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Online Unsupervised Tai Chi Intervention for Knee Pain and Function in People With Knee Osteoarthritis: The RETREAT Randomized Clinical Trial

Author/s: 
Shiyi Julia Zhu, Rana S. Hinman, Rachel K. Nelligan

Importance Tai chi is a type of exercise recommended for knee osteoarthritis, but access to in-person tai chi can be limited.

Objective To evaluate the effects of an unsupervised multimodal online tai chi intervention on knee pain and function for people with knee osteoarthritis.

Design, Setting, and Participants The RETREAT study was a 2-group superiority randomized clinical trial enrolling participants who met clinical criteria for knee osteoarthritis in Australian communities from August 2023 and November 2024.

Interventions Participants in the control group received access to a purpose-built website containing information about osteoarthritis and exercise benefits. Participants in the intervention group received the My Joint Tai Chi intervention comprising access to the same website plus tai chi information, a 12-week unsupervised video-based Yang-style tai chi program, and encouragement to use an app to facilitate program adherence.

Main Outcomes and Measures Changes in knee pain during walking (Numeric Rating Scale; range 0-10 with higher scores indicating greater pain) and difficulty with physical function (Western Ontario and McMaster Universities Osteoarthritis Index; range 0-68 with higher scores indicating greater dysfunction) during 12 weeks. Secondary outcomes included another knee pain measure, sport and recreation function, quality of life, physical and mental well-being, fear of movement, self-efficacy, balance confidence, positive activated affect, sleep quality, global improvement, and oral medication use.

Results Of 2106 patients screened, 178 met inclusion criteria and were randomized, 89 (mean [SD] age, 61.0 [8.7] years; 66 female [74%] and 23 [26%] male participants) to the control group and 89 (mean [SD] age, 62.1 [7.3] years; 59 [66%] female and 30 male [34%] participants) to the tai chi intervention. Of the total, 170 (96%) completed both of the primary outcomes at 12 weeks. The tai chi group reported greater improvements in knee pain (control, −1.3; tai chi, −2.7; mean difference, −1.4 [95% CI, −2.1 to −0.7] units; P < .001) and function (control, −6.9; tai chi, −12.0; mean difference, −5.6 [95% CI, −9.0 to −2.3] units; P < .001) compared to the control group. More participants in the tai chi than in the control group achieved a minimal clinically important difference in pain (73% vs 47%; risk difference, 0.3; 95% CI, 0.1 to 0.4; P < .001) and function (72% vs 52%; risk difference, 0.2; 95% CI, 0.1 to 0.3; P = .007). Between-group differences for most secondary outcomes favored tai chi, including another knee pain measure, sport and recreation function, quality of life, physical and mental well-being, global improvement, pain self-efficacy, and balance confidence. No associated serious adverse events were reported.

Conclusions and Relevance This randomized clinical trial found that this unsupervised multimodal online tai chi intervention improved knee pain and function compared with the control at 12 weeks. This free-to-access web-based intervention offers an effective, safe, accessible, and scalable option for guideline-recommended osteoarthritis exercise.

Keywords 
Tai Chi Arthralgia Knee osteoarthritis osteoarthritis pain management

A Simplified Approach to Evaluate and Manage Shoulder Pain

Author/s: 
Kartik Sidhar, Hyung Jin Lim, Laurel Gutierrez

With the lifetime prevalence of shoulder pain approaching 70%, accurate diagnosis and management remains essential. The shoulder is a complex joint with a vast range of motion making it susceptible to injury due to limited bony stabilization. This manuscript shares a simplified, novel approach to evaluating and managing atraumatic shoulder pain based on triaging symptoms on presence or loss of range of motion. In patients with loss of active and passive range of motion, the likely etiologies of pain include adhesive capsulitis or glenohumeral joint arthritis depending on imaging. In patients with preserved active and passive range of motion, implementing specific special testing can help pinpoint the diagnosis, and further guide appropriate management. Ultrasound plays an increasingly key role in diagnosing and managing shoulder pathology.

Keywords 
Shoulder Shoulder Pain pain management Pain Bursitis

Conservative Treatments in the Management of Acute Painful Vertebral Compression Fractures: A Systematic Review and Network Meta-Analysis

Author/s: 
Assil-Ramin Alimy, Athanasios D Anastasilakis, John J Carey, Stella D'Oronzo, Anda M Naciu, Julien Paccou, Maria P Yavropoulou, Willem F Lems, Tim Rolvien

Importance: Osteoporotic vertebral compression fractures (VCFs) frequently cause substantial pain and reduced mobility, posing a major health problem. Despite the critical need for effective pain management to restore functionality and improve patient outcomes, the value of various conservative treatments for acute VCF has not been systematically investigated.

