Population-Based Study of Changes in Arthritis Prevalence and Arthritis Risk Factors Over Time: Generational Differences and the Role of Obesity

Estimating the prevalence and predictors of musculoskeletal disorders in Tanzania: a cross-sectional pilot study

Introduction

musculoskeletal (MSK) disorders account for approximately 20% of all years lived with disability worldwide however studies of MSK disorders in Africa are scarce. This pilot study aimed to estimate the community-based prevalence of MSK disorders, identify predictors, and assess the associated disability in a Tanzanian population.

Methods

a cross-sectional study was conducted in one village in the Kilimanjaro region from March to June 2019. The Gait, Arms, Legs, Spine (GALS) or paediatric GALS (pGALS) examinations were used during household and school visits. Individuals positive in GALS/pGALS screening were assessed by the regional examination of the musculoskeletal system (REMS) and Modified Health Assessment Questionnaire (MHAQ).

Results

among the 1,172 individuals enrolled in households, 95 (8.1%, 95% CI: 6.6 - 9.8) showed signs of MSK disorders using the GALS/pGALS examination and 37 (3.2%, 95% CI: 2.2 - 4.3) using the REMS. Among 682 schools enrolled children, seven showed signs of MSK disorders using the GALS/pGALS examination (1.0%, 95% CI: 0.4 - 2.1) and three using the REMS (0.4%, 95% CI: 0.0 - 1.3). In the household-enrolled adult population, female gender and increasing age were associated with GALS and REMS-positive findings. Among GALS-positive adults, increasing age was associated with REMS-positive status and increasing MHAQ score.

Conclusion

this Tanzanian study demonstrates a prevalence of MSK disorders and identifies predictors of MSK disorders comparable to those seen globally. These findings can inform the development of rheumatology services and interventions in Tanzania and the design of future investigations of the determinants of MSK disorders, and their impacts on health, livelihoods, and well-being.

I don’t know what type of arthritis I have: A population-based comparison of people with arthritis who knew their specific type and those who didn’t

Objective

To understand differences between people with arthritis who do not know their type (DK) compared to those reporting osteoarthritis (OA) or inflammatory and autoimmune types of arthritis (IAA), including the receipt of appropriate health care, information, and services.

Methods

Analysis of the Survey on Living with Chronic Disease in Canada–Arthritis Component. Respondents aged ≥20 years with health professional-diagnosed arthritis (n = 4,385) were characterized as reporting DK, OA or IAA. Variables: arthritis characteristics (duration, number and site of joints affected), arthritis impact (current pain and fatigue, difficulty in sleeping and daily activities, impact on life), health (self-rated general and mental health, life stress), arthritis management strategies (seeing health professionals, medication use, assistive devices, receipt of arthritis information, self-management activities). Multinomial logistic and log-Poisson regressions were used, as appropriate, to compare the DK to the OA and IAA groups.

Results

In this arthritis sample, 44.2% were in the DK group, 38.3% reported OA and 17.5% reported IAA. Those in the DK group were more likely to be younger, have low income, low education, and be of non-white cultural background compared to those with OA. There were no significant differences in arthritis impact, but the DK group was less likely to have received information on, or have used, arthritis management strategies.

Conclusions

The sociodemographic characteristics of the DK group suggest they likely have lower health literacy. They were less likely to have accessed health care and other support services, indicating this is an important group for health education, both for individuals with arthritis and health care providers.

Body mass index and treatment survival in patients with RA starting treatment with TNFα-inhibitors: long-term follow-up in the real-life METEOR registry

Objectives

To study whether there is an association between body mass index (BMI) category and survival of various tumour necrosis factor inhibitors (TNFi) in rheumatoid arthritis (RA) patients in a real-life longitudinal international registry.

Methods

Data from 5230 patients with RA starting treatment with any TNFi were selected from the METEOR registry. Patients were divided into six BMI categories: 3.7% underweight, BMI<18.5 kg/m²; 46% normal weight, BMI 18.5–25 kg/m²; 32% pre-obesity, BMI 25–30 kg/m²; 13% obesity class I, BMI 30–35 kg/m²; 3.4% obesity class II, BMI 35–40 kg/m²; and 1.6% obesity class III, BMI >40 kg/m². Time on treatment in the different BMI categories was compared for all TNFi combined and for the infliximab, adalimumab and etanercept separately, using Kaplan–Meier curves and Cox regression analyses. Cox regression analyses were adjusted for potential confounders, with follow-up censored at 5000 days.

