Anxiety and depression in patients with osteoarthritis: impact and management challenges

The impact of pain on quality of life in patients with osteoarthritis: a cross-sectional study from Palestine

BACKGROUND

Osteoarthritis is one of the most common musculoskeletal problems. Pain is the most common complaint and the most significant cause of decreased health-related quality of life (HRQOL) among osteoarthritic patients. The objectives of this study were to assess the impact of pain on quality of life among patients with osteoarthritis and to assess the association of sociodemographic and clinical factors with HRQOL.

METHODS

Using a cross-sectional study design, we collected data from osteoarthritis patients in orthopedic outpatient clinics from four hospitals in the Palestine-West bank between November 2020 and March 2021. We used the Brief Pain Inventory (BPI) scale to assess pain and the Quality of Life scale five dimensions (EQ-5D) with the visual analog scale of the European Quality of Life (EQ-VAS) to assess HRQOL.

RESULTS

In our study, 196 patients composed the final sample, with an average of 60.12 ± 13.63 years. The medians for the EQ-5D score and EQ-VAS score were 0.72 (0.508-0.796) and 70 (55-85), respectively. The pain severity score was found to have a significant negative association with both the EQ-5D and EQ-VAS scores with r of - 0.620, p <  0.001, and - 0.554, p <  0.001, respectively. Similar associations were found between pain interference score and both EQ-5D (r = - 0.822, p <  0.001) and EQ-VAS scores (r = - 0.609, p <  0.001). Multiple regression analysis showed that participants with higher educational level (p = 0.028), less diseased joints (p = 0.01), shorter duration of disease (p = 0.04), and lesser pain severity and interference scores (both with p < 0.001) had significantly higher HRQOL scores.

CONCLUSIONS

We found that many variables have a significant negative impact on HRQOL among patients with osteoarthritis. Our finding provides a well-founded database to use by clinicians and healthcare professionals who work with patients with osteoarthritis, as well as educational and academic institutions.

Health, Psychological and Demographic Predictors of Depression in People with Fibromyalgia and Osteoarthritis

Depression is common in people with fibromyalgia (FM) and osteoarthritis (OA) and has been linked to adverse health outcomes in these conditions. The purpose of this study was to examine differences in predictors of depression among individuals with FM and OA using a range of health, demographic, and psychological variables. Of the total 963 participants, 600 were diagnosed with FM, and 363 with OA. The Quality of Well-Being Scale (QWB) was used to assess health status. The Fibromyalgia Impact Questionnaire (FIQ) and the Arthritis Impact Measurement Scale (AIMS) were used to measure disease-specific impact. Additionally, participants completed self-efficacy and helplessness assessments. Depression was measured using the Center for Epidemiological Studies Scale (CES-D). The results of a moderated linear regression showed that higher depression scores were associated with lower health status and a greater condition impact, especially in the FM group. Self-efficacy and helplessness predicted depression in both groups, but more strongly in FM. White participants with OA were more depressed than their non-White counterparts, while the opposite was true for FM. These findings indicate that improving health status and psychological well-being might alleviate depression in both FM and OA.

Quantifying the Employer Burden of Persistent Musculoskeletal Pain at a Large Employer in the United Kingdom: A Non-interventional, Retrospective Study of Rolls-Royce Employee Data

OBJECTIVE

To quantify the burden of work-relevant persistent musculoskeletal (MSK) pain to a large UK employer.

METHODS

A retrospective, longitudinal, analytical cohort study using linked Rolls-Royce data systems. Cases were employees with a MSK-related referral to occupational health; controls were age-, sex-, and job role-matched employees without such a referral. Outcomes were compared during 12 months' follow-up.

RESULTS

Overall, 2382 matched case-control pairs were identified (mean age: 46 y; 82% male). Cases took 39,200 MSK-related sickness absence days in total (equating to £50 million in sickness absence costs). Cases took significantly more all-cause sickness absence days than controls (82,341 [£106 million] versus 19,628 [£26 million]; P < 0.0001).

CONCLUSIONS

Despite access to extensive occupational health services, the burden of work-relevant persistent MSK pain remains high in Rolls-Royce. There is a clear need to better understand how to effectively reduce this burden.

Antibiotics exposure attenuates chronic unpredictable mild stress-induced anxiety-like and depression-like behavior

Antibiotics exposure leads to gut microbiota dysbiosis, which increases the risk of anxiety and depression. However, the impact of ciprofloxacin and metronidazole exposure on chronic unpredictable mild stress-induced anxiety-like and depression-like behavior and underlying regulatory mechanism have not been well established. Here, chronic unpredictable mild stress model was established in adult male Sprague-Dawley rats. 16 S rRNA gene sequencing was used to decipher the gut microbiota. Enzyme-linked immunosorbent assay (ELIZA) was used to measure circulating cytokines in blood, gut barrier permeability biomarkers in feces, blood-brain barrier permeability biomarkers in brain. We found that antibiotics exposure significantly reduced the body weight, weight gain and liver health in chronic unpredictable mild stress treated rats. Behavioral testing suggested that antibiotics exposure reduced anxiety-like and depression-like behavior of rat. Antibiotics exposure possessed lower bacterial richness and diversity than that in the chronic unpredictable mild stress treated group. Compared with CUMS or CUMS-e group, higher abundances of Bacteroides, Lactobacillus, Lachnospiraceae and Akkermansia, lower abundances of S24-7, Blautia, Ruminocaceae, Ruminococcus and Prevotella were found in the gut microbiota from antibiotics exposure group. In addition, short-term antibiotics exposure increased the level of 5-hydroxytryptamine (5-HT) in brain. A significant correlation between certain bacteria and behavior of rats was observed, such as Roseburia. Our study uncovers the role for antibiotics in regulating chronic unpredictable mild stress-induced anxiety-like and depression-like behavior and suggest that short-term antibiotics exposure may be could reverse chronic unpredictable mild stress-induced anxiety-like and depression-like behavior.

Magnitude and factors associated with postoperative depression among adult orthopedics patients during COVID-19 pandemics: A multi-center cross-sectional study

BACKGROUND

Postoperative depression is one of the devastating problems and important health concerns in adult orthopedics surgical patients. It is often under-diagnosed and appropriate perioperative management of patients is recommended. This study aimed to determine the magnitude and factors associated with postoperative depression among orthopedics patients in Ethiopia.

MATERIALS AND METHODS

This multi-center cross-sectional study was conducted on 443 adult post-orthopedics surgical patients. All the data were entered and analyzed with SPSS version 25. Bivariable and multivariable logistic regression was used to identify the associated factors with the outcome variable. P-values <0.05 were taken as statistically significant with 95% CI. Data were collected after distributing 9-item standard patient health questionnaires and the Oslo-3 item social support scale tool.

RESULT

Based on our study result, the magnitude of postoperative depression among adult orthopedics surgical patients was 61.8% (95% CI: 56.8-65.7). Using multivariable logistic regression analysis, factors which had an association with postoperative depression were female in gender, Farmer in occupation, having a history of previous substance use, history of anxiety, Patients who had moderate to poor social support, BMI <18.5 kg/m², and patients who had an open fracture.

CONCLUSION

The magnitude of postoperative depression was high. Due emphasis needs to be given to screening and treatment of postoperative depression, especially among patients of the female gender, farmer occupation, moderate to poor social support, history of substance use and anxiety, low BMI, and open fracture.

Shared genetic liability between major depressive disorder and osteoarthritis

Aims

Deciphering the genetic relationships between major depressive disorder (MDD) and osteoarthritis (OA) may facilitate an understanding of their biological mechanisms, as well as inform more effective treatment regimens. We aim to investigate the mechanisms underlying relationships between MDD and OA in the context of common genetic variations.

Methods

Linkage disequilibrium score regression was used to test the genetic correlation between MDD and OA. Polygenic analysis was performed to estimate shared genetic variations between the two diseases. Two-sample bidirectional Mendelian randomization analysis was used to investigate causal relationships between MDD and OA. Genomic loci shared between MDD and OA were identified using cross-trait meta-analysis. Fine-mapping of transcriptome-wide associations was used to prioritize putatively causal genes for the two diseases.

Results

MDD has a significant genetic correlation with OA (r_g = 0.29) and the two diseases share a considerable proportion of causal variants. Mendelian randomization analysis indicates that genetic liability to MDD has a causal effect on OA (b_xy = 0.24) and genetic liability to OA conferred a causal effect on MDD (b_xy = 0.20). Cross-trait meta-analyses identified 29 shared genomic loci between MDD and OA. Together with fine-mapping of transcriptome-wide association signals, our results suggest that Estrogen Receptor 1 (ESR1), SRY-Box Transcription Factor 5 (SOX5), and Glutathione Peroxidase 1 (GPX1) may have therapeutic implications for both MDD and OA.

Conclusion

The study reveals substantial shared genetic liability between MDD and OA, which may confer risk for one another. Our findings provide a novel insight into phenotypic relationships between MDD and OA.

Cite this article: Bone Joint Res 2022;11(1):12–22.

