Evaluation of the Combined Application of Neuromuscular Electrical Stimulation and Volitional Contractions on Thigh Muscle Strength, Knee Pain, and Physical Performance in Women at Risk for Knee Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of disability that is associated with quadriceps weakness. However, strengthening in people with or with risk factors for knee OA can be poorly tolerated.

OBJECTIVE

To assess the efficacy of a 12-week low-load exercise program, using a hybrid training system (HTS) that uses the combination of neuromuscular electrical stimulation and volitional contractions, for improving thigh muscle strength, knee pain relief, and physical performance in women with or with risk factors for knee OA.

DESIGN

Randomized, single-blinded, controlled trial.

SETTING

Exercise training laboratory.

PARTICIPANTS

Forty-two women 44-85 years old with risk factors for knee OA.

INTERVENTIONS

Participants randomized to 12 weeks of biweekly low-load resistance training with the HTS or on an isokinetic dynamometer (control).

OUTCOMES

Maximum isokinetic knee extensor torque. Secondary measures included maximum isokinetic knee flexor torque, knee pain (Knee Injury and Osteoarthritis Outcome Score), and timed 20-m walk and chair stand tests.

RESULTS

The HTS and control treatments resulted in muscle strengthening, decreased knee pain, and improved physical performance. HTS group quadriceps and hamstring strength increased by 0.06 ± 0.04 Nm/kg (P > .05) and 0.05 ± 0.02 Nm/kg (P = .02), respectively. Control group quadriceps and hamstring strength increased by 0.03 ± 0.04 Nm/kg (P > .05) and 0.06 ± 0.02 Nm/kg (P = .009), respectively. Knee pain decreased by 11.9 ± 11.5 points (P < .001) for the HTS group and 14.1 ± 15.4 points (P = .001) for the control group. The 20-m walk time decreased by 1.60 ± 2.04 seconds (P = .005) and 0.95 ± 1.2 seconds (P = .004), and chair stand time decreased by 4.8 ± 10.0 seconds (P > .05) and 1.9 ± 4.7 seconds (P > .05) in the HTS and control groups, respectively. These results did not differ statistically between the HTS and control groups.

CONCLUSIONS

These results suggest the HTS is effective for alleviating pain and improving physical performance in women with risk factors for knee OA. However, the HTS does not appear to be superior to low-load resistance training for improving muscle strength, pain relief, or physical function.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02802878.

LEVEL OF EVIDENCE

I.

Self-perceived care needs in older adults with joint pain and comorbidity

Background

The aim of this study was to explore self-perceived care needs and determinants of identified needs in older adults with joint pain and comorbidity.

Methods

This is a cross-sectional study using baseline data from a cohort study of older adults in the Netherlands (≥65 years) with joint pain and comorbidity (n = 407). We used the Camberwell Assessment of Need for the Elderly (CANE) to assess self-perceived care needs. Regression analyses were conducted to examine the associations between needs and sociodemographic factors (age, gender, partner status and educational level), physical factors (pain intensity, comorbidity, frailty and physical functioning) and psychosocial factors (anxiety, depression and social support).

Results

Older adults with joint pain and comorbidity reported on average 4.0 care needs out of 13 CANE items, of which 0.3 were unmet. High levels of environmental and physical needs were reported, such as needs with regard to physical illness (91%), household (61%) and mobility/falls (53%). However, most of these needs were met. Only few people reported psychosocial needs, but a large proportion of these needs was unmet, especially regarding company (66.7%) and daytime activities (37%). Psychosocial needs were more often present in frail participants (OR 2.40, 95% CI 1.25–4.61), and those with less perceived social support (OR 1.05, 95% CI 1.01–1.08) and more depressive symptoms (OR 1.17, 95% CI 1.07–1.26).

Discussion/Conclusions

Unmet needs are mainly present in the psychosocial domain. Specific attention targeted at these unmet needs may improve psychosocial well-being of older adults with joint pain and comorbidity.

