Improving Patient Reported Outcomes and Preventing Depression and Anxiety in Older Adults With Knee Osteoarthritis: Results of a Sequenced Multiple Assignment Randomized Trial (SMART) Study

Study protocol of a sequential, multiple assignment, randomised trial using an adaptive intervention to reduce loneliness among Chinese older adults in Hong Kong

BACKGROUND

Loneliness is a prevalent and alarming issue among older adults that requires effective interventions. While randomised controlled trials have been commonly undertaken to explore reduction in loneliness, there is a growing recognition that a comprehensive treatment strategy involving multiple interventions may yield better outcomes. Therefore, this study aims to develop and identify a two-stage adaptive intervention that combines telephone-delivered behavioural activation (Tele-BA) and mindfulness techniques (Tele-MF) to reduce loneliness in older adults in Hong Kong.

METHODS

A Sequential, Multiple Assignment, Randomised Trial (SMART) design will be adopted. 244 lonely older adults will be recruited from the community and randomly assigned to either one of the 4-week two-stage, embedded adaptive interventions involving different sequences and dosages of Tele-BA and Tele-MF (eg, 4 weeks of Tele-BA followed by booster sessions for responders or 4 weeks of Tele-BA followed by 4 weeks of Tele-BA with motivational component or 4 weeks of Tele-MF for non-responders) based on a set of decision rules. The primary outcome will be loneliness measured by the Revised University of California Los Angeles (UCLA) Loneliness Scale. Secondary outcomes, such as De Jong Gierveld Loneliness Scale, perceived stress, sleep quality and depressive and anxiety symptoms, will be assessed. Adhering to the intention-to-treat principles, the data will be analysed using linear mixed models. The findings may have implications for the development of psychosocial adaptive interventions involving BA and MF to reduce loneliness and improve well-being among older adults in Hong Kong using the SMART design.

ETHICS AND DISSEMINATION

Ethical approval was obtained by the Human Research Ethics Committee at The Education University of Hong Kong (reference: 2022-2023-0117). The findings from this study will be presented in academic conferences and submitted for publication.

TRIAL REGISTRATION NUMBER

ChiCTR2300077472.

What improvements do general exercise training and traditional Chinese exercises have on knee osteoarthritis? A narrative review based on biological mechanisms and clinical efficacy

Background

Knee osteoarthritis (KOA) is a disease that significantly affects the quality of life of patients, with a complex pathophysiology that includes degeneration of cartilage and subchondral bone, synovitis, and associations with mechanical load, inflammation, metabolic factors, hormonal changes, and aging.

Objective

This article aims to comprehensively review the biological mechanisms and clinical effects of general exercise training and traditional Chinese exercises (such as Tai Chi and Qigong) on the treatment of KOA, providing references for the development of clinical exercise prescriptions.

Methods

A systematic search of databases including PubMed, Web of Science, Google Scholar, and China National Knowledge Infrastructure (CNKI) was conducted, reviewing studies including randomized controlled trials (RCTs), observational studies, systematic reviews, and meta-analyses. Keywords included "knee osteoarthritis," "exercise therapy," "physical activity," and "traditional Chinese exercise."

Results and conclusion

General exercise training positively affects KOA by mechanisms such as promoting blood circulation, improving the metabolism of inflammatory factors, enhancing the expression of anti-inflammatory cytokines, and reducing cartilage cell aging. Traditional Chinese exercises, like Tai Chi and Qigong, benefit the improvement of KOA symptoms and tissue repair by regulating immune function and alleviating joint inflammation. Clinical studies have shown that both types of exercise can improve physical function, quality of life, and pain relief in patients with KOA. Both general exercise training and traditional Chinese exercises are non-pharmacological treatment options for KOA that can effectively improve patients' physiological function and quality of life. Future research should further explore the long-term effects and biological mechanisms of these exercise interventions and develop personalized exercise programs based on the specific needs of patients.

Osteoporosis, Osteoarthritis, and Subchondral Insufficiency Fracture: Recent Insights

The increased incidence of osteoarthritis (OA), particularly knee and hip OA, and osteoporosis (OP), owing to population aging, have escalated the medical expense burden. Osteoarthritis is more prevalent in older women, and the involvement of subchondral bone fragility spotlights its association with OP. Notably, subchondral insufficiency fracture (SIF) may represent a more pronounced condition of OA pathophysiology. This review summarizes the relationship between OA and OP, incorporating recent insights into SIF. Progressive SIF leads to joint collapse and secondary OA and is associated with OP. Furthermore, the thinning and fragility of subchondral bone in early-stage OA suggest that SIF may be a subtype of OA (osteoporosis-related OA, OPOA) characterized by significant subchondral bone damage. The high bone mineral density observed in OA may be overestimated due to osteophytes and sclerosis and can potentially contribute to OPOA. The incidence of OPOA is expected to increase along with population aging. Therefore, prioritizing OP screening, early interventions for patients with early-stage OA, and fracture prevention measures such as rehabilitation, fracture liaison services, nutritional management, and medication guidance are essential.