Psychological profiles in adults with knee OA-related pain: a replication study

Introduction

Psychological factors have been associated with knee osteoarthritis pain severity and treatment outcomes, yet their combined contribution to phenotypic heterogeneity is poorly understood. In particular, empirically derived psychological profiles must be replicated before they can be targeted or considered for treatment studies. The objectives of this study were to (1) confirm previously identified psychological profiles using unsupervised clustering methods in persons with knee osteoarthritis pain, (2) determine the replicability of profiles using supervised machine learning in a different sample, and (3) examine associations with clinical pain, brain structure, and experimental pain.

Methods

Participants included two cohorts of individuals with knee osteoarthritis pain recruited as part of the multisite UPLOAD1 (n = 270, mean age = 56.8 ± 7.6, male = 37%) and UPLOAD2 (n = 164, mean age = 57.73 ± 7.8, male = 36%) studies. Similar psychological constructs (e.g. optimism, coping, somatization, affect, depression, and anxiety), sociodemographic and clinical characteristics, and somatosensory function were assessed across samples. UPLOAD2 participants also completed brain magnetic resonance imaging. Unsupervised hierarchical clustering analysis was first conducted in UPLOAD1 data to derive clusters, followed by supervised linear discriminative analysis to predict group membership in UPLOAD2 data. Associations among cluster membership and clinical variables were assessed, controlling for age, sex, education, ethnicity/race, study site, and number of pain sites.

Results

Four distinct profiles emerged in UPLOAD1 and were replicated in UPLOAD2. Identified psychological profiles were associated with psychological variables (ps < 0.001), and clinical outcomes (ps = 0.001-0.03), indicating good internal and external validation of the cluster solution. Significant associations between psychological profiles and somatosensory function and brain structure were also found.

Conclusions

This study highlights the importance of considering the biopsychosocial model in knee osteoarthritis pain assessment and treatment.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

The association between sleep quality, preoperative risk factors for chronic postoperative pain and postoperative pain intensity 12 months after knee and hip arthroplasty

BACKGROUND

Chronic postoperative pain following total joint replacement (TJA) is a substantial clinical problem, and poor sleep may affect predictive factors for postoperative pain, such as pain catastrophizing. However, the magnitude of these associations is currently unknown. This exploratory study investigated (1) the relationship between preoperative sleep quality, clinical pain intensity, pain catastrophizing, anxiety, and depression and (2) their associations with chronic postoperative pain following TJA.

METHODS

This secondary analysis from a larger randomized controlled trial included rest pain intensity (preoperative and 12 months postoperative; visual analogue scale, VAS), preoperative Pittsburgh Sleep Quality Index (PSQI), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS) data from 74 knee and 89 hip osteoarthritis (OA) patients scheduled for TJA. Poor sleepers were identified based on preoperative PSQI scores higher than 5.

RESULTS

Poor sleepers demonstrated higher preoperative VAS, pain catastrophizing, anxiety, and depression compared with good sleepers (all p < 0.003). Preoperative PSQI (β = 0.23, p = 0.006), PCS (β = 0.44, p < 0.005), and anxiety (β = 0.18, p = 0.036) were independent factors for preoperative VAS. Preoperative VAS (β = 0.32, p < 0.005), but not preoperative sleep quality (β = -0.06, p = 0.5), was an independent factor for postoperative VAS.

CONCLUSION

The OA patients reporting poor preoperative sleep quality show higher preoperative pain, pain catastrophizing, anxiety, and depression. High preoperative pain intensity, but not poor sleep quality, was associated with higher chronic postoperative pain intensity. Future studies are encouraged to explore associations between sleep and chronic postoperative pain.

The Recovery of Cognitive and Affective Deficiencies Linked with Chronic Osteoarthritis Pain and Implicated Pathways by Slow-Releasing Hydrogen Sulfide Treatment

Chronic osteoarthritis pain is accompanied by several comorbidities whose treatment has not been completely resolved. The anti-inflammatory, analgesic, and antidepressant effects of slow-releasing hydrogen sulfide (H₂S) donors during osteoarthritic pain have been shown, but their actions in the accompanying memory impairment and anxious-like behaviors have not yet been demonstrated. Using female mice with chronic osteoarthritic pain, the effects of natural, diallyl disulfide (DADS) or synthetic, morpholin-4-ium 4-methoxyphenyl(morpholino) phosphinodithioate dichloromethane complex (GYY4137) slow-releasing H₂S donors, on associated cognitive and grip strength deficits and anxiodepressive-like behaviors, were assessed. Their effects on specific brain areas implicated in the modulation of pain and emotional responses were also determined. Results demonstrated an improvement in memory and grip strength deficits, as well as in the anxious-like behaviors associated with chronic pain in GYY4137 and/or DADS treated mice. The painkiller and antidepressant properties of both treatments were also established. Treatment with DADS and/or GYY4137 inhibited: oxidative stress in the amygdala; phosphoinositide 3-kinase overexpression in the amygdala, periaqueductal gray matter, and anterior cingulate cortex; protein kinase B activation in the amygdala and infralimbic cortex; up-regulation of inducible nitric oxide synthase in the amygdala, periaqueductal gray matter and infralimbic cortex and apoptotic responses in the amygdala. These results might explain the recovery of memory and grip strength and the inhibition of allodynia and associated anxiodepressive-like behaviors by these treatments. In conclusion, this study revealed new properties of slow-releasing H₂S donors in cognitive impairment and affective disorders linked with chronic osteoarthritis pain and their effects on the central nervous system.

Assessing demographic access to hip replacement surgery in the United Kingdom: a systematic review

Persisting evidence suggests significant socioeconomic and sociodemographic inequalities in access to medical treatment in the UK. Consequently, a systematic review was undertaken to examine these access inequalities in relation to hip replacement surgery. Database searches were performed using MEDLINE, PubMed and Web of Science. Studies with a focus on surgical need, access, provision and outcome were of interest. Inequalities were explored in the context of sociodemographic characteristics, socioeconomic status (SES), geographical location and hospital-related variables. Only studies in the context of the UK were included. Screening of search and extraction of data were performed and 482 articles were identified in the database search, of which 16 were eligible. Eligible studies consisted of eight cross-sectional studies, seven ecological studies and one longitudinal study. Although socioeconomic inequality has somewhat decreased, lower SES patients and ethnic minority patients demonstrate increased surgical needs, reduced access and poor outcomes. Lower SES and Black minority patients were younger and had more comorbidities. Surgical need increased with age. Women had greater surgical need and provision than men. Geographical inequality had reduced in Scotland, but a north-south divide persists in England. Rural areas received greater provision relative to need, despite increased travel for care. In all, access inequalities remain widespread and policy change driven by research is needed.

Driving factors for the utilisation of healthcare services by people with osteoarthritis in Portugal: results from a nationwide population-based study

Background

Worldwide, the current management of knee osteoarthritis appears heterogeneous, high-cost and often not based on current best evidence. The absence of epidemiological data regarding the utilisation of healthcare services may conceal the need for improvements in the management of osteoarthritis. The aim of this study is to explore the profiles of healthcare services utilisation by people with knee osteoarthritis, and to analyse their determinants, according to Andersen’s behavioural model.

Methods

We analysed a sample of 978 participants diagnosed with knee osteoarthritis from the population-based study EpiReumaPt, in Portugal. Data was collected with a structured interview, and the diagnosis of knee osteoarthritis was validated by a rheumatologist team. With the Two-step Cluster procedure, we primarily identified different profiles of healthcare utilisation according to the services most used by patients with knee osteoarthritis. Secondly, we analysed the determinants of each profile, using multinomial logistic regression, according to the predisposing characteristics, enabling factors and need variables.

Results

In our sample, a high proportion of participants are overweight or obese (82,6%, n = 748) and physically inactive (20,6%, n = 201) and a small proportion had physiotherapy management (14,4%, n = 141). We identified three profiles of healthcare utilisation: “HighUsers”; “GPUsers”; “LowUsers”. “HighUsers” represents more than 35% of the sample, and are also the participants with higher utilisation of medical appointments. “GPUsers” represent the participants with higher utilisation of general practitioner appointments. Within these profiles, age and geographic location – indicated as predisposing characteristics; employment status and healthcare insurance - as enabling factors; number of comorbidities, physical function, health-related quality of life, anxiety and physical exercise - as need variables, showed associations (p < 0,05) with the higher utilisation of healthcare services profiles.

Conclusions

Healthcare utilisation by people with knee osteoarthritis is not driven only by clinical needs. The predisposing characteristics and enabling factors associated with healthcare utilisation reveal inequities in the access to healthcare and variability in the management of people with knee osteoarthritis. Research and implementation of whole-system strategies to improve equity in the access and quality of care are paramount in order to diminish the impact of osteoarthritis at individual-, societal- and economic-level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07045-4.

