Today's blog is written by Dr Leticia Deveza from the Institute of Bone and Joint Research. Dr Deveza is a rheumatologist hailing from Brazil and is a current PhD student working with Professor David Hunter. Leticia has a keen interest in the different phenotypes of osteoarthritis and enjoys running in her free time.

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Learning point: This post uses the term “acute” a few times. In this context “acute” refers to a sudden onset.

Changes in weather are frequently reported to trigger increases in pain by people with osteoarthritis and other chronic pain conditions. Around two-thirds of people with knee, hip or hand osteoarthritis reported that the weather affects their pain and, for most people, increases in pain could actually be perceived even before the weather changed!

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There are a few theories about the mechanisms behind this phenomenon, including that changes in air pressure associated with weather changes are actually responsible for causing pain flare ups. However, at present, that is no conclusive evidence from studies to support the relationship between weather changes and acute increases in pain in people with knee osteoarthritis.

A recent study was conducted in Australia, intending to shed light on this intriguing, commonly reported association. It included people with knee osteoarthritis and investigated whether temperature, relative humidity, air pressure and precipitation were associated with an increase of at least 20% from the mildest pain reported at the beginning of the study. After 3 months of follow-up, the study found no association between weather and knee pain increases in the 171 participants who experienced at least 1 flare throughout the study.
However, it is important to note that more extreme temperatures (e.g. < 10oC) were uncommon during the study and hence these findings cannot be transferred to other regions that may experience more dramatic weather. Nevertheless, results of this study suggested that there is no relationship between weather and knee pain caused by osteoarthritis and, therefore, it is possible that other factors may play a role in these acute increases in knee pain.

Link to the study: http://www.ncbi.nlm.nih.gov/pubmed/27492467

Ferreira ML, Zhang Y, Metcalf B, Makovey J, Bennell KL, March L, Hunter DJ. The influence of weather on the risk of pain exacerbation in patients with knee osteoarthritis - a case-crossover study. Osteoarthritis Cartilage. 2016 Aug 1. pii: S1063-4584(16)30205-9.doi: 10.1016/j.joca.2016.07.016.

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It's been rather quiet on the blog lately but fret not!! We have an insightful new post for you to read at the Bristish Journal of Sport Medicine Blog. The post entitled "Cutting sporting Australians to their knees: time for more investment in sports injury prevention" was penned by our very own Professor David Hunter.

Professor Hunter is a rheumatology clinician researcher whose main research focus has been clinical and translational research in osteoarthritis (OA). He is the Florance and Cope Chair of Rheumatology and Professor of Medicine at University of Sydney and the Royal North Shore Hospital and Consultant Rheumatologist at North Sydney Orthopaedic and Sports Medicine Centre.

Click here to read Professor Hunter post

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Dr Joanna Makovey is a scientist with over 20 years experience in medical research. She has been a member of the musculoskeletal research group at the Department of Rheumatology of the RNSH since 1996. She completed her PhD in 2009 and has over 30 publications. She is affiliated with the Institute of Bone and Joint Research (Northern Clinical School, the University of Sydney). Outside of work, Joanna enjoys yoga and travelling.

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Mindfulness is about being here, now. It’s about being 'present' or in the moment. While the idea is really very simple, embodying mindfulness is not always easy. We’ve all had experiences of being completely absorbed in what we are doing - perhaps walking on the beach, playing with a child, looking up at a magnificent sunset, or enjoying the first mouthful of a delicious meal. These moments are moments of mindful awareness and we have them all the time. It’s just that they are brief and fleeting.

Soon enough our minds wander off into streams of consciousness – analysis, remembering, planning and a myriad of other distractions. We might pull into the driveway and suddenly come to our senses, unable to remember the drive home because we were replaying the day’s events in our minds.

What does mindfulness meditation involve?
The practice of mindfulness meditation is really just about stretching out these moments of present-focused awareness by training our minds to keep coming back to what is happening right now. It is described as shifting out of the 'doing' mode and into the ‘being’ mode, or switching out of autopilot.
At first this involves picking something to pay attention to – like the flow of your breathing, the shifting sensations in your body, or the many sounds around you – and noticing each time you end up distracted so that you can gently coax your attention back. This returning to the now, over and over, becomes a habit, just as practising scales on a piano or kicking the footy develops muscle memory. We stop 'missing precious moments' and start being fully engaged with what is happening as it unfolds.