Objective: To assess and compare different conservative treatment options in managing acute pain related to VCF.

Data sources: On May 16, 2023, 4 databases-PubMed, Embase, Scopus, and CINAHL-were searched. In addition, a gray literature search within Scopus and Embase was also conducted.

Study selection: Included studies were prospective comparative and randomized clinical trials that assessed conservative treatments for acute VCF.

Data extraction and synthesis: Data extraction and synthesis were performed by 2 authors according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses recommendations. A frequentist graph-theoretical model and a random-effects model were applied for the meta-analysis.

Main outcomes and measures: Primary outcomes were short-term (4 weeks) pain during activity and long-term (latest available follow-up) nonspecified pain in patients with acute VCF.

Results: The study included 20 trials, encompassing 2102 patients, and evaluated various interventions for managing VCF. Calcitonin (standardized mean difference [SMD], -4.86; 95% CI, -6.87 to -2.86) and nonsteroidal anti-inflammatory drugs (NSAIDs; SMD, -3.94; 95% CI, -7.30 to -0.58) were beneficial regarding short-term pain during activity compared with placebo. For long-term nonspecific pain management, bisphosphonates were associated with inferior pain outcomes compared with daily (SMD, 1.21; 95% CI, 0.11 to 2.31) or weekly (SMD, 1.13; 95% CI, 0.05 to 2.21) administration of teriparatide, with no treatment being superior to NSAIDs. The qualitative analysis of adverse events highlighted that typical adverse events associated with these medications were observed.

Conclusions and relevance: NSAIDs and teriparatide may be the preferred treatment options for pain management in acute osteoporotic VCF. Although calcitonin also proved to be beneficial, its safety profile and potential adverse effects restrict its widespread application. The limited evidence on braces and analgesics underscores the urgent need for future research.

Keywords 
pain management Spinal Fractures acute pain pain management Compression Fractures

I Am Worried I Have Sciatica-What Do I Need to Know?

Author/s: 
Grace Y Zhang, Michael A Incze

This JAMA Internal Medicine Patient Page reviews sciatica, its symptoms, and treatment options for those who have it.

Sciatica is a type of pain that is caused by irritation of the sciatic nerve. This nerve travels from the low back down the legs. Sciatica most commonly happens when a disk in your spine gets damaged or worn out and presses on the sciatic nerve.

Keywords 
Sciatica physical therapy pain management back pain numbness

Topical Nonprescription Pain Medications for Adults

Author/s: 
Sarah E. Vordenberg

This JAMA Patient Page describes the types of topical nonprescription pain medications and tips for using them.

Topical nonprescription pain medications are over-the-counter drugs applied to the skin to treat pain.

Topical pain medications can effectively treat pain caused by several acute and chronic conditions. Because they are applied directly to the skin, topical pain medications are easy to use and less likely to cause side effects or interact with other medications than oral pain medications. Pain relief typically occurs within several days of starting a topical pain medication.

Keywords 
clinical pharmacy and pharmacology pain management Emergency Care orthopedics rheumatology

Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis

Author/s: 
Dimitris Challoumas, Rohan Ramasubbu, Elliot Rooney, Emily Seymour-Jackson, Amit Putti, Neal L. Millar

Importance: There is a plethora of treatment options for patients with de Quervain tenosynovitis (DQT), but there are limited data on their effectiveness and no definitive management guidelines.

Objective: To assess and compare the effectiveness associated with available treatment options for DQT to guide musculoskeletal practitioners and inform guidelines.

Data sources: Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org were searched for published studies, and the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, The European Union Clinical Trials Register, and the ISRCTN registry were searched for unpublished and ongoing studies from inception to August 2022.

Study selection: All randomized clinical trials assessing the effectiveness of any intervention for the management of DQT.

Data extraction and synthesis: This study was prospectively registered on PROSPERO and conducted and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) guidance. The Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations tool were used for risk of bias and certainty of evidence assessment for each outcome.

Main outcomes and measures: Pairwise and network meta-analyses were performed for patient-reported pain using a visual analogue scale (VAS) and for function using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale. Mean differences (MD) with their 95% CIs were calculated for the pairwise meta-analyses.

