Correlates and predictors of pain intensity and physical function among individuals with chronic knee osteoarthritis in Nigeria

Exploring the role of the built environment and psychosocial mediators on knee function in knee osteoarthritis patients in Singapore: a cross-sectional study

OBJECTIVES

(1) To examine if a more accessible built environment (BE) is significantly associated with better knee function outcomes in knee osteoarthritis (OA) patients. (2) To assess if the relationship between BE and knee function is mediated by fear of movement and self-efficacy.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in Singapore.

PARTICIPANTS

212 knee OA patients (mean: 63.81±8.27 years old), majority female (69.8%).

INCLUSION CRITERIA

(i) meets National Institute for Health and Care Excellence criteria for knee OA, (ii) independent community ambulant.

EXCLUSION CRITERIA

(i) alternative diagnosis to knee OA, (ii) secondary osteoarthritis, (iii) severe medical and/or cognitive comorbidity impairing activities of daily living, (iv) previous knee arthroplasty, (v) wheelchair bound, or (vi) pregnant. PRIMARY AND SECONDARY OUTCOME MEASURES; STATISTICS: How self-efficacy (Arthritis Self-Efficacy Scale-8 (ASES-8)) and fear of movement (Brief Fear of Movement (BFOM)) mediates impact of overall BE (IPAQ-Environment module: Access to Destinations) and five item-specific domains of BE accessibility on knee function (Knee Injury and Osteoarthritis Outcome Score-12 (KOOS-12)). For variables significantly correlated with BE and KOOS-12 in bivariate Pearson correlation tests, mediation analysis was performed with confounders adjusted.

RESULTS

Total BE (r=0.142, p=0.038) and accessibility to transit station (r=0.161, p=0.019) were positively correlated with KOOS-12. Structural barriers (r=-0.138, p=0.045) were negatively correlated with KOOS-12. ASES-8 was a significant mediator in the relationship between accessibility to transit station and KOOS-12 (coeff=0.87, 95% CI=(0.24, 1.69), p=0.005) and between total BE and KOOS-12 (coeff=0.25, 95% CI=(0.10, 0.45), p=0.004). BFOM was a marginally significant mediator between structural barriers and KOOS-12 (coeff=-0.36, 95% CI=(-0.86, -0.02); p=0.054).

CONCLUSION

More accessible BE and lesser structural barriers in the BE are associated with better knee function. Self-efficacy mediates the relationship between overall BE accessibility and knee function. Fear of movement mediates the negative association between barriers in the BE and knee function.Applications include assessing BE barriers and psychosocial mediators in clinician consultations, developing multidisciplinary integrated care models and urban designers planning mobility friendly BEs.

TRIAL REGISTRATION NUMBER

The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

Association of kinesiophobia with pain, disability and functional limitation in adults with knee osteoarthritis: A systematic review and meta-analysis

Knee osteoarthritis (KOA) is a prevalent degenerative joint disease associated with pain, disability, and functional limitations. Kinesiophobia, the fear of movement, has been linked to disability and pain in KOA patients. This study aimed to analyze the relationship between kinesiophobia and symptoms of KOA. A comprehensive literature search was conducted in four electronic databases (PubMed/Medline, Web of Science, Scopus and Science Direct) with the following inclusion criteria: 1) recruited participants with diagnostic of knee osteoarthritis; 2) measures of pain, disability and/or functional limitation through questionnaires or physical tests; 3) articles exploring the correlation between kinesiophobia, and pain, disability, and/or functional limitation as principal or secondary outcome; 4) primary data studies (observational and experimental). A total of 17 studies involving 1,574 participants (mean age 61.04 ± 5.79 years) were included in the corresponding meta-analyses. Results showed a moderate correlation between kinesiophobia and disability (r = 0.519; p-value=0.004), and fair correlations of kinesiophobia with pain (r = 0.362; p-value<0.001), and functional limitation (r = 0.270; p-value<0.001). Despite high heterogeneity (I2: 89.4% for pain, 94.6% for disability, and 90.4% for functional limitation), 52% of studies displayed low risk of bias. In conclusion, kinesiophobia positively correlates with pain, disability, and functional limitation in KOA patients.

