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Molecular Pathways Involved in Knee Pain

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT04443452
Recruitment Status : Not yet recruiting
First Posted : June 23, 2020
Last Update Posted : June 23, 2020
Sponsor:
Collaborator:
Versus Arthritis
Information provided by (Responsible Party):
University of Nottingham

Brief Summary:

Knee osteoarthritis (OA) is the most common form of arthritis and the most common cause of knee pain in the world. The rate of knee arthritis is as high as that of cardiac disease and is the most common problem in individuals over the age of 65.

Central Sensitization (CS) is a marker of widespread pain sensitivity that can occur throughout the central nervous system distribution, leading to changes in the spinal cord as well as in the brain. The presence of CS increases the complexity of the clinical picture and can negatively affect treatment outcomes. CS is present in >20% of patients suffering from knee OA indicating that in the majority of individuals suffering with painful knee OA, knee pain should be related to molecular changes in the joint. CS might be also associated with discrete synovial fluid proteomic signatures due to the generation by the joint of chemical mediators (e.g. nerve growth factor) that drive CS, or CS might moderate the relationship between synovial fluid proteomic signatures and symptoms due to alterations in pain processing.

The aim of this study is to explore the potential molecular links between pain and structure on knee pain using synovial fluid proteomics. A secondary purpose is to explore the association of knee pain with biomarkers of stress, metabolism and dietary habits.

In a single session, ultrasound-guided synovial fluid, blood urine and saliva extraction, clinical assessment, completion of a questionnaire booklet and knee x-rays will be conducted. The clinical assessment will measure three features of central sensitisation (sensitivity to blunt pressure on the most painful knee, changes in pain felt during repeated light pricking of the knee skin, and reduction in pain that accompanies inflation of a blood pressure cuff on the non-dominant arm), features of leg strength (dynamometer, time up-and-go test) and features of balance (sway). Participant involvement at each session is expected to last less than 3 hours.

Individuals over 45 having complaints of knee pain for 3-6 months are eligible to participate. The clinical assessments, questionnaire completion and subsequent statistical analysis are expected to be completed within 18 months of study commencement.

The findings can provide more insight into the traits of knee pain, allow the examination of possible correlations to each other, and highlight potential detrimental effects of them on knee joint health.


Condition or disease Intervention/treatment
Knee Osteoarthritis Knee Pain Chronic Diagnostic Test: Quantitative Sensory Testing Radiation: Radiographic Evaluation Procedure: Ultrasound-guided Aspiration Diagnostic Test: Muscle Strength Assessment Diagnostic Test: Function Assessment (A) Diagnostic Test: Function Assessment (B) Diagnostic Test: Balance Assessment

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Study Type : Observational
Estimated Enrollment : 140 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: Molecular Pathways Involved in Knee Pain: an Observational Study
Estimated Study Start Date : September 2020
Estimated Primary Completion Date : March 2022
Estimated Study Completion Date : April 2022

Resource links provided by the National Library of Medicine


Group/Cohort Intervention/treatment
Prevalent Central Sensitisation
Participants with sensitisation that significantly deviates from the normal mean as assessed by Quantitative Sensory Testing
Diagnostic Test: Quantitative Sensory Testing

PPT: An electronic data collection unit will be used featuring an electronic algometer connected with a laptop where the amount of pressure will be displayed on the screen. When the pressure pain detection threshold is reached (the point where the pressure sensation starts to be experienced as pain), the individual will press a button at a handheld device, that will automatically store the pressure value in the system and serve as an indication, for the examiner, to stop the testing.

TS: A pinprick stimulator (Weight: 256mNewton) will be used. The examiner will apply the pen that features a retractable blunt needle in a repetitive manner (once per second for ten seconds). The individual will be asked for the intensity of pain (NRS) at the first and at the last time and the given score will be noted.

CPM: A manual blood pressure sphygmomanometer will be used in conjunction with the electronic algometer described above (PPT).