Results: A total of 30 studies with 1663 patients (mean [SD] age, 46 [7] years; 80% female) were included, of which 19 studies were included in quantitative analyses. From the pairwise meta-analyses, based on evidence of moderate certainty, adding thumb spica immobilization for 3 to 4 weeks to a corticosteroid injection (CSI) was associated with statistically but not clinically significant functional benefits in the short-term (MD, 10.5 [95% CI, 6.8-14.1] points) and mid-term (MD, 9.4 [95% CI, 7.0-11.9] points). In the network meta-analysis, interventions that included ultrasonography-guided CSI ranked at the top for pain. CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function.

Conclusions and relevance: This network meta-analysis found that adding a short period of thumb spica immobilization to CSI was associated with statistically but not clinically significant short- and mid-term benefits. These findings suggest that administration of CSI followed by 3 to 4 weeks immobilization should be considered as a first-line treatment for patients with DQT.

Keywords 
de Quervain tenosynovitis DQT pain management Visual Analog Scale VAS Q-DASH corticosteroid injection CSI ultrasonography tendonitis

Diagnosis and acute management of migraine

Author/s: 
Tzankova, V., Becker, W. J., Chan, T. L. H.

Migraine is a leading cause of disability across all age groups.
• Routine imaging is not recommended in patients with migraine
who have no red flags, atypical symptoms or abnormal findings
on neurologic examination.
• A stratified approach for acute migraine treatment empowers
patients to choose from different treatment options
depending on attack symptoms and severity and encourages
patients to combine medications from different classes.
• Effective acute migraine treatment includes acetaminophen,
nonsteroidal anti-inflammatory drugs and triptans.
• Ubrogepant and rimegepant are new, effective migraine
treatments, suitable for patients with cardiovascular disease in
whom triptans are contraindicated.

Keywords 
migraines acetaminophen Migraine Disorders Pain therapy pain management

AAFP Chronic Pain Management Toolkit

Chronic pain is common in the U.S., with anywhere from 11% to 40% of the adult population reporting daily pain.1 Approximately one-third of patients experiencing pain receive a pain medication.2 While the number of prescriptions for pain management have declined in recent years3, opioid misuse remains a significant public health crisis. Roughly 21-29% of patients who are prescribed opioids for chronic pain will misuse them.4

This increase leads to a rise in opioid overdoses—at least half are attributed to prescription medications—and morbidity and mortality. Numerous groups—including the AAFP, other medical societies, the National Academy of Medicine and the U.S. Congress—are emphasizing the need to improve chronic pain care.

Keywords 
RISEOK opioids chronic pain pain management Opiate Overdose

Association of Current Opioid Use With Serious Adverse Events Among Older Adult Survivors of Breast Cancer

Author/s: 
Winn, Aaron N., Check, Devon K., Farkas, Amy, Fergestrom, Nicole M., Neuner, Joan M., Roberts, Andrew W.

Importance: National efforts to improve safe opioid prescribing focus on preventing misuse, overdose, and opioid use disorder. This approach overlooks opportunities to better prevent other serious opioid-related harms in complex populations, such as older adult survivors of cancer. Little is known about the rates and risk factors for comprehensive opioid-related harms in this population.

Objective: To determine rates of multiple opioid-related adverse drug events among older adults who survived breast cancer and estimate the risk of these events associated with opioid use in the year after completing cancer treatment.

Design, setting, and participants: This retrospective cohort study used 2007 to 2016 Surveillance, Epidemiology and End Results-Medicare data from fee-for-service Medicare beneficiaries with first cancer diagnosis of stage 0 to III breast cancer at age 66 to 90 years from January 1, 2008, through December 31, 2015, who completed active breast cancer treatment. Data were analyzed from October 31, 2019, to June 10, 2020.

Exposures: Repeated daily measure indicating possession of any prescription opioid supply in Medicare Part D prescription claims.

Main outcomes and measures: Adjusted risk ratios (aRRs), estimated using modified Poisson generalized estimating equation models, for adverse drug events related to substance misuse (ie, diagnosed opioid abuse, dependence, or poisoning), other adverse drug events associated with opioid use (ie, gastrointestinal events, infections, falls and fractures, or cardiovascular events), and all-cause hospitalization associated with opioid supply the prior day, controlling for patient characteristics.

Conclusions and relevance: These findings suggest that among older adults who survived breast cancer, continued prescription opioid use in the year after completing active cancer treatment was associated with an immediate increased risk of a broad range of serious adverse drug events related to substance misuse and other adverse drug events associated with opioid use. Clinicians should consider the comprehensive risks of managing cancer pain with long-term opioid therapy.

Keywords 
RISEOK aged elderly Opioid-Related Disorders opioids pain management
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