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McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014; 22:363-88. [PMID: 24462672 DOI: 10.1016/j.joca.2014.01.003] [Citation(s) in RCA: 1880] [Impact Index Per Article: 188.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/06/2014] [Accepted: 01/15/2014] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop concise, up-to-date, patient-focused, evidence-based, expert consensus guidelines for the management of knee osteoarthritis (OA), intended to inform patients, physicians, and allied healthcare professionals worldwide. METHOD Thirteen experts from relevant medical disciplines (primary care, rheumatology, orthopedics, physical therapy, physical medicine and rehabilitation, and evidence-based medicine), three continents and ten countries (USA, UK, France, Netherlands, Belgium, Sweden, Denmark, Australia, Japan, and Canada) and a patient representative comprised the Osteoarthritis Guidelines Development Group (OAGDG). Based on previous OA guidelines and a systematic review of the OA literature, 29 treatment modalities were considered for recommendation. Evidence published subsequent to the 2010 OARSI guidelines was based on a systematic review conducted by the OA Research Society International (OARSI) evidence team at Tufts Medical Center, Boston, USA. Medline, EMBASE, Google Scholar, Web of Science, and the Cochrane Central Register of Controlled Trials were initially searched in first quarter 2012 and last searched in March 2013. Included evidence was assessed for quality using Assessment of Multiple Systematic Reviews (AMSTAR) criteria, and published criticism of included evidence was also considered. To provide recommendations for individuals with a range of health profiles and OA burden, treatment recommendations were stratified into four clinical sub-phenotypes. Consensus recommendations were produced using the RAND/UCLA Appropriateness Method and Delphi voting process. Treatments were recommended as Appropriate, Uncertain, or Not Appropriate, for each of four clinical sub-phenotypes and accompanied by 1-10 risk and benefit scores. RESULTS Appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, exercise (land-based and water-based), self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs; COX-2 selective and non-selective), and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Treatments voted not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation). CONCLUSION These evidence-based consensus recommendations provide guidance to patients and practitioners on treatments applicable to all individuals with knee OA, as well as therapies that can be considered according to individualized patient needs and preferences.
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Ravi B, Croxford R, Austin PC, Hollands S, Paterson JM, Bogoch E, Kreder H, Hawker GA. Increased Surgeon Experience With Rheumatoid Arthritis Reduces the Risk of Complications Following Total Joint Arthroplasty. Arthritis Rheumatol 2014; 66:488-96. [DOI: 10.1002/art.38205] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 09/19/2013] [Indexed: 01/01/2023]
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Ravi B, Croxford R, Hollands S, Paterson JM, Bogoch E, Kreder H, Hawker GA. Increased Risk of Complications Following Total Joint Arthroplasty in Patients With Rheumatoid Arthritis. Arthritis Rheumatol 2014; 66:254-63. [DOI: 10.1002/art.38231] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 10/10/2013] [Indexed: 01/04/2023]
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Fraenkel L, Suter L, Weis L, Hawker GA. Variability in recommendations for total knee arthroplasty among rheumatologists and orthopedic surgeons. J Rheumatol 2013; 41:47-52. [PMID: 24293580 DOI: 10.3899/jrheum.130762] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The most rapidly growing population of patients undergoing total knee arthroplasty (TKA) is under the age of 65. The objective of our study was to gain insight into the factors influencing physicians' recommendations for persons in this age group with moderate osteoarthritis (OA). METHODS Rheumatologists and orthopedic surgeons attending national meetings were asked to complete a survey including a standardized scenario of a 62-year-old person with knee OA who has moderate knee pain limiting strenuous activity despite medical management. We used an experimental 2 × 2 × 2 design to examine the effects of sex, employment status, and severity of radiographic OA on physicians' recommendations. Each physician was asked to rate a single scenario. RESULTS The percentage of physicians recommending TKA varied from 30% to 55% for scenarios describing a patient with mild radiographic OA, and from 39% to 71% for scenarios describing a patient with moderate radiographic OA. Surgeons were less likely to recommend TKA for women compared to men of the same age, employment status, symptom severity, and functional status, and radiographs. Rheumatologists practicing in academic settings were more likely to recommend TKA compared to those practicing in nonacademic settings, and American surgeons were more likely to recommend TKA compared to their European counterparts. CONCLUSION Orthopedic surgeons and rheumatologists vary significantly in their recommendations for patients with moderate knee pain and functional limitations. Both patient and physician characteristics influence physicians' recommendations, and rheumatologists and orthopedic surgeons display different patterns of decision making.