Fall experiences from the perspectives of people with osteoarthritis: in their own words

PURPOSE

To explore real-life experiences of people with osteoarthritis (OA) to increase understanding of how they perceive contributing factors to falls, circumstances at time of falls, and consequences of falls.

MATERIALS AND METHODS

Four focus groups of 3-7 people with OA from the Chicago, IL, USA, and neighboring areas were conducted remotely via web-based videoconferencing. Inclusion criteria included history of falls in previous 12 months and hip and/or knee OA. Focus group transcripts were coded and analyzed using a modified grounded theory approach to identify themes.

RESULTS

Focus group participants (n = 17) described experiences associated with fall-related events that resulted in the identification of four themes: (1) perception of falls and fall risks can be influenced by OA symptoms, (2) ability to remember circumstances of falls are influenced by consequences, (3) behaviors and attitudes that address OA symptoms and avoidance of falls are similar and (4) OA symptoms and falls have common psychological impacts on lives.

CONCLUSION

Our study highlights how people with OA define falls, perceive contributing factors to falls, and describe general and OA-related factors that contributed to their fall experiences. The shared experiences contributed to the creation of themes that represented various aspects of the circumstances and impact of falls. Consideration for the identified themes may enhance recording and reporting of falls, contribute to development of improved fall risk assessment tools, and prioritize research into the biopsychosocial effects of falls in people with OA.IMPLICATIONS FOR REHABILITATIONInformation about circumstances of a fall such as location, activity, and symptoms of osteoarthritis may be beneficial in creating tailored fall prevention training and education.Falls are a common problem for people with lower limb osteoarthritis that can lead to negative changes in activity and quality of life.The psychological impact of osteoarthritis symptoms may be contributing to fear of falling and decrease participation in daily activities.Awareness of the perceptions people with osteoarthritis have about their symptoms may provide educational and training opportunities to address the benefits of different therapeutic treatments.Awareness of perceptions people with osteoarthritis have about their risk of falling may provide educational and training opportunities to address the benefits of different therapeutic treatments.

Psychosocial Determinants of Knee Osteoarthritis Progression: Results from the Promoting Independence in Our Seniors with Arthritis Study

BACKGROUND

Knee osteoarthritis (OA) is a common cause of physical disability among older adults. While established risk factors for knee OA include age and increased body weight, few studies have examined psychosocial risk factors or progression of knee OA.

METHODS

The Promoting Independence in our Seniors with Arthritis study recruited participants aged 65 years and over from orthopedic outpatients and community engagement events. Participants were invited to annual visits during which knee OA symptoms were assessed with the Knee Injury and Osteoarthritis Outcome Score (KOOS), social network using the 6-item Lubben Social Network Scale and anxiety and depression using the Hospital Anxiety and Depression scale. Knee OA worsening was defined by a 5% reduction in mean KOOS scores at the last visit compared to the first visit.

RESULTS

Data were available from 148 participants, mean age 66.2±6.5 years and 74.1% female, of whom 28 (18.9%) experienced OA worsening over a median follow-up period of 29 months. Univariate analyses revealed that age, sex, height, grip strength, and social network were associated with OA worsening. Social network remained statistically significantly associated with OA worsening after adjustment for age and sex difference (odds ratio=0.924; 95% confidence interval, 0.857-0.997). The relationship between social network and OA worsening were attenuated by both depression and handgrip strength at baseline.

CONCLUSION

Psychological status and muscle strength may be modifiable risk factors for social network which may in turn prevent knee OA worsening and should be targeted in future intervention studies.

Physical and psychosocial characteristics differ between individuals with knee pain and different knee osteoarthritis diagnostic criteria

PURPOSE

Knee pain and osteoarthritis (OA) are common and often lead to disability among older adults. Existing published evidence, however, utilizes differing criteria to define studies' knee OA populations. We, therefore, aimed to determine whether differences exist in the characteristics of individuals with the presence of knee pain and different diagnostic criteria for knee OA.

METHODS

The Promoting Independence in Seniors with Arthritis (PISA) study is a longitudinal observational study of individuals with and without knee pain and knee OA recruited from the orthopaedics clinic of the Universiti Malaya Medical Centre and the local hospital catchment. Patients were diagnosed with OA based on the American College of Rheumatology (ACR) criteria, the presence of knee pain, and a history of physician-diagnosed knee OA. Psychosocial parameters were measured using validated measures for social participation, independence, and ability to perform activities of daily living, and life satisfaction.