Correlates of musculoskeletal pain and kinesiophobia in older adults with heart failure: A structural equation model

The study aimed to study the influence of musculoskeletal pain on kinesiophobia in patients with heart failure. This cross-sectional study recruited 107 heart failure patients aged 73.18±12.68 years (57% men) from an outpatient setting. Participants self-reported pain using the Musculoskeletal System Assessment Inventory and the Cornell Musculoskeletal Discomfort Questionnaire. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia-11. About 62% reported musculoskeletal pain, with knees (16.8%) and lower back (12.%) being the most painful locations. About 31% reported moderate levels and 24% indicated high levels of kinesiophobia. There were positive and significant associations between the indicators of pain and kinesiophobia. Results showed an adequate structural equation model fit to the data with musculoskeletal pain factors explaining 22.09% of the variance in kinesiophobia. Assessment of kinesiophobia in patients with heart failure with musculoskeletal pain is essential to improve self-care and overall quality of life.

Is it Possible to Reduce Pain-Related Fear in Individuals with Knee Osteoarthritis? a Systematic Review of Randomised Clinical Trials

OBJECTIVE

To evaluate the effectiveness of different interventions in reducing pain-related fear outcomes in people with knee osteoarthritis who have or have not had previous knee surgery, and to analyze whether included trials reported their interventions in full detail.

METHODS

Systematic searches were carried out in the Cochrane CENTRAL, CINAHL, EMBASE, PEDro, PsycINFO, PubMed, and SPORTDiscus from the inception of the database up to November 2019. Searches were manually updated to July 2021. We included randomized clinical trials that evaluated pain-related fear outcomes as a primary or secondary outcome in adults with knee osteoarthritis. The Cochrane Risk of Bias Tool 2 and the GRADE approach evaluated the risk of bias and the certainty of the evidence, respectively.

RESULTS

Eighteen trials were included. Four trials evaluated pain-related fear as a primary outcome and all evaluated kinesiophobia in samples that had previously undergone a knee surgical procedure. These trials found that interventions based primarily on cognitive aspects (e.g. cognitive-behavioral principles) can be effective in reducing kinesiophobia. Trials evaluating pain-related fear as the secondary outcome also found that interventions that included cognitive aspects (e.g. pain neuroscience education) decreased the levels of pain-related fear (e.g. fear of falling or kinesiophobia) in patients with or without a previous knee surgery. However, serious to very serious risk of bias and imprecisions were found in included trials. Thus, the certainty of the evidence was judged as low and very low using the GRADE approach. All trials reported insufficient details to allow a complete replication of their interventions.

CONCLUSIONS

Interventions that include cognitive aspects may be the best option to reduce pain-related fear in people with knee osteoarthritis. However, we found a general low and very low certainty of the evidence and the findings should be considered with caution.

Psychological factors associated with instrumental activities of daily living disability in older adults with moderate to severe knee osteoarthritis

BACKGROUND

The population of older adults with knee osteoarthritis (OA)-related disabilities is increasing globally. However, studies regarding instrumental activities of daily living (IADL) in older adults with knee OA are limited.

OBJECTIVE

This study investigated the psychological factors associated with IADL disability in older adults with moderate to severe knee OA.

METHODS

A cross-sectional study was conducted on 179 patients with knee OA aged ⩾ 65 years. The six-item short form of the Pain Catastrophizing Scale (PCS-6), the four-item short form of the Pain Self-Efficacy Questionnaire (PSEQ-4), and the fifteen-item Geriatric Depression Scale (GDS-15) were used to assess psychological factors. The participants were divided into IADL disabled and non-disabled groups. Binary logistic regression analyses were performed with the IADL disability status as the dependent variable. The PCS-6, PSEQ-4, and GDS-15 tools were included as independent variables in the logistic regression model.