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Ravi B, Croxford R, Austin PC, Lipscombe L, Bierman AS, Harvey PJ, Hawker GA. The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis. BMJ 2013; 347:f6187. [PMID: 24174640 PMCID: PMC3813386 DOI: 10.1136/bmj.f6187] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To examine whether total joint arthroplasty of the hip and knee reduces the risk for serious cardiovascular events in patients with moderate-severe osteoarthritis. DESIGN Propensity score matched landmark analysis. SETTING Ontario, Canada. PARTICIPANTS 2200 adults with hip or knee osteoarthritis aged 55 or more at recruitment (1996-98) and followed prospectively until death or 2011. MAIN OUTCOME MEASURE Rates of serious cardiovascular events for those who received a primary total joint arthroplasty compared with those did not within an exposure period of three years after baseline assessment. RESULTS The propensity score matched cohort consisted of 153 matched pairs of participants with moderate-severe arthritis. Over a median follow-up period of seven years after the landmark date (start of the study), matched participants who underwent a total joint arthroplasty during the exposure period were significantly less likely than those who did not to experience a cardiovascular event (hazards ratio 0.56, 95% confidence interval 0.43 to 0.74, P<0.001). Within seven years of the exposure period the absolute risk reduction was 12.4% (95% confidence interval 1.7% to 23.1%) and number needed to treat was 8 (95% confidence interval 4 to 57 patients). CONCLUSIONS Using a propensity matched landmark analysis in a population cohort with advanced hip or knee osteoarthritis, this study found a cardioprotective benefit of primary elective total joint arthroplasty.
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Cadarette SM, Lévesque L, Mamdani M, Perreault S, Juurlink DN, Paterson JM, Carney G, Gunraj N, Hawker GA, Tadrous M, Wong L, Dormuth CR. Comparison of orally administered bisphosphonate drugs in reducing the risk of hip fracture in older adults: a population-based cohort study. CMAJ Open 2013; 1:E97-E105. [PMID: 25077113 PMCID: PMC3986012 DOI: 10.9778/cmajo.20130036] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Orally administered bisphosphonate drugs (i.e., alendronate, etidronate, risedronate) can reduce the risk of vertebral fracture. However, only alendronate and risedronate have proven efficacy in reducing the risk of hip fracture. We sought to examine the comparative effectiveness of orally administered bisphosphonate drugs in reducing hip fractures among older adults. METHODS We identified new users of orally administered bisphosphonate drugs in British Columbia and Ontario between 2001 and 2008. We used province- and sex-specific propensity score-matching strategies to maximize comparability between exposure groups. We used Cox proportional hazards models to compare time-to-hip fracture within 1 year of treatment between exposures by sex in each province. Our secondary analyses considered hip fracture rates within 2 and 3 years' follow-up. We used alendronate as the reference for all comparisons and pooled provincial estimates using random effects variance-weighted meta-analysis. RESULTS We identified 321 755 patients who were eligible for inclusion in the study. We found little difference in fracture rates between men (pooled hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.74-1.14) or women (pooled HR 1.15, 95% CI 0.73-1.56) taking risedronate and those taking alendronate. We similarly identified little difference in fracture rates between women taking etidronate and those taking alendronate (pooled HR 1.00, 95% CI 0.82-1.18). However, we identified lower rates of hip fracture among men taking etidronate relative to alendronate (pooled HR 0.77, 95% CI 0.60-0.94). Results extended to 2 and 3 years' follow-up were similar. However, with 3 years' follow-up, rates of hip fracture were lower among women in British Columbia who had taken alendronate. INTERPRETATION We identified little overall difference between alendronate and risedronate in reducing the risk of hip fracture in men or women. Our finding that etidronate is associated with lower fracture risk among men is likely due to selection bias. The long-term comparative effects of orally administered bisphosphonate drugs warrant further study.