Other Names:
  • Pressure Pain Detection Threshold (PPT)
  • Temporal Summation (TS)
  • Conditioned Pain Modulation (CPM)

Radiation: Radiographic Evaluation
Tibiofemoral and patellofemoral radiographs of the most painful knee will be taken using a standardised protocol (standing posterior-anterior (PA) and skyline views) and will be scored by a single experienced observer in order to generate data for correlation analyses with the primary and secondary outcomes. A Perspex Rosenberg template with lead beads is used for the standing PA view to standardising the degree of knee flexion, foot rotation and magnification. PA radiographs are taken with the participant facing the x-ray tube while standing on the Rosenberg jig and leaning forwards with their thighs touching the anterior aspect of the jig, the x-ray beams passing from the posterior aspect through to the anterior aspect of the knee. Variable jigs are used for the skyline view to obtaining 300 of knee flexion with the participant lying in a reclined supine position on a couch. Grading of radiographs for changes of OA will be based on the Kellgren and Lawrence (K/L) score.
Other Name: X-rays

Procedure: Ultrasound-guided Aspiration
Ultrasound scanning will be conducted on the most painful knee to identify synovial effusion. During the ultrasound scan, the supra-patellar pouch, medial and lateral recess of the knees will be assessed for synovial thickening, synovial fluid/effusion and for positive power Doppler. An ultrasonic probe will be used to direct ultrasonic waves onto the knee joint during sonography, and a computer converts the signals received so that they can be presented on the screen. During skin application, a sterile probe cover and sterile acoustic gel will be used. Once the best aspiration location is identified and the location of the needle insertion marked, the skin will be prepared with a cleansing agent such as iodine or chlorhexidine. The needle may be introduced into the skin either parallel to the probe or perpendicular to the probe. Once the aspiration is completed, the needle will be removed, the skin cleansed, and a bandage will be applied.
Other Name: Synovial Fluid Extraction

Diagnostic Test: Muscle Strength Assessment
Isometric testing will be done at 30 and 60 degrees of flexion as done in the previous study and the participant will be in sitting position with hips and knees strapped to keep the position standardised.
Other Name: Isometric Dynamometer

Diagnostic Test: Function Assessment (A)

The participant will start in a seated position. The participant will stand up upon therapist's command, walk 3 meters, turn around, walk back to the chair and sit down. The time will stop when the participant is seated. The subject can use an assistive device. If the assistive device is used, it will be documented.

Important Note: A practice trial will be completed before the timed trial.

Other Name: Time Up-and-Go Test

Diagnostic Test: Function Assessment (B)
The 30-Second Chair Test is administered using a chair. The participant is seated in the middle of the chair with arms crossed at the wrists and held against the chest. The participant will practice a repetition or 2 before completing the test. If a participant must use their arms to complete the test, they are scored 0. The participant is encouraged to complete as many full stands as possible within 30 seconds. The participant is instructed to fully sit between each stand. While monitoring the participant's performance to ensure proper form, the tester silently counts the completion of each correct stand. The score is the total number of stands within 30 seconds (more than halfway up at the end of 30 seconds counts as a full stand). Incorrectly executed stands are not counted. The 30-second chair stand involves recording the number of stands a person can complete in 30 seconds rather than the amount of time it takes to complete a pre-determined number of repetitions.
Other Name: 30 seconds Sit-to-Stand Test

Diagnostic Test: Balance Assessment
Static balance and postural sway either in the medial-lateral or antero-posterior direction will be assessed using the RS Scan force plate. The participant will be asked to stand on the plate looking straight forward for 30 seconds in two conditions: first with their eyes open and then with eyes closed. Medial-lateral, antero-posterior and total sway will be recorded.
Other Names:
  • Static Balance Test
  • Postural Sway Test

Non-prevalent Central Sensitisation
All other participants with sensitisation that is not significantly deviating from the normal mean as assessed by Quantitative Sensory Testing
Diagnostic Test: Quantitative Sensory Testing

PPT: An electronic data collection unit will be used featuring an electronic algometer connected with a laptop where the amount of pressure will be displayed on the screen. When the pressure pain detection threshold is reached (the point where the pressure sensation starts to be experienced as pain), the individual will press a button at a handheld device, that will automatically store the pressure value in the system and serve as an indication, for the examiner, to stop the testing.