Joint involvement in Mexican patients with ulcerative colitis: a hospital-based retrospective study

The most frequent extra-intestinal manifestation in ulcerative colitis (UC) around the world is joint involvement. There are no previous data in Latin America that is about this aspect of disease; hence, the aim of this study was to determine the frequency and factors associated to joint involvement in Mexican patients with UC. A total of 295 patients with histological diagnosis of UC were studied, divided into two groups: (1) 154 cases with at least one joint affection (arthralgia, peripheral, or axial arthropathy (sacroilitis (SI) or ankylosing spondylitis (AS))) and (2) 141 controls that had never presented any joint involvement during the clinical course of UC. Demographic, clinical, and laboratory variables were collected from the clinical records, at the time of presentation of the joint involvement for the cases and with the last information available for controls. A total of 52.2% of the patients had joint involvement, which was also the most frequent extra-intestinal manifestation (EIM). The frequency of peripheral arthralgia was 46.8% and of axial arthropathy was 5.4% (2.7% AS, 2.4% SI, and 0.3% both). The female gender (P = 0.01, OR = 3.061 95% CI: 1.311-7.15), elevated erythrocyte sedimentation rate (ESR) (P = 0.07, OR = 8.04 95% CI: 1.759-36.764), and moderate disease activity by Truelove and Witts criteria (P = 0.024, OR = 4.37 95% CI: 1.211-15.78) were factors associated at the time of presentation of the joint affection. Joint involvement is the most frequent EIM in Mexican patients with UC. The female gender, elevated ESR, and disease activity are factors associated with its presentation.

Three Cases of Spondyloepiphyseal Dysplasia Tarda in One Korean Family

Spondyloepiphyseal dysplasia (SED) tarda is an inherited skeletal arthropathy. Because SED tarda involves the joints and resemble the clinical findings of chronic arthropathies, this disease is frequently misdiagnosed as juvenile idiopathic arthritis (JIA). We report here on three patients (father and his two daughters) in one family with SED tarda. All patients had back pain and polyarthralgia. Their radiographs revealed typical changes for SED tarda including platyspondyly and dysplastic bone changes. This rare disease has major clinical importance in that it is similar with JIA or rheumatoid arthritis.

The relationship between the presence of depressive symptoms and the severity of self-reported knee pain in the middle aged and elderly

PURPOSE

Knee pain is a very common symptom of knee osteoarthritis (OA), and identification of the major contributors to knee pain is important to establish management plans for patients with knee OA. Among the potential contributors, we hypothesized that coexisting depressive symptoms might increase the severity of knee pain because the increased cytokine levels and neurotransmitter changes related to depression are known to influence the threshold of physical pain perception. Therefore, a possible relationship between self-reported depressive symptoms and self-reported knee pain has been explored. Additionally, we sought to determine factors influencing the severity of knee pain in a middle-aged and elderly Korean population using data from the fifth Korean National Health and Nutrition Examination Survey.

METHODS

In total, 6599 persons aged ≥50 years were evaluated in terms of the radiographic severity of OA and pain severity using 10-point numerical rating scales. Depressive mood was assessed using a polar question: "Had the subject felt despair or depression every day for more than 2 weeks during the past year?"

RESULTS

The Kellgren-Lawrence knee OA grade, depression, gender, educational level, household income, smoking status, marital status, living place, comorbidity status, BMI, and age were identified by multiple linear regression as variables affecting knee pain severity. The presence of depressive symptoms was associated with an increased risk of severe knee pain (odds ratio 2.55 [95 % confidence interval 1.77-3.66]). After stratifying the group in terms of the radiographic severity of knee OA, the relationship with depression persisted in the minimal (2.89 [1.90-4.32]) and moderate OA subgroups (2.29 [1.33-3.94]), but not in the severe OA subgroup.

CONCLUSIONS

Severe knee pain was independently associated with the presence of depressive symptoms in middle-aged and elderly Korean subjects. This suggests that screening for and treatment of depression may help improve knee pain in elderly individuals.

LEVEL OF EVIDENCE

II.

Bone Scintigraphy in the Diagnosis of Rheumatoid Arthritis: Is There Additional Value of Bone Scintigraphy with Blood Pool Phase over Conventional Bone Scintigraphy?

We aimed to investigate the value of bone scintigraphy with additional blood pool phase (BSBP), compared with conventional bone scintigraphy (CBS), in the assessment of rheumatoid arthritis (RA). A total of 242 patients (43 males, 199 females; 14-78 years) with arthralgia, and underwent BSBP were retrospectively analyzed. On the first physical examination, active arthritis was found in 128 of the 242 patients. Clinical diagnosis was made by a rheumatologist on the basis of the 1987 American College of Rheumatology (ACR) criteria, which are considered to be the gold standard. The diagnostic performances and prognostic value of BSBP and CBS were analyzed in the total patients with arthralgia and in the patients with arthritis. The sensitivity of BSBP (84.2%, 80/95) were significantly higher than that of CBS (74.8%, 72/95) in the patients with arthralgia (P = 0.039). When BSBP was interpreted with the results of elevated/positive anti-CCP antibody, its accuracy over CBS also became significantly higher (86.0%, 208/242 vs. 83.1%, 201/242 respectively, P = 0.021). The diagnostic odds ratio of BSBP positivity was higher than CBS positivity in the patients with arthralgia (26.0, 12.9-52.4 vs. 21.1, 10.8-41.3) and with arthritis (12.0, 4.9-29.4 vs. 10.0, 4.2-23.4). Both BSBP and CBS appear to provide acceptable accuracy and comparable diagnostic performance for diagnosis of RA. However, in the patients with arthralgia, BSBP was found to be more sensitive than CBS and more accurate when interpreted with the result of anti-CCP antibody. This could help physicians diagnose RA in daily clinical practice.