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Hochman JR, Davis AM, Elkayam J, Gagliese L, Hawker GA. Neuropathic pain symptoms on the modified painDETECT correlate with signs of central sensitization in knee osteoarthritis. Osteoarthritis Cartilage 2013; 21:1236-42. [PMID: 23973136 DOI: 10.1016/j.joca.2013.06.023] [Citation(s) in RCA: 182] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 06/21/2013] [Accepted: 06/25/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Clinical tools are needed to identify and target a neuropathic-like phenotype, which may be associated with central sensitization (CS), in osteoarthritis (OA). The modified painDETECT questionnaire (mPD-Q) has face and content validity for identifying neuropathic-like symptoms in knee OA. To further validate the mPD-Q, this study assessed the unknown relationship between mPD-Q scores and signs of CS on quantitative sensory testing (QST) in knee OA. DESIGN 36 Individuals were recruited with chronic, symptomatic, knee OA without other pain/neurological conditions. Reference QST data were obtained from 18 controls/32 eligible knees, enabling identification of sensory abnormalities/CS among case knees. A standardized questionnaire assessed psychological factors (depressive symptoms and pain catastrophizing), and for individual knees, mPD-Q and pain intensity scores. A standardized/comprehensive QST protocol was conducted for each knee. QST signs of CS were defined as: mechanical hyperalgesia and/or enhanced temporal summation and/or allodynia. The relationship between the presence of CS (yes/no) and a pre-selected mPD-Q score (≤12 or >12), by knees, was assessed using generalized estimating equations. RESULTS Among 57 eligible case knees, 45.6% had ≥1 sign of CS. Controlling for age, knees with higher mPD-Q scores (>12.0) had higher odds of having QST signs of CS (adjusted odds ratio (OR) = 5.6; 95% confidence interval (CI), 1.3-22.9). This relationship was unaffected by controlling for depression and pain intensity, but was attenuated by pain catastrophizing. CONCLUSIONS Among painful OA knees, higher mPD-Q scores were associated with greater odds of having signs of CS. Thus, the mPD-Q may aid the identification of CS in people with chronic knee OA.
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Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. Influence of Patients' Gender on Informed Decision Making Regarding Total Knee Arthroplasty. Arthritis Care Res (Hoboken) 2013; 65:1281-90. [DOI: 10.1002/acr.21970] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/18/2013] [Indexed: 11/11/2022]
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French MR, Vernace-Inserra F, Hawker GA. A Prospective Study to Identify Factors Affecting Adherence to Recommended Daily Calcium Intake in Women with Low Bone Mineral Density. J Am Coll Nutr 2013; 27:88-95. [DOI: 10.1080/07315724.2008.10719679] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hawker GA, Badley EM, Borkhoff CM, Croxford R, Davis AM, Dunn S, Gignac MA, Jaglal SB, Kreder HJ, Sale JEM. Which Patients Are Most Likely to Benefit From Total Joint Arthroplasty? ACTA ACUST UNITED AC 2013; 65:1243-52. [DOI: 10.1002/art.37901] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 02/07/2013] [Indexed: 01/14/2023]
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Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2013; 26:637-47. [PMID: 23218428 DOI: 10.1016/j.berh.2012.07.014] [Citation(s) in RCA: 155] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND The rates of total joint arthroplasty (TJA) of the hip and knee have increased in North America over the last decade. While initially designed for elderly patients (>70 years of age), several reports suggest that an increasing number of younger patients are undergoing joint replacements. This suggests that more people are meeting the indication for TJA earlier in their lives. Alternatively, it might indicate a broadening of the indications for TJA. METHODS We used the administrative databases available at the Healthcare Cost and Utilization Project (HCUP) and the Institute for Clinical Evaluative Sciences (ICES) to determine the rates of TJA of the hip and knee in the United States, and Ontario, Canada, respectively. We determined the crude rates of THA and TKA in both areas for four calendar years (2001, 2003, 2005 and 2007). We also calculated the age- and sex-standardised rates of THA and TKA in both areas for each time period. We compared the age distribution of TJA recipients between the US and Ontario, and within each area over time. RESULTS The crude and standardised rates of THA and TKA increased over time in both the US and Ontario. The crude rates of THA were higher in the US in 2001 and 2003, but were not significantly different from the rate in Ontario in 2005 and 2007. The crude rates of TKA were consistently higher in the US for all time periods. In addition, the US consistently had more THA and TKA recipients in 'younger' age categories (<60 years of age). While the age- and sex-standardised rates of TKA were greater in the US in all time periods, the relative increase in rates from 2001 to 2007 was greater in Ontario (US - 59%, Ontario - 73%). For both the US and Ontario, there was a significant shift in the demographic of THA and TKA recipients to younger patients (p < 0.0001). CONCLUSIONS The utilisation of primary hip and knee arthroplasty has increased substantially in both the US and Ontario in the period from 2001 to 2007. This increase has been predominantly in knee replacements. The demographics of joint replacement recipients has become younger, with substantial increases in the prevalence of patients <60 years old amongst TJA recipients, and significant increases in the incidence of TJA in these age groups in the general population, in both the US and Ontario.
