Subjective impact of osteoarthritis flare-ups on patients' quality of life

Osteoarthritis Increases the Frequency and Duration of Postoperative Hand Clinic Visits after Carpal Tunnel Release

Background

Carpal tunnel syndrome affects up to 6% of the general population, and surgical intervention is often required to ameliorate symptoms. Osteoarthritis (OA) is a common condition that often coexists with carpal tunnel syndrome. We hypothesized that patients with preexisting OA use more healthcare resources after carpal tunnel release (CTR) than patients without arthritis.

Methods

This was a retrospective cohort study at a single academic center between January 1, 2018 and November 1, 2021. Patients who underwent CTR were included. Preoperative carpal tunnel symptoms, diagnostic tests, medications, and concomitant OA were abstracted. Hand, wrist, and basal joint arthritis were specified. The primary outcome was healthcare utilization represented by duration and frequency of hand clinic and occupational therapy (OT) follow-up. In total, 312 hands were included. Multivariable analysis was performed.

Results

The average duration of hand clinic follow-up among patients without arthritis was 25.3 days compared with 87.1 days for patients with any arthritis (P = 0.0375) and 172 days for patients with wrist arthritis (P = 0.012). The average number of postoperative surgeon visits was increased in patients with hand arthritis, with an average of 2.3 visits versus 1.34 visits for patients without arthritis (P = 0.003). Both the number of OT visits and the duration of OT follow-up did not differ between cohorts.

Conclusion

After CTR, patients with preexisting OA use more healthcare resources than patients without OA.

Course of pain and fluctuations in pain related to suspected early hip osteoarthritis: the CHECK study

OBJECTIVES

To evaluate the prevalence during a 10-year follow-up of clinically relevant fluctuations in pain and the course of hip pain in participants with hip complaints suspected to be early stage hip osteoarthritis (OA). To distinguish between participants with relevant fluctuations in pain and those without based on baseline characteristics.

METHODS

Data were collected at baseline and after 2, 5, 8, and 10 years on 495 participants from the Cohort Hip and Cohort Knee Study (CHECK) with hip pain at baseline. Baseline demographic, anamnestic, and physical-examination characteristics were assessed. The primary outcome was levels of pain in the past week (scored using 0-10 Numeric Rating Scale) at follow-up assessments. Relevant fluctuation was defined as average absolute residuals greater than 1 after fitting a straight line to the participant's pain scores over time.

RESULTS

The majority of the participants (76%) had stable or decreasing pain. Relevant fluctuations were found in 37% of the participants. The following baseline variables were positively associated with the presence of relevant fluctuations: higher levels of pain in the past week, use of pain transformation as a coping style, higher number of comorbidities, use of pain medication, and higher levels of high-sensitivity C-reactive protein. No associations were found for baseline radiographic hip OA or clinical hip OA.

CONCLUSION

During a 10-year follow-up, the majority of participants had stable or decreasing pain levels. In those participants with relevant fluctuation (37%), a limited number of baseline variables were associated with increased odds of having relevant fluctuations in pain.

Development and validation of the Flare-OA questionnaire for measuring flare in knee and hip osteoarthritis

OBJECTIVE

Ability to assess flares in osteoarthritis (OA) of the knee and hip (KHOA) is important in clinical care and research. Using mixed methods, we developed a self-reported instrument measuring flare and assessed its psychometric properties.

METHODS

We constructed questionnaire items from semi-structured interviews and a focus group (patients, clinicians) by using a dual-language (English-French) approach. A Delphi consensus method was used to select the most relevant items. Patients with OA from Australia, France and the United States completed the preliminary Flare-OA, HOOS, KOOS and Mini-OAKHQOL questionnaires online. We used a factor analysis and content approach to reduce items and determine structural validity. We tested the resulting questionnaire (score 0-100) for internal consistency, convergent and known-groups validity.