RESULTS

Of the 230 included participants, mean age was 66.9 years (standard deviation: 7.2) and 166 (72.2%) were women. Kappa agreement between ACR criteria and knee pain was 0.525 and for ACR and physician-diagnosed OA it was 0.325. Binomial logistic regression analysis showed that weight, anxiety, and handgrip strength (HGS) were predictive of ACR OA. Knee pain was only predicted by HGS but not weight and anxiety. Physician-diagnosed OA was predicted by weight and HGS but not anxiety. HGS was predictive of ACR OA, knee pain, and physician-diagnosed OA.

CONCLUSION

Our study showed that the characteristics of patients with OA are different, physically and psychosocially, depending on the criteria used. Poor agreement was observed between radiological diagnosis and the other diagnostic criteria. Our findings have important implications for the interpretation and comparison of published studies using different OA criteria.

KEY MESSAGES

Efficient and robust approaches for analysis of sequential multiple assignment randomized trials: Illustration using the ADAPT-R trial

Personalized intervention strategies, in particular those that modify treatment based on a participant's own response, are a core component of precision medicine approaches. Sequential multiple assignment randomized trials (SMARTs) are growing in popularity and are specifically designed to facilitate the evaluation of sequential adaptive strategies, in particular those embedded within the SMART. Advances in efficient estimation approaches that are able to incorporate machine learning while retaining valid inference can allow for more precise estimates of the effectiveness of these embedded regimes. However, to the best of our knowledge, such approaches have not yet been applied as the primary analysis in SMART trials. In this paper, we present a robust and efficient approach using targeted maximum likelihood estimation (TMLE) for estimating and contrasting expected outcomes under the dynamic regimes embedded in a SMART, together with generating simultaneous confidence intervals for the resulting estimates. We contrast this method with two alternatives (G-computation and inverse probability weighting estimators). The precision gains and robust inference achievable through the use of TMLE to evaluate the effects of embedded regimes are illustrated using both outcome-blind simulations and a real-data analysis from the Adaptive Strategies for Preventing and Treating Lapses of Retention in Human Immunodeficiency Virus (HIV) Care (ADAPT-R) trial (NCT02338739), a SMART with a primary aim of identifying strategies to improve retention in HIV care among people living with HIV in sub-Saharan Africa.

Effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

The objective of the study was to evaluate the effectiveness of home-based exercise interventions on pain, physical function and quality of life in individuals with knee osteoarthritis (KOA).

METHODS

Five databases (PubMed, Embase, Cochrane Library, CINAHL, Web of Science Core Collection) were searched for relevant randomized controlled trials (RCTs) published from database inception to 2 August 2022. The Cochrane Collaboration's standards were followed for study selection, eligibility criteria, data extraction and statistics, using the Cochrane Collaboration Risk of Bias Tool and PEDro for quality assessment. A meta-analysis and subgroup analyses, stratified by control condition and intervention duration, were conducted using RevMan 5.4. The study was reported in compliance with the PRISMA statement.

RESULTS

A total of 12 independent RCTs with 1442 participants were included. The meta-analysis showed that the home-based exercise interventions significantly reduced pain in individuals with KOA (SMD =  - 0.32, 95% CI [- 0.41, - 0.22], p < .01) and improved physical function (SMD =  - 0.25, 95% CI [- 0.47, - 0.02], p = .03) and quality of life (SMD = 0.63, 95% CI [0.41, 0.85], p < .001). Subgroup analysis revealed that home-based exercise interventions were superior to health education and no treatment, in terms of pain and physical function, and similar to clinic-based exercise and pharmacologic treatment.

CONCLUSIONS

The effect of home-based exercise intervention is significantly better than health education and no treatment for reducing knee pain and improving physical function, and was able to achieve the effects of clinic-based exercise treatment and pharmacologic treatment. With regard to quality of life, the unsupervised home strength exercise intervention showed a significant effect compared with the health education control and combined with cognitive behavioural therapies may produce better results. Although home-based intervention provides effective treatment options for individuals with clinical treatment limitations, individual disease complications and the dosimetry of exercise need to be considered in practice. Furthermore, growing evidence supports the effectiveness of Tai Chi in the rehabilitation of KOA.

Interim monitoring in sequential multiple assignment randomized trials

A sequential multiple assignment randomized trial (SMART) facilitates the comparison of multiple adaptive treatment strategies (ATSs) simultaneously. Previous studies have established a framework to test the homogeneity of multiple ATSs by a global Wald test through inverse probability weighting. SMARTs are generally lengthier than classical clinical trials due to the sequential nature of treatment randomization in multiple stages. Thus, it would be beneficial to add interim analyses allowing for an early stop if overwhelming efficacy is observed. We introduce group sequential methods to SMARTs to facilitate interim monitoring based on the multivariate chi-square distribution. Simulation studies demonstrate that the proposed interim monitoring in SMART (IM-SMART) maintains the desired type I error and power with reduced expected sample size compared to the classical SMART. Finally, we illustrate our method by reanalyzing a SMART assessing the effects of cognitive behavioral and physical therapies in patients with knee osteoarthritis and comorbid subsyndromal depressive symptoms.