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Frankel L, Sanmartin C, Conner-Spady B, Marshall DA, Freeman-Collins L, Wall A, Hawker GA. Osteoarthritis patients' perceptions of "appropriateness" for total joint replacement surgery. Osteoarthritis Cartilage 2012; 20:967-73. [PMID: 22659599 DOI: 10.1016/j.joca.2012.05.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/22/2012] [Accepted: 05/23/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To understand patients' perspectives on 'appropriateness' for hip and knee total joint arthroplasty (TJA). METHODS Focus groups were conducted, stratified by history of a previous TJA, in English-speaking men and women aged 40+ years with moderate to severe hip and knee osteoarthritis. Participants discussed: their appropriateness for TJA; the ideal candidate; patients' role in TJA decision making; and the relationship between appropriateness and willingness to consider TJA. Participants self-completed a questionnaire assessing demographics, arthritis severity (Western Ontario McMaster University Osteoarthritis index - WOMAC), perceived TJA candidacy and willingness to consider TJA. Focus groups were audio-taped and transcribed verbatim. Content analysis was performed. RESULTS Eleven focus groups were conducted with 58 participants in total: mean age 72 years; 79% female; 25 (43%) with prior TJA; mean WOMAC summary score 43.1. Half reported willingness to consider TJA and 43% felt they were appropriate for TJA. Appropriateness was equated with candidacy for the procedure. Pain intensity and the ability to cope with pain were identified as the most important factors determining surgical candidacy, but felt to be inadequately evaluated by physicians. TJA appropriateness and willingness were felt to be distinct, yet related, concepts; those unwilling had stricter criteria about candidacy than those who were willing. CONCLUSIONS Participants equated appropriateness for TJA with surgical candidacy. Patients' pain experience (intensity, impact on quality of life, ability to cope) was seen as most important in determining appropriateness, but felt to be inadequately evaluated currently. Enhanced patient-physician communication, possibly through use of patient decision aids, has potential to improve patient selection for TJA.
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Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2012; 63 Suppl 11:S240-52. [PMID: 22588748 DOI: 10.1002/acr.20543] [Citation(s) in RCA: 2707] [Impact Index Per Article: 225.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Johnson SR, Granton JT, Tomlinson GA, Grosbein HA, Le T, Lee P, Seary ME, Hawker GA, Feldman BM. Warfarin in systemic sclerosis-associated and idiopathic pulmonary arterial hypertension. A Bayesian approach to evaluating treatment for uncommon disease. J Rheumatol 2012; 39:276-85. [PMID: 22247353 DOI: 10.3899/jrheum.110765] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Warfarin is recommended in systemic sclerosis-associated pulmonary arterial hypertension (SSc-PAH) and idiopathic PAH (IPAH) to improve survival. There is no evidence to support this in SSc-PAH and the evidence in IPAH is conflicting. We evaluated the ability of warfarin to improve survival using 2 large SSc-PAH and IPAH cohorts. METHODS The effect of warfarin on all-cause mortality was evaluated. Bayesian propensity scores (PS) were used to adjust for baseline differences between patients exposed and not exposed to warfarin, and to assemble a matched cohort. Bayesian Cox proportional hazards models were constructed using informative priors based on international PAH expert elicitation. RESULTS Review of 1138 charts identified 275 patients with SSc-PAH (n = 78; 28% treated with warfarin) and 155 patients with IPAH (n = 91; 59% treated with warfarin). Baseline differences in PAH severity and medications were resolved using PS matching. In the matched cohort of 98 patients with SSc-PAH (49 treated with warfarin), the posterior median hazard ratio (HR) was 1.06 [95% credible interval (CrI) 0.70, 1.63]. In the matched cohort of 66 patients with IPAH (33 treated with warfarin), the posterior median HR was 1.07 (95% CrI 0.57, 1.98). The probability that warfarin improves median survival by 6 months or more is 23.5% in SSc-PAH and 27.7% in IPAH. Conversely, there is a > 70% probability that warfarin provides no significant benefit or is harmful. CONCLUSION There is a low probability that warfarin improves survival in SSc-PAH and IPAH. Given the availability of other PAH therapies with demonstrable benefits, there is little reason to use warfarin to improve survival for these patients.