Pain Pressure Threshold in the Region of the Sacroiliac Joint in Patients Diagnosed with Sacroiliac Joint Pain

BACKGROUND

Although the prevalence of sacroiliac joint (SIJ) pain is relatively high (15 - 30%), there is no unambiguous reference standard to diagnose SIJ pain. Pressure tenderness in the SIJ region is used for diagnostic purposes, but the clinimetric properties of this procedure remain to be determined.

OBJECTIVES

The aim of this study is to determine the reliability of pain pressure threshold (PPT) measurements in the SIJ region and the difference in PPTs in the SIJ region between healthy volunteers and PPTs in patients with SIJ pain.

STUDY DESIGN

Prospective cohort study.

SETTING

Outpatient pain clinic VU University Medical Center.

METHODS

Forty-one healthy volunteers and 31 patients diagnosed with SIJ pain were included. PPTs were obtained from 5 measurement points in the region of the SIJ with a pressure pain algometer using a standardized protocol. The inter-rater reliability of this method was calculated by means of the Intraclass Correlation Coefficients (ICC) of individual assessment performed by 2 individual raters of SIJs of healthy volunteers on both sides. PPTs of healthy volunteers were compared to those of the affected side in patients with SIJ pain.

RESULTS

PPT measurement showed moderate to good inter-rater reliability (ICC 0.6 - 0.82).The median PPTs of 5 points was comparable for both sides in healthy volunteers (right: 8.5 kg/cm2 [IQR 6.0 - 10.0]; left 8.3 kg/cm2 (5.8 - 10.0]). Median PPTs for the affected sides of patients with SIJ pain were significantly lower compared to the same side of healthy volunteers (right: 2.4 kg/cm2 [IQR 2.2 - 3.2, n = 15]; left: 2.5 kg/cm2 [2.3 - 3.2, n = 16]; P < 0.001 for both sides).

LIMITATIONS

Only the SIJ on one side of was measured in patients with SIJ pain, where both sides would be desirable.

CONCLUSIONS

Pressure pain algometry appears to be a reliable method to establish differences in PPTs between healthy volunteers and patients with SIJ pain. The diagnostic accuracy of this test should be investigated further.

Prospective change in daily walking over 2 years in older adults with or at risk of knee osteoarthritis: the MOST study

OBJECTIVE

Radiographic disease and knee pain are thought to decrease physical activity in people with knee osteoarthritis (OA), but this has not been formally studied. We examined change in objectively measured daily walking over 2 years and evaluated the association of certain risk factors with reduced walking among adults with or at risk of knee OA.

DESIGN

Steps/day over 7 days were collected at baseline and 2 years later in subjects with or at risk of knee OA from the Multicenter Osteoarthritis Study using a StepWatch. We evaluated the presence of radiographic knee osteoarthritis (ROA), knee pain, worsening of ROA and pain over 2 years, obesity, depressive symptoms, living situation, catastrophizing, fatigue, widespread pain and comorbidities with 2-year change in daily walking using regression models adjusted for potential confounders.

RESULTS

1318 met inclusion criteria (age 66.9 ± 7.7, 59% women, BMI 30.6 ± 5.9) and walked 126 ± 1700 steps/day fewer steps at 2 years (95% CI [-218, -35]). People with depressive symptoms at baseline walked 455 fewer steps/day [-872, -68], and there was a trend for people with ROA worsening to walk 183 fewer steps/day [-377.5, 11.7]. No other factors met statistical significance for change in daily walking.

CONCLUSION

Adults with or at risk of knee OA experienced only minimal declines in daily walking over 2 years. Nonetheless, depressive symptoms and may be worsening ROA are associated with a decline in steps/day in adults with or at risk of knee OA.

Effectiveness of intra-articular injections of sodium hyaluronate-chondroitin sulfate in knee osteoarthritis: a multicenter prospective study

Background

Intra-articular injection of hyaluronic acid is a well-established therapy for the treatment of knee osteoarthritis. The aim of the study was to assess the effectiveness and safety of the use of Arthrum HCS^® (40 mg hyaluronic acid and 40 mg chondroitin sulfate in 2 mL).