RESULTS

Initially, 180 statements were generated and reduced to 33 items in five domains (response 0 = not at all, to 10 = absolutely) by Delphi consensus (50 patients, 116 professionals) and an expert meeting. After 398 patients (mean [SD] age 64 [8.5] years, 70.4% female, 86.7% knee OA) completed the questionnaire, it was reduced to 19 items by factor analysis and a content approach (RMSEA = 0.06; CFI = 0.96; TLI = 0.94). The Cronbach's alpha was >0.9 for the five domains and the whole questionnaire. Correlation coefficients between Flare-OA and other instrument scores were as predicted, supporting construct validity. The difference in Flare-OA score between patients with and without flare (31.8) largely exceeded 2 SEM (10.2).

CONCLUSION

Flare-OA is a valid and reliable patient-reported instrument for assessing the occurrence and severity of flare in patients with KHOA in clinical research.

Short-term pain trajectories in patients with knee osteoarthritis

AIM

It is unknown if pain in knee osteoarthritis (KOA) follows distinct patterns over the short term. Therefore, the aim of this study was to identify whether persons with a previous history of KOA pain fluctuations have distinct trajectories of pain over 90 days and to examine associations between baseline characteristics and pain trajectories.

METHOD

People with a previous history of KOA were selected from a web-based longitudinal study. Baseline variables were sex, age, being obese/overweight, years of KOA, knee injury, knee buckling, satisfactory Lubben Social Support Score, pain and stress scales, Intermittent Constant Osteoarthritis Pain Score (ICOAP), medication use, and physical activity. Participants completed a Knee Injury and Osteoarthritis Outcomes Score (KOOS) pain subscale (KOOS-p, rated 0 = extreme to 100 = no knee problems) at 10-day intervals for 90 days. Short-term KOOS-p trajectories were identified using latent growth mixture modeling and the baseline risk factors for these pain trajectories were examined.

RESULTS

Participants (n = 313) had a mean age of 62.2 (SD ± 8.1) years and and a body mass index of 29.8 (SD ± 6.6) kg/m² . The three-class latent growth mixture modeling quadratic model with best fit indices was chosen (based on lowest sample-size-adjusted Bayesian Information Criterion, high probability of belonging, interpretability). Three distinct pain trajectory clusters (over 90 days) were identified: low-moderate pain at baseline with large improvement (n = 11), minimal change in pain over 90 days (n = 248), and moderate-high pain with worsening (n = 46). Higher ICOAP (intermittent scale), perceived stress, negative affect score, and knee buckling at baseline were associated with a worse knee pain trajectory (P < 0.05).

CONCLUSIONS

Persons with KOA showed unique short-term pain trajectories over 90 days, with distinct characteristics at baseline associated with each trajectory.

Impact of Rehabilitation on Health Related Quality of Life in Patients with Hip Osteoarthritis

Hip osteoarthritis (OA) is a degenerative, progressive musculoskeletal system disease in adult individuals. Both genders demonstrate a similar prevalence at 11.5% for men and 11.6% for women. During the initial stage of hip OA, conservative treatments may significantly decrease pain, provide functional improvement and enhance health related quality of life (HRQoL).

The aims of the study were to evaluate the quality of life of patients with hip osteoarthritis and to estimate the impact of a comprehensive rehabilitation intervention on their HRQoL.

This was a prospective, observational study of 50 consecutive patients with hip osteoarthritis who were referred to an outpatient rehabilitation intervention. To assess their HRQoL before and after rehabilitation, we used the SF-36 and the Lequesne index for hip OA.

The mean age was 61.7±8.3 years, and 56% of the patients were women. After rehabilitation, the SF-36 RE and RP subscales and the Lequesne pain subscale showed the most significant improvement, although all of the SF-36 and Lequesne domains showed significant improvement. Before rehabilitation, the Lequesne ADL subscale was most correlated with the SF-36 PF subscale (rho=−0.908). After rehabilitation, the total Lequesne score was highly correlated with the SF-36 PF subscale (rho=−0.895). Age, education and the duration of disease were significantly correlated with all of the Lequesne subscales before and after rehabilitation.