TS: A pinprick stimulator (Weight: 256mNewton) will be used. The examiner will apply the pen that features a retractable blunt needle in a repetitive manner (once per second for ten seconds). The individual will be asked for the intensity of pain (NRS) at the first and at the last time and the given score will be noted.

CPM: A manual blood pressure sphygmomanometer will be used in conjunction with the electronic algometer described above (PPT).

Other Names:
  • Pressure Pain Detection Threshold (PPT)
  • Temporal Summation (TS)
  • Conditioned Pain Modulation (CPM)

Radiation: Radiographic Evaluation
Tibiofemoral and patellofemoral radiographs of the most painful knee will be taken using a standardised protocol (standing posterior-anterior (PA) and skyline views) and will be scored by a single experienced observer in order to generate data for correlation analyses with the primary and secondary outcomes. A Perspex Rosenberg template with lead beads is used for the standing PA view to standardising the degree of knee flexion, foot rotation and magnification. PA radiographs are taken with the participant facing the x-ray tube while standing on the Rosenberg jig and leaning forwards with their thighs touching the anterior aspect of the jig, the x-ray beams passing from the posterior aspect through to the anterior aspect of the knee. Variable jigs are used for the skyline view to obtaining 300 of knee flexion with the participant lying in a reclined supine position on a couch. Grading of radiographs for changes of OA will be based on the Kellgren and Lawrence (K/L) score.
Other Name: X-rays

Procedure: Ultrasound-guided Aspiration
Ultrasound scanning will be conducted on the most painful knee to identify synovial effusion. During the ultrasound scan, the supra-patellar pouch, medial and lateral recess of the knees will be assessed for synovial thickening, synovial fluid/effusion and for positive power Doppler. An ultrasonic probe will be used to direct ultrasonic waves onto the knee joint during sonography, and a computer converts the signals received so that they can be presented on the screen. During skin application, a sterile probe cover and sterile acoustic gel will be used. Once the best aspiration location is identified and the location of the needle insertion marked, the skin will be prepared with a cleansing agent such as iodine or chlorhexidine. The needle may be introduced into the skin either parallel to the probe or perpendicular to the probe. Once the aspiration is completed, the needle will be removed, the skin cleansed, and a bandage will be applied.
Other Name: Synovial Fluid Extraction

Diagnostic Test: Muscle Strength Assessment
Isometric testing will be done at 30 and 60 degrees of flexion as done in the previous study and the participant will be in sitting position with hips and knees strapped to keep the position standardised.
Other Name: Isometric Dynamometer

Diagnostic Test: Function Assessment (A)

The participant will start in a seated position. The participant will stand up upon therapist's command, walk 3 meters, turn around, walk back to the chair and sit down. The time will stop when the participant is seated. The subject can use an assistive device. If the assistive device is used, it will be documented.

Important Note: A practice trial will be completed before the timed trial.

Other Name: Time Up-and-Go Test

Diagnostic Test: Function Assessment (B)
The 30-Second Chair Test is administered using a chair. The participant is seated in the middle of the chair with arms crossed at the wrists and held against the chest. The participant will practice a repetition or 2 before completing the test. If a participant must use their arms to complete the test, they are scored 0. The participant is encouraged to complete as many full stands as possible within 30 seconds. The participant is instructed to fully sit between each stand. While monitoring the participant's performance to ensure proper form, the tester silently counts the completion of each correct stand. The score is the total number of stands within 30 seconds (more than halfway up at the end of 30 seconds counts as a full stand). Incorrectly executed stands are not counted. The 30-second chair stand involves recording the number of stands a person can complete in 30 seconds rather than the amount of time it takes to complete a pre-determined number of repetitions.
Other Name: 30 seconds Sit-to-Stand Test

Diagnostic Test: Balance Assessment
Static balance and postural sway either in the medial-lateral or antero-posterior direction will be assessed using the RS Scan force plate. The participant will be asked to stand on the plate looking straight forward for 30 seconds in two conditions: first with their eyes open and then with eyes closed. Medial-lateral, antero-posterior and total sway will be recorded.
Other Names:
  • Static Balance Test
  • Postural Sway Test