What does mindfulness meditation have to do with pain?
Practising mindfulness meditation can be helpful for people with persistent pain, which has shown moderate effect in reducing pain intensity. Compared to standard care for pain, meditation also seems to improve other aspects of life, such as depression, quality of life, acceptance, sleep quality and physical function. When it comes to short term pain, people report less distress and can tolerate more pain when they have had meditation training, compared to people who do not meditate6.
Overall, the current evidence suggests that mindfulness-based treatments are about as good as well-established psychological treatments for pain, like Cognitive Behaviour Therapy (CBT). However, since the research on meditation is newer, it is not yet as strong and convincing as the research on CBT. We still need to do more high quality studies to figure out which types of pain meditation helps most with, what doses of meditation work best, and what the essential ingredients are that make meditation helpful.

How does mindfulness meditation help with pain?
While research on meditation and pain are still in its early days, there a few important ingredients that we know of:

1.Relaxation
Relaxation is a helpful side effect of meditation and is very important for coping with pain. This is because while pain is stressful in itself, the stress also exacerbates and maintains pain. Relaxation helps to calm down your nervous system, which often becomes 'sensitised' when pain persists for a long time and boosts your body’s natural pain modifiers, such as "feel good" hormones.

2.Acceptance
Mindfulness is about accepting what is here right now as best we can, including pain, so that we can soften and be more receptive to what happens next. This is very different from being resigned to a life of pain. Mindfulness is all about curiosity and what some people call 'beginner’s mind'. Research shows that people who learn how to accept their pain respond better to various treatments and have better overall pain outcomes.

3.Mental flexibility
Negative thoughts drive negative feelings, which can sensitise our nervous systems and increase our pain. Thinking very negatively about pain, or what we call 'pain catastrophising', is one of the strongest predictors that short-term acute pain will become longer-term persistent pain. Mindfulness meditation can reduce the burden of these negative thoughts because it changes our relationship to thinking itself. We start to see thoughts as just 'mental events' rather than facts, which lessens their impact. In other words, we don’t as easily buy into the negative story around our pain. This is especially important in overcoming the upsetting emotional impacts of pain, such as depression and anxiety.

4.Pain with less distress
Exciting research using brain scanning technology like functional magnetic resonance imaging (fMRI) is beginning to shed light on patterns of activity in the brain when a person is in pain and when they are meditating. It looks like people are still aware of the sensory aspects of pain during mindfulness meditation but they experience it as less unpleasant since it does not activate as many of the brain networks related to memory and emotion. In other words, meditation trains your brain to experience pain with less distress.

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Rachel Choi is a PhD student at the Murray Maxwell Biomechanics Lab and the Raymond Purves Research Lab at the IBJR. Her research interest in tendon biology coincides with a personal interest in music and sporting performance, and associated injuries. She graduated in 2012 from the University of Sydney (B. Engineering (Biomedical), B. Commerce (Economics)), while squeezing in academic credit for wind orchestra and symphony orchestra during her year of study abroad at the University of California Irvine.

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The surf was perfect this morning, as was my post-surf breakfast at the local cafe. Equipped with one functioning leg and one walker boot, I had surmounted the last of the cafe stairs when a familiar conversation begins: “What have you been doing to yourself”, in reference to my boot. I’ve had a total rupture of my right Achilles tendon. “How did it happen?” Playing touch footy. “Ah, some really rough fields eh?” Well, actually no, I was just taking off in a straight line with the ball in hand. “Achilles tendon, gee that must’ve really hurt”. Nope. It took me a good half minute to deduce that I might have a total Achilles tendon rupture. The pain only really set in after the operation.

Just as I appreciate the kindness shown to me as a crutch user, I really do enjoy these “crutch/cast conversations”. However, I find it awkward anticipating the complete mismatch in how much we know about tendons.

Irony alert: Yes, I am a PhD student in tendon biology with an Achilles tendon rupture.

I find myself in a unique position where I’m a tendon rupture patient (right leg), a chronic tendinopathy patient (left leg), and also a tendon basic science researcher in training (brain, bilateral). So Bob, my dear waiter, how much did you want to know about my tendon exactly?

If two years of PhD research has taught me anything, it’s that tendon injuries and pain occur with many variations. What we know is only a small part of what’s happening inside and around our tendons. And so it’s natural that my waiter’s guesses about my conditions didn’t match up with my very own, unique patient experience. MyInjury™? iRupture™?

But let’s start with what we know.

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Dr Rodrigo Megale is a Brazilian physician specialising in geriatrics , graduated from Medical School (UFMG) in 2002, with advanced training in Internal Medicine (2002-2004) followed by Geriatrics (2004-2006) through accredited residency programs (MEC). He has Masters Degree in Public Health (Epidemiology) from Fiocruz and is, currently, undertaking his PhD in The University of Sydney - Medical School.