Materials and methods

This was an open, multicenter, prospective study. Men or women over 40 years of age with documented knee osteoarthritis and WOMAC subscore A (severity of pain) ≥25 were enrolled. They received three weekly intra-articular injections of sodium hyaluronate 2 % and chondroitin sulfate 2 % in combination. WOMAC subscore A was assessed at 1, 3 and 6 months after the last injection.

Results

One hundred and twelve patients were included (women, 66 %). The mean (SD) WOMAC subscore A decreased from 52.1 (15.2) at inclusion to 20.5 (19.7) at month 6 (P < 0.0001). The mean subscore was already significantly decreased 1 month after the last injection at 25.7 (P < 0.0001). Pain relief and consumption of analgesic drugs, both assessed with visual analogic scale (VAS), consistently decreased. The investigators were satisfied/very satisfied as regards the therapeutic effectiveness of sodium hyaluronate-chondroitin sulfate in reducing pain (77 %), improving mobility (78 %) and reducing the consumption of analgesics (74 %). Only one adverse effect was reported by one patient (knee tumefaction).

Conclusion

These results suggest that intra-articular injections of Arthrum HCS^® (sodium hyaluronate plus chondroitin sulfate) in patients with knee osteoarthritis are efficient and safe. These results should be confirmed in a randomized controlled study.

Level of evidence

IV.

Pain and falls and fractures in community-dwelling older men

BACKGROUND

Pain may reduce stability and increase falls and subsequent fractures in older men.

OBJECTIVES

To examine the association between joint pain and any pain with falls, hip and non-spine fractures in older community-dwelling men.

DESIGN

A cohort study.

SETTING AND PARTICIPANTS

Analyses included 5,993 community-dwelling men aged ≥65 years from the MrOS cohort.

MEASUREMENTS

Pain at hip, knee and elsewhere (any) was assessed by self-report. Men reported falls via questionnaires mailed 3× per year during the year following the baseline visit. Fractures were verified centrally. Mean follow-up time for fractures was 9.7 (SD 3.1) years. Logistic regression models estimated likelihood of falls and proportional hazards models estimated risk of fractures. Models were adjusted for age, BMI, race, smoking, alcohol use, medications use, co-morbidities and arthritis; fracture models additionally adjusted for bone mineral density.

RESULTS

One quarter (25%, n = 1,519) reported ≥1 fall; 710 reported ≥2 falls in the year after baseline. In multivariate models, baseline pain at hip, knee or any pain increased likelihood of ≥1 fall and ≥2 falls over the following year. For example, knee pain increased likelihood of ≥1 fall (odds ratio, OR 1.44; 95% confidence interval, CI 1.25-1.65) and ≥2 falls (OR 1.75; 95% CI 1.46-2.10). During follow-up, 936 (15.6%) men suffered a non-spine fracture (n = 217, 3.6% hip). In multivariate models, baseline pain was not associated with incident hip or non-spine fractures.

CONCLUSIONS

Any pain, knee pain and hip pain were each strong independent risk factors for falls in older men. Increased risk of falls did not translate into an increased risk of fractures.

Gait energetic efficiency in older adults with and without knee pain: results from the Baltimore Longitudinal Study of Aging

With aging, customary gait patterns change and energetic efficiency declines, but the relationship between these alterations is not well understood. If gait characteristics that develop with aging explain part of the decline in energetic efficiency that occur in most aging individuals, then efforts to modify these characteristics could delay or prevent mobility limitation. This study characterizes gait patterns in older persons with and without knee pain and tests the hypothesis that changes in gait characteristics due to knee pain are associated with increased energetic cost of walking in older adults. Study participants were 364 men and 170 women aged 60 to 96 years enrolled in the Baltimore Longitudinal Study of Aging (BLSA), of whom 86 had prevalent knee pain. Gait patterns were assessed at participant self-selected usual pace in the gait laboratory, and the energetic cost of walking was assessed by indirect calorimetry during self-selected usual pace walking over 2.5 min in a tiled corridor using a portable equipment. Participants with knee pain were less energetically efficient than those without pain (oxygen consumption 0.97 vs. 0.88 ml/(10 m · 100 kg); p = 0.002) and had slower gait speed and smaller range of motion (ROM) at the hip and knee joints (p < 0.05, for all). Slower gait speed and lower knee ROM in participants with knee pain and longer double support time and higher ankle ROM in participants without knee pain were associated with lower energetic efficiency (p < 0.05, for all). Slower gait speed and lower knee ROM were correlates of knee pain and were found to mediate the association between age and oxygen consumption. Although knee pain is associated with a higher energetic cost of walking, gait characteristics associated with energetic efficiency differ by pain status which suggests that compensatory strategies both in the presence and absence of pain may impact gait efficiency.