Adjunctive therapies in addition to land-based exercise therapy for osteoarthritis of the hip or knee

BACKGROUND

Land-based exercise therapy is recommended in clinical guidelines for hip or knee osteoarthritis. Adjunctive non-pharmacological therapies are commonly used alongside exercise in hip or knee osteoarthritis management, but cumulative evidence for adjuncts to land-based exercise therapy is lacking.

OBJECTIVES

To evaluate the benefits and harms of adjunctive therapies used in addition to land-based exercise therapy compared with placebo adjunctive therapy added to land-based exercise therapy, or land-based exercise therapy only for people with hip or knee osteoarthritis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, Physiotherapy Evidence Database (PEDro) and clinical trials registries up to 10 June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of people with hip or knee osteoarthritis comparing adjunctive therapies alongside land-based exercise therapy (experimental group) versus placebo adjunctive therapies alongside land-based exercise therapy, or land-based exercise therapy (control groups). Exercise had to be identical in both groups. Major outcomes were pain, physical function, participant-reported global assessment, quality of life (QOL), radiographic joint structural changes, adverse events and withdrawals due to adverse events. We evaluated short-term (6 months), medium-term (6 to 12 months) and long-term (12 months onwards) effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data, and assessed risk of bias and certainty of evidence for major outcomes using GRADE.

MAIN RESULTS

We included 62 trials (60 RCTs and 2 quasi-RCTs) totalling 6508 participants. One trial included people with hip osteoarthritis, one hip or knee osteoarthritis and 59 included people with knee osteoarthritis only. Thirty-six trials evaluated electrophysical agents, seven manual therapies, four acupuncture or dry needling, or taping, three psychological therapies, dietary interventions or whole body vibration, two spa or peloid therapy and one foot insoles. Twenty-one trials included a placebo adjunctive therapy. We presented the effects stratified by different adjunctive therapies along with the overall results. We judged most trials to be at risk of bias, including 55% at risk of selection bias, 74% at risk of performance bias and 79% at risk of detection bias. Adverse events were reported in eight (13%) trials. Comparing adjunctive therapies plus land-based exercise therapy against placebo therapies plus exercise up to six months (short-term), we found low-certainty evidence for reduced pain and function, which did not meet our prespecified threshold for a clinically important difference. Mean pain intensity was 5.4 in the placebo group on a 0 to 10 numerical pain rating scale (NPRS) (lower scores represent less pain), and 0.77 points lower (0.48 points better to 1.16 points better) in the adjunctive therapy and exercise therapy group; relative improvement 10% (6% to 15% better) (22 studies; 1428 participants). Mean physical function on the Western Ontario and McMaster (WOMAC) 0 to 68 physical function (lower scores represent better function) subscale was 32.5 points in the placebo group and reduced by 5.03 points (2.57 points better to 7.61 points better) in the adjunctive therapy and exercise therapy group; relative improvement 12% (6% better to 18% better) (20 studies; 1361 participants). Moderate-certainty evidence indicates that adjunctive therapies did not improve QOL (SF-36 0 to 100 scale, higher scores represent better QOL). Placebo group mean QOL was 81.8 points, and 0.75 points worse (4.80 points worse to 3.39 points better) in the placebo adjunctive therapy group; relative improvement 1% (7% worse to 5% better) (two trials; 82 participants). Low-certainty evidence (two trials; 340 participants) indicates adjunctive therapies plus exercise may not increase adverse events compared to placebo therapies plus exercise (31% versus 13%; risk ratio (RR) 2.41, 95% confidence interval (CI) 0.27 to 21.90). Participant-reported global assessment was not measured in any studies. Compared with land-based exercise therapy, low-certainty evidence indicates that adjunctive electrophysical agents alongside exercise produced short-term (0 to 6 months) pain reduction of 0.41 points (0.17 points better to 0.63 points better); mean pain in the exercise-only group was 3.8 points and 0.41 points better in the adjunctive therapy plus exercise group (0 to 10 NPRS); relative improvement 7% (3% better to 11% better) (45 studies; 3322 participants). Mean physical function (0 to 68 WOMAC subscale) was 18.2 points in the exercise group and 2.83 points better (1.62 points better to 4.04 points better) in the adjunctive therapy plus exercise group; relative improvement 9% (5% better to 13% better) (45 studies; 3323 participants). These results are not clinically important. Mean QOL in the exercise group was 56.1 points and 1.04 points worse in the adjunctive therapies plus exercise therapy group (1.04 points worse to 3.12 points better); relative improvement 2% (2% worse to 5% better) (11 studies; 1483 participants), indicating no benefit (low-certainty evidence). Moderate-certainty evidence indicates that adjunctive therapies plus exercise probably result in a slight increase in participant-reported global assessment (short-term), with success reported by 45% in the exercise therapy group and 17% more individuals receiving adjunctive therapies and exercise (RR 1.37, 95% CI 1.15 to 1.62) (5 studies; 840 participants). One study (156 participants) showed little difference in radiographic joint structural changes (0.25 mm less, 95% CI -0.32 to -0.18 mm); 12% relative improvement (6% better to 18% better). Low-certainty evidence (8 trials; 1542 participants) indicates that adjunctive therapies plus exercise may not increase adverse events compared with exercise only (8.6% versus 6.5%; RR 1.33, 95% CI 0.78 to 2.27).