RESULTS

Of the 179 participants, 88 (49.1%) showed disability in conducting IADL. PSEQ-4 (odds ratio = 0.90, 95%; confidence interval = 0.82-0.99, p= 0.02) was a significant independent variable among all psychological factors.

CONCLUSION

Even after controlling for cofounders, our study found that self-efficacy, assessed using the PSEQ-4, was related to IADL disability in older adults with moderate to severe knee OA.

Demographic and disease characteristics associated with pain intensity, kinesiophobia, balance, and fall self-efficacy among people with osteoarthritis: a cross-sectional study

BACKGROUND

Osteoarthritis (OA) is a common degenerative joint disease leading to significant pain, mobility limitation, economic burden, reduced quality of life, and disability among adults globally. Psychological factors related to pain intensity (PI), kinesiophobia, fall self-efficacy (FSE), and balance may lead to a poor OA prognosis. This study was designed to explore the association between PI, kinesiophobia, FSE, balance, and age, gender, marital status, site of OA, duration, symmetry, comorbidity, and adaptive behaviours among patients with knee or hip OA.

METHODS

This cross-sectional study involved 70 purposively selected participants aged 59.91 ± 11.12 years. Numeric pain rating scale, Tampa scale for kinesiophobia, fall-efficacy scale, and timed up and go test were used to measure PI, kinesiophobia, FSE, and balance, respectively. Statistical analyses were completed with the Pearson correlation test, independent samples t-test, and multiple linear regression.

RESULTS

The participants were mainly women (n = 59, 84.3%). However, there was no gender difference in the reported PI, kinesiophobia, FSE, and balance. There was a significant correlation between FSE and balance (r = 0.422, p<0.001). Kinesiophobia was significantly associated with the presence of comorbidity (β = 0.240, p = 0.001) and knee OA (β = 0.208, p<0.042). There was an association between FSE and the use of a walking aid (β = -0.442, p<0.042), stop-for-rest during walking (β = -0.292, p = 0.002), presence of comorbidity (β = 0.209, p = 0.014), and bilateral lower limb OA (β = 0.167, p = 0.057). Balance was associated with the use of a walking aid (β = -0.421, p<0.001) and stop-for-rest during walking (β = - 0.294, p = 0.006).

CONCLUSION

Osteoarthritis-related psychological distress affects both men and women. This study support integration of psychological outcomes in the assessment, management, and follow-up of people with lower limb osteoarthritis. Moreover, comorbidity worsened psychological distress among people with osteoarthritis. Therefore, the traditional biomedical management of osteoarthritis can be optimised by timely diagnosis and treatment of comorbidities, and the inclusion of psychotherapy.

Construct validity and reliability of the 2-minute step test in patients with knee osteoarthritis

Objective

To validate and evaluate the intra- and inter-rater reliability of the 2-min step test (2MST) in measuring the functional performance of patients with knee pain associated with osteoarthritis (OA).

Methods

Forty-one patients with knee OA was included. Two examiners assessed the patients at two times with interval between the test and retest from 7 to 14 days. All executions of 2MST were recorded in real time by the examiners and were also recorded by video. The intraclass correlation coefficient (ICC) and 95% confidence interval (CI), standard error of measurement (SEM) and minimum detectable difference (MDD) were used to determine reliability. In the construct validity, we correlate the score of the 2MST with the other instruments used in the study: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Numerical Pain Scale (NPS), Pain-Related Catastrophizing Thoughts Scale (PCTS) and Chronic Pain Self-Efficacy Scale (PSEQ). The agreement between the face-to-face assessment and the evaluation based on the video record was assessed using the Bland-Altman methodology in the 4 moments of the 2MST.

Results

2MST presented excellent intra- (ICC = 0.94, SEM = 4.47, MDD = 12.40) and inter-rater reliability (ICC = 0.97, SEM = 3.07, MDD = 8.52). The agreement was acceptable between face-to-face assessments and the analyzes performed on video. All instruments showed a statistically significant correlation with 2MST, except the PCTS. A correlation magnitude above 0.50 was found between the 2MST and pain and function domains of the WOMAC, and a correlation magnitude between 0.30 and 0.50 with the joint stiffness domain of the WOMAC, NRPS and PSEQ.