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Waugh EJ, Woodside DB, Beaton DE, Coté P, Hawker GA. Effects of exercise on bone mass in young women with anorexia nervosa. Med Sci Sports Exerc 2011; 43:755-63. [PMID: 20962688 DOI: 10.1249/mss.0b013e3181ff3961] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE The response of bone to exercise in women with anorexia nervosa (AN) is unclear. We investigated the associations between bone mineral density (BMD) and exercise performed while ill and while recovered in women with a history of AN. METHODS A cross-sectional study was conducted with 141 women with AN (85 ill; 56 recovered), aged 17-40 yr. BMD at the lumbar spine (LS), femoral neck (FN), and total body (TB) was measured by dual-energy x-ray absorptiometry. Life History Calendar and Minnesota Leisure Time Physical Activity interviews were used to collect lifetime illness and exercise histories (amount and bone loading type). Average hours per week of each of moderate (MOD) and high (HI) bone loading exercise were determined for three illness phases: "before ill," "while ill," and "while recovered." Participants were categorized into four exercise groups for each phase: MOD-ONLY, HI-ONLY, BOTH, and NEITHER (reference group). Weight-adjusted BMD z-scores were compared in the exercise groups by multivariable linear regression, adjusting for illness duration and severity, and exercise during the other illness phases. RESULTS In ill participants, MOD-ONLY "while ill" had lower BMD at LS (β = -0.69, 95% confidence interval (CI) = -1.02 to -0.05) and TB (β = -0.73, 95% CI = -1.31 to -0.15) than the NEITHER group. In recovered participants, HI-ONLY "while recovered" had higher BMD at FN (β = 0.95, 95% CI = 0.15-1.75) and TB (β = 0.79, 95% CI = 0.07-1.51) than the NEITHER group. CONCLUSIONS The effect of exercise on bone in AN patients is dependent on both the type of mechanical loading and the phase of illness during which it was performed. Excessive moderate loading exercise while ill may put patients at higher risk of low bone mass, but high bone loading activities may provoke bone accrual during recovery.
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Lane JM, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A, Lane JM. Bisphosphonate use for ≥5 years increased risk for subtrochanteric or femoral shaft fractures. J Bone Joint Surg Am 2011; 93:1546. [PMID: 22204012 DOI: 10.2106/jbjs.9316.ebo781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Borkhoff CM, Hawker GA, Wright JG. Patient gender affects the referral and recommendation for total joint arthroplasty. Clin Orthop Relat Res 2011; 469:1829-37. [PMID: 21448775 PMCID: PMC3111793 DOI: 10.1007/s11999-011-1879-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients' preferences for surgery, gender bias influencing physicians' clinical decision-making, and the patient-physician interaction. QUESTIONS/PURPOSES We propose a framework of how patient gender affects the patient and physician decision-making process of referral and recommendation for total joint arthroplasty and consider potential interventions to close the gender gap in total joint arthroplasty utilization. METHODS The process involved in the referral and recommendation for total joint arthroplasty involves eight discrete steps. A systematic review is used to describe the influence of patient gender and related clinical and nonclinical factors at each step. WHERE ARE WE NOW?: Patient gender plays an important role in the process of referral and recommendation for total joint arthroplasty. Female gender primarily affects Steps 3 through 8, suggesting barriers unique to women exist in the patient-physician interaction. WHERE DO WE NEED TO GO?: Developing and evaluating interventions that improve the quality of the patient-physician interaction should be the focus of future research. HOW DO WE GET THERE?: Potential interventions include using decision support tools that facilitate shared decision-making between patients and their physicians and promoting cultural competency and shared decision-making skills programs as a core component of medical education. Increasing physicians' acceptance and awareness of the unconscious biases that may be influencing their clinical decision-making may require additional skills programs.