AUTHORS' CONCLUSIONS

Moderate- to low-certainty evidence showed no difference in pain, physical function or QOL between adjunctive therapies and placebo adjunctive therapies, or in pain, physical function, QOL or joint structural changes, compared to exercise only. Participant-reported global assessment was not reported for placebo comparisons, but there is probably a slight clinical benefit for adjunctive therapies plus exercise compared with exercise, based on a small number of studies. This may be explained by additional constructs captured in global measures compared with specific measures. Although results indicate no increased adverse events for adjunctive therapies used with exercise, these were poorly reported. Most studies evaluated short-term effects, with limited medium- or long-term evaluation. Due to a preponderance of knee osteoarthritis trials, we urge caution in extrapolating the findings to populations with hip osteoarthritis.

Exploring the perspectives of people with stroke, caregivers and healthcare professionals on the design and delivery of a mHealth adaptive physical activity intervention: a qualitative study protocol

Background: Despite recent advances in acute stroke intervention, secondary prevention strategies are lacking. Physical activity (PA) is the second-largest predictor of stroke and a cornerstone of secondary prevention therapies. Interventions to promote PA post-stroke include components aimed at reducing sedentary behaviour and increasing participation in lifestyle PA and structured exercise. Despite guidelines to adapt PA to individuals’ needs, there is no evidence on the empirical development of adaptive PA interventions post-stroke. This study will explore patient, caregiver and multidisciplinary healthcare professional perspectives on the design and delivery of adaptive, personalised PA interventions, delivered using a smartphone application, following mild-to-moderate stroke. Findings will directly inform the protocol of an experimental trial, using a novel adaptive trial design.   Methods: A descriptive qualitative study will be undertaken to inform the design, delivery and subsequent acceptability of a smartphone application to reduce sedentary behaviour and promote PA post-stroke. Data will be collected via one-to-one interviews and focus groups and analysed according to a six-step thematic analysis. Findings will be reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. One-to-one interviews and focus group interviews will be conducted with three stakeholder groups: 1) People post-stroke, who are independently mobile, without communication and cognitive deficits, living in the community, and without other diagnosed neurological conditions. 2) Caregivers (formal and informal) involved in post-stroke care.  3) Healthcare professionals who are members of multidisciplinary stroke teams. Ethics and dissemination: Ethical approval has been granted by the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick [Ref: 2019_10_03_ EHS]. Findings will be shared locally with all stakeholder groups, submitted for publication, and will inform the protocol and conduct for a novel and flexible experimental trial, examining the effectiveness of an adaptive PA intervention post-stroke.

Effects of Non-Face-to-Face and Noncontact Interventions on Knee Pain and Physical Activity in Older Adults With Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Increased physical activity is an effective treatment for knee osteoarthritis that causes knee pain. However, due to the coronavirus disease 2019, noncontact and non-face-to-face interventions have increased, but the quality of evidence supporting their effectiveness remains unclear. The purpose of the study was to assess the quality of evidence of the effects of non-face-to-face and noncontact interventions on knee pain and physical activity in older adults with knee osteoarthritis. A meta-analysis was conducted to determine the effects of different intervention methods (education and exercise). The Cochrane Central Register of Controlled Trials, PubMed, Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database were systematically searched. Four randomized controlled trials were included in the analysis. The meta-analysis demonstrated that the educational intervention group was significantly effective, although supportive evidence was low quality. Educational intervention may be effective, but the effects need to be confirmed by higher quality clinical trials.