Conclusion

2MST proved to be valid for assessing functional capacity in patients with knee OA, with excellent reliability.

Ergonomic assessment of work-related musculoskeletal disorder and its determinants among commercial mini bus drivers and driver assistants (mini bus conductors) in Nigeria

Introduction

Work-related musculoskeletal disorder (WMSD) is a leading causes of occupational injury and disability among drivers and workers in the transport industry. This study evaluated the ergonomically assessed WMSD and its determinants among Nigerian commercial mini bus drivers (BD) and mini bus conductors (BC)

Method

A total of 379 participants (BD = 200, BC = 179) were purposively sampled for this exploratory cross-sectional study. Participants’ WMSD and work related variables were respectively assessed using the standardized Nordic questionnaire and a content-validated, Driving Work Station Assessment (DWSA) form. Data were analyzed descriptively and inferentially using chi-square and logistic regression. The level of significance was set at α = 0.05.

Results

The participants were aged between 20 and 66 years, with a mean age of 33.26±10.76years (BD = 38.42±10.22years, BC = 27.50±8.13years); most of whom consumed alcohol (84.4%) and experienced severe job stress (73.4%). There was a high prevalence (95.8%; BD = 94.5%, BC = 97.8%) of WMSDs, the lower back (66.8%) and upper back (54.1%) had the highest regional prevalence of WMSD. The BC (BC vs BD) had significantly (p<0.05) higher prevalence of Neck (47.7% vs 21.5%) and upper back (80.4% vs 30.5%) WMSDs. Conversely, the BD (BD vs BC) had significantly (p<0.05) higher prevalence of low-back (85.0% vs 46.4%), knee (25.0% vs 9.5%), elbow (11.5% vs 3.9%), and wrist (10.5% vs 3.4%) WMSD. There was a significant association between WMSD and each of work duration (X² = 11.634, p = 0.009), work frequency (X² = 8.394, p = 0.039), job dissatisfaction (X2 = 10.620, p = 0.001) and job stress (X² = 16.879, p = 0.001). Working beyond 4days/week (OR = 10.019, p = 0.001), job dissatisfaction (OR = 1.990, p = 0.031), constrained working postures (OR = 5.324, p = 0.003) and fatigue (OR = 4.719, p = 0.002) were the predictors of WMSD.

Conclusion

Job stress, work duration and work frequency, posture and fatigue are important determinants of WMSDs among mini bus drivers and their assistants in Nigeria. Ergonomics training intervention for this population is recommended.

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.

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.

Mind-Body Activity Program for Chronic Pain: Exploring Mechanisms of Improvement in Patient-Reported, Performance-Based and Ambulatory Physical Function

BACKGROUND

Improving physical function among patients with chronic pain is critical for reducing disability and healthcare costs. However, mechanisms underlying improvement in patient-reported, performance-based, and ambulatory physical function in chronic pain remain poorly understood.

PURPOSE

To explore psychosocial mediators of improvement in patient-reported, performance-based, and objective/accelerometer-measured physical function among participants in a mind-body activity program.

METHODS

Individuals with chronic pain were randomized to one of two identical 10-week mind-body activity interventions aimed at improving physical function with (GetActive-Fitbit; N=41) or without (GetActive; N=41) a Fitbit device. They completed self-reported (WHODAS 2.0), performance-based (6-minute walk test), and objective (accelerometer-measured step-count) measures of physical function, as well as measures of kinesiophobia (Tampa Kinesiophobia Scale), mindfulness (CAMS-R), and pain resilience (Pain Resilience Scale) before and after the intervention. We conducted secondary data analyses to test mediation via mixed-effects modeline.