This study showed that patients with hip osteoarthritis had a substantially low HRQoL, but all health dimensions showed statistically significant improvements after outpatient rehabilitation intervention.

Quality of Life and Functional Independence in Patients with Osteoarthritis of the Knee

PURPOSE

To verify the association between functional independence (FI) and quality of life (QOL) in patients with knee osteoarthritis.

MATERIALS AND METHODS

A cross-sectional study composed of 93 patients with knee osteoarthritis was performed. Osteoarthritis was stratified according the classification of Ahlbach. For evaluation of the patient's overall FI, the Barthel index was used. The patient's QOL was measured by means of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) questionnaire.

RESULTS

The mean age of the patients was 60 years (range, 54.0 to 69.5 years) and only 32 patients (34.3%) were found to be independent. Dependent or independent individuals presented difference in all domains of the QOL including physical function (p=0.001), role-physical (p=0.005), bodily pain (p=0.001), general health (p=0.004), vitality (p=0.009), social function (p=0.010), role-emotional (p=0.002) and mental health (p=0.001). Correlation between FI and QOL was different for all domains of the SF-36. Correlation with FI was strongest for physical function (r=0.609, p<0.001), followed by the domains of bodily pain (r=0.410, p<0.001) and mental health (r=0.402, p<0.001).

CONCLUSIONS

Our data demonstrated a strong association of FI with QOL and positive correlations with all QOL domains, indicating the greater the FI is, the higher the QOL is.

Effects of Adding an Internet-Based Pain Coping Skills Training Protocol to a Standardized Education and Exercise Program for People With Persistent Hip Pain (HOPE Trial): Randomized Controlled Trial Protocol

BACKGROUND

Persistent hip pain in older people is usually due to hip osteoarthritis (OA), a major cause of pain, disability, and psychological dysfunction.

OBJECTIVE

The purpose of this study is to evaluate whether adding an Internet-based pain coping skills training (PCST) protocol to a standardized intervention of education followed by physical therapist-instructed home exercise leads to greater reductions in pain and improvements in function.

DESIGN

An assessor-, therapist-, and participant-blinded randomized controlled trial will be conducted.

SETTING

The study will be conducted in a community setting.

PARTICIPANTS

The participants will be 142 people over 50 years of age with self-reported hip pain consistent with hip OA.

INTERVENTION

Participants will be randomly allocated to: (1) a control group receiving a 24-week standardized intervention comprising an 8-week Internet-based education package followed by 5 individual physical therapy exercise sessions plus home exercises (3 times weekly) or (2) a PCST group receiving an 8-week Internet-based PCST protocol in addition to the control intervention.

MEASUREMENTS

Outcomes will be measured at baseline and 8, 24, and 52 weeks, with the primary time point at 24 weeks. Primary outcomes are hip pain on walking and self-reported physical function. Secondary outcomes include health-related quality-of-life, participant-perceived treatment response, self-efficacy for pain management and function, pain coping attempts, pain catastrophizing, and physical activity. Measurements of adherence, adverse events, use of health services, and process measures will be collected at 24 and 52 weeks. Cost-effectiveness will be assessed at 52 weeks.

LIMITATIONS

A self-reported diagnosis of persistent hip pain will be used.

CONCLUSIONS

The findings will help determine whether adding an Internet-based PCST protocol to standardized education and physical therapist-instructed home exercise is more effective than education and exercise alone for persistent hip pain. This study has the potential to guide clinical practice toward innovative modes of psychosocial health care provision.