Results

Patients in obesity class II (HR 1.28, 95% CI 1.06 to 1.54) and III (HR 1.67, 95% CI 1.29 to 2.18) and underweight patients (HR 1.30, 95% CI 1.07 to 1.58) showed statistically significantly shorter TNFi survival than normal weight patients. The effect in underweight patients was strongest for infliximab (HR 1.82, 95% CI 1.20 to 2.76), the effect in overweight patients was strongest for infliximab (category II (HR 1.49, 95% CI 0.98 to 2.26); category III (HR 1.46, 95% CI 0.79 to 2.71)) and etanercept (category II (HR 1.27 95% CI 0.98 to 1.65); category III (HR 1.79, 95% CI 1.25 to 2.55)). No significant effect modification from reported pain was found.

Conclusion

Both underweight and overweight patients discontinued TNFi treatment earlier than normal weight patients, without evidence of reported pain as the main determinant. It remains uncertain what determines TNFi survival in individual patients.

Association between childhood conditions and arthritis among middle-aged and older adults in China: the China Health and Retirement Longitudinal Study

This study examined the association between childhood conditions and arthritis among middle-aged and older adults in China. The data were derived from the 2015 wave and the life-history module of the China Health and Retirement Longitudinal Study. Face-to-face interviews were conducted with respondents age 45 and over across China. Multiple imputation was used to handle the missing data, generating a final analytic sample of 19,800. Doctor-diagnosed arthritis was the main outcome variable. Random-effects logistic regression models were used to test the proposed models. Approximately 8 per cent of the respondents had better family financial status in childhood than their neighbours. Close to 8 per cent had been hospitalised or encountered similar conditions (e.g. confined to bed or home) for at least one month in childhood. Around one-third reported better subjective health in childhood than their peers. The majority of the respondents (80%) reported that they had stable health resources, and that their mothers were illiterate during their childhood. Childhood family financial status, subjective health, mother's education, access to health care and medical catastrophic events were found to be significant factors associated with arthritis in later life, after controlling for adulthood and older-age conditions (family financial status: odds ratio (OR) = 0.885, 95 per cent confidence interval (95% CI) = 0.848–0.924; subjective health: OR = 0.924, 95% CI = 0.889–0.960; mother's education: OR = 0.863, 95% CI = 0.750–0.992; access to health care: OR = 0.729, 95% CI = 0.552–0.964; medical catastrophic events: OR = 1.266, 95% CI = 1.108–1.446). The study results highlight an important role that childhood conditions play in affecting the onset of arthritis in late life in China. Health-care providers may consider childhood conditions as a valuable screening criterion to identify risk populations, which could be used to guide health promotion and prevention programmes, and promote healthy ageing.

Patterns of opioid use (codeine, morphine or meperidine) in the Canadian population over time: analysis of the Longitudinal National Population Health Survey 1994-2011

OBJECTIVE

This study aimed to investigate cohort effects in selected opioids use and determine whether cohort differences were associated with changes in risk factors for use over time.

DESIGN

This study presents secondary analyses of a longitudinal survey panel of the general population that collected data biannually.

SETTING

Data from the Canadian Longitudinal National Population Health Survey 1994-2011.

POPULATION

This study included 12 542 participants from the following birth cohorts: post-World War I (born 1915-1924), pre-World War II (born 1925-1934), World War II (born 1935-1944), Older Baby Boom (born 1945-1954), Younger Baby Boom (born 1955-1964), Older Generation X (born 1965-1974) and Younger Generation X (born 1975-1984).

MAIN OUTCOME

Responses to a single question asking about the use of codeine, morphine or meperidine in the past month (yes/no) were examined.

RESULTS

Over and above age and period effects, there were significant cohort differences in selected opioids use: each succeeding recent cohort had greater use than their predecessors (eg, Gen Xers had greater use than younger baby boomers). Selected opioids use increased significantly from 1994 to 2002, plateauing between 2002 and 2006 and then declining until 2011. After accounting for cohort and period effects, there was a decline in use of these opioids with increasing age. Although pain was significantly associated with greater selected opioids use (OR=3.63, 95% CI 3.39 to 3.94), pain did not explain cohort differences. Cohort and period effects were no longer significant after adjusting for the number of chronic conditions. Cohort differences in selected opioids use mirrored cohort differences in multimorbidity. Use of these opioids was significantly associated with taking antidepressants or tranquillisers (OR=2.52, 95% CI 2.27 to 2.81 and OR=1.60, 95% CI 1.46 to 1.75, respectively).

CONCLUSIONS

The findings underscore the need to consider multimorbidity including possible psychological disorders and associated medications when prescribing opioids (codeine, morphine, meperidine), particularly for recent birth cohorts. Continued efforts to monitor prescription patterns and develop specific opioid use guidelines for multimorbidity appear warranted.

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

Background

High-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.

Methods

Sub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.

Results

After excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P <  0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P <  0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].

Conclusions

Facility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2570-8) contains supplementary material, which is available to authorized users.