Primary Outcome Measures :
  1. Pain Sensitivity: Pressure Pain Detection Threshold (PPT) [ Time Frame: 18 months ]
    PPT is a non-invasive test during which the sensitivity of the nerves is assessed by recording the amount of pressure applied to the skin. Pressure is applied through a probe. The pressure probe used is mounted in a handheld device connected to a computer. Pressure applied to the skin is gradually increased until the participant indicates (by pressing a button) that the sensation has changed from pressure to pain. The probe will be used on 3 sites at the knee area (2cm above the medial and lateral edge of the patella and laterally on the joint line), proximal shin (tibialis anterior muscle - 5cm inferior to the tibial tuberosity) and over the contralateral forearm (brachioradialis muscle) using a standardised protocol used in other studies within the Pain Centre. Each region will be tested one time with short rest periods between each. The participants will be familiarised with the test before it is administered so that they know what to expect and how to respond.

  2. Pain Sensitivity: Temporal Summation Pain (TS) [ Time Frame: 18 months ]
    TS is a non-invasive test during which repetitive mechanical stimulation is applied over a short period to get their augmented response. A 256mN weighted pinprick stimulator will be used and applied perpendicular to the skin of suprapatellar region of the painful knee (5cm proximal from the centre of patella). The participant will be asked to rate the pain or sharpness they experience from 0-10 where 0 indicates no pain or sharpness and 10 indicates the most intense pain or sharpness imaginable. The response of the participant will be recorded. The same stimulator at the same site will be applied ten times repeatedly at a rate of 1/second. At the end of the series of 10 pinpricks, the participant will be asked to rate the average pain or sharpness they experienced out of the 10 stimuli using the same scale. The TS value will be calculated as the difference between the two ratings (single stimulus minus the average of the 10 stimuli).

  3. Pain Sensitivity: Conditioned Pain Modulation (CPM) [ Time Frame: 18 months ]
    CPM is the application of PPT before and while a pressure cuff is inflated. A 7.5cm wide tourniquet cuff will be wrapped around the arm contra-laterally to the most painful knee. The lower rim of tourniquet cuff will be kept 3cm proximal to cubital fossa. The cuff will be inflated with the aim to reach above-systolic pressure with a maximum of 270mm/Hg. After target pressure is achieved, the participant will be asked to repeatedly make a handgrip or squeeze a foam ball until they develop ischemic pain ≥4 out of 10 on a 0-10 scale. Once NRS of 4/10 will be achieved, the probe of algometer will be applied in the same manner as during PPT testing. Once the participant presses the button, the probe will be withdrawn, and the cuff will be deflated released from the participants arm. The difference in PPT score (PPT with conditioning minus PPT without conditioning) will be considered the CPM value. A positive value indicates efficient CPM whereas a negative value indicates impaired CPM.


Secondary Outcome Measures :
  1. Central aspects of knee pain (CAP-Knee) [ Time Frame: 18 months ]
    Central augmented pain assessed on a 8-item CAP-Knee questionnaire, where items 1-7 are scored from 0-3, 0 indicating "never" and 3 indicating "often" or "always". Item 8 (pain distribution manikin) was allocated a score of 0 if at most 1 knee is shades, and no other regions below the waist, or a score of 3 if both knees were shaded, or one knee plus any additional shaded areas below the waist. A total sum score ranging from 0-24 will be calculated.

  2. Anxiety [ Time Frame: 18 months ]
    Anxiety will be assessed with the Anxiety part of the Hospital Anxiety and Depression Scale (HADS) where patients are asked to indicate their levels of emotion frequency with a 4-level scale (0-3: 0 indicates never and 3 all the time) at 7 questions. A sum of all responses is calculated (21 being the maximum) for analysis. The higher the value the higher the levels of anxiety.

  3. Depression [ Time Frame: 18 months ]
    Depression will be assessed with the Depression part of the Hospital Anxiety and Depression Scale (HADS) where patients are asked to indicate their levels of emotion frequency with a 4-level scale (0-3: 0 indicates all the time and 3 never) at 7 questions. A sum of all responses is calculated (21 being the maximum) for analysis. The higher the value the higher the levels of depression.