Subthreshold depression - concept, operationalisation and epidemiological data. A scoping review

Purpose: In diagnostic systems (e.g., DSM-5, ICD-10), depression is defined categorically. However, the concept of subthreshold depression (SD) has gained increasing interest in recent years. The purpose of the present paper was to review, based on a scoping review, the relevant papers in this field published between October 2011 and September 2020.Materials and methods: Of the 1,160 papers identified, 64 records could be included in further analysis. The scoping review was conducted using both electronic and manual methods.Results: The main result of the analysis is that the operationalisation criteria used are highly heterogeneous, which also leads to very heterogenous epidemiological data.Conclusions: Clear conclusions are not possible scrutinising the reported results. Most definitions seem to be arbitrary, with considerable overlap (e.g., between SD and minor depression). The review also revealed that the impact of SD on quality of life and related parameters appear to be in the range of the respective impact of major depression (MD) and therapeutic approaches might be helpful for SD and also for the prevention of conversion from SD to MD. Keeping the presented difficulties in mind, a proposal for the definition of SD is made in the present paper in order to facilitate the discussion leading to more homogeneous criteria.

Neuroimaging Mechanism of Cognitive Behavioral Therapy in Pain Management

Purpose. To review the recent neuroimaging studies on cognitive-behavioral therapy (CBT) for pain management, with the aim of exploring possible mechanisms of CBT. Recent Findings. Current studies can be divided into four categories, mixed pain, fibromyalgia, migraine, and experimental pain, based on the type of disease included, with the same or different changes of brain regions after CBT intervention. According to structural and functional MRI analyses, changes of brain gray matter volume, activation and deactivation of brain regions, and intrinsic connectivity between brain regions were observed after CBT sessions. The brain regions involved mainly included some areas related to cognitive and emotional regulation. After comparison, the DLPFC, OFC, VLPFC, PCC and amygdala were found to be recurrent in multiple studies and may be key regions for CBT intervention in pain management. In the treatment of mixed chronic pain, CBT may decrease the gray matter volume of DLPFC, reduce ICN connection of OFC within the DAN network, and increase fALFF of the PCC. For FM intervention, CBT may activate the bilateral OFC and VLPFC, while in migraine, only the right OFC, VLPFC, and DLPFC were found to be more activated after CBT. In addition, the differential action of the left and right amygdala has also been shown in the latest study of migraine. In heat-evoked pain, CBT may increase the deactivation of the PCC, the connectivity between the DMN and right VLPFC, while diminishing the deactivation of VLPFC. Summary. After CBT, the brain showed stronger top-down pain control, cognitive reassessment, and altered perception of stimulus signals (chronic pain and repeated acute pain). The DLPFC, OFC, VLPFC, PCC, and amygdala may be the key brain regions in CBT intervention of pain.

Comparison of Health Care Expenditures Among U.S. Older Adults With Pain Who Reported Frequent Exercise Versus Nonfrequent Exercise

This cross-sectional study included a nationally representative sample of U.S. adults aged ≥50 years with self-reported pain in the past 4 weeks from the 2018 Medical Expenditure Panel Survey. Adjusted linear regression analyses accounted for the complex survey design and assessed differences in several types of annual health care expenditures between individuals who reported frequent exercise (≥30 min of moderate-vigorous intensity physical activity ≥5 times per week) and those who did not. Approximately 23,940,144 of 56,979,267 older U.S. adults with pain reported frequent exercise. In adjusted analyses, individuals who reported frequent exercise had 15% lower annual prescription medication expenditures compared with those who did not report frequent exercise (p = .007). There were no statistical differences between frequent exercise status for other health care expenditure types (p > .05). In conclusion, adjusted annual prescription medication expenditures were 15% lower among older U.S. adults with pain who reported frequent exercise versus those who did not.

Sequential multiple assignment randomized trial studies should report all key components: a systematic review

OBJECTIVE

Sequential Multiple Assignment Randomised Trial (SMART) designs allow multiple randomisations of participants; this allows assessment of stage-specific questions (individual randomisations) and adaptive interventions (i.e. treatment strategies). We assessed the quality of reporting of the information required to design SMART studies.

STUDY DESIGN AND SETTING

We systematically searched four databases (PubMed, Ovid, Web of Science and Scopus) for all trial reports, protocols, reviews, and methodological papers which mentioned SMART designs up to June 15, 2020.

RESULTS

Of the 157 selected records, 12 (7.64%) were trial reports, 24 (15.29%) were study protocols, 91 (58%) were methodological papers, and 30 (19.1%) were review papers. All these trials were powered using stage-specific aims. Only four (33.33%) of these trials reported parameters required for sample size calculations. A small number of the trials (16.67 %) were interested in determining the best embedded adaptive interventions. Most of the trials did not report information about multiple testing adjustment. Furthermore, most of records reported designs that were mainly focused on stage-specific aims.

CONCLUSIONS

Some features of SMART designs are seldomly reported and/or used. Furthermore, studies using this design tend to not adequately report information about all the design parameters, limiting their transparency and interpretability.