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It is usual among older adults to think that musculoskeletal pain is a benign symptom related to the “wear and tear” of ageing. If you are in your 70s or 80s, you probably have already heard from health professionals that chronic pain is something that you should get used to, and that it is a very common age-related condition. I, myself, have said that to many of my patients. It turns out that having chronic or persistent musculoskeletal pain is not as benign as it was thought to be.
Several studies have shown an association between chronic pain and frailty, a pre-disability condition, clinically characterised by weight loss, exhaustion, weakness, slowness and low physical activity. Those who have been experiencing bothersome joint or low back pain might be worried at this moment; however, there is no reason for that. If your pain is not interfering in your daily living activities, and your doctor has already assessed it in order to rule out any serious condition, there are some tips that can help you cope with your symptoms.

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The first important thing that you need to know about chronic pain is that, in many cases, the source of pain is not only joint inflammation, cartilage damage or disc degeneration/ protrusion. Actually, it seems that our brains play a very important role in this condition. Chronic pain usually involves a problem in the so called “descending inhibitory pathway”, which is part of your body’s pain management system, and it is controlled by your brain. That is probably why some patients report less pain when they are surrounded by loved ones or when they are on a pleasant trip. Our brain is capable of modulating the pain we feel. If you focus on your pain and drive all your attention towards your suffering, your behaviour could probably “enhance” your pain. On the other hand, if you drive your attention away from your suffering and try to focus on positive aspects of your life, there is a reasonable chance of achieving pain improvement.

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Today's blog post is brought to you by Dr Helen Liang of the Sutton Arthritis Research Laboratory led by Professor Chris Jackson.

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I am a Postdoctoral Research Fellow from the Sutton Arthritis Research Laboratory, who is currently supported by the Ulysses Club Arthritis Research Fellowship, to carry out a research project that aims towards developing new medicines to provide better treatment for rheumatoid arthritis patients.

Rheumatoid arthritis is the second most common type of arthritis and one of the most damaging forms. People with this condition not only suffer severe pain, but their death rate within the first 10 years of diagnosis is also 3 times that of healthy individuals. The common clinical symptoms of arthritis include pain, swelling and stiffness of joints, inflammation, and damage to joint structures that results in joint weakness and deformity, which ultimately interferes with the most basic daily tasks such as walking and standing.

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Weight loss is very commonly spoken about when it comes to OA. Today we have a post exploring some studies about how weight loss is related to knee OA.

Today's post is written by Dr Sarah Meneses, a researcher and physiotherapist based at the Institute of Bone and Joint Research. Dr Meneses completed her PhD on laser therapy and stretching exercises at the University of Sao Paulo and takes a strong interest in conservative management of osteoarthritis.

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It is well known that being overweight or obese can lead to health issues over the time. The joints that carry this extra load suffer and it is common to see a high prevalence of osteoarthritis (OA) within overweight and obese people.

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A recent study showed that losing either 5 kg or 5% of body weight has preventive effects on both the structural and clinical signs of knee OA in middle-aged, overweight and obese women without OA.

The authors stated that is necessary to design strategies that are implementable in primary care and effective in reducing body weight of overweight and obese subjects at high-risk of developing knee OA. However, it is important to note that this was an observational study (where researcher are unable to control as much), and we cannot assume a causal relationship (where one variable results in a particular outcome), as there may have been other factors that influenced the results.

Another recent study showed the effect of bariatric surgery (to reduce the size of the stomach) prior to total knee replacement as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis.

The authors advised that ideally, a team approach should be used to treat severely obese patients with knee arthritis in which various health care professionals are in place to help a patient lose weight, improve his or her health, and optimize nutrition before joint replacement to maximize its benefits. The outcomes of this study may assist physicians when counseling patients and developing an individualized treatment plan that includes optimization of overall health, nutrition and weight prior to knee replacement.

These two studies had different subtypes of overweight or obese participants. In the first were included people without OA and in the other were included people in the end-stage of the disease. However, both studies showed a positive effect of weight reduction in the prevention or management of OA. So, keep track of your weight! Speak with your GP and find a real weight loss target for yourself. A weight reduction of 5% already promotes benefits to your health!

Runhaar J, de Vos BC, van Middelkoop M, Vroegindeweij D, Oei EH, Bierma-Zeinstra SM. Moderate weight loss prevents incident knee osteoarthritis in overweight and obese female. Arthritis Care Res (Hoboken). 2016 Feb 11. doi: 10.1002/acr.22854. [Epub ahead of print]

McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am. 2016 Jan 20;98(2):e6. doi: 10.2106/JBJS.N.00416.

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