Association Between Self-Reported Spinal Morning Stiffness and Radiographic Evidence of Lumbar Disk Degeneration in Participants of the Cohort Hip and Cohort Knee (CHECK) Study

Prognostic factors and the value of radiographic osteoarthritis for persistent complaints after referral for ankle radiography

BACKGROUND

Ankle symptoms are a common reason to consult the general practitioner and often persist for years. In a population referred for ankle radiography, the prevalence of radiographic osteoarthritis (OA) is substantial, but its additional predictive value for persistent symptoms is unknown. Therefore, we examined the prognosis of symptoms 2-3 years after referral for ankle radiography, assessed clinical prognostic factors, and the additional predictive value of radiographic OA for persistent ankle complaints.

METHODS

We included 893 adults referred for ankle radiography and studied the following candidate prognostic factors at baseline: age, sex, body mass index (BMI), referral for chronic complaints (>3 months), pain during activity (NRS-11) and presence of stiffness and functional loss as predominant symptom. X-rays were scored for radiographic OA. After 2-3 years participants were invited for a follow-up questionnaire including persistence of ankle complaints. To assess prognostic factors for persistent complaints, uni- and multivariable logistic regression were used.

RESULTS

Of the 194 responders at follow-up, ankle complaints persisted in 71(36.6 %). BMI (OR 1.08; 95 % CI 1.01-1.15), stiffness as predominant symptom (OR 1.69; 95 % CI 0.89-3.21), and chronic complaints (OR 2.84; 95 % CI 1.45-5.57) were in the initial model for persistent complaints (AUC=0.69). After adding radiographic OA (OR 2.36; 95 % CI 1.01-5.50), the AUC of the final model became 0.70.

CONCLUSION

Ankle complaints persist in a considerable proportion of patients 2-3 years after referral for ankle radiography. BMI, chronic complaints and radiographic OA are prognostic factors for persistent complaints, but the additional predictive value of radiographic OA on top of clinical factors is negligible.

Diagnostic models to predict structural spinal osteoarthritis on lumbar radiographs in older adults with back pain: Development and internal validation

Objective

It is difficult for health care providers to diagnose structural spinal osteoarthritis (OA), because current guidelines recommend against imaging in patients with back pain. Therefore, the aim of this study was to develop and internally validate multivariable diagnostic prediction models based on a set of clinical and demographic features to be used for the diagnosis of structural spinal OA on lumbar radiographs in older patients with back pain.

Design

Three diagnostic prediction models, for structural spinal OA on lumbar radiographs (i.e. multilevel osteophytes, multilevel disc space narrowing (DSN), and both combined), were developed and internally validated in the 'Back Complaints in Older Adults' (BACE) cohort (N ​= ​669). Model performance (i.e. overall performance, discrimination and calibration) and clinical utility (i.e. decision curve analysis) were assessed. Internal validation was performed by bootstrapping.

Results

Mean age of the cohort was 66.9 years (±7.6 years) and 59% were female. All three models included age, gender, back pain duration and duration of spinal morning stiffness as predictors. The combined model additionally included restricted lateral flexion and spinal morning stiffness severity, and exhibited the best model performance (optimism adjusted c-statistic 0.661; good calibration with intercept -0.030 and slope of 0.886) and acceptable clinical utility. The other models showed suboptimal discrimination, good calibration and acceptable decision curves.

Conclusion

All three models for structural spinal OA displayed lesuboptimal discrimination and need improvement. However, these internally validated models have potential to inform primary care clinicians about a patient with risk of having structural spinal OA on lumbar radiographs. External validation before implementation in clinical care is recommended.

Is radiographic osteoarthritis associated with pain and disability of the ankle?

Objective

Ankle osteoarthritis (OA) is relatively understudied. It often affects younger people compared to OA in other joints. Evidence on the association between radiographic OA and ankle symptoms remains contradicting. We therefore examined the association of degree of radiographic talocrural, subtalar and talonavicular OA with severity of ankle pain, disability and predominant symptoms.

Method

A cross-sectional study was conducted in a radiology department serving primary and secondary care. From the total study population (adults referred for ankle radiography), patients with chronic ankle complaints were selected (N ​= ​231). Before radiography, participants completed a questionnaire on severity of ankle pain and disability using the Ankle Osteoarthritis Scale (AOS), and on their predominant symptoms, i.e. pain, functional loss, stiffness and/or instability. To assess the associations of the Kellgren-Lawrence scores (0, 1 or ≥2) with the primary outcomes (AOS), linear regression, and with the secondary outcomes predominant symptoms, logistic regression analyses were applied.

Results

Radiographic OA was not associated with AOS-pain and -disability. Radiographic talocrural OA was associated with functional loss (OR 3.26, 95% CI: 1.31; 8.11). A positive trend was seen between radiographic talonavicular OA and stiffness (OR 2.63, 95% CI: 0.97; 7.15).

Conclusion

The presence of radiographic OA is not associated with severity of ankle pain and disability in patients with chronic ankle complaints referred for ankle radiography. However, radiographic talocrural OA is associated with functional loss and radiographic talonavicular OA with stiffness as predominant symptom. These findings may contribute to better recognition of ankle OA in clinical practice.