Cross-Disorder Genomics Data Analysis Elucidates a Shared Genetic Basis Between Major Depression and Osteoarthritis Pain

Osteoarthritis (OA) and major depression (MD) are two debilitating disorders that frequently co-occur and affect millions of the elderly each year. Despite the greater symptom severity, poorer clinical outcomes, and increased mortality of the comorbid conditions, we have a limited understanding of their etiologic relationships. In this study, we conducted the first cross-disorder investigations of OA and MD, using genome-wide association data representing over 247K cases and 475K controls. Along with significant positive genome-wide genetic correlations (r g = 0.299 ± 0.026, p = 9.10 × 10-31), Mendelian randomization (MR) analysis identified a bidirectional causal effect between OA and MD (βOA → MD = 0.09, SE = 0.02, z-score p-value < 1.02 × 10-5; βMD → OA = 0.19, SE = 0.026, p < 2.67 × 10-13), indicating genetic variants affecting OA risk are, in part, shared with those influencing MD risk. Cross-disorder meta-analysis of OA and MD identified 56 genomic risk loci (P meta ≤ 5 × 10-8), which show heightened expression of the associated genes in the brain and pituitary. Gene-set enrichment analysis highlighted "mechanosensory behavior" genes (GO:0007638; P gene_set = 2.45 × 10-8) as potential biological mechanisms that simultaneously increase susceptibility to these mental and physical health conditions. Taken together, these findings show that OA and MD share common genetic risk mechanisms, one of which centers on the neural response to the sensation of mechanical stimulus. Further investigation is warranted to elaborate the etiologic mechanisms of the pleiotropic risk genes, as well as to develop early intervention and integrative clinical care of these serious conditions that disproportionally affect the aging population.

Association of Hypertension with Knee Pain Severity Among People with Knee Osteoarthritis

PURPOSE

To examine the association of hypertension with knee pain severity in individuals with knee osteoarthritis (OA).

DESIGN

Cross-sectional study of baseline data collected by the Osteoarthritis Initiative.

METHODS

Participants with knee OA (N=1,363) were categorized into four groups based on blood pressure (BP): 1) systolic < 120 mm HG and diastolic < 80 mm Hg; 2) 120 ≤ systolic < 130 mm Hg and diastolic < 80 mm Hg; 3) 130 ≤ systolic < 140 mm Hg or 80 ≤ diastolic < 90 mm Hg; 4) systolic ≥ 140 mm Hg or diastolic ≥ 90 mm Hg. OA knee pain severity was measured by Pain subscale of Western Ontario and McMaster Universities Osteoarthritis Index in the past 48 hours, Pain subscale of Knee Injury and Osteoarthritis Outcome Score (KOOS) in the past 7 days, and numeric rating scale (NRS) in the past 30 days. Linear regression was used to examine the relationship between hypertension and knee pain severity.

RESULTS

Compared with the normal BP group, individuals with stage 2 hypertension reported significantly higher OA knee pain severity by KOOS in the past 7 days (β=-2.05 [95% CI -4.09, -0.01], p=0.049) and by NRS in the past 30 days (β=0.31 [95% CI 0.01, 0.62], p=0.045) after adjustments for demographic and medical factors.

CONCLUSIONS

Hypertension was associated with higher OA knee pain severity in individuals with knee OA.

CLINICAL IMPLICATIONS

Nurses can recommend adjunctive non-pharmacological treatments and adherence strategies to help control hypertension, which may help decrease OA knee pain.

Epidemiological study of post-traumatic ankle osteoarthritis after ankle sprain in 195,393 individuals over middle age using the National Health Insurance Database: A retrospective design

OBJECTIVES

This study aimed to determine the risk of ankle OA onset after an incidence of sprain, relative to the risk of onset in healthy population, and to investigate the effect of gender, age, BMI, and exercise on the development of ankle OA after sprain.

DESIGN

Retrospective cohort study.

METHODS

Using a sample cohort dataset from 2002 to 2013 provided by the Korean National Health Insurance Sharing Service, we calculated the mean survival time and cumulative incidence rate in sprained and healthy populations using Kaplan-Meier analysis. A Cox proportional hazards model was used to analyze the adjusted hazard ratio (HR) of sprain for the development of OA with 95% confidence intervals (CIs). Adjusted HRs of gender, age, BMI, and exercise (yes/no) were analyzed in the sprained group.

RESULTS

Among the selected population of 195,393 individuals, 40,876 (20.9%) were diagnosed with an ankle sprain, and 1543 (3.85%) of those individuals developed ankle OA. Of the 154,517 healthy individuals (79.1%), 4062 (2.66%) cases had progressed to OA. The sprained group had 46% (HR, 1.46; 95% CI, 1.38-1.55) greater rate of progression to ankle OA than did healthy individuals. In the sprain group, individuals who were female, obese, and overweight had 40% (HR, 1.40; 95% CI, 1.26-1.55), 43% (HR, 1.43; 95% CI, 1.12-1.82), and 22% (HR, 1.22; 95% CI, 1.10-1.35) higher incidence to develop ankle OA, respectively, compared to those who were male, underweight and normal.

CONCLUSIONS

This study found that ankle sprain was a significant risk factor for a diagnosis of early OA. Female gender and high BMI increased the incidence of ankle OA after sprain.

Comparative effectiveness of exercise programs for psychological well-being in knee osteoarthritis: A systematic review and network meta-analysis

OBJECTIVES

The benefits of exercise are well established for psychological well-being, but it is unknown whether one type of exercise can be recommended over another for psychological well-being in knee osteoarthritis (OA). This study aimed to compare the effectiveness of different types of exercise on psychological well-being in people with knee OA.

METHODS

Five databases including MEDLINE, EMBASE, Cochrane Register of Controlled Trials, CINAHL and PEDro) were searched from inception until April 2021. Randomised controlled trials comparing the effect of exercise with a non-exercise control or another type of exercise on overall mental health, depressive symptoms or anxiety in people with knee OA. Trial data were extracted independently by two researchers. Network meta-analyses using random-effect models were conducted. The Grading of Recommendations, Assessment, Development and Evaluation framework was used to appraise evidence certainty.

RESULTS

Strengthening exercise was more beneficial for overall mental health on the Short Form survey compared to aerobic (mean difference 15.88, 95%CI [6.77, 24.99]), mixed (12.77, 95%CI [5.12, 20.42]) and mind-body (12.51, [4.25, 20.77]) exercise based on 13 trials (n = 796). Strengthening exercise (standardised mean difference 6.81, [5.03, 8.58]), and mixed exercise (6.64, [4.88, 8.40]),) were more beneficial for depressive symptoms than stretching exercise based on 6 trials (n = 627). No differences were observed for anxiety based on 4 trials (n = 557). Certainty of the evidence ranged from very low to low.

CONCLUSION

The available evidence supports the recommendation of strengthening exercise as the most beneficial for overall mental health, and strengthening exercise or mixed exercise over stretching exercise for depressive symptoms. No exercise recommendations can be made for anxiety.

Ear wound healing in MRL/MpJ mice is associated with gut microbiome composition and is transferable to non-healer mice via microbiome transplantation

OBJECTIVE

Adult elastic cartilage has limited repair capacity. MRL/MpJ (MRL) mice, by contrast, are capable of spontaneously healing ear punctures. This study was undertaken to characterize microbiome differences between healer and non-healer mice and to evaluate whether this healing phenotype can be transferred via gut microbiome transplantation.

METHODS

We orally transplanted C57BL/6J (B6) mice with MRL/MpJ cecal contents at weaning and as adults (n = 57) and measured ear hole closure 4 weeks after a 2.0mm punch and compared to vehicle-transplanted MRL and B6 (n = 25) and B6-transplanted MRL (n = 20) mice. Sex effects, timing of transplant relative to earpunch, and transgenerational heritability were evaluated. In a subset (n = 58), cecal microbiomes were profiled by 16S sequencing and compared to ear hole closure. Microbial metagenomes were imputed using PICRUSt.

RESULTS

Transplantation of B6 mice with MRL microbiota, either in weanlings or adults, improved ear hole closure. B6-vehicle mice healed ear hole punches poorly (0.25±0.03mm, mm ear hole healing 4 weeks after a 2mm ear hole punch [2.0mm-final ear hole size], mean±SEM), whereas MRL-vehicle mice healed well (1.4±0.1mm). MRL-transplanted B6 mice healed roughly three times as well as B6-vehicle mice, and half as well as MRL-vehicle mice (0.74±0.05mm, P = 6.9E-10 vs. B6-vehicle, P = 5.2E-12 vs. MRL-vehicle). Transplantation of MRL mice with B6 cecal material did not reduce MRL healing (B6-transplanted MRL 1.3±0.1 vs. MRL-vehicle 1.4±0.1, p = 0.36). Transplantation prior to ear punch was associated with the greatest ear hole closure. Offspring of transplanted mice healed significantly better than non-transplanted control mice (offspring:0.63±0.03mm, mean±SEM vs. B6-vehicle control:0.25±0.03mm, n = 39 offspring, P = 4.6E-11). Several microbiome clades were correlated with healing, including Firmicutes (R = 0.84, P = 8.0E-7), Lactobacillales (R = 0.65, P = 1.1E-3), and Verrucomicrobia (R = -0.80, P = 9.2E-6). Females of all groups tended to heal better than males (B6-vehicle P = 0.059, MRL-transplanted B6 P = 0.096, offspring of MRL-transplanted B6 P = 0.0038, B6-transplanted MRL P = 1.6E-6, MRL-vehicle P = 0.0031). Many clades characteristic of female mouse cecal microbiota vs. males were the same as clades characteristic of MRL and MRL-transplanted B6 mice vs. B6 controls, including including increases in Clostridia and reductions in Verrucomicrobia in female mice.

