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Overton M, Swain N, Falling C, Gwynne-Jones D, Fillingim R, Mani R. Understanding the biopsychosocial knee osteoarthritis