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Hochman JR, Gagliese L, Davis AM, Hawker GA. Neuropathic pain symptoms in a community knee OA cohort. Osteoarthritis Cartilage 2011; 19:647-54. [PMID: 21440077 DOI: 10.1016/j.joca.2011.03.007] [Citation(s) in RCA: 188] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Revised: 03/11/2011] [Accepted: 03/17/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE A neuropathic pain (NP) questionnaire may facilitate the identification of a neuropathic component to osteoarthritis (OA) pain. An existing questionnaire, the painDETECT, was modified for use in knee OA and administered to measure the prevalence and correlates of NP symptoms among adults with this condition. METHOD Sensibility of the modified painDETECT (mPD-Q) was assessed in 20 OA subjects followed by mail administration in an established knee OA cohort. NP symptoms were defined using a previously established, painDETECT cut-point. Correlates of NP symptoms, including OA severity (Western Ontario and McMaster Universities Osteoarthritis Index, Von Korff Chronic Pain Grade pain subscale score), psychological factors (Centre for Epidemiological Studies Depression Scale, Pain Catastrophizing Scale), and concomitant medical conditions, were evaluated using logistic regression. Construct validity of the mPD-Q was evaluated through co-administration with another NP questionnaire (S-LANSS). RESULTS The mPD-Q had face and content validity. Of 259 eligible cohort members, 171 (66%) completed the questionnaire; 28% had NP symptoms on the mPD-Q (19% among those without neurological conditions). Independent correlates of NP symptoms were: pain intensity (adjusted odds ratio [OR]=2.1 per 10 unit increase, P<0.0001), the presence of referred back/hip pain (adjusted OR=2.9, P=0.024), number of painful joints (OR=1.2, P=0.20) and one or more self-reported neurological condition (OR=3.0, P=0.026). CONCLUSIONS Among older adults with chronic symptomatic knee OA, over one-quarter had NP symptoms localized to their knees using the mPD-Q. The mPD-Q may facilitate the identification of a neuropathic component to pain in adults with knee OA who may benefit from further evaluation and/or treatment for NP.
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Wright JG, Hawker GA, Hudak PL, Croxford R, Glazier RH, Mahomed NN, Kreder HJ, Coyte PC. Variability in physician opinions about the indications for knee arthroplasty. J Arthroplasty 2011; 26:569-575.e1. [PMID: 20580197 DOI: 10.1016/j.arth.2010.04.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 04/25/2010] [Indexed: 02/01/2023] Open
Abstract
To determine how much of variability in physician opinion about the indications for knee arthroplasty is due to inconsistency in individual physicians' opinions. We surveyed 201 orthopedic surgeons, 141 rheumatologists, and 455 family physicians. Physicians were asked how 34 patient characteristics affected their decision to perform or refer for knee arthroplasty. Surgeons and referring physicians agreed on how 4 and 2 of 34 patient characteristics affected their decision about knee arthroplasty, respectively. Half of the variability in opinion among physicians could be accounted for by inconsistency in their individual responses to the survey 6 weeks apart (mean intraclass correlation coefficient = 0.49). Although surgeons and referring physicians vary in their opinion, half of the variability could be attributed to individual physician inconsistency.