CONCLUSION

In this study, we found an association between the microbiome and tissue regeneration in MRL mice and demonstrate that this trait can be transferred to non-healer mice via microbiome transplantation. We identified several microbiome clades associated with healing.

The association between psychological factors and pain exacerbations in hip osteoarthritis

OBJECTIVES

To evaluate the association between psychological factors and pain exacerbations in people with hip OA.

METHODS

Eligible participants with symptomatic hip OA were instructed to complete online questionnaires every 10 days over a 90-day follow-up period. In addition, they were required to complete the questionnaire whenever they perceived they were experiencing a hip pain exacerbation. Hip pain exacerbation was defined as an increase of 2 points in pain intensity compared with baseline on an 11-point numeric rating scale (0-10). The Depression, Anxiety and Stress Scale-21 Items, Positive and Negative Affect Schedule, Pain Catastrophizing Scale and Pain Self-Efficacy Questionnaire were used to evaluate psychological factors. The associations of these with risk of hip pain exacerbation were examined by conditional logistic regression.

RESULTS

Of 252 participants recruited, 131 (52.0%) contributed both case and control period data and were included in the analysis. A significant association was found between Pain Catastrophizing Scale overall score (1 point increase) with hip pain exacerbations (odds ratio: 1.07, 95% CI: 1.04, 1.11). An increase of a minimal important change (5.5 points) of Pain Self-Efficacy Questionnaire score was associated with a lower odds of pain exacerbations (odds ratio: 0.74, 95% CI: 0.65, 0.85). No significant associations were found between Depression, Anxiety and Stress Scale-21 Items or Positive and Negative Affect Schedule scores with hip pain exacerbations.

CONCLUSION

Both pain catastrophizing and pain self-efficacy beliefs were associated with pain exacerbations in people with hip OA, but other psychological factors including depression, anxiety and stress or positive and negative affects, were not associated with pain exacerbations.

A new integrated behavioural intervention for knee osteoarthritis: development and pilot study

Background

Exercise-based approaches have been a cornerstone of physiotherapy management of knee osteoarthritis for many years. However, clinical effects are considered small to modest and the need for continued adherence identified as a barrier to clinical efficacy. While exercise-based approaches focus on muscle strengthening, biomechanical research has identified that people with knee osteoarthritis over activate their muscles during functional tasks. Therefore, we aimed to create a new behavioural intervention, which integrated psychologically informed practice with biofeedback training to reduce muscle overactivity, and which was suitable for delivery by a physiotherapist.

Methods

Through literature review, we created a framework linking theory from pain science with emerging biomechanical concepts related to overactivity of the knee muscles. Using recognised behaviour change theory, we then mapped a set of intervention components which were iteratively developed through ongoing testing and consultation with patients and physiotherapists.

Results

The underlying framework incorporated ideas related to central sensitisation, motor responses to pain and also focused on the idea that increased knee muscle overactivity could result from postural compensation. Building on these ideas, we created an intervention with five components: making sense of pain, general relaxation, postural deconstruction, responding differently to pain and functional muscle retraining. The intervention incorporated a range of animated instructional videos to communicate concepts related to pain and biomechanical theory and also used EMG biofeedback to facilitate visualization of muscle patterns. User feedback was positive with patients describing the intervention as enabling them to “create a new normal” and to be “in control of their own treatment.” Furthermore, large reductions in pain were observed from 11 patients who received a prototype version of the intervention.

Conclusion

We have created a new intervention for knee osteoarthritis, designed to empower individuals with capability and motivation to change muscle activation patterns and beliefs associated with pain. We refer to this intervention as Cognitive Muscular Therapy. Preliminary feedback and clinical indications are positive, motivating future large-scale trials to understand potential efficacy. It is possible that this new approach could bring about improvements in the pain associated with knee osteoarthritis without the need for continued adherence to muscle strengthening programmes.

Trial registration

ISRCTN51913166 (Registered 24-02-2020, Retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04389-0.

On a Trajectory for Success-9 in Every 10 People With a Degenerative Meniscus Tear Have Improved Knee Function Within 2 Years After Treatment: A Secondary Exploratory Analysis of a Randomized Controlled Trial

OBJECTIVE

To identify trajectories of patient-reported knee function over 5 years in patients with degenerative meniscal tears, and to explore whether baseline characteristics were associated with trajectories of sport and recreational function.

DESIGN

Prospective cohort study.

METHODS

We conducted a secondary exploratory analysis of the Odense-Oslo Meniscectomy Versus Exercise randomized controlled trial. Patient-reported knee function was assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline, 3 months, 1 year, 2 years, and 5 years. We used group-based trajectory modeling to identify subgroups of patients who followed distinctive patterns of change. Multinomial logistic regression was used to examine the associations of patient demographics, knee function, and disease-related factors with KOOS sport and recreational function subscale trajectories.

RESULTS

The analysis of data from a sample of 140 participants identified 3 trajectories for all KOOS subscales: (1) low, minimal improvement (10%-12% of the participants), (2) moderate, gradual improvement (20%-36%), and (3) high, early improvement (53%-70%). Baseline prognostic factors for deteriorating function in sport and recreational activities were higher body mass index, poorer mental health, greater knee pain, lower perceived knee function, poorer quadriceps and hamstrings muscle strength, poorer functional performance, more meniscal extrusion, and radiographic signs of knee osteoarthritis.

CONCLUSION

We found 3 distinct trajectories of patient-reported knee function over 5 years: (1) low, minimal improvement, (2) moderate, gradual improvement, and (3) high, early improvement. Nine in every 10 participants improved at least gradually over 2 years after diagnosis of a degenerative meniscal tear. J Orthop Sports Phys Ther 2021;51(6):289-297. Epub 10 May 2021. doi:10.2519/jospt.2021.10025.

Association between sleep disorders and osteoarthritis: A case-control study of 351,932 adults in the UK

This study aimed to analyse the association between sleep disorders and osteoarthritis in adults in the UK. This case-control study included patients aged ≥ 18 years who were diagnosed with osteoarthritis for the first time in one of 256 general practices in the UK between 1997 and 2016 (index date). Patients without osteoarthritis were matched (1:1) to those with osteoarthritis by sex, age, index year, general practice, observation time prior to index date (in years), obesity, injuries, and other types of arthritis. For patients without osteoarthritis, the index date was a randomly selected visit date between 1997 and 2016. The presence of sleep disorders prior to index date was assessed in the two groups. Finally, conditional logistic regression analyses were conducted to investigate the association between sleep disorders and osteoarthritis. This case-control study included 351,932 adults (61.5% women; mean [SD] age 64.9 [14.2] years). Overall, there was a significant association between sleep disorders and osteoarthritis (odds ratio = 1.25, 95% confidence interval = 1.22-1.29). This finding was corroborated in all sex and age subgroups, except in patients aged > 80 years. In terms of the type of sleep disorder, non-organic sleep disorders, hypersomnia and sleep apnea were associated to a significant extent with higher odds of developing osteoarthritis. Finally, the relationship between sleep disorders and osteoarthritis was significant in all osteoarthritis subgroups, except in that of patients with knee osteoarthritis. Based on these results, it can be concluded that sleep disorders may play a role in the development of osteoarthritis.

Are Psychosocial Factors Determinant in the Pain and Social Participation of Patients with Early Knee Osteoarthritis? A Cross-Sectional Study

The main objective of this research is to determine the psychosocial differences between patients with knee pain or early osteoarthritis (EOA) and healthy subjects at risk of developing osteoarthritis. The secondary objective is to determine how psychosocial factors might influence pain and social participation in patients with EOA. A cross-sectional study was performed. Participants were divided according to the presence of pain or EOA. Pain intensity both at rest and walking, psychological variables such as anxiety and depression, and social participation were evaluated. A total of 105 participants were included (64 with knee pain and 41 without pain), with a mean age of 51.42 ± 5.92 (35 men and 70 women). Patients with knee pain had higher levels of anxiety (MD = −2.35; p < 0.01; d = 0.66) and depression (MD = −2.45; p < 0.01; d = 0.87), regardless of the presence of EOA. In addition, patients with higher depression levels had lower levels of social participation. The results revealed a relationship between the psychological variables, anxiety and depression, with knee pain and the onset of symptomatic OA, as well as an influence of depression levels on social participation. Improving these psychological characteristics may be useful in delaying the onset of symptomatic OA and enhancing social participation.

Effectiveness of Stepped-Care Intervention in Overweight and Obese Patients With Medial Tibiofemoral Osteoarthritis: A Randomized Controlled Trial

OBJECTIVE

To test the effectiveness of a 32-week, stepped-care intervention on disease remission rates in overweight and obese patients with medial tibiofemoral osteoarthritis (OA) compared to controls.