  4. Cognitive function [ Time Frame: 18 months ]
    Cognitive function will be assessed with the Cognitive Failures Questionnaire (CFQ) where participants are asked to indicate symptom frequency with a 0-4 scale (0 indicates never and 4 very often) on 25 statements. A sum of all responses is calculated (100 being the maximum) for analysis. The higher the value the more impaired cognitive function is.

  5. Sleep Quality [ Time Frame: 18 months ]
    Sleep quality will be assessed with the Pittsburgh Sleep Quality Index (PSQI) where participants are asked to respond to 18 statements indicating their: 1) sleep duration in minutes/hours on 4 questions, 2) symptom frequency with 4 possible answers spreading from 'not during the past month' to 'three or more times a week' on 12 statements, 3) symptom severity with 4 possible answers spreading from 'no problem at all' to 'very big problem' on 1 statement and 4) sleep quality with 4 possible answers spreading from 'very good' to 'very bad' on 1 statement. Responses are coded from 0-4 (0 indicating no sleeping issues and 4 frequent and severe sleeping problems). A sum of all 18 responses is calculated (72 being the maximum) for analysis. The higher the value the less sleep quality there is.

  6. Knee Pain, Stiffness, and Physical Functioning [ Time Frame: 18 months ]
    Knee pain, stiffness and physical functioning will be assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) where participants are asked to rate their symptom severity with a 0-4 scale (0 indicates never and 4 extreme) five items for pain (score range 0-20), two for stiffness (score range 0-8), and 17 for functional limitation (score range 0-68). The higher the value in each domain the more pain, stiffness and physical dysfunction there is.

  7. General Musculoskeletal Health [ Time Frame: 18 months ]
    General health will be assessed with the Musculoskeletal Health Questionnaire (MSK-HQ) where participants are asked to indicate symptom frequency with a 0-4 scale (0 indicates very severe and 4 not at all severe) on 14 statements. A sum of all responses is calculated (56 being the maximum) for analysis. The lower the value the more reduced general musculoskeletal health is.

  8. Frailty [ Time Frame: 18 months ]
    Frailty will be measured with a modified questionnaire where participants will be asked to respond to 8 Yes/No questions (Yes is marked with 1 and No with 0) about inability to walk, using aids, weight loss, co-morbidities and levels of physical activity. A total out of all responses (8 being the maximum) is calculated for analysis. The higher the score, the higher the levels of frailty


Other Outcome Measures:
  1. Dietary Habits (OPTIONAL) [ Time Frame: 18 months ]
    Dietary habits will be assessed with the Food Frequency Questionnaire (FFQ) where participants are asked to indicate the consumption frequency of different types of food materials with a 0-9 scale (0 indicates 'never or less than once a month' and 9 'more than 6 times per day') on 150 distinct foods divided into dairy, fruits, vegetables, meat and fish, soups, bread, sweets, potatoes, and beverages. A total score is calculated for each category with the maximum depending on the amount of items in each category. The larger the total value the more frequent the consumption of a food category per day is.

  2. Biosamples (Synovial fluid A) [ Time Frame: 18 months ]
    Concentration of inflammatory markers (cytokines) identified in extracted synovial fluid.

  3. Biosamples (Synovial fluid B) [ Time Frame: 18 months ]
    Concentration of proteomic concentrations (fibronectin) identified in extracted synovial fluid.

  4. Biosamples (Synovial fluid C) [ Time Frame: 18 months ]
    Concentration of gene expression molecules (RNA polymerase II) identified in extracted synovial fluid.

  5. Biosamples (Blood A) [ Time Frame: 18 months ]
    Concentration of stress markers (cortisol) identified in participants' blood samples.

  6. Biosamples (Blood B) [ Time Frame: 18 months ]
    Concentration of insulin resistance markers (fasting blood glucose) identified in participants' blood samples.

  7. Biosamples (Blood C) [ Time Frame: 18 months ]
    Concentration of metabolic rate markers (triglycerides) identified in participants' blood samples.

  8. Biosamples (Urine A) [ Time Frame: 18 months ]
    Concentration of metabolic rate markers (UTXII collagen degradation marker) identified in participants' urine samples.

