Introduction

Diabetes has become one of the leading causes of disability and loss of function in the United States. The prevalence of diabetes mellitus (DM 2) is approximately 50% both diagnosed and un-diagnosed (1). Diabetes costs the US healthcare system $327 billion annually and is responsible for $1 in every $7 spent on healthcare (2). Diabetes can speed up the rate at which osteoarthritis progress, which worsens pain and all functional symptoms, and potentially worsens the outcomes of total knee arthroplasties (TKA), also known as a knee replacement (3). Previous studies have associated diabetes with a higher risk of surgical complications, however no meta-analysis has been performed on functional outcomes after a TKA until now.

Results & Discussion

Of the 2,132 studies identified as potentially meeting the inclusion criteria, only 21 met the eligibility criteria to be included. The results were broken down in to preoperative, early postoperative phase (0-12 months post op) and late postoperative phase (1-14 years post op). The overall early and late postoperative findings suggest that people with DM 2 are in worse physical function and have worse quality of life, worse early postoperative pain and strength, and worse late postoperative function, ROM, and QOL than those without DM 2 (3). Many inconsistencies in the studies that were analyzed presented either very low-quality evidence or inconsistent conclusions.

Conclusion

Patients with DM2 have overall increased pain and worse functional outcomes in respect to a TKA compared to patients without diabetes. The overall quality of evidence on this topic is poor and lacks consistent study design. None of the 21 studies included followed by the same rehabilitation protocol post-surgery, which also limits the consistency of the results. The overall message in this article show that overall metabolic health is an important factor in both the development of osteoarthritis and chronic joint pain, and also slows the process of recovery post-surgery.

Physical Therapy First Implications:

The Physical Therapists at Physical Therapy First will create an individualized care plan for you both pre- and post- surgery. All patients at Physical Therapy First receive a 1 hour 1-on-1 appointment at all PT appointments with a doctor of physical therapy. Call today or request an appointment online for any of our 4 locations in Greater Baltimore.

References:

1: Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activ­ity among adults with diabetes—United States, 2005 and 2007. MMWR Morb Mortal Wkly Rep. 2008;57:486-489

2: https://www.diabetes.org/resources/statistics/cost-diabetes

3: Neumann J, Guimaraes JB, Heilmeier U, et al. Diabetics show accelerated progression of knee cartilage and meniscal lesions: data from the Osteoarthritis Initiative. Skeletal Radiol. 2019;48:919-930. https://doi.org/10.1007/ s00256-018-3088-0

4: Na A, Opperman LM, Jupiter DC, Lindsey RW, Coronado RA.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health- Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients  J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515

Ehlers-Danlos Syndrome (EDS) is a genetically inherited connective tissue disorder that can result in joint hypermobility, skin extensibility, and tissue fragility.  As a result, many patients with EDS experience chronic pain related to joint instability. Past studies have demonstrated that resistance training can increase the stiffness of tendon structures for healthy individuals, and in the case of EDS, these physiologic changes to tendon properties may be beneficial in improving joint stability and function. This pilot study observed three subjects diagnosed with classical Ehlers-Danlos Syndrome (cEDS) who underwent a resistance training program to examine its feasibility and efficacy.

• Subjects were between the age 28-64 years old with two females and one male subject included.
• No extreme adverse reactions to training were recorded for any of the subjects
• Training protocol was for 3 days a week consisting of both upper and lower body exercises. Resistance was slowly progressed first using a familiarization period over the course of 12 sessions followed by increasing the load per each individual’s specific capacity.
• Researchers examined patellar tendon mechanical properties, muscle power and strength, balance, body composition, fatigue levels, and patients’ subjective opinion of the program.
• Trends examined:
  • Stiffness (N/mm) of the patellar tendon increased 38.4% and maximal deformity (mm) decreased 14.9% across subjects
  • Isometric strength of leg extension increased 7.97% and leg extension power increased 10.6% across subjects
  • On average, lower body exercises load increased 31% and upper body load increased 34% using a 5 RM test.
  • Subjects all improved in their functional strength and balance test parameters
  • Fatigue decreased 15.6% and 21.4% respectively for the written measure and subjective measure across all subjects.
  • Overall, subjects had a positive experience with training with minor complaints about the program relating to speed of progression and frequency of treatment. Additionally, subjects generally reported no change to their pain levels before or after treatment, and all subjects reported feeling “more tired” during training.
• Study limitations:
  • This study was limited to only three subjects so that the statistical significance of the findings was unable to be examined.
  • Authors acknowledge that resistance training may not be appropriate for all cEDS patients given the variability of each individual’s symptoms and capabilities and may be most appropriate when tailored for each individual’s specific needs and problematic body regions.

While further studies are necessary to determine the effectiveness of resistance training, this study demonstrates that resistance training can be feasible and safe for patients with EDS. Additionally, the results indicate that resistance training may serve to improve the biomechanical properties of tendinous structures as well as improve balance, strength, and fatigue. At Physical Therapy First, your physical therapist can develop and individualized and safe resistance training program for your own rehabilitative needs. If you have been diagnosed with EDS, talk to your physical therapist about what interventions are appropriate for you at this time for the most optimum treatment and benefits.

References

Moller MB, Kjaer M, Svensson RB, Anderson JL, Magnusson SP, Nielsen RH. Functional adaptation of tendon and skeletal muscle to resistance training in three patients with genetically verified classic Ehlers Danlos Syndrome. Muscles, Ligaments and Tendons J. 2014; 4 (3): 315-323.