Pain trajectory groups in persons with, or at high risk of, knee osteoarthritis: findings from the Knee Clinical Assessment Study and the Osteoarthritis Initiative

OBJECTIVE

The authors aimed to characterize distinct trajectories of knee pain in adults who had, or were at high risk of, knee osteoarthritis using data from two population-based cohorts.

METHOD

Latent class growth analysis was applied to measures of knee pain severity on activity obtained at 18-month intervals for up to 6 years between 2002 and 2009 from symptomatic participants aged over 50 years in the Knee Clinical Assessment Study (CAS-K) in the United Kingdom. The optimum latent class growth model from CAS-K was then tested for reproducibility in a matched sample of participants from the Osteoarthritis Initiative (OAI) in the United States.

RESULTS

A 5-class linear model produced interpretable trajectories in CAS-K with reasonable goodness of fit and which were labelled "Mild, non-progressive" (N = 201, 35%), "Progressive" (N = 162, 28%), "Moderate" (N = 124, 22%) "Improving" (N = 68, 12%), and "Severe, non-improving" (N = 15, 3%). We were able to reproduce "Mild, non-progressive", "Moderate", and "Severe, non-improving" classes in the matched sample of participants from the OAI, however, absence of a "Progressive" class and instability of the "Improving" classes in the OAI was observed.

CONCLUSIONS

Our findings strengthen the grounds for moving beyond a simple stereotype of osteoarthritis as "slowly progressive". Mild, non-progressive or improving symptom trajectories, although difficult to reproduce, can nevertheless represent a genuinely favourable prognosis for a sizeable minority.

Psychological profiles and pain characteristics of older adults with knee osteoarthritis

OBJECTIVE

To identify psychological profiles in persons with knee osteoarthritis (OA) and to determine the relationship between these profiles and specific pain and sensory characteristics, including temporal summation and conditioned pain modulation.

METHODS

Individuals with knee OA (n = 194) completed psychological, health, and sensory assessments. Hierarchical cluster analysis was used to derive psychological profiles that were compared across several clinical pain/disability and experimental pain responses.

RESULTS

Cluster 1 had high optimism with low negative affect, pain vigilance, anger, and depression, along with the lowest self-reported pain/disability and the lowest sensitivity to mechanical, pressure, and thermal pain (P < 0.01 for all). Cluster 2 had low positive affect with high somatic reactivity, while cluster 3 showed high pain vigilance with low optimism. Clusters 2 and 3 had intermediate levels of self-reported pain/disability and cluster 3 experienced central sensitization to mechanical stimuli. Participants in cluster 3 also displayed significant pain facilitation (P < 0.05). Cluster 4 exhibited the highest pain vigilance, reactivity, negative affect, anger, and depression. These individuals experienced the highest self-reported pain/disability, including widespread pain (P < 0.001 for all). Cluster 4 was most sensitive to mechanical, pressure, and thermal stimuli, and showed significant central sensitization to mechanical and thermal stimuli (P < 0.001 for all).

CONCLUSION

Our findings demonstrate the existence of homogeneous psychological profiles displaying unique sets of clinical and somatosensory characteristics. Multidisciplinary treatment approaches consistent with the biopsychosocial model of pain should provide significant advantages if targeted to profiles such as those in our OA sample.

Frequency and predictors of premature work loss in primary care consulters for osteoarthritis: prospective cohort study

Objective. The objective of this study was to describe the extent of premature work loss (PWL) in OA consulters across a 6-year observation period, and associated factors.

Methods. We conducted a population-based prospective cohort study set in primary care. Participants were 1098 adults age 50 years to statutory retirement age at baseline, who completed questionnaires at baseline, 3- and 6-year follow-ups. OA was defined by consultation to primary care (Read code N05) during the study period. PWL was defined as retirement prior to state retirement age (65 years for men, 60 years for women), off work due to health or unemployment. The frequency of PWL was calculated overall and stratified by consultation for OA. Bivariate and multivariate logistic regression was used to investigate the predictors of PWL in consulters for OA.

Results. Over the 6-year study period, one in four consulters for OA left the workplace prematurely. Predictors included being male, pain interference with function and lower co-worker support, but not the extent of arthritis, co-morbidity, obesity or psychological or other job factors.