Gait retraining using real-time feedback in patients with medial knee osteoarthritis: Feasibility and effects of a six-week gait training program

BACKGROUND

The knee adduction moment (KAM) is often elevated in medial knee osteoarthritis (KOA). The aim of this study was to evaluate effects on KAM and patient-reported outcomes of a six-week gait training program.

METHODS

Twenty-one patients (61 ± 6 years) with KOA participated in a six-week biofeedback training program to encourage increased toe-in (all patients) and increased step-width (five patients). Patients received real-time visual feedback while walking on an instrumented treadmill. We analysed the effect of the gait modification(s) on peak KAM in week six and three and six months post-training. We also evaluated the effect on pain and functional ability.

RESULTS

Of 21 patients starting the program, 16 completed it with high attendance (15 and 16 respectively) at the three and six month follow-ups. First peak KAM was significantly reduced by up to 14.0% in week six with non-significant reductions of 8.2% and 5.5% at the follow-ups. Functional ability (assessed using the WOMAC questionnaire) improved significantly after the training (eight point reduction, p = 0.04 in week six and nine point reduction, p = 0.04 at six-month follow-up). There was also a trend towards reduction in WOMAC pain (p = 0.06) at follow-up.

CONCLUSIONS

Biofeedback training to encourage gait modifications is feasible and leads to short-term benefits. However, at follow-up, reductions in KAM were less pronounced in some participants suggesting that to influence progression of KOA in the longer term, a permanent regime to reinforce the effects of the training program is needed. Trial number: ISRCTN14687588.

Brief communication: use of the minimal important difference for a meta-analysis on exercise and anxiety in adults with arthritis

A recent meta-analysis reported statistically significant improvements in anxiety as a result of exercise in adults with arthritis and other rheumatic diseases (AORD) using the traditional standardized mean difference (SMD) effect size (ES). The objective of this study was to use the more recently developed and clinically relevant minimal important difference (MID) approach to examine this association. Data from a previous meta-analysis of 14 randomized controlled trials representing 926 initially enrolled adults ≥ 18 years of age (539 exercise, 387 control) was used to calculate the ES using the MID approach. Minimal important difference data were derived from previously reported anchor-based values that represented the different instruments used to assess anxiety. Effect sizes were pooled using the inverse heterogeneity (IVhet) model. Overall, exercise resulted in a mean ES reduction in anxiety of - 0.80 (95% CI, - 1.60 to 0.001, p = 0.05; Q = 92.1, p < 0.001, I ²  = 83.7%, 95% CI, 74.9%, 89.5%), suggesting that overall, exercise may benefit an appreciable number of patients. Nonetheless, this effect spanned the range from many patients gaining important benefits to no patients improving. The clinically relevant effects of exercise on anxiety in adults with AORD are varied. However, these results should be interpreted with caution given the absence of anchor-based MID data specific to the instruments and questions used to assess anxiety in adults with AORD. A need exists for future research to establish instrument-specific, anchor-based MID values for questions assessing anxiety in adults with AORD.

Updated Estimates Suggest a Much Higher Prevalence of Arthritis in United States Adults Than Previous Ones

OBJECTIVE

National estimates of arthritis prevalence rely on a single survey question about doctor-diagnosed arthritis without using survey information on joint symptoms, even though some subjects with only the latter have been shown to have arthritis. The sensitivity of the current surveillance definition is only 53% and 69% in subjects ages 45-64 years and ages ≥65 years, respectively, resulting in misclassification of nearly one-half and one-third of subjects in those age groups. This study was undertaken to estimate arthritis prevalence based on an expansive surveillance definition that is adjusted for the measurement errors in the current definition.

METHODS

Using the 2015 National Health Interview Survey, we developed a Bayesian multinomial latent class model for arthritis surveillance based on doctor-diagnosed arthritis, joint symptoms, and whether symptom duration exceeded 3 months.

RESULTS

Of 33,672 participants, 19.3% of men and 16.7% of women ages 18-64 years and 15.7% of men and 13.5% of women ages ≥65 years affirmed joint symptoms without doctor-diagnosed arthritis. The measurement error-adjusted prevalence of arthritis was 29.9% (95% Bayesian probability interval [95% PI] 23.4-42.3) in men ages 18-64 years, 31.2% (95% PI 25.8-44.1) in women ages 18-64 years, 55.8% (95% PI 49.9-70.4) in men ages ≥65 years, and 68.7% (95% PI 62.1-79.9) in women ages ≥65 years. Arthritis affected 91.2 million adults (of 247.7 million; 36.8%) in the US in 2015, which included 61.1 million persons between 18 and 64 years of age (of 199.9 million; 30.6%). Our arthritis prevalence estimate was 68% higher than the previously reported national estimate.

CONCLUSION

Arthritis prevalence in the US population has been substantially underestimated, especially among adults younger than 65 years of age.