METHODS

In this randomized controlled trial, eligible participants were ≥50 years of age with a body mass index of ≥28 kg/m² and radiographic evidence of medial tibiofemoral OA. Participants were randomized to stepped-care (n = 87) or control group (n = 84). The stepped-care group received a 2-step intervention. The first step consisted of an 18-week diet and exercise program. The second step consisted of 4 treatment subgroups: 1) diet and exercise maintenance; 2) cognitive-behavioral therapy; 3) unloader knee brace; and 4) muscle strengthening exercises. Allocation into subgroups was based on disease remission state and clinical characteristics. The primary end point was the disease remission rate (yes/no) at 32 weeks, which was reached when participants achieved the Patient Acceptable Symptom State cutoff value for pain and for the patient global assessment of disease activity and/or functional impairment.

RESULTS

Disease remission at 32 weeks was achieved by 18 of 68 (26%) in the control group and 32 of 82 (39%) in the stepped-care group (difference 12.6% [95% confidence interval -2.3, 27.4], P = 0.10). The stepped-care group showed an improvement in pain and function between baseline and 20 weeks. While functional improvement was maintained at 32 weeks, pain levels tended to get worse between weeks 20 and 32.

CONCLUSION

The proposed intervention did not promote a significant difference in the rate of disease remission in comparison to the control group for overweight or obese patients with medial tibiofemoral OA.

Development of a mind body program for obese knee osteoarthritis patients with comorbid depression

Knee osteoarthritis (OA) is the most common joint disorder in the U.S. and a leading cause of disability. Depression and obesity are highly comorbid among knee OA patients, and the combination of obesity and depression is associated with decreased physical activity, higher pain and disability, and more rapid cartilage degradation. Depression, obesity and OA exacerbate one another and share a common pathophysiology involving systemic inflammation and pro-inflammatory cytokines, reflecting a complex mind-body interaction. Current treatments for knee OA offer little to no benefit over placebo, and do not emphasize mind-body practices or physical activity to target the underlying pathophysiology. Mind-body interventions to lessen depressive symptoms and increase physical activity offer the ability to target biological, mechanical and psychological mechanisms of OA progression. Our long-term goals are to evaluate the mechanisms by which the Relaxation Response Resiliency Program (3RP) delivered via secure telehealth, and adapted for patients with depression, obesity and knee OA (GetActive-OA) promotes increases in physical activity and improved knee health. We hypothesize that the synergistic interaction between mindfulness, adaptive thinking, positive psychology and healthy living skills of the GetActive-OA will slow the progression of symptomatic knee OA by reducing pro-inflammatory cytokine expression and promoting optimal mechanical loading of the cartilage. Here we present the protocol for a mixed methods study that will adapt the 3RP for the needs of knee OA patients with depression and obesity with a focus on increasing physical activity (GetActive-OA), and iteratively maximize the feasibility, credibility and acceptability of the programs and research procedures.

Factors associated with fatigue in hip and/or knee osteoarthritis: a systematic review and best evidence synthesis

Objective

The aim was systematically to identify and evaluate factors related to fatigue in individuals with hip and/or knee OA.

Methods

A systematic literature search was conducted using AMED, CINAHL, MEDLINE, ProQuest and Web of Science Core Collections databases. Inclusion criteria comprised cross-sectional, case–control or longitudinal studies on patients with a diagnosis of hip and/or knee OA that included self-reported fatigue measures. Study quality was assessed using the National Heart, Lung and Blood Institute quality appraisal tool, and factors were synthesized within a bio-behavioural framework. Study designs and quality were combined to determine current evidence levels using best evidence synthesis grading. The full review protocol is available from PROSPERO (PROSPERO 2019: CRD42019138571).

Results

Twenty-four studies were included, of which 19 were high, 4 moderate and 1 low quality. There was strong evidence of an association between poor self-reported physical function and high depressive symptoms with higher fatigue. Moderate evidence of an association was found between severe pain, high numbers of co-morbidities and low physical activity levels with higher fatigue. There was moderate or limited evidence of no association between most sociodemographic factors and radiographic OA severity with fatigue.

Conclusion

Targets for fatigue management might include improving physical function, reducing depressive symptoms, pain and co-morbidities, and increasing physical activity levels. There is a need for more rigorous longitudinal studies to understand the causal effect of fatigue determinants within the hip and knee OA populations.

I exercise to postpone death - Interviews with persons with hip and/or knee osteoarthritis who are attending an osteoarthritis school

Background: Physical activity (PA) and exercise constitute the first line of treatment for osteoarthritis (OA) of the hip and/or knee. Even though the symptoms may vary, OA should be considered a chronic disease and therefore PA and exercise should be performed lifelong. That needs knowledge and motivation.Purpose: The purpose of this study was to explore and create a deeper understanding of the motivational processes for PA and exercise for persons with hip and/or knee OA who have participated in a self-management program OA school that included long-term exercise supervised by physical therapists.Methods: Twenty-two in-depth interviews were conducted with 18 participants recruited from the OA school at a Physical Therapy Rehabilitation Clinic in Sweden. The interviews were analyzed with qualitative content analysis.Results: The analysis resulted in one main theme, Developing health literacy to encourage motivational processes for PA and exercise in OA and four themes: 1) meeting an established self-management program; 2) carrying my life history; 3) understanding the intelligence of the body; and 4) growing in existential motivationConclusion: Motivation for being physically active and to exercise, the life history in relation to PA and what creates existential motivation are important areas to ask questions about when people come to OA schools. Knowledge about the signals of the body connected to OA should be implemented in OA schools in order to motivate people to live an active life despite OA. Health literacy and the awareness of how PA can postpone death are likely to be important for existential motivation.

Discrepancies in conservative treatment for thumb carpometacarpal arthritis: a comparison between different specialities and patient characteristics

Non-surgical treatment is successful in controlling pain and preventing disease progress in treating thumb carpometacarpal arthritis. We used Optum's de-identified Clinformatics® Data Mart Databases between 2015 and 2018 to conduct a study of the patient and provider characteristics associated with three types of non-surgical treatment (hand therapy, splinting and corticosteroid injection) prior to surgery. In this population-based cohort study, we found that non-surgical providers were more likely to provide three different types of non-surgical treatments, as compared with hand surgeons. In addition, women and patients with comorbid conditions, including carpal tunnel syndrome, obesity, chronic pain and depression, were less likely to exhaust the available non-surgical management options for thumb carpometacarpal arthritis. Therefore, we suggest that these specific patient populations can potentially benefit from additional non-surgical treatments that may delay or obviate surgery for this disease. These groups are target populations for future efforts to ensure that all patients receive equitable care.Level of evidence: II.

Perspectives of ESCAPE-Pain Programme for Older People With Knee Osteoarthritis in the Community Setting

Background: Functional limitationscommonly affect patients with knee osteoarthritis (OA) which reduces quality of life. The Enabling Self-management and Coping with Arthritic Pain using Exercise (ESCAPE-pain) is an evidence-based programme identified to be suitable for adaptation for the Malaysian health care system. It is important to understand the acceptance from a sociocultural context of the ESCAPE-pain programme from the perspectives of patients with knee OA and healthcare professionals. This qualitative study aims to explore the perspectives of stakeholders to inform the adaptation of the ESCAPE-pain programme into the Malaysian health care system. Method: Semi-structured interviews using interview guides were conducted with 18 patients with knee OA and 14 healthcare professionals including nurses, physiotherapists, occupational therapists, medical doctors, and orthopedic surgeons. The data were transcribed and analyzed using framework analysis. Results: The findings show that patients and healthcare professionals positively accept the programme into their daily living activities and recommend some modifications related to the Malaysian context. This study also highlights strategies to adopt when providing ESCAPE-pain to patients with knee OA. Conclusion: The findings reveal how sociocultural considerations could facilitate uptake and engagement with the ESCAPE-pain programme for home exercise among patients with knee osteoarthritis. These findings may benefit t patients with knee OA in the Malaysian healthcare system, although future research is recommended.

Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models

Objective

To establish the frequency of concordant, discordant, and clinically dominant comorbidities among Medicare beneficiaries with knee osteoarthritis (KOA) and to identify common concordant condition subgroups.

Participants and Methods

We used a 5% representative sample of Medicare claims data to identify beneficiaries who received a diagnosis of KOA between January 1, 2012, and September 30, 2015, and matched control group without an osteoarthritis (OA) diagnosis. Frequency of 34 comorbid conditions was categorized as concordant, discordant, or clinically dominant among those with KOA and a matched sample without OA. Comorbid condition phenotypes were characterized by concordant conditions and derived using latent class analysis among those with KOA.

Results

The study sample included 203,361 beneficiaries with KOA and 203,361 non-OA controls. The largest difference in frequency between the two cohorts was for co-occurring musculoskeletal conditions (23.7% absolute difference), chronic pain syndromes (6.5%), and rheumatic diseases (4.5%), all with a higher frequency among those with knee OA. Phenotypes were identified as low comorbidity (53% of cohort with classification), hypothyroid/osteoporosis (27%), vascular disease (10%), and high medical and psychological comorbidity (10%).

Conclusions

Approximately 47% of Medicare beneficiaries with KOA in this sample had a phenotype characterized by one or more concordant conditions, suggesting that existing clinical pathways that rely on single or dominant providers might be insufficient for a large proportion of older adults with KOA. These findings could guide development of integrated KOA-comorbidity care pathways that are responsive to emerging priorities for personalized, value-based health care.

Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis

OBJECTIVE

While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.

METHODS

A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.

RESULTS

In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02).

CONCLUSION

Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.

Risk factors of pain, physical function, and health-related quality of life in elderly people with knee osteoarthritis: A cross-sectional study

Data on the precise mechanisms of the complex interactions of factors related to clinical impact of knee osteoarthritis (KOA) in the elderly population remain limited. To find predictors that explain pain intensity, physical function, and quality of life in elderly KOA subjects, we performed a cross-sectional analysis of the baseline data from a randomized trial. The trial included 104 subjects (aged ≥60) with KOA pain and dysfunctional endogenous pain-inhibitory system activity assessed by conditioned pain modulation (CPM). Three multiple linear regression models were performed to understand the independent predictors of Brief Pain Inventory (BPI), WOMAC function subscale (WOMACFunc), and SF-12 physical subscale (SF12-PCS). Model 1 showed that BPI pain score was predicted by low CPM response, high von-Frey light touch threshold, worse radiological severity as indexed by Kellgren-Lawrence grade (KL), high von-Frey punctate pain intensity and high levels of anxiety (adjusted R2 = 27.1%, F (6,95) = 7.27, P < 0.0001). In model 2, von-Frey light touch threshold, KL, depressive symptoms indexed by Beck Depression Inventory (BDI), level of sleepiness and pain pressure threshold were risk factors for SF12-PCS (adjusted R2 = 31.9%, F (5,96) = 10.5, P < 0.0001). Finally, model 3 showed that WOMACFunc was predicted by BDI, KL and BPI (adjusted R2 = 41%, F (3,98) = 24.42, P < 0.0001). Our data provides an interesting framework to understand the predictors of KOA pain in the elderly and highlights how its related outcomes are affected by disease-specific factors, somatosensory dysfunction and emotional factors.

What General and Pain-associated Psychological Distress Phenotypes Exist Among Patients with Hip and Knee Osteoarthritis?

BACKGROUND

Psychological distress can negatively influence disability, quality of life, and treatment outcomes for individuals with hip and knee osteoarthritis (OA). Clinical practice guidelines recommend a comprehensive disease management approach to OA that includes the identification, evaluation, and management of psychological distress. However, uncertainty around the best psychological screening and assessment methods, a poor understanding of the heterogeneity of psychological distress in those with OA, and lack of guidance on how to scale treatment have limited the growth of OA care models that effectively address individual psychological needs.

QUESTIONS/PURPOSES

(1) Across which general and pain-related psychological distress constructs do individuals seeking conservative care for hip or knee OA report higher scores than the general population of individuals seeking conservative care for musculoskeletal pain conditions? (2) What common psychological phenotypes exist among nonsurgical care-seeking individuals with hip or knee OA?

METHODS

The sample included participants from the Duke Joint Health Program (n = 1239), a comprehensive hip and knee OA care program, and the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies (n = 871) comprising individuals seeking conservative care for knee, shoulder, low back, or neck pain. At the initial evaluation, patients completed the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool, which assesses 11 general and pain-related psychological distress constructs (depression, anxiety, fear of movement, self-efficacy for managing one's own pain). We used OSPRO-YF scores to compare levels of psychological distress between the cohorts. Cohen's d effect sizes were calculated to determine the magnitude of differences between the groups, with d = 0.20, d = 0.50, and d = 0.80 indicating small, medium, and large effect sizes, respectively. We used a latent class analysis to derive psychological distress phenotypes in people with OA based on the 11 OSPRO-YF psychological distress indicators. Psychological distress phenotypes are characterized by specific mood, belief, and behavioral factors that differentiate subgroups within a population. Phenotyping can help providers develop scalable treatment pathways that are better tailored to the common needs of patients.

RESULTS

Patients with OA demonstrated higher levels of general and pain-related psychological distress across all psychological constructs except for trait anxiety (that is, anxiety level as a personal characteristic rather than as a response to a stressful situation, like surgery) with small-to-moderate effect sizes. Characteristics with the largest effect sizes in the OA and overall OSPRO cohort were (Cohen's d) general anxiety (-0.66, lower in the OA cohort), pain catastrophizing (the tendency to ruminate over, maginfiy, or feel helpless about a pain experience, 0.47), kinesiophobia (pain-related fear of movement, 0.46), pain self-efficacy (confidence in one's own ability to manage his or her pain, -0.46, lower in the OA cohort), and self-efficacy for rehabilitation (confidence in one's own ability to perform their rehabilitation treatments, -0.44, lower in the OA cohort). The latent class analysis yielded four phenotypes (% sample): high distress (52%, 647 of 1239), low distress (26%, 322 of 1239), low self-efficacy and acceptance (low confidence in managing and willingness to accept pain) (15%, 186 of 1239), and negative pain coping (exhibiting poor pain coping skills) (7%, 84 of 1239). The classification error rate was near zero (2%), and the median of posterior probabilities used to assign subgroup membership was 0.99 (interquartile range 0.98 to 1.00), both indicating excellent model performance. The high-distress group had the lowest mean age (61 ± 11 years) and highest levels of pain intensity (6 ± 2) and disability (HOOS JR: 50 ± 15; KOOS JR: 47 ± 15), whereas the low-distress group had the highest mean age (63 ± 10 years) and lowest levels of pain (4 ± 2) and disability (HOOS JR: 63 ± 15; KOOS JR: 60 ± 12). However, none of these differences met or exceeded anchor-based minimal clinically important difference thresholds.

CONCLUSIONS

General and pain-related psychological distress are common among individuals seeking comprehensive care for hip or knee OA. Predominant existing OA care models that focus on biomedical interventions, such as corticosteroid injection or joint replacement that are designed to directly address underlying joint pathology and inflammation, may be inadequate to fully meet the care-related needs of many patients with OA due to their underlying psychological distress. We believe this because biomedical interventions do not often address psychological characteristics, which are known to influence OA-related pain and disability independent of joint pathology. Healthcare providers can develop new comprehensive hip and knee OA treatment pathways tailored to these phenotypes where services such as pain coping skills training, relaxation training, and psychological therapies are delivered to patients who exhibit phenotypes characterized by high distress or negative pain coping. Future studies should evaluate whether tailoring treatment to specific psychological phenotypes yields better clinical outcomes than nontailored treatments, or treatments that have a more biomedical focus.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Does screening for depressive symptoms help optimize duloxetine use in knee OA patients with moderate pain? A cost-effectiveness analysis

OBJECTIVE

Duloxetine is an FDA-approved treatment for both osteoarthritis (OA) pain and depression, but uptake of duloxetine in knee OA management varies. We examined the cost-effectiveness of adding duloxetine to knee OA care with or without depression screening.

METHODS

We used the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA, to examine the value of duloxetine for knee OA patients with moderate pain by comparing three strategies: 1) usual care (UC); 2) duloxetine for those who screen positive for depression on the Patient Health Questionnaire 9 (PHQ-9) + UC; and 3) universal duloxetine + UC. Outcomes included quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Model inputs, drawn from published literature and national databases, included: annual cost of duloxetine, $721-$937; average pain reduction for duloxetine, 17.5 points on the WOMAC pain scale (0-100); likelihood of depression remission with duloxetine, 27.4%. We considered two willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY. We varied parameters related to the PHQ-9 and duloxetine's cost, efficacy, and toxicities to address uncertainty in model inputs.

RESULTS

The screening strategy led to an additional 17 QALYs per 1,000 subjects and increased costs by $289/subject (ICER=$17,000/QALY). Universal duloxetine led to an additional 31 QALYs per 1,000 subjects and $1,205/subject (ICER=$39,300/QALY). Under the majority of sensitivity analyses, universal duloxetine was cost-effective at the $100,000/QALY threshold.

CONCLUSION

Adding duloxetine to usual care for knee OA patients with moderate pain, regardless of depressive symptoms, is cost-effective at frequently-used WTP thresholds.

A patients' view of OA: the Global Osteoarthritis Patient Perception Survey (GOAPPS), a pilot study

BACKGROUND

Globally, osteoarthritis (OA) is the third condition associated with disability. There is still poor treatment in OA but science holds the key to finding better treatments and a cure. It is essential to learn what's important to patients from them to implement the most effective OA management. The OA Patients Task Force, conducted the Global OA Patient Perception Survey (GOAPPS)-the first global survey made by patients to analize the quality of life (QoL) & patient perceptions of care. The goal was to collect data on OA patients' perception of OA to understand patients' needs and expectations to improve OA management.

METHODS

Observational, cross-sectional study by online survey data collection from six countries, translated into three languages. The questionnaire was comprised of 3 sections: patient demographics and clinical symptomology characteristics; relationship with physicians: perception of attention, treatment, and information provided; and OA impact on daily activity and QoL. The results of the survey were evaluated using the Limited Data Set. The survey results were analyzed using descriptive statistics to characterize the patients' answers. Additionally, Cronbach's alpha was calculated to determine internal consistency validity.

