A dual THC + FI intervention led to substantial improvements in step count and physical activity following TKR.

Objective Summarize the comparative effectiveness of oral non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in reducing knee osteoarthritis (OA) pain. Methods Two reviewers independently screened reports of randomized controlled trials, published in English between 1982 and 2015, evaluating oral NSAIDs or opioids for knee OA. Included studies were at least eight weeks duration, conducted in Western Europe, the Americas, New Zealand, or Australia, and reported baseline and follow-up pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain subscale (0–100, 100-worst). Effectiveness was evaluated as reduction in pain, accounting for study dropout and heterogeneity. Results 27 treatment arms (9 celecoxib, 4 non-selective NSAIDs [diclofenac, naproxen, piroxicam], 11 less potent opioids [tramadol], and 3 potent opioids [hydromorphone, oxycodone]) from 17 studies were included. NSAID and opioid studies reported similar baseline demographics and efficacy withdrawal rates; NSAID studies reported lower baseline pain and toxicity withdrawal rates. Accounting for efficacy-related withdrawals, all drug classes were associated with similar pain reductions (NSAIDs: −18; less potent opioids: −18; potent opioids: −19). Meta-regression did not reveal differential effectiveness by drug class but found that study cohorts with a higher proportion of male subjects and worse mean baseline pain had greater pain reduction. Similarly, results of the network meta-analysis did not find a significant difference in WOMAC Pain reduction for the three analgesic classes. Conclusion NSAIDs and opioids offer similar pain relief in OA patients. These data could help clinicians and patients discuss likely benefits of alternative analgesics.

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To estimate the lifetime risk of knee osteoarthritis (OA) and total knee replacement (TKR) in persons sustaining ACL tear by age 25. Methods We used the Osteoarthritis Policy Model to project the cumulative incidence of symptomatic knee OA requiring TKR in persons with: 1) no prevalent or incident injury; 2) isolated ACL tear, surgically treated; 3) isolated ACL tear, non-operatively treated; or 4) prevalent history or surgically treated ACL and meniscal tear (MT). We estimated MT prevalence and incidence and increased risk of knee OA associated with ACL injury and MT from published literature. We conducted a range of sensitivity analyses to examine the impact of uncertainty in input parameters. Results Estimated lifetime risk of symptomatic knee OA was 34% for the cohort with ACL injury and MT, compared to 14% for the no injury cohort. ACL injury without MT was associated with a lifetime risk of knee OA between 16%–17%, depending on ACL treatment modality. Estimated lifetime risk of TKR ranged from 6% in the no injury cohort to 22% for the ACL injury and MT cohort. Subjects in the ACL injury and MT cohort developed OA ~1.5 years earlier (55.7 vs. 57.1) and underwent TKR ~2 years earlier (66 vs. 68) than the cohort without knee injuries. Conclusions Sustaining ACL injury early in adulthood leads to greater lifetime risk and earlier onset of knee OA and TKR; concomitant MTs compound this risk. These data provide insight into the impact of sustainable injury prevention interventions in young adults.

Objective To evaluate long-term clinical and economic outcomes of naproxen, ibuprofen, celecoxib or tramadol for OA patients with cardiovascular disease (CVD) and diabetes. Design We used the Osteoarthritis Policy Model to examine treatment with these analgesics after standard of care -- acetaminophen and corticosteroid injections -- failed to control pain. NSAID regimens were evaluated with and without proton pump inhibitors (PPIs). We evaluated over-the-counter (OTC) regimens where available. Estimates of treatment efficacy (pain reduction, occurring in ~ 57% of patients on all regimens) and toxicity (major cardiac or gastrointestinal toxicity or fractures, risk ranging from 1.09% with celecoxib to 5.62% with tramadol) were derived from published literature. Annual costs came from Red Book Online®. Outcomes were discounted at 3%/year and included costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs). Key input parameters were varied in sensitivity analyses. Results Adding ibuprofen to standard of care was cost saving, increasing QALYs by 0.07 while decreasing cost by $800. Incorporating OTC naproxen rather than ibuprofen added 0.01 QALYs and increased costs by $300, resulting in an ICER of $54,800/QALY. Using prescription naproxen with OTC PPIs led to an ICER of $76,700/QALY, while use of prescription naproxen with prescription PPIs resulted in an ICER of $252,300/QALY. Regimens including tramadol or celecoxib cost more but added fewer QALYs and thus were dominated by several of the naproxen-containing regimens. Conclusions In patients with multiple comorbidities, naproxen- and ibuprofen-containing regimens are more effective and cost-effective in managing OA pain than opioids, celecoxib or standard of care.

BackgroundWe designed and implemented the Brigham and Women’s Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees.MethodsWe enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently.ResultsB-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently.ConclusionsOur data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial.Trial registrationClinicaltrials.gov, NCT02850094. Registered July 27, 2016 [retrospectively registered].

Objective Evaluate the cost-effectiveness of incorporating tramadol or oxycodone into knee osteoarthritis (OA) treatment. Methods We used the Osteoarthritis Policy model (OAPol) to evaluate long-term clinical and economic outcomes of knee OA patients with mean age 60 with persistent pain despite conservative treatment. We evaluated three strategies: 1) opioid-sparing (OS); 2) tramadol (T); and 3) tramadol followed by oxycodone (T+O). We obtained estimates of pain reduction and toxicity from published literature and annual costs for tramadol ($600) and oxycodone ($2,300) from Red Book. Based on published data, in the base-case we assumed a 10% reduction in TKA effectiveness in opioid-based strategies. Outcomes included quality-adjusted life years (QALYs), lifetime cost, and incremental cost-effectiveness ratios (ICERs) and were discounted 3%/year. Results In the base case, T and T+O strategies delayed TKA by 7 and 9 years and led to reduction in TKA utilization by 4% and 10% respectively. Both opioid-based strategies increased cost and decreased QALYs compared to the OS strategy. Tramadol’s ICER was highly sensitive to its effect on TKA outcomes. Reduction in TKA effectiveness by 5% (compared to base case 10%) resulted in an ICER for T strategy of $110,600/QALY; with no reduction in TKA effectiveness, the ICER was $26,900/QALY. When TKA was not considered a treatment option, the ICER for T was $39,600/QALY. Conclusion Opioids do not appear to be cost-effective in OA patients without comorbidities, principally because of their negative impact on pain relief after TKA. The influence of opioids on TKA outcomes should be a research priority.

In knee OA patients with no comorbidities, generic celecoxib is not cost-effective at its current price.