Randomized Controlled Trial of Etodolac versus Combination of Etodolac and Eperisone in Patients of Knee Osteoarthritis

Objective. To compare the efficacy and tolerability of etodolac versus etodolac in combination with eperisone in patients of Osteoarthritis knee. Patients and Methods. A prospective, randomized, open label, parallel group, comparative study was conducted in 60 patients of knee OA over a period of 2 months. Thirty patients received etodolac 600 mg once daily and 30 patients received eperisone 50 mg thrice daily in addition to etodolac 600 mg once daily for 8 weeks. Efficacy assessment was done on the basis of improvement in mean scores of spontaneous pain on Visual analog scale (VAS), pain on movement, functional capacity, joint tenderness, swelling, erythema on Likert scale, and patient's overall arthritic condition on a five-point investigator scale at the end of study period as compared with the baseline scores. Assessment of tolerability was done by recording the occurrence of adverse events. Data was analyzed using Chi square test and students t-test. Results. All the enrolled patients completed the study and were compliant to the treatment regimens that they were allocated to. Both the treatment groups showed a statistically significant improvement in all the efficacy parameters at the end of 8 weeks as compared to baseline (P < 0.05) with no statistically significant difference between the groups. Adverse events were few and mild in nature. Conclusion. Combination of etodolac and eperisone is as effective as etodolac alone in patients of OA knee. Thus, it is concluded that additional use of muscle relaxant has no adjuvant value in patients of OA knee and is not recommended. The study is registered with the Clinical Trial Registry of India vide registration number CTRI/2013/03/003442.

Cost-effectiveness analysis of early versus late total hip replacement in Italy

OBJECTIVE

To assess the cost-effectiveness of early primary total hip replacement (THR) for functionally independent older adult patients with osteoarthritis (OA) versus 1) nonsurgical therapy followed by THR once the patient has progressed to a functionally dependent state ("delayed THR") and 2) nonsurgical therapy alone ('medical therapy'), from the Italian National Health Service perspective.

METHODS

Individual patient data and evidence from published literature on disease progression, economic costs and THR outcomes in OA, including utilities, perioperative mortality rates, prosthesis survival, and costs of prostheses, THR, rehabilitation, follow-up, revision, and nonsurgical management, combined with population life tables, were synthesized in a Markov model of OA. The model represents the lifetime experience of a patient cohort following their treatment choice, discounting costs and benefits (quality-adjusted life-years) at 3% annually.

RESULTS

At age 65 years, the incremental cost per quality-adjusted life-year of THR over delayed THR was €987 in men and €466 in women; the figures for delayed THR versus medical therapy were €463 and €82, respectively. Among 80-year-olds, early THR is (extended) dominant. With gradual utility loss after primary THR, delaying surgery may be more appealing in women than in men in their 50s, because longer female life expectancy implies longer latter periods of low health-related quality of life (HRQOL) with early THR.

CONCLUSIONS

THR is cost-effective. Patients' HRQOL benefits forgone with delayed THR are worth more than the costs it saves to the Italian National Health Service. This analysis might help to explain women's consistently lower HRQOL by the time of primary operation.

Prevalence and characteristics of flare-ups of chronic nonspecific back pain in primary care: a telephone survey

OBJECTIVES

To describe the prevalence and characteristics of flare-ups of chronic nonspecific back pain (CNSBP) among primary care patients, and to examine associations with measures of pain severity and psychosocial factors.

METHODS

Six hundred thirty-four participants with nonspecific back pain were interviewed by telephone 2 years after an initial primary care visit for back pain. Participants experiencing flare-ups in the last 6 months reported on frequency, duration, and other characteristics of flare-ups. Using bivariate and multivariate analyses, we compared individuals with and without CNSBP flare-ups with respect to demographic characteristics, measures of pain severity, and psychosocial factors.

RESULTS

Approximately 51% of the participants reported flare-ups. Physical activities, including lifting and bending, were the most common perceived triggers of flare-ups. Participants with flare-ups experienced greater levels of pain intensity, disability, opioid medication use, and psychosocial comorbidities. After adjustment for demographic factors, pain intensity, and pain frequency, participants with flare-ups were more disabled than those without [mean (95% confidence interval) disability score 4.2 (3.9-4.4) vs. 3.3 (2.9-3.6); P<0.0001] and demonstrated higher levels of passive coping [mean passive coping score 4.1(3.8-4.3) vs. 3.4 (3.1-3.7); P=0.0008].