RESULTS

Improvements in patient-reported physical function were fully and uniquely mediated by kinesiophobia (Completely Standardized Indirect Effect (CSIE)=.18; CI=0.08, 0.30; medium-large effect size), mindfulness (CSIE=-.14; CI=-25, -.05; medium effect size) and pain resilience (CSIE=-.07; CI=-.16, -.005; small-medium effect size). Improvements in performance-based physical function were mediated only by kinesiophobia (CSIE=-.11; CI=-23, -.008; medium effect size). No measures mediated improvements in objective (accelerometer measured) physical function.

CONCLUSION

Interventions aiming to improve patient-reported physical function in patients with chronic pain may benefit from skills that target kinesiophobia, mindfulness, and pain resilience, while those focused on improving performance-based physical function should target primarily kinesiophobia. More research is needed to understand mechanisms of improvement in objective, accelerometer-measured physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03412916.

Is There a Relationship Between Kinesiophobia and Physical Activity Level in Patients with Knee Osteoarthritis?

OBJECTIVE

To investigate the levels of kinesiophobia, physical activity, depression, disability, and quality of life in patients with knee osteoarthritis.

DESIGN

A cross-sectional study.

SETTING

A tertiary health care center.

SUBJECTS

Ninety-six patients with knee osteoarthritis.

METHODS

Pain intensity was evaluated by the Visual Analog Scale, kinesiophobia by the Tampa Scale of Kinesiophobia and Brief Fear of Movement Scale, depression by the Beck Depression Inventory, disability by the Western Ontario and McMaster Universities Arthritis Index, physical activity level by the International Physical Activity Questionnaire short form, and quality of life by the Short Form 12 Health Survey Questionnaire.

RESULTS

Of the patients, 85.7% had high-level kinesiophobia, 70.6% had depression, and 64.4% had low, 27.8% moderate, and 7.8% high physical activity levels. Age, activity-related pain score of the Visual Analog Scale, Tampa Scale of Kinesiophobia and Brief Fear of Movement Scale scores, and Western Ontario and McMaster Universities Arthritis Index and Beck Depression Inventory scores were higher in the group with high-level kinesiophobia, whereas the mental, physical, and total scores obtained from the Short Form 12 Health Survey Questionnaire were higher in the group with low-level kinesiophobia (P < 0.05).

CONCLUSIONS

As the treatment of pain alone in patients with knee osteoarthritis is not sufficient to reduce fear of movement, we suggest that approaches to increase awareness of fear of movement and physical activity and cognitive behavioral therapy related to fear of movement should be included in the treatment program.

Association between pain catastrophizing, physical function and pain at first visit in the outpatient knee clinic

BACKGROUND

Pain catastrophizing has been associated with pain severity and disability in patients with knee osteoarthritis (OA). However, the literature is not consistent and other studies have failed to find this association. We examined the preoperative association between pain catastrophizing and physical function and pain, as well as the correlation between radiographic OA and physical symptoms and knee arthroplasty (KA).

METHODS

This study was a cross-sectional study of all patients referred to the orthopaedic outpatient Knee Clinic from March to October 2013 with clinical symptoms of knee OA. Prior to clinical examination, the patients completed EuroQol-5D (EQ-5D), The Short Form-36 (SF-36 (PF)), The Oxford Knee Score (OKS) and The Pain Catastrophizing Scale (PCS). The severity of radiographic OA was graded with the Kellgren-Lawrence Scale (KLS).

RESULTS

Of the 325 patients, 158 (48.6%) patients received a knee arthroplasty, 130 (40%) were treated conservatively, and 37 (11.4%) were scheduled for a knee arthroscopy. Mean age was 64.3 (SD 11.1) years and 53.9% were females. We found a strong correlation between PCS and OKS (r = -0.60, P = 0.000). Furthermore, the regression analysis showed statistically significant associations between PCS and both physical function and pain. We found no correlation between radiographic OA and physical function or pain.

CONCLUSIONS

Our results reveal that PCS is an important psychological factor when dealing with patients with OA. Furthermore, our results confirm the importance of a combined evaluation of symptoms, clinical examination, and radiographs when deciding on the right treatment for individual knee patients.