Conclusion. PWL in persons consulting primary care general practitioners with OA is common. Those at risk could be identified by brief questions about pain interference with function and workplace support. These results suggest that early identification, treatment strategies focusing on maintaining function and maximizing workplace support should be investigated for their potential to prevent PWL. Good communication with employers may help to improve support for workers with OA.

[Clinical features and risk factors associated with interstitial lung disease in patients with classic dermatomyositis or clinical amyopathic dermatomyositis]

OBJECTIVE

To investigate the clinical features and risk factors associated with interstitial lung disease (ILD) in patients with classic dermatomyositis (classic DM) or clinical amyopathic dermatomyositis (CADM).

METHODS

Medical records of 121 DM patients (77 with classic DM and 44 with CADM) were reviewed retrospectively. The risk factors associated with ILD were identified through Binary Logistic Regression analyses.

RESULTS

ILD presented in 40. 3% (31/77) of patients with classic DM and 50. 0% (22/44) of patients with CADM. Overall, the DM patients had a prevalence of ILD of 43. 8%. Univariate analyses showed that arthralgia, cough, dyspnea, anti-Jo-1 antibody, malignant tumors, and the levels of Erythrocyte sedimentation rate (ESR) and Albumin (ALB) were associated with ILD. The Multivariate Logistic Regression analysis identified arthralgia (beta= 1. 119, P= 0. 023), cough (beta= 2. 423, P= 0. 003) and ESR (beta= 0. 041, P= 0. 009) as risk factors of ILD.

CONCLUSION

ILD is a common complication of classic DM/CADM and arthralgia, cough and high level of ESR are independent risk factors of ILD.

Urticarial vasculitis: a retrospective study of 15 cases

INTRODUCTION

Urticarial vasculitis is a subtype of vasculitis characterized clinically by urticarial lesions and histologically by necrotizing vasculitis.

OBJECTIVE

To study the clinical and histologic features of urticarial vasculitis in patients seen in the dermatology department of Hospital Universitario Virgen de Rocío in Seville, Spain, and to examine the association between hypocomplementemia and systemic disease.

MATERIAL AND METHODS

We performed a chart review of histologically confirmed cases of urticarial vasculitis in the database of our department covering a period of 10 years.

RESULTS

Fifteen patients (9 women and 6 men with a median age of 51 years) were included. In 14 patients (93%), the lesions persisted for more than 24hours, and in 9 cases (60%) the lesions resolved leaving residual purpura or hyperpigmentation. Seven patients (47%) had low complement levels in the blood, 12 (80%) had extracutaneous symptoms, and 8 (53%) had associated systemic disease, the most common of which was systemic lupus erythematosus.

CONCLUSIONS

Urticarial vasculitis may be underdiagnosed. Response to treatment is variable, and hypocomplementemia and extracutaneous symptoms may indicate the presence of associated systemic disease.

Neuropathic features of joint pain: a community-based study

OBJECTIVE

Quantitative sensory testing (QST) and questionnaire-based assessments have been used to demonstrate features of neuropathic pain in subjects with musculoskeletal pain. However, their direct relationship has not been investigated in the community. The purpose of this study was to conduct an observational study to describe the characteristics of joint pain and to examine the relationship between QST measures and the PainDETECT Questionnaire (PD-Q).

METHODS

Warm detection, heat pain, and mechanical pain thresholds as well as mechanical pain sensitivity over the sternum were determined and the PD-Q scores were calculated in a cross-sectional study of 462 participants in the Chingford Study. Comparisons were made between subjects with and those without joint pain. Logistic regression modeling was used to describe the association between neuropathic pain features, as determined by the PD-Q score, and each of the QST measures individually, adjusting for age, body mass index, and use of pain-modifying medications.

RESULTS

A total of 66.2% of the subjects reported recent joint pain, with a median average pain severity of 5 of 10. There was increased sensitivity to painful stimuli in the group with pain as compared to the pain-free group, and this persisted after stratification by pain-modifying medication use. While only 6.7% of subjects had possible neuropathic pain features and 1.9% likely neuropathic pain features according to the standard PD-Q thresholds, features of neuropathic pain were common and were present in >50% of those reporting pain of at least moderate severity. Heat pain thresholds and mechanical pain sensitivity were significantly associated with features of neuropathic pain identified using the PD-Q, with an odds ratio (OR) of 0.88 (95% confidence interval [95% CI] 0.79-0.97; P = 0.011) and an OR of 1.24 (95% CI 1.04-1.48; P = 0.018), respectively.

CONCLUSION

QST measures and the PD-Q identified features of neuropathic pain in subjects in this community-based study, with significant overlap between the findings of the two techniques.