DISCUSSION

Flare-ups of CNSBP are common among primary care patients, and are independently associated with higher levels of pain intensity, disability, and passive coping. The presence of flare-ups and the perception of activity as a trigger may predispose patients with flare-ups to experience disability not explained by pain intensity alone. Further longitudinal studies are required to better characterize CNSBP flare-ups and determine their clinical implications.

Treatment of Osteoarthritis with Continuous Versus Intermittent Celecoxib

Objective.

To determine whether “continuous” celecoxib is more efficacious than “intermittent” use in preventing osteoarthritis (OA) flares of the knee and/or hip.

Methods.

A double-blind, randomized, multicenter international study comparing efficacy and safety of continuous (daily) versus intermittent (as required during predefined OA flare) celecoxib 200 mg/day in 858 subjects, aged 18–80 years. The study consisted of 3 periods: (I) screening/washout visit; (II) open-label run-in with celecoxib; and (III) 22-week blinded treatment. Only subjects whose OA flares resolved in Period 2 (without subsequent flare) were randomized. The primary endpoint, number of flares per time of exposure during Period III (number of flares per month), was compared using analysis of variance with treatment as the independent variable. Acetaminophen was available as rescue medication.

Results.

Of 875 subjects randomized to treatment, 858 subjects received treatment. At randomization > 70% were female; mean age 58.6 years; mean disease duration 6.5 years; total Western Ontario and McMaster Universities Osteoarthritis Index mean score 25.8; ∼45% had hypertension; and ∼20% were using aspirin (for cardiovascular prophylaxis). Subjects receiving continuous treatment reported 42% fewer OA flares/month than intermittent users (p < 0.0001) or 2.0 fewer OA flares over 22 weeks. Statistical and clinically meaningful benefits in secondary outcomes were also evident with continuous treatment. There were no differences in adverse events (AE) or new-onset/aggravated hypertension.

Conclusion.

Continuous treatment with celecoxib 200 mg/day was significantly more efficacious than intermittent use in preventing OA flares of the hip and knee, without an increase in overall AE, including gastrointestinal disorders and hypertension, during 22 weeks of treatment. ClinicalTrials.gov identifier NCT00139776.

Assessment of the impact of flares in ankylosing spondylitis disease activity using the Flare Illustration

OBJECTIVES

Many AS patients report periods of perceived higher disease activity (flares). This pilot study aims to document disease activity patterns reported by AS patients and examine associations with disease-specific health status measures.

METHODS

Consecutive AS patients (n = 114) were asked whether they experience flares, and if they experience symptoms of AS between flares. They were shown the Flare Illustration of disease patterns over time and asked to select the pattern that best described their disease (i) since symptom onset and (ii) in the past year. Associations between reported disease pattern and disease activity (Bath AS Disease Activity Index, BASDAI); functional impairment (Bath AS Functional Index, BASFI); AS Quality of Life (ASQoL); Back Pain (Nocturnal and Overall) and demographic features were assessed in a subsample (n = 83) (statistical significance defined at P <or= 0.05).

RESULTS

Since disease onset 108/113 patients (96%) reported flares, and 82/99 (83%) reported symptoms of AS between flares. Flares typically lasted days or weeks. When patients were asked to characterize their disease pattern using the Flare Illustration, patterns with constant symptoms predominated (>70% of patients) and patterns with constant symptoms since onset (vs intermittent symptoms) were associated with worse health status (ASQoL: P = 0.007; BASDAI: P = 0.029; BASFI: P = 0.013, overall back pain: P = 0.025).

CONCLUSIONS

Almost all AS patients report flares in disease activity: 70-80% report constant symptoms with single/repeated flares, while 20-30% report flares with no intermittent symptoms. The former is associated with a significantly poorer health status. These findings will be validated in a prospective study.