Association between clinical findings and the presence of lumbar spine osteoarthritis imaging features: A systematic review

OBJECTIVE

Spinal osteoarthritis is difficult to study and diagnose, partly due to the lack of agreed diagnostic criteria. This systematic review aims to give an overview of the associations between clinical and imaging findings suggestive of spinal osteoarthritis in patients with low back pain to make a step towards agreed diagnostic criteria.

DESIGN

We searched MEDLINE, Embase, Web of Science, and CINAHL from inception to April 29, 2021 to identify observational studies in adults that assessed the association between selected clinical and imaging findings suggestive of spinal osteoarthritis. Risk of bias was assessed using the Newcastle Ottawa Scale and the quality of evidence was graded using an adaptation of the GRADE approach.

RESULTS

After screening 7902 studies, 30 met the inclusion criteria. High-quality evidence was found for the longitudinal association between low back pain (LBP) intensity, and both disc space narrowing and osteophytes, as well as for the association between LBP-related physical functioning and lumbar disc degeneration, the presence of spinal morning stiffness and disc space narrowing and for the lack of association between physical functioning and Schmorl's nodes.

CONCLUSIONS

There is high- and moderate-quality evidence of associations between clinical and imaging findings suggestive of spinal osteoarthritis. However, the majority of the studied outcomes had low or very low-quality of evidence. Furthermore, clinical and methodological heterogeneity was a serious limitation, adding to the need and importance of agreed criteria for spinal osteoarthritis, which should be the scope of future research.

Performance of knee image digital analysis of radiographs of patients with end-stage knee osteoarthritis

OBJECTIVE

Knee Image Digital Analysis (KIDA) is standardized radiographic analysis software for measuring osteoarthritis (OA) characteristics. It was validated in mild OA, but used for severe OA as well. The current goal was to evaluate the performance of KIDA in severe OA.

DESIGN

Of 103 patients, standardized radiographs were performed before and one and 2 years after treatment for severe OA. All radiographs were evaluated on subchondral bone density, joint space width (JSW), osteophytes, eminence height, and joint angle, twice within years by the same observer. Part of the radiographs were randomly selected for reevaluation twice within 1 month and evaluation by another observer. The intraclass correlation coefficient (ICC), smallest detectable difference (SDD) and coefficient of variation (CV) were calculated; the SDD and CV were compared to those in mild OA. The relation of severity with KIDA parameters and with observer differences was calculated with linear regression.

RESULTS

Intra-observer ICCs were higher in the 98 severe radiographs reanalyzed within 1 month (all >0.8) than the 293 reanalyzed within years (all >0.5; most >0.8) and than inter-observer ICCs (all >0.7). SDDs and CVs were smaller when reanalyzed within a month and comparable to those in mild OA. Some parameters showed bias between readings. Severity showed significant relation with osteophytes and JSW parameters, and with the observer variation in these parameters (all P < 0.04).

CONCLUSIONS

KIDA is a well-performing tool also for severe OA. In order to decrease variability and SDDs, images should be analyzed in a limited time frame and randomized order.

Clinical and radiographic features of spinal osteoarthritis predict long-term persistence and severity of back pain in older adults

BACKGROUND

Patients with back pain can show one or more features of spinal osteoarthritis (OA), such as morning stiffness, limited or painful range of motion (ROM), and lumbar disc degeneration (LDD). However, it has not been investigated whether these features are prognostic of long-term back pain.

OBJECTIVES

This study assessed whether spinal morning stiffness, ROM and LDD are prognostic factors for back pain after 1 year in older adults with back pain.

METHODS

This prospective observational study (BACE cohort) included patients aged>55 years visiting a general practitioner for a back-pain episode. Baseline patient-reported morning stiffness, physical examined ROM and radiographic LDD features (i.e., multilevel osteophytes and disc space narrowing) were analysed as potential prognostic factors in unadjusted and adjusted regression models with the outcomes of persistent back pain (yes/no) and back pain severity after 1-year follow-up.

RESULTS

This study included 543 patients with mean (SD) age 67 (8) years, 59% female, and 62% reporting back pain at 1-year follow-up. When studied in separate adjusted models, persistent back pain was associated with morning stiffness>30min (OR 3.0, 95%CI 1.3; 5.5), restricted lateroflexion (OR 1.8, 95%CI 1.0; 3.2), pain during rotation (OR=1.7, 95%CI 1.0; 2.9), multilevel osteophytes (OR 2.4, 95%CI 1.4; 4.1), and multilevel disc space narrowing (OR 1.5, 95%CI 0.9; 2.4). When investigated in the same adjusted model, persistent back pain remained associated with only morning stiffness>30min (OR 2.4, 95%CI 1.0; 3.9), pain during rotation (OR 1.6, 95%CI 0.9; 2.8), and multilevel osteophytes (OR 2.1, 95%CI 1.2; 3.7). The same spinal OA-related features were associated with back pain severity.

CONCLUSIONS

Spinal morning stiffness, painful rotation, and multilevel osteophytes are prognostic factors for persistent back pain and back pain severity after 1 year. Evaluating these clinical and radiographic features of spinal OA could help clinicians identify older patients who will experience long-term back pain.