Tibial coverage, meniscus position, size and damage in knees discordant for joint space narrowing - data from the Osteoarthritis Initiative

INTRODUCTION

Meniscal extrusion is thought to be associated with less meniscus coverage of the tibial surface, but the association of radiographic disease stage with quantitative measures of tibial plateau coverage is unknown. We therefore compared quantitative and semi-quantitative measures of meniscus position and morphology in individuals with bilateral painful knees discordant on medial joint space narrowing (mJSN).

METHODS

A sample of 60 participants from the first half (2,678 cases) of the Osteoarthritis Initiative cohort fulfilled the inclusion criteria: bilateral frequent pain, Osteoarthritis Research Society International (OARSI) mJSN grades 1-3 in one, no-JSN in the contra-lateral (CL), and no lateral JSN in either knee (43 unilateral mJSN1; 17 mJSN2/3; 22 men, 38 women, body mass index (BMI) 31.3 ± 3.9 kg/m(2)). Segmentation and three-dimensional quantitative analysis of the tibial plateau and meniscus, and semi-quantitative evaluation of meniscus damage (magnetic resonance imaging (MRI) osteoarthritis knee score = MOAKS) was performed using coronal 3T MR images (MPR DESSwe and intermediate-weighted turbo spin echo (IW-TSE) images). CL knees were compared using paired t-tests (between-knee, within-person design).

RESULTS

Medial tibial plateau coverage was 36 ± 9% in mJSN1 vs 45 ± 8% in CL no-JSN knees, and was 31 ± 9% in mJSN2/3 vs 46 ± 6% in no-JSN knees (both P < 0.001). mJSN knees showed greater meniscus extrusion and damage (MOAKS), but no significant difference in meniscus volume. No significant differences in lateral tibial coverage, lateral meniscus morphology or position were observed.

CONCLUSIONS

Knees with medial JSN showed substantially less medial tibial plateau coverage by the meniscus. We suggest that the less meniscal coverage, i.e., less mechanical protection may be a reason for greater rates of cartilage loss observed in JSN knees.

Objectively measured physical activity in patients with end stage knee or hip osteoarthritis

BACKGROUND

Patients with lower extremity osteoarthritis (OA) have increased all cause and disease specific mortality compared to the general population and epidemiological data suggests that OA management should include increased physical activity.

AIM

To measure physical activity assessed as daily energy expenditure and accumulated steps day-1 in patients with severe OA of the hip or knee and compare with healthy controls. Furthermore, to investigate if gender, age, BMI and affected joint influence measures of physical activity.

DESIGN

Cross sectional study.

SETTING

Community.

POPULATION

Fifty-one patients (49% women, age: 68±5 years, BMI: 28.4±4.6) with severe knee (N.=25) or hip (N.=26) OA scheduled for total joint replacement and 15 healthy population-based controls (53 % women, age: 68±5 years, BMI: 26.9±4.3).

METHODS

Subjects wore an accelerometer (SenseWear™ Pro2 Armband) on 5 consecutive days. Time on body, total energy expenditure, average intensity (METS), time being sedentary, time above 3 METS and numbers of steps day(-1) were calculated.

RESULTS

Patients had similar daily energy expenditure to controls (2632 vs. 2633 calories per day) but walked on average 29.3% fewer steps day(-1) (6632 vs. 8576 P=0.033). Gender and affected joint (hip or knee) did not influence the results. Age and BMI explained 15.4%-32.7% of the variation in total energy expenditure, average METS, time being sedentary, and steps day(-1).

CONCLUSION

The present data indicate a need for interventions improving walking ability in patients with severe hip and knee OA. This need is independent regarding gender and affected joint but higher for older and heavier patients. Simultaneously assessed measures of physical activity gave different results, raising concern about validity of physical activity measures in patients with lower extremity OA and indicating caution when comparing results from studies applying different measures.

CLINICAL REHABILITATION IMPACT

It is of potential interest for patients and practitioners that a relative high physical activity is possible for end-stage OA patients since this may reduce the increased all cause and disease specific mortality.

Are clinical features in Löfgren's syndrome-related erythema nodosum different from idiopathic erythema nodosum?

BACKGROUND AND OBJECTIVES

We retrospectively evaluated acute sarcoidosis (Löfgren's syndrome) patients diagnosed at 2 centers and compared the clinical features of Löfgren's syndrome (LS) related erythema nodosum (EN) to patients with idiopathic IEN who were diagnosed within the same time frame.

METHODS

Thirty patients (10 males, 20 females) who were diagnosed with LS and were being followed up for the last 8 years at 2 centers were included. Thirty patients (4 males, 26 females) who were admitted to the rheumatology outpatient clinics for IEN during that time period were taken as controls. The clinical and laboratory features at the initial admission, treatment modalities and response were recorded.