RESULTS

A total of 1512 surveys were completed in 6 countries. 84.2% of respondents reported pain/tenderness and 91.1% experienced limitations to physical activities. 42.3% of patients were not satisfied with their current OA treatment. 86% had comorbidities, especially hypertension, and obesity. 51.3 and 78% would like access to additional drug or additional non-drug/non-surgical treatments respectively. 48.2% of patients perceived their QoL to be affected by OA. The Cronbach's alpha was 0.61.

CONCLUSIONS

OA has a significant impact on patients' daily activities and their desire to play an active role in managing this disease. Patients are seeking additional treatments, especially no pharmacological/no surgical treatments stressing the need for investing in clinical research, implementing OA preventive measures, and managing interventions to improve the healthcare value chain in OA.

High levels of preoperative pain and fatigue are red flags for moderate-severe pain 12 months after total knee arthroplasty-A longitudinal cohort study

Background

Moderate/severe pain after total knee arthroplasty (TKA) is a poor surgical outcome. Many studies have identified preoperative risk factors of pain after TKA, but studies of the joint contributions of co‐occurring symptoms are lacking.

Methods

Patients undergoing primary TKA (n = 202) were enrolled in a longitudinal cohort study. Preoperatively, patients completed questionnaires measuring demographics and symptoms (pain, fatigue, sleep problems and depression). Pain was re‐assessed 12 months after TKA. Logistic regression analysis was used to compute the probabilities of moderate‐severe pain at 12 months based on preoperative symptom levels, and results were combined into a risk matrix.

Results

More than one‐third (40%) of patients (n = 187) reported moderate‐severe pain after TKA. Among preoperative risk factors included in the logistic regression analyses were age, sex, pain, fatigue, sleep problems and depression. Adjusting for possible confounders, fatigue (p = 0.02) and pain (p = 0.01) were significant risk factors for moderate‐severe pain at 12‐months follow‐up and were retained in the final risk matrix. The co‐occurrence of high‐preoperative fatigue and pain scores resulted in 57% estimated probability of moderate‐severe pain at 12 months. Similarly, the co‐occurrence of low‐preoperative fatigue and pain scores resulted in 14% estimated probability of moderate‐severe pain 12 months after TKA.

Conclusion

The combination of high fatigue and pain scores prior to surgery was a key risk factor for moderate‐severe pain 12 months after TKA. Mapping of these factors could be used preoperatively to identify patients who are at risk to experience a poor outcome of TKA.

Collaborative model of care between Orthopaedics and allied healthcare professionals in knee osteoarthritis (CONNACT): study protocol for an effectiveness-implementation hybrid randomized control trial

Background

Knee Osteoarthritis (OA) is a leading cause of global disability. The Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT) Model of Care (MoC) was developed by optimizing evidence-based non-surgical treatments to deliver value-based care for people with knee OA. The primary aim of this study is to determine the clinical effectiveness of the CONNACT MoC (3 months) compared to usual care. The secondary aims are: a) To determine the cost-effectiveness and b) To develop an evaluation and implementation framework to inform large scale implementation for this MoC.

Methodology

Type 1 Effectiveness-Implementation Hybrid Trial using an explanatory sequential mixed-method approach. The study consists of 3 components. The first component is the pragmatic, parallel-arm, single-blinded randomized control trial. Inclusion criteria are patients with knee OA based on the National Institute of Health and Care Excellence (NICE) criteria with radiographic severity of greater than Kellgren-Lawrence 1, and Knee Injury and OA Outcome Score (KOOS₄) of equal or less than 75. Exclusion criteria include other forms of arthritis, history of previous knee arthroplasty or wheelchair-bound patient. KOOS₄ is the primary outcome measure at 3 months, 6 months and 1 year. Secondary outcomes include KOOS individual subscales, quality of life scoring, functional performance, global, diet and psychological related outcomes. The second component is an economic evaluation of the cost-effectiveness of the CONNACT MoC using a societal perspective. The third component is an implementation and evaluation framework using process evaluation under the RE-AIM framework using a mixed-method approach. Sample size of 100 patients has been calculated.

Discussion

CONNACT MoC is a complex intervention. In line with the MRC guidance for developing and evaluating complex interventions, a pilot feasibility study was completed and a comprehensive approach including an RCT, economic evaluation and process evaluation is described in this study protocol. Results from this study will help clinicians, healthcare administrators and policymakers guide the sustainable and effective implementation of the CONNACT MoC for knee OA and serve as a basis for similar multidisciplinary MoC for chronic degenerative musculoskeletal conditions to be developed.

Trial registration

Clinicaltrials.gov Identifier: NCT03809975. Registered January 182,019.

Influence of Health Status, Cognitive Function, and Social Capital on Depressive Symptoms in Korean Older Adults

The current study explored the influence of health status, cognitive function, and social capital on depressive symptoms in Korean older adults. Data from the National Survey of Older Koreans, conducted by the Korean Institute for Health and Social Affairs in 2017, were used. Social capital was measured by dividing it into structural and cognitive social capital. Final analysis included 6,100 individuals aged ≥65 years (mean age = 72.6, SD = 5.8 years; 3,466 males [56.8%], 2,634 females [43.2%]). Multiple hierarchical regression analysis indicated that age, income, economic activity status, religion, household type, self-rated health, apoplexy (e.g., stroke, cerebral infarction), cognitive function, structural social capital, and cognitive social capital were significant predictors of depressive symptoms in older adults. This study suggests that researchers and clinicians should consider the factors associated with self-rated health, cognitive social capital, and economic status (income and economic activity) to prevent or alleviate depressive symptoms in older adults. [Journal of Psychosocial Nursing and Mental Health Services, 58(10), 24-31.].

Modifiability of Depression's Impact on Early Revision, Narcotic Usage, and Outcomes After Total Hip Arthroplasty: The Impact of Psychotherapy

BACKGROUND

Depression is known to negatively influence functional recovery, patient satisfaction, narcotic requirements, implant survivorship, and perioperative resource utilization after total hip arthroplasty (THA). The degree to which this effect is modifiable is largely unknown, with mixed results on preoperative pharmacological intervention, and concomitant concerns over side effects. We aim to investigate the influence of psychotherapy before THA on surgical outcomes, medical complications, and resource utilization.

METHODS

A retrospective chart review of Truven MarketScan Databases was performed to generate 3 cohorts: patients without depression, patients with depression who did not receive preoperative psychotherapy, and patients with depression who received psychotherapy before surgery. Outcomes of interest were resource utilization, surgical and medical complications, narcotic requirements, and 1-year and 3-year revision rates.

RESULTS

On multivariate analysis, depressed patients who did not receive psychotherapy were more likely to be discharged to inpatient rehabilitation facility (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.10-1.48, P < .001) and require 2 or more postoperative narcotic prescriptions (OR 1.20, 95% CI 1.06-1.37, P = .004) than depressed patients who received psychotherapy. Patients who did not receive psychotherapy were more likely to have continued narcotic requirements within 1 year after surgery (OR 1.23, 95% CI 1.08-1.39, P < .001) and undergo revision at 1 year (OR 1.74, 95% CI 1.17-2.58, P = .006) and 3 years (OR 1.92, 95% CI 1.10-3.34, P = .021) than depressed patients who received psychotherapy.

CONCLUSION

The negative influence of depression on narcotic requirements, resource utilization, and implant survivorship after THA appears to be modifiable with preoperative psychotherapy.

Collaborative model of care between Orthopaedics and allied healthcare professionals trial (CONNACT) - a feasibility study in patients with knee osteoarthritis using a mixed method approach

Background

Osteoarthritis is a leading cause of global disability resulting in significant morbidity and cost to the healthcare system. Current guidelines recommend lifestyle changes such exercises and weight loss as first line treatment prior to surgical consideration. Our current model of care is inefficient with suboptimal allied health intervention for effective behaviour changes. A 12-week community based, individualized, multidisciplinary new model of care for knee osteoarthritis was developed in light of current deficiencies.

Methods

The primary aim of this study was to determine the feasibility of a full randomized controlled trial evaluating this new model of care using pre-defined progression criteria. The secondary aim was to optimize the intervention and study design through a process evaluation. A pilot exploratory, parallel arm, single blinded randomized trial design using a mixed method approach was utilized. Progression criteria for a full trial including key domains of patient recruitment and retention, outcome measure acceptability and improvement, adverse events were developed. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 12-weeks. Secondary outcomes included quality of life, functional and psychological assessments. Semi-structured interviews were conducted with the patients at 12-weeks.

Results

20 patients (3 males, 17 females) were randomized (10 intervention, 10 control). Intervention arm patients reported better improvements in their knee function, quality of life, psychological outcome, dietary improvement and weight loss compared to the control arm at 12-weeks. Semi-structured interviews revealed several themes pertaining to feasibility and intervention optimization. 5 out of the 6 progression criteria’s domains were met (recruitment criteria not met).

Conclusion

This pilot has demonstrated the feasibility of a full randomized control trial investigating the potential effectiveness of the new proposed model of care for knee osteoarthritis using pre-defined progression criteria and process evaluation. Results from the qualitative study were used to modify and improve the intervention content, delivery model and study design for a large effectiveness-implementation hybrid randomized control trial that is currently underway.