Among older adults, distal radius fractures (DRF) are a common injury usually sustained after falling on an outstretched hand. Past studies have shown that adults with low bone mineral density, associated with malnutrition, are at a higher risk for DRF, and likewise, those with a previous DRF are at a higher risk for subsequent falls. Thus, this retrospective cohort study attempts to bridge the relationship between nutritional status and outcomes after DRF in older adults.

• The prevalence for malnutrition in the older adult population is generally between 13.5-17.9%
• 229 participants were enrolled. Participants were 65+ years old who underwent surgical treatment and rehabilitation after a DRF, and they were placed into the malnutrition or nutrition group based upon their nutritional score on the Geriatric Nutritional Risk Index (GNRI)
  • 198 adults were placed in the normal nutrition group and 31 adults were placed in the malnutrition group
• GNRI was calculated based on the level of serum albumin relative to each participant’s body weight.
• Functional outcomes for performing and activities of daily living (ADL’s) and wrist function were measured using the Barthel Index (BI) and Mayo wrist score.
• Those in the malnutrition group had a lower functional status (BI score), greater number of subsequent falls, and greater degree of post-surgical complications compared to the normal group at 1 year follow-up.
• Nutritional status (GNRI) was significantly correlated to the number of subsequent falls and level of functional gains made (BI efficacy), and serum albumin levels additionally have the ability to determine the probability of subsequent falls.
• No relationship was significantly found relating to wrist function (Mayo wrist score)
• Bone mineral density was not significantly correlated to any of the outcome measures; however, researchers hypothesize that this may be due to the high proportion of participants who were taking medication to address decreased BMD prior to this study.

From this study, we can conclude that nutritional status, as determined by serum albumin levels, plays a role in the functional outcomes and risk of subsequent falls for older adults who have sustained a distal radius fracture. Serum albumin is important in maintaining muscle synthesis and skeletal muscle mass, and researchers hypothesize that the effects of low albumin levels lead to decreased balance and walking ability thus resulting in greater risk for falls. At Physical Therapy First, your physical therapist can discuss ways to incorporate nutrition and create an individualized falls avoidance program to initiate a safe exercise plan that can improve your balance, improve your walking ability, and increase your strength.

Nagai T, Tanimoto K, Tomizuka Y, Uei H, Nagoaka M. Nutrition status and functional prognosis among elderly patients with distal radius fracture: a retrospective cohort study. Journal of Orthopaedic Surgery and Research 2020; 15(133): 1-7.

Mesenchymal stem cells (MSCs) are a prospective intervention for treating osteoarthritis for the potential of cartilage tissue repair and regenerative ability. MSC therapies primarily work by reducing inflammatory cell properties, expressing anti-inflammatory cell signals, and increasing the activity of cartilage-producing cells. In this randomized controlled trial of 30 participants, researchers specifically aimed to determine if adipose-derived mesenchymal stem cell (ADMSC) therapy was a safe and effective intervention for decreasing pain, improving function, and modifying the progression of disease in patients with moderate knee OA.

• Patients were randomly allocated into either a single or double injection treatment group or a control group. Injections were given at baseline and at 6 months for the two-injection group. The control group underwent conservative management, including analgesics, weight management, and exercise.
• Patients were on average in their early to mid 50’s, had moderate (grade II-III) knee OA in one leg.
• Outcome measurements were recorded at 1, 3, 6 and 12 months follow-up using the Numeric Pain Rating Scale (NPRS), Knee Injury and Osteoarthritis Outcome Measures Scale (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), MRI, and the MRI Osteoarthritis Knee Score (MOAKS).
• The effectiveness of ADMSC treatment on pain and function
  • Both single and double injection groups had significantly improved pain scores on the NPRS and KOOS subscales compared to conservative management at 12 months
  • Both single and double injection groups had significantly improved function on the WOMAC and KOOS subscales compared to conservative management at 12 months
  • Comparing single and double injection groups, neither had a more significant effect than the other for pain and function, but the single injection group generally also had significant improvements over the control group at 3 and 6 months.
• Minimal clinically important differences at 12-month follow-up were achieved on average in 84.1% of subjects in the single injection group, 87.1% in the double injection group, and 25.7% in the control group
• The effectiveness of ADMSC treatment on disease progression at 12-month follow-up
  • The two-injection group had the greatest improvements in cartilage or the prevention of progressive of cartilage loss (89%) as well as prevention of osteophyte formation (89%) suggesting it may assist with the stabilization of knee OA
  • In comparison, the single-injection group was able to improve or prevent degradation of cartilage in 70% of subjects; however, 50% of subjects experienced a progression of osteophyte formation.
• Limitations of the study include:
  • sample size may or may not have been sufficient
  • starting BMI between the three groups were significantly different potentially affecting the results
  • some subjects experienced pain and swelling after the second injection at 6 months potentially altering results of the two-injection group

In conclusion, ADMSC is a promising treatment for osteoarthritis that is being currently researched. This study demonstrates that ADMSC is safe and effective at reducing pain, improving function, and moderating disease progression for those with moderate knee OA. Differences between the effectiveness of one versus two injections can be debated as the one-injection group experienced more significant changes at 3 and 6 months, but the two-injection group saw a greater number of subjects with minimal clinically important difference and stabilization of OA. At Physical Therapy First, your physical therapist can discuss MSC and other alternative treatments for your knee osteoarthritis to determine if you are a potential candidate to benefit from ADMSC, as well as provide you with other conservative rehabilitative interventions.

Freitag, Julien. Bates, Dan. Wickham, James. Shah, Kiran. Huguenin, Leesa, Tenen, Abi. Paterson, Kade. Boyd, Richard. Adipose-derive mesenchymal stem cell therapy in the treatment of knee osteoarthritis: a randomized controlled trial. Regenerative Medicine 2019; 14 (3), 213-230.