Correlation between pain severity and levels of anxiety and depression in osteoarthritis patients: a systematic review and meta-analysis

OBJECTIVES

Osteoarthritis (OA) is a chronic degenerative musculoskeletal disease that causes articular damage and chronic pain, with a prevalence of up to 50% in individuals >60 years of age. Patients suffering from chronic painful conditions, including OA, also frequently report anxiety or depression. A systematic review and meta-analysis were performed to assess the correlation between pain severity and depressive and anxious symptomatology in OA patients.

METHODS

A systematic search was conducted using four databases (PubMed, Medline, Scopus, and Web of Science) from inception up to 14th January of 2020. We included original articles evaluating pain severity and anxiety and/or depression severity in OA-diagnosed patients. Detailed data were extracted from each study, including patients' characteristics and pain, anxiety, and depression severity. When available, the Pearson correlation coefficient between pain and depression severity and pain and anxiety severity was collected and a meta-analysis of random effects was applied.

RESULTS

This systematic review included 121 studies, with a total of 38085 participants. The mean age was 64.3 years old and subjects were predominantly female (63%). The most used scale to evaluate pain severity was the Western Ontario and the McMaster Universities Osteoarthritis Index, while for anxiety and depression, the Hospital Anxiety and Depression Scale was the most used. The meta-analysis showed a moderate positive correlation between pain severity and both anxious (r = 0.31, p < 0.001) and depressive symptomatology (r = 0.36, p < 0.001).

CONCLUSIONS

Our results demonstrate a significant correlation between pain and depression/anxiety severity in OA patients, highlighting the need for its routine evaluation by clinicians.

Predictors of Mental Health Status among Older United States Adults with Pain

Poor mental health is common among older adults with pain, resulting in high economic burden and impaired quality of life. This retrospective, cross-sectional database study aimed to identify characteristics associated with good mental health status among United States (US) adults aged ≥50 years with self-reported pain in the last four weeks using a weighted sample of 2017 Medical Expenditure Panel Survey data. Hierarchical multivariable logistic regression models were used to identify statistically significant predictors of good (versus poor) perceived mental health status. From a weighted population of 57,074,842 individuals, 85.5% (95% confidence interval (CI) = 84.4%, 86.7%) had good perceived mental health. Good mental health was associated most strongly with physical health status (adjusted odds ratio (AOR) = 9.216, 95% CI = 7.044, 12.058). Employed individuals were 1.7 times more likely to report good mental health versus unemployed (AOR = 1.715, 95% CI = 1.199, 2.452). Individuals who had completed less than high school education (AOR = 0.750, 95% CI = 0.569, 0.987) or who reported having a limitation (AOR = 0.513, 95% CI = 0.384, 0.684) were less likely to report good mental health. These key characteristics can be utilized to predict mental health status, which may be investigated to better manage concurrent pain and poor mental health.

Subjective Sleep Quality and Trajectories of Interleukin-6 in Older Adults

BACKGROUND

We aimed to identify trajectories of inflammation in older adults at elevated risk for syndromal depression and anxiety and to determine whether baseline physical, cognitive, and psychosocial factors could distinguish 15-month longitudinal trajectories.

METHODS

Older adults (N = 195, mean age (±SD) = 74.4 years (9.0) participating in three depression and anxiety prevention protocols completed a comprehensive battery of psychosocial assessments and provided blood samples for analysis of interleukin-6 (IL-6) every 3 months over a maximum of 15 months. Group-based trajectory modeling identified trajectories. Adjusted logistic regression examined associations between baseline factors and trajectory groups.

RESULTS

Two 15-month trajectories were identified: stable lower IL-6 levels (84%; mean (±SD) = 3.2 (2.1) pg/mL); and consistently higher IL-6 levels (16%; mean = 9.5 (7.4) pg/mL). Poor sleep quality predicted consistently higher levels of IL-6 (OR = 1.9, 95% CI = 1.03-3.55).

CONCLUSION

Poor sleep quality may represent a therapeutic target to reduce inflammation.

The Effects of Gait Speed and Psychomotor Speed on Risk for Depression and Anxiety in Older Adults with Medical Comorbidities

BACKGROUND/OBJECTIVES

Gait speed and psychomotor speed slow with age and may predict neuropsychiatric disease such as depression and anxiety. We explored the relative predictive values of gait speed, psychomotor slowing, and a composite index of these two measures on time to new episode depression or anxiety in older adults at risk for these common psychiatric conditions.

DESIGN

Randomized controlled prevention trial with 15-month follow-up.

SETTING

University-based late-life mental health research clinic.

PARTICIPANTS

Two hundred thirteen individuals, age 60+ years, with subsyndromal symptoms of depression or anxiety and one of the following risk factors for these common conditions: mild cognitive impairment, knee osteoarthritis, or disabilities requiring home-based care.