Trial registration

Retrospectively registered on 18 January 2019 at http://clinicaltrial.gov ID: NCT03809975.

An exploration of the experiences of people living with painful ankle osteoarthritis and the non-surgical management of this condition

OBJECTIVES

Osteoarthritis (OA) of the ankle joint is associated with life-long joint pain and disability if not appropriately managed. There is a dearth of research concerning ankle OA and the impact on those living with the condition.

AIM

To explore the experiences of people living with painful OA ankle and their views about the non-surgical management of this condition.

DESIGN

Qualitative design, using semi-structured interviews.

PARTICIPANTS

Nine participants, recruited from an orthopaedic clinic at a UK hospital and the general population. All had a clinical and radiographic diagnosis of OA ankle. Interviews were digitally recorded and transcribed verbatim. Thematic analysis was undertaken to identify emerging themes. Ethical approval was obtained.

RESULTS

Nine semi-structured interviews were undertaken. Eight participants were male, median age=55 years (IQR=42.5-64.5). Mechanism of onset was due to trauma (falls, repeated inversion injuries or road traffic collisions) (n=7), or the effects of haemophilia (n=2). The median duration of symptoms was 2 years (IQR=1.5-10). Data saturation was achieved. Four themes were identified: CONCLUSIONS: This is the first study to explore the experiences of people with symptomatic OA ankle. Our findings suggest that those with OA ankle suffer with severe pain, which has a substantial negative impact on a person's physical and mental wellbeing. The findings of this study may be used to inform future research.

Validity and Reliability of the Fibromyalgia Rapid Screening Tool Among Individuals with Chronic Daily Headache: A Clinic-Based Study

BACKGROUND

Fibromyalgia is a common chronic pain disorder typically associated with headache disorders, particularly chronic daily headache. However, fibromyalgia is typically underdiagnosed and undertreated. The Fibromyalgia Rapid Screening Tool questionnaire is a brief, self-administered questionnaire composed of six "yes/no" questions for detecting fibromyalgia. The Fibromyalgia Rapid Screening Tool questionnaire has demonstrated high sensitivity and specificity among patients with chronic diffuse pain conditions. This study assessed the validity and reliability of the aforementioned questionnaire for detecting fibromyalgia among patients with chronic daily headache.

METHODS

Consecutive first-visit headache patients with primary chronic daily headache (≥15 days/month for three or more months) at the outpatient clinics of four university hospitals were enrolled in this study from April 2015 to October 2015, and the validity and reliability of the Fibromyalgia Rapid Screening Tool questionnaire for determining fibromyalgia were evaluated. Fibromyalgia was diagnosed according to the American College of Rheumatology criteria of 2010.

RESULTS

A total of 171 patients with primary chronic daily headache were recruited, and 100 (58.4%) were determined to have fibromyalgia. Receiver operating characteristic curve analysis revealed that a cutoff score of 5 (corresponding to the number of positive items) provided the highest rate of correct identification of patients (77.2%), with a sensitivity of 70.0% and specificity of 87.3%. The positive and negative predictive values were 88.6% and 67.4%, respectively. The Cronbach's alpha coefficient was 0.684.

CONCLUSIONS

The Fibromyalgia Rapid Screening Tool is a valid and reliable instrument for identifying fibromyalgia among patients with chronic daily headache.

Effect of vitamin D supplementation on pain and physical function in patients with knee osteoarthritis (OA): an OA Trial Bank protocol for a systematic review and individual patient data (IPD) meta-analysis

INTRODUCTION

Observational data suggest that vitamin D deficiency is associated with the onset and progression of knee osteoarthritis (OA). However, randomised controlled trials (RCTs) to date investigating the efficacy of vitamin D supplementation in knee OA have reported conflicting results. Further research is needed to clarify the effects of vitamin D on patient-reported outcomes and determine whether there are patient subgroups who may benefit from the supplementation. The aim of this individual patient data (IPD) meta-analysis is to identify patient-level predictors of treatment response to vitamin D supplementation on pain and physical function.

METHODS AND ANALYSIS

A systematic literature search will be conducted for RCTs of vitamin D supplementation on knee OA. Authors of original RCTs will be contacted to obtain the IPD. The primary outcomes will include long-term (≥12 months) pain and physical function. Secondary outcomes will include medium-term (≥6 months and <12 months) and short-term (<6 months) pain and physical function, as well as patient global assessment, quality of life and adverse events. Potential treatment effect modifiers to be examined in the subgroup analyses include age, gender, body mass index, baseline knee pain severity and physical function, baseline vitamin D level, radiographic stage, presence of bone marrow lesions on MRI, presence of clinical signs of local inflammation and concomitant depressive symptoms. Both one-step and two-step modelling methods will be used to determine the possible modifiable effect of each subgroup of interest.

ETHICS AND DISSEMINATION

Research ethical or governance approval is exempt for this study as no new data are being collected. This study will be the first IPD meta-analysis to clarify the effect of vitamin D supplementation on clinical symptoms in different subgroups of patients with knee OA. The findings will be disseminated through peer-review publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018107740.

The knowledge and self-management educational needs of older adults with knee osteoarthritis: A qualitative study

Knee osteoarthritis (KOA) is closely related with ageing, physical disability and functional dependency. The course of KOA is considered progressive and irreversible. Engagement with self-management may, however, minimize the impact of KOA. To be fully engaged with self-management activities, knowledge about KOA is a prerequisite. There is limited empirical data on older adults’ understanding on KOA and their information needs about KOA. Therefore, the aims of this study were to explore older adults’ knowledge about KOA and their perspectives on the information required to enable self-management. Three focus groups were conducted with 16 older adults with KOA. The sample consisted of three men and thirteen women with the mean age 73.2 years (range from 61 to 89). Thematic content analysis revealed two themes which were understanding about KOA and information needed about KOA. Participants’ knowledge about KOA varied between individuals with many expressing that they needed more information about KOA. A targeted strategy is needed to educate older adults about KOA in order to support and prepare them for self-management.

Disparity of health services in patients with knee osteoarthritis before total knee arthroplasty

Background

Recent evidence describes which interventions are driving insurance payments in the management of osteoarthritis (OA) before total knee arthroplasty (TKA); however, relatively little is known about how these costs are distributed among patients.

Methods

We reviewed the Humana claims database for patients who underwent primary TKA from 2009 to 2016. Insurance payments for treatment, imaging, and evaluation and management were calculated from OA diagnosis to TKA, the distribution of payments was determined, and a high-payment group was identified by determining the point at which patients began to account for a disproportionate percentage of payments. This group of high-payment patients was compared with remaining patients (low-payment patients) based on demographic factors and nonarthroplasty payments and utilization.

Results

The top 30% of patients accounted for more than 70% of nonarthroplasty payments. High-payment patients were more likely to be younger, female, and more comorbid. Median time from diagnosis to TKA for high-payment patients was 3 times longer than that for low-payment patients (654 days [320-1191] vs 204 days [68-582], P < .001), and median payment per patient was more than 5 times higher ($1891 [1405-2782] vs $362 [198-613], P < .001).

Conclusions

Identification of high-payment patients in the management of knee OA may allow for targeted care pathways and cost-reduction strategies in the nonarthroplasty period, although additional studies are necessary to further characterize this population and efficiently recognize appropriate TKA candidates and timing.

Synergistic effects of hip/knee osteoarthritis and comorbidities on mobility and self-care limitations among older adults: Cross-sectional analysis of the Oxford pain, Activity and Lifestyle study

OBJECTIVE

To estimate synergistic effects of hip/knee osteoarthritis (OA) and comorbidities on mobility or self-care limitations among older adults.

METHODS

We used baseline, cross-sectional data from the Oxford Pain, Activity and Lifestyle (OPAL) study. Participants were community-dwelling adults aged 65 years or older who completed a postal questionnaire. Participants reported demographic information, hip/knee OA, comorbidities and mobility and self-care limitations. We used modified Poisson regression models to estimate the independent and combined relative risks (RR) of mobility or self-care limitations, the relative excess risk due to interaction (RERI) between hip/knee OA and comorbidities, attributable proportion of the risk due to the interaction and the ratio of the combined effect and the sum of the individual effects, known as the synergy index.

RESULTS

Of the 4,972 participants included, 1,532 (30.8%) had hip/knee OA, and of them 42.9% reported mobility limitations and 8.4% reported self-care limitations. Synergistic effects impacting self-care limitations were observed between hip/knee OA and anxiety (RR: 3.09, 95% Confidence Interval (CI): 2.00 to 4.78; RERI: 0.93, 95% CI: 0.01 to 1.90), and between hip/knee OA and depressive symptoms (RR: 2.71, 95% CI: 1.75 to 4.20; RERI: 0.58, 95% CI: 0.03 to 1.48). The portion of the total RR attributable to this synergism was 30% and 22% respectively.

CONCLUSIONS

This study demonstrates that synergism between hip/knee OA and anxiety or depressive symptoms contribute to self-care limitations. These findings highlight the importance of assessing and addressing anxiety or depressive symptoms when managing older adults with hip/knee OA to minimize self-care limitations.