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Hawker GA, Mian S, Bednis K, Stanaitis I. Osteoarthritis year 2010 in review: non-pharmacologic therapy. Osteoarthritis Cartilage 2011; 19:366-74. [PMID: 21324369 DOI: 10.1016/j.joca.2011.01.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 01/15/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To highlight seminal publications in the past year on the topic of non-pharmacologic management of osteoarthritis (OA). DESIGN A systematic search of the PUBMED and Cochrane databases from September 2009 to September 2010 was conducted to identify articles reporting on studies examining the safety or efficacy of non-pharmacologic therapies in the management of OA. Non-pharmacologic therapies were those considered in the 2008 OARSI OA guidelines. Identified articles were reviewed for quality; those of highest quality and deemed to have greatest potential impact on the management of OA were summarized. RESULTS The search identified 117 unique articles. Of these, four studies were chosen to highlight. A nested two-stage trial found that traditional Chinese acupuncture (TCA) was not superior to sham acupuncture, but that the providers' style affected both pain reduction and satisfaction with treatment, suggesting that the analgesic benefits of acupuncture may be partially mediated by the acupuncturists' behavior. A systematic review found little evidence of a significant effect for electrostimulation vs sham or no intervention on pain in knee OA. A single-blinded trial of Tai Chi vs attention controls found that 12 weeks of Tai Chi was associated with improvements in symptoms and disability in patients with knee OA. A randomized trial of early ACL reconstructive surgery and rehabilitation vs structured rehabilitation alone in subjects with acute anterior cruciate ligament tears found that, at 24 months following randomization, all study participants had improved, suggesting that a strategy of structured rehabilitation followed acute ACL injury may preclude the need for surgical reconstruction. CONCLUSIONS High quality studies of the safety and efficacy of non-pharmacologic agents in the management of OA remain challenging due to difficulties with adequate blinding and appropriate selection of attention controls. High quality studies suggest modest, if any, benefit of many non-pharmacologic therapies over attention control or placebo, but a significant impact of both over no intervention at all.
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Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, Whelan DB, Weiler PJ, Laupacis A. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAMA 2011; 305:783-9. [PMID: 21343577 DOI: 10.1001/jama.2011.190] [Citation(s) in RCA: 273] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Osteoporosis is associated with significant morbidity and mortality. Oral bisphosphonates have become a mainstay of treatment, but concerns have emerged that long-term use of these drugs may suppress bone remodeling, leading to unusual fractures. OBJECTIVE To determine whether prolonged bisphosphonate therapy is associated with an increased risk of subtrochanteric or femoral shaft fracture. DESIGN, SETTING, AND PATIENTS A population-based, nested case-control study to explore the association between bisphosphonate use and fractures in a cohort of women aged 68 years or older from Ontario, Canada, who initiated therapy with an oral bisphosphonate between April 1, 2002, and March 31, 2008. Cases were those hospitalized with a subtrochanteric or femoral shaft fracture and were matched to up to 5 controls with no such fracture. Study participants were followed up until March 31, 2009. MAIN OUTCOME MEASURES The primary analysis examined the association between hospitalization for a subtrochanteric or femoral shaft fracture and duration of bisphosphonate exposure. To test the specificity of the findings, the association between bisphosphonate use and fractures of the femoral neck or intertrochanteric region, which are characteristic of osteoporotic fractures, was also examined. RESULTS We identified 716 women who sustained a subtrochanteric or femoral shaft fracture following initiation of bisphosphonate therapy and 9723 women who sustained a typical osteoporotic fracture of the intertrochanteric region or femoral neck. Compared with transient bisphosphonate use, treatment for 5 years or longer was associated with an increased risk of subtrochanteric or femoral shaft fracture (adjusted odds ratio, 2.74; 95% confidence interval, 1.25-6.02). A reduced risk of typical osteoporotic fractures occurred among women with more than 5 years of bisphosphonate therapy (adjusted odds ratio, 0.76; 95% confidence interval, 0.63-0.93). Among 52,595 women with at least 5 years of bisphosphonate therapy, a subtrochanteric or femoral shaft fracture occurred in 71 (0.13%) during the subsequent year and 117 (0.22%) within 2 years. CONCLUSION Among older women, treatment with a bisphosphonate for more than 5 years was associated with an increased risk of subtrochanteric or femoral shaft fractures; however, the absolute risk of these fractures is low.