INTERVENTION

Participants in each of the risk factor groups were randomized to a depression-specific preventive intervention or usual care.

MEASUREMENTS

Gait speed: 4-m walk test from the Short Physical Performance Battery. Psychomotor speed: Coding task of the Repeatable Battery for the Assessment of Neuropsychological Status. We created a composite index of slowing by determining whether participants exceeded established cut-offs for slow performance in both gait speed (≤0.8 m/s) and psychomotor speed (<7 on the coding task). Time to new onset syndromal depression/anxiety was measured using research diagnostic criteria.

RESULTS

Fifty-four participants developed syndromal depression/anxiety (19.5%) over the course of 15 months. Participants with slowing in both areas were over twice as likely to experience new onset depression/anxiety (hazard ratio (HR) = 2.11; 95% confidence interval (CI) = 1.02-4.40, P = .046) compared to participants with no slowing in either area. Slowed gait (HR = 1.88; 95% CI = 0.992-3.55; P = .052) or slowed psychomotor speed (HR = 0.60; 95% CI = 0.14-2.58; P = .488) alone did not increase risk for depression/anxiety.

CONCLUSION

Evaluating both gait and psychomotor speed in older adults with medical comorbidities and sub-syndromal depression may predict incident mental illness and inform prevention planning. Future research is needed to validate our observations and explore shared neurobiological mechanisms that explain this elevated risk.

Effectiveness of Health-Led Cognitive Behavioral-Based Group Therapy on Pain, Functional Disability and Psychological Outcomes among Knee Osteoarthritis Patients in Malaysia

Background: Psychosocial interventions for patients with osteoarthritis (OA) of the knee to reduce pain and improve physical and psychological functioning are still lacking in Malaysia. Methods: A parallel-group unblinded randomized controlled trial involving 300 patients was conducted in two hospital orthopedics clinics in Malaysia. Patients were randomly assigned to receive cognitive behavioral-based group therapy (n = 150) or no further intervention (n = 150). The primary outcome was the change from baseline in knee pain as determined by the Knee injury and Osteoarthritis Outcome Score (KOOS) at 6 months. The data collected were analyzed by covariate-adjusted mixed design repeated measures analysis of variance. All analyses were performed under the terms of intention-to-treat. Results: At 6 months, mean change from baseline in the KOOS knee pain score was 0.6 points (95% CI −1.73 to 2.94) in the control group and 8.9 points (95% CI 6.62 to 11.23) (denoting less knee pain intensity) in the intervention group (significant treatment effect p < 0.0001). Patients treated with such an approach also experienced significant improvement in functional ability when performing activities of daily living and had improved ability to cope with depression, anxiety and pain catastrophizing. Conclusion: The intervention module delivered by healthcare professionals had a sustained effect on knee OA pain and functionality over 6 months, thereby leading to an overall improvement in psychological well-being, thus benefitting most of the Malaysian knee OA patients.

Anxiety and Osteoarthritis Disability: Updated Overview and Commentary

Introduction:

Osteoarthritis, a widespread highly painful often incapacitating joint disease continues to impose immense personal and societal challenges among adults of all ages, especially among older adults. In the absence of any effective cure or treatment, it has become essential to explore all correlates of this chronic disabling disease, especially those that might be preventable or modifiable. Anxiety, a potentially remediable state of mental distress - found linked to chronically disabling forms of arthritis, in various imperceptible ways, and which may have an immense bearing on the outcomes of osteoarthritis, has not received as much attention in the related literature as other topics, such as surgery.

Objective:

In line with previous promising work, this narrative review elected to explore the extent to which current researchers in the field are pursuing this topic, and if so, the degree to which prevailing peer-reviewed data sources support an important role for continued research in this realm, and in what regard.

Methods:

Primarily explored were the key databases housing relevant publications that emerged over Aug 1, 2018-Feb 26, 2020 using the keywords Osteoarthritis and Anxiety. Using a descriptive approach, the relative progress made over the past five previous years in this regard was assessed, in addition to what joints have been studied and with what frequency, and how the degree of interest compares to other currently researched osteoarthritis themes. The potential for intervening in the osteoarthritis pain cycle by addressing anxiety was also examined.

Results:

Findings show a high level of current interest in this topic, and that despite the paucity of prospective studies, studies on joints other than the knee and hip joints, some equivocal conclusions, small numbers of anxiety-related studies compared to other topics, and substantive design limitations, it appears that future research in this realm is strongly indicated.

Conclusion:

This topic if examined further is likely to produce highly advantageous results at all stages of the osteoarthritic disease process and in the context of primary, secondary, as well as tertiary measures to ameliorate osteoarthritis pain and disability.