  9. Biosamples (Urine B) [ Time Frame: 18 months ]
    Concentration of inflammatory regulator markers (maresins) identified in participants' urine samples.

  10. Biosamples (Saliva) [ Time Frame: 18 months ]
    Concentration of stress markers (cortisol) in participants' saliva samples.

  11. Biosamples (Faeces A) [OPTIONAL] [ Time Frame: 18 months ]
    Concentration of metabolic rate markers (glucosamine) in participants' faecal samples.

  12. Biosamples (Faeces B) [OPTIONAL] [ Time Frame: 18 months ]
    Concentration of metabolic rate markers (chondroitin sulfate) in participants' faecal samples.


Biospecimen Retention:   Samples With DNA
Blood, Urine, Saliva, Synovial fluid from the most painful knee, Faeces (OPTIONAL)


Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


Layout table for eligibility information
Ages Eligible for Study:   45 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Non-Probability Sample
Study Population
Adults equal or above the age of 45 with a history of knee pain of at least 3 months duration that may or may not have been radiographically and no-radiographically classified as having knee pain due to osteoarthritis.
Criteria

Inclusion Criteria:

  • have the ability to give informed consent
  • be 45 years or over
  • have complaints of knee pain for 3-6 months with or without radiographically established OA (K/L scale score ≥ 1)
  • have complaints of knee pain for 3-6 months with or without satisfying the non-radiographic American College of Rheumatology criteria for knee OA
  • are willing to undertake knee synovial fluid aspiration
  • be able to speak, read, and write in English as all instructions and questionnaires are designed in the English language

Exclusion Criteria:

  • Inability to give informed consent due to cognitive impairment or otherwise - (capacity levels are already established under General Practitioner care)
  • Inability to understand key aspects of the study due to cognitive impairment or otherwise
  • Giving history of additional co-morbidities such as cancer, neurological conditions, inflammatory joint diseases including rheumatoid arthritis, diabetic neuropathies, fractures or other conditions causing greater disability than their knee pain
  • Acute soft tissue injury to the knee within last 3 months before potential recruitment

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04443452


Contacts
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Contact: Vasileios Georgopoulos, PhD +44 (0) 115 823 1942 vasileios.georgopoulos@nottingham.ac.uk
Contact: Ana M Valdes, PhD +44 (0) 115 82 31954 ana.valdes@nottingham.ac.uk

Sponsors and Collaborators
University of Nottingham
Versus Arthritis
Investigators
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Principal Investigator: Ana M Valdes, PhD University of Nottingham
  Study Documents (Full-Text)

Documents provided by University of Nottingham:
Informed Consent Form  [PDF] March 25, 2020

Publications:
McCormick, A. Morbidity statistics from general practice. Fourth national study 1991-1992. Office of population censuses and surveys.1995.
Evans KD, Douglas B, Bruce N, Drummond PD. An exploratory study of changes in salivary cortisol, depression, and pain intensity after treatment for chronic pain. Pain Medicine. 2008;9(6):752-8.
National Institutes of Health. National Cancer Institute (2017) Dietary assessment primer, food frequency questionnaire at a glance. 2017.
Hill J, Kang S, Benedetto E, Myers H, Blackburn S, Smith S, et al. PMS74 - Development of the Musculoskeletal Health Questionnaire (MSK-HQ) for Use in Different Conditions and Different Healthcare Pathways. Value in Health. 2016;19(7):A544.

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Responsible Party: University of Nottingham
ClinicalTrials.gov Identifier: NCT04443452    
Other Study ID Numbers: 19098
22473 ( Other Grant/Funding Number: Versus Arthritis )
275727 ( Other Identifier: IRAS )
First Posted: June 23, 2020    Key Record Dates
Last Update Posted: June 23, 2020
Last Verified: June 2020
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided
Plan Description: Considerations about data sharing will be taken once the main results of this study have been published

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No
Additional relevant MeSH terms:
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Osteoarthritis
Osteoarthritis, Knee
Arthritis
Joint Diseases
Musculoskeletal Diseases
Rheumatic Diseases