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Borkhoff CM, Wieland ML, Myasoedova E, Ahmad Z, Welch V, Hawker GA, Li LC, Buchbinder R, Ueffing E, Beaton D, Cardiel MH, Gabriel SE, Guillemin F, Adebajo AO, Bombardier C, Hajjaj-Hassouni N, Tugwell P. Reaching those most in need: A scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis. Arthritis Care Res (Hoboken) 2010; 63:39-52. [DOI: 10.1002/acr.20349] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Johnson SR, Granton JT, Tomlinson GA, Grosbein HA, Hawker GA, Feldman BM. Effect of warfarin on survival in scleroderma-associated pulmonary arterial hypertension (SSc-PAH) and idiopathic PAH. Belief elicitation for Bayesian priors. J Rheumatol 2010; 38:462-9. [PMID: 21159827 DOI: 10.3899/jrheum.100632] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Warfarin use in scleroderma (SSc)-associated pulmonary arterial hypertension (PAH) and idiopathic PAH (IPAH) is controversial. A prerequisite for a trial is the demonstration of community uncertainty. We evaluated experts' beliefs about the effect of warfarin on 3-year survival in SSc-PAH and IPAH, and factors that influence warfarin use. METHODS PAH experts attending the 2008 American College of Rheumatology or American Thoracic Society meetings expressed the probability of 3-year survival without and with warfarin and their degree of uncertainty by applying adhesive dots, each representing a 5% weight of probability, in "bins" on a line, creating a prior probability distribution or prior. Using a numeric rating scale, participants rated factors that influence their use of warfarin. RESULTS Forty-five experts (44% pulmonologists, 38% rheumatologists, 16% cardiologists, 2% internists) underwent the belief elicitation interview. In SSc-PAH, the mean probabilities of 3-year survival without and with warfarin were 54% and 56%, respectively. Pessimistic experts believe that warfarin worsens survival by 7%. Optimistic experts believe that warfarin improves survival by 13%. In IPAH, the mean probabilities of 3-year survival without and with warfarin were 68% and 76%. Factors (mean rating out of 10, 0 = not at all important, 10 = extremely important) that influence experts' use of warfarin were functional class (5.4), age (5.4), pulmonary artery pressure (5.2), peripheral vascular disease (3.6), disease duration (2.8), and sex (1.7). CONCLUSION Bayesian priors effectively quantify and illustrate experts' beliefs about the effect of warfarin on survival in SSc-PAH and IPAH. This study demonstrates the presence of uncertainty about the effect of warfarin, and provides justification for a clinical trial.
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Hawker GA, French MR, Waugh EJ, Gignac MAM, Cheung C, Murray BJ. The multidimensionality of sleep quality and its relationship to fatigue in older adults with painful osteoarthritis. Osteoarthritis Cartilage 2010; 18:1365-71. [PMID: 20708004 DOI: 10.1016/j.joca.2010.08.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 06/04/2010] [Accepted: 08/02/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate subjective sleep quality and its relationship to fatigue in older adults with osteoarthritis (OA). METHOD In a community cohort with hip/knee OA, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and fatigue was measured by the Profile of Mood States - Fatigue subscale (POMS-F). Correlates of sleep quality and fatigue were determined by standardized interviews including socio-demographics, OA severity (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) summary score), comorbidity, depression (Center for Epidemiologic Studies Depression Scale, CES-D), stressful life events, daytime napping, symptoms of restless legs syndrome (RLS) and prior sleep disorder diagnoses. Logistic regression examined correlates of poor sleep (PSQI score>5). Linear regression evaluated the relationship between poor sleep and fatigue, and the effect of napping on this relationship. RESULTS In 613 respondents, mean age was 78 years, 78% were female, 11% had concomitant fibromyalgia, and 26% had 3+ comorbid conditions. Responses indicated moderate OA severity. Seventy percent reported poor sleep; 25% met criteria for RLS and 6.5% reported a diagnosed sleep disorder. Independent correlates of poor sleep were: greater arthritis severity (adjusted odds ratio (OR) per unit increase in WOMAC score=1.03, P<0.0001), 3+ comorbid conditions (adjusted OR=1.88; P=0.03), depressed mood (adjusted OR per unit increase in CES-D score=1.09, P<0.0001), and RLS (adjusted OR=1.87; P=0.02). Controlling for previously reported fatigue correlates, poor sleep was significantly associated with greater fatigue (parameter estimate=1.63, P=0.0003) and napping did not moderate this relationship (P=0.55 for the interaction between napping and poor sleep). CONCLUSIONS Among older people with OA, poor sleep is highly prevalent and significantly linked with fatigue. Identifying the nature of sleep disturbances in OA is important as treatment of sleep disturbances may reduce OA-related fatigue.
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