RESULTS

Twentyfour (80%) patients with LS related EN had arthritis and/or arthralgia. Fifteen of them had only findings of periarticular ankle inflammation and 4 had polyarthritis. When LS related EN patients were compared to IEN patients, the former group had more arthritis and/or arthralgia (p < 0.001), leucocytosis (p = 0.02), lymphopenia (p = 0.005) and thrombocytosis (p = 0.05), and higher ESR (p = 0.02). Twentyfive (83.3%) patients with LS related EN were administered oral corticosteroids. In 21 patients, hilar lymphadenopathy disappeared on control chest x-ray and CT; in 3 patients, minimal residual lymph node enlargement was persistent. During a median follow-up of 54 months (range: 10-84 months), none of the LS related EN patients had clinical relapse.

CONCLUSIONS

Apart from BHL, arthritis and/or arthralgia especially periarticular ankle inflammation is the feature which could be used to differentiate LS related EN from IEN. There is more need for steroids in LS patients and the symptoms quickly resolve with steroids.

Granulomatous mastitis complicated by arthralgia and erythema nodosum successfully treated with prednisolone and methotrexate

A 23-year-old woman was admitted with complaints of swelling and pain in the left breast, fever, polyarthralgia and erythema nodosum. A fine-needle biopsy of the mass in the left breast revealed non-caseous granulomatous lobulitis. A diagnosis of granulomatous mastitis was thus made. The administration of prednisolone 40 mg/day resulted in the resolution of the patient's symptoms, and the breast mass thereafter decreased in size. The mass relapsed during the subsequent prednisolone taper. Additional therapy with methotrexate resulted in complete remission. Granulomatous mastitis should therefore be included in the differential diagnosis of polyarthralgia.

Assessment of pain-related fear in patients with the thrust plate prosthesis (TPP): due to hip fracture and hip osteoarthritis

The aim of this study is to determine the differences between hip fracture and hip arthrosis groups and to assess pain related fear of injury in patients who were operated using the TPP following hip fracture or hip arthrosis. Fifty-eight patients (mean age = 63.9 ± 10.3 years) who were operated using the TPP, following hip fracture (hip fracture group; n = 25) or coxarthrosis (coxarthrosis group; n = 33) were recruited. All of the measurements were performed after a follow-up time of at least 2 years. Functional level by Harris Hip Scoring System (HHS), pain related fear by Tampa Scale for Kinesiophobia (TSK) and pain intensity by numerical rating scale (NRS) was evaluated. There were no significant differences between demographic and clinical characteristics of two groups. However, pain intensity was higher in coxarthrosis group than hip fracture group. There was no correlation between the TSK scores and either Harris scores or NRS scores (p > 0.05) in the hip fracture group. No correlation between NRS and TSK was found in coxarthrosis group but there was a significant correlation between TSK and HHS. TSK scores were high in both groups. High TSK scores proved us that the patients with TPP had fear of movement even they had enough physical performance. The coxarthrosis group had higher pain intensity. Rehabilitation clinicians should consider pain-related belief which is more important than pain intensity and functional level in coxarthrosis patients.

Chronic pain conditions and depression in the Ibadan Study of Ageing

BACKGROUND

Chronic pain is quite common in the elderly and is often associated with comorbid depression, limitation of functioning and reduced quality of life. The aim of this study was to ascertain whether there is a differential risk of depression among persons with pain in different anatomical sites and to determine which pain conditions are independent risk factors for depression.

METHODS

Data are from the Ibadan Study of Ageing (ISA), a community-based longitudinal survey of persons aged 65 years and older from eight contiguous Yoruba-speaking states in Nigeria (n = 2152). Data were collected in face-to-face interviews; depression was assessed using the World Mental Health initiative version of the Composite International Diagnostic Interview (CIDI) while chronic pain was assessed by self-report (response rate = 74%).

RESULTS

Estimates of persistent pain (lasting more than six months), in different anatomical sites range from 1.3% to 12.8%, with the commonest being joint pains (12.8%), neck or back (spinal) pain (7.6%) and chest pain (3.0%). Significantly more pain conditions were reported by females and by respondents who were aged over 80 years. The risk for depression was higher in respondents with spinal, joint and chest pain. However, only chest pain was independently associated with depression after adjustments were made for pains at other sites and for functional disability.

CONCLUSION

Our data suggests that, among elderly persons, there is a differential association of depression with chronic pain that is related to the anatomical site of the pain.