperatively before ACL reconstruction results in improved IKDC and KOOS outcomes at 2 years. Since a percentage of patients can function well with rehabilitation alone, a percentage will have meniscus and articular cartilage injuries where surgery is believed to indicated leaving a population with acute ACL that for instability reasons in sport or ADL will require ACL reconstruction. How we predict which group an individual should be placed has not been investigated in appropriate prospective clinical studies. In addition if the hemarthrosis is “toxic” to articular cartilage then the resulting postoperative injury to articular cartilage from hemarthrosis, particle fragments of bone and collagen, and rinsing of HA and lubricin from the joint could be worse. Until we mitigate the “collateral damage” to the articular cartilage from injury and from appropriate ACL reconstruction delaying posttraumatic OA will remain an enigma. Appropriate clinical studies should be designed to answer these questions which initially should be prospective longitudinal cohorts identifying modifiable risk factors of posttraumatic OA to then be systematically studied in RCT's. Further the definition of structural OA and symptomatic OA should be clearly defined in these studies.
S5
I-20 YOGA AND HEALING THERAPIES FOR OSTEOARTHRITIS L. Sandell y, P. Dieppe z. y Washington Univ., St. Louis, MO, USA; z Univ. of Exeter, Exeter, United Kingdom Purpose: Important treatment options for osteoarthritis include a variety of different non-pharmacologic therapies, especially symptom management strategies in which patients take an active role. Among these, mind-body therapies may have particular promise for alleviating the distressful symptoms associated with osteoarthritis. The purpose of this Workshop is to explore the role of healing therapies for the management of osteoarthritis, particularly the use of yoga. Methods: The Workshop will use lecture, discussion and demonstration and participation formats. Results: Yoga employs a combination of mindfulness, specific movements, breathing and meditation to reduce many of the symptoms associated with OA. Yoga can be a significant stimulation for lifestyle modifications that can result in reduced stress, weight reduction, lowered pain and improved movement. It is not clear why interventions like yoga can be so effective, it may be through activation of the mechanisms involved in placebo responses, which can be re-conceptualized as the healing response - improving general wellbeing as well as relieving symptoms. This session will introduce you to healing strategies for OA, as well as yoga therapy. Conclusions: Participants will learn the concepts of the healing response and be introduced to the use of yoga as a therapy. I-21 BEYOND QUANTITATIVE IMAGING OF KNEE CARTILAGE IN OA (OTHER JOINT TISSUES AND OTHER JOINTS) H. Potter. Hosp. for Special Surgery, New York City, NY, USA Standardized, reproducible MR pulse sequences have been applied to assess articular cartilage morphology and are suitable for the assessment of rate of progression of osteoarthritis in cohorts at risk following mechanical, pharmaceutical or surgical intervention. When combined with parametric mapping to assess both proteoglycan (Na23, dGEMRIC, T1 rho, GAG-CEST) and collagen (T2 mapping, T2* mapping, UTE), these provide noninvasive assessment of tissue biochemistry and matrix depletion. More recently, these have been applied outside the knee joint in order to investigate areas of matrix depletion in additional joints subject to early osteoarthritis such as the hip (e.g., developmental dysplasia (DDH) and femoroacetabular impingement (FAI)), and to cartilage repair models in smaller joints such as the ankle. dGEMRIC has been applied to the DDH population, demonstrating that indices derived from dGEMRIC data may be helpful in selecting suitable candidates for periacetabular osteotomy as well as identifying risk factors associated with hip osteoarthritis(1,2). In addition, dGEMRIC has been used as a noninvasive means by which to assess improvement in cartilage matrix composition following periacetabular osteotomy(3). Similarly, T1 rho has been used in femoroacetabular impingement discerning preferential matrix depletion in patients with FAI compared to controls(4). More recently, attention has been applied to the use of parametric mapping in short T2 species such as meniscus and ligament. In an ovine repair model, ultrashort echo times (UTE imaging) has been shown to be predictive of meniscal structural integrity following repair compared to multiphoton microscopy(5). Additional interest has been imparted to active loading of meniscal tissue and the assessment of parametric mapping as response to load. Both T1 rho and T2 relaxation times have noted to be elevated as a response to meniscal load, which provides important preliminary data regarding load transmission to the articular cartilage(6). MR compatible loading devices now allow for the assessment of biologically or surgically manipulated tissue to be imaged under load, thus simulating more clinically relevant conditions. Further research will be focused on expanding these links between parametric mapping, morphologic assessment including 3D modeling and links to mechanical properties of hard and soft tissue(7). 1. Cunningham et al JBJS 2006 88:1540-8. 2. Jessel et al JBJS 2009 91:1120-9. 3. Hingsammer et al JBJS 2015 97:544-50. 4. Rakhra et al JBJS British 2012 94:1187-92. 5. Koff et al Osteoarthritis and Cartilage 2013 21:1083-91. 6. Subburaj et al JMRI 2015 41:536-43. 7. Koff et al Journal of Biomechanics 2014 47:3428-32.
approaches, we also discovered that endothelial hypoxia-inducible factor 1a promotes angiogenesis in the postnatal skeletal system and thereby bone formation. The sum of these findings establish a molecular framework coupling angiogenesis, angiocrine signals and osteogenesis through endothelial Notch and HIF signaling, which may prove significant for the development of future therapeutic applications. Acknowledgement: This study has been supported by the Max Planck Society, the University of Muenster, the European Research Council, and the German Research Foundation. I-18 STRATEGIES FOR PREVENTING OA AFTER ACUTE ACL INJURY: BIOLOGICAL VS SURGICAL? E.M. Roos. Sports Sci. and Clinical Biomechanics, Odense M, Denmark ACL injuries occur during sport and physical activity and are often disrupting athletic careers. Current treatment practice includes surgical reconstruction to mechanically stabilize the knee, with or without varying degree of concurrent rehabilitation. Rehabilitation strategies vary but have the overall aim to improve dynamic stability and knee function. A primary goal of ACL injury treatment is return to pre-injury sport, with about half reaching that goal. Actually, in many patients an ACL injury is the starting point for a new career as a patient with frequent visits and procedures by surgeons, physicians and therapists, sometimes for decades to come. Multiple surgical procedures are common, and knee replacement is performed at younger ages in those with a prior knee injury. About half have radiographic signs of OA already in their thirties. An alternative treatment pathway following ACL injury is starting with focused supervised rehabilitation alone, and later reconstruction for those needing it. The only high-quality randomized study available found that 50% of surgical reconstructions could be avoided, with no difference in outcomes as 2 and 5 years. This presentation will give the rationale and evidence for this alternative treatment strategy for ACL injury of the knee. I-19 PLENARY DEBATE: STRATEGIES FOR PREVENTING POSTTRAUMATIC OA AFTER ACUTE ACL INJURIES: BIOLOGICAL VS. SURGICAL K.P. Spindler. Vanderbilt Univ. Med. Ctr., Nashville, TN, USA High quality evidence establishes that an acute ACL tear substantially increases the risk of posttraumatic OA after injury regardless of rehabilitation alone or ACL reconstruction. What is also clear is that a strategy of rehabilitation only or ACL reconstruction for everyone will not prevent posttraumatic OA for the following reasons. First meniscus injury and “loss” partial menisectomy results in more radiographic OA. Second after initial injury and hemarthrosis in the first several weeks a global loss of proteoglycans in the articular cartilages surfaces throughout the knee that is not recovered. Third in assessing radiographic OA on specialized standing radiographs, joint space changes occur less with meniscus repair then partial meniscetomy. Fourth the outstanding KANON RCT clearly demonstrates that >50% will elect ACL reconstruction failing rehabilitation alone. Fifth that a structured rehabilitation strategy preoperatively before ACL reconstruction results in improved IKDC and KOOS outcomes at 2 years. Since a percentage of patients can function well with rehabilitation alone, a percentage will have meniscus and articular cartilage injuries where surgery is believed to indicated leaving a population with acute ACL that for instability reasons in sport or ADL will require ACL reconstruction. How we predict which group an individual should be placed has not been investigated in appropriate prospective clinical studies. In addition if the hemarthrosis is “toxic” to articular cartilage then the resulting postoperative injury to articular cartilage from hemarthrosis, particle fragments of bone and collagen, and rinsing of HA and lubricin from the joint could be worse. Until we mitigate the “collateral damage” to the articular cartilage from injury and from appropriate ACL reconstruction delaying posttraumatic OA will remain an enigma. Appropriate clinical studies should be designed to answer these questions which initially should be prospective longitudinal cohorts identifying modifiable risk factors of posttraumatic OA to then be systematically studied in RCT's. Further the definition of structural OA and symptomatic OA should be clearly defined in these studies.
S5
I-20 YOGA AND HEALING THERAPIES FOR OSTEOARTHRITIS L. Sandell y, P. Dieppe z. y Washington Univ., St. Louis, MO, USA; z Univ. of Exeter, Exeter, United Kingdom Purpose: Important treatment options for osteoarthritis include a variety of different non-pharmacologic therapies, especially symptom management strategies in which patients take an active role. Among these, mind-body therapies may have particular promise for alleviating the distressful symptoms associated with osteoarthritis. The purpose of this Workshop is to explore the role of healing therapies for the management of osteoarthritis, particularly the use of yoga. Methods: The Workshop will use lecture, discussion and demonstration and participation formats. Results: Yoga employs a combination of mindfulness, specific movements, breathing and meditation to reduce many of the symptoms associated with OA. Yoga can be a significant stimulation for lifestyle modifications that can result in reduced stress, weight reduction, lowered pain and improved movement. It is not clear why interventions like yoga can be so effective, it may be through activation of the mechanisms involved in placebo responses, which can be re-conceptualized as the healing response - improving general wellbeing as well as relieving symptoms. This session will introduce you to healing strategies for OA, as well as yoga therapy. Conclusions: Participants will learn the concepts of the healing response and be introduced to the use of yoga as a therapy. I-21 BEYOND QUANTITATIVE IMAGING OF KNEE CARTILAGE IN OA (OTHER JOINT TISSUES AND OTHER JOINTS) H. Potter. Hosp. for Special Surgery, New York City, NY, USA Standardized, reproducible MR pulse sequences have been applied to assess articular cartilage morphology and are suitable for the assessment of rate of progression of osteoarthritis in cohorts at risk following mechanical, pharmaceutical or surgical intervention. When combined with parametric mapping to assess both proteoglycan (Na23, dGEMRIC, T1 rho, GAG-CEST) and collagen (T2 mapping, T2* mapping, UTE), these provide noninvasive assessment of tissue biochemistry and matrix depletion. More recently, these have been applied outside the knee joint in order to investigate areas of matrix depletion in additional joints subject to early osteoarthritis such as the hip (e.g., developmental dysplasia (DDH) and femoroacetabular impingement (FAI)), and to cartilage repair models in smaller joints such as the ankle. dGEMRIC has been applied to the DDH population, demonstrating that indices derived from dGEMRIC data may be helpful in selecting suitable candidates for periacetabular osteotomy as well as identifying risk factors associated with hip osteoarthritis(1,2). In addition, dGEMRIC has been used as a noninvasive means by which to assess improvement in cartilage matrix composition following periacetabular osteotomy(3). Similarly, T1 rho has been used in femoroacetabular impingement discerning preferential matrix depletion in patients with FAI compared to controls(4). More recently, attention has been applied to the use of parametric mapping in short T2 species such as meniscus and ligament. In an ovine repair model, ultrashort echo times (UTE imaging) has been shown to be predictive of meniscal structural integrity following repair compared to multiphoton microscopy(5). Additional interest has been imparted to active loading of meniscal tissue and the assessment of parametric mapping as response to load. Both T1 rho and T2 relaxation times have noted to be elevated as a response to meniscal load, which provides important preliminary data regarding load transmission to the articular cartilage(6). MR compatible loading devices now allow for the assessment of biologically or surgically manipulated tissue to be imaged under load, thus simulating more clinically relevant conditions. Further research will be focused on expanding these links between parametric mapping, morphologic assessment including 3D modeling and links to mechanical properties of hard and soft tissue(7). 1. Cunningham et al JBJS 2006 88:1540-8. 2. Jessel et al JBJS 2009 91:1120-9. 3. Hingsammer et al JBJS 2015 97:544-50. 4. Rakhra et al JBJS British 2012 94:1187-92. 5. Koff et al Osteoarthritis and Cartilage 2013 21:1083-91. 6. Subburaj et al JMRI 2015 41:536-43. 7. Koff et al Journal of Biomechanics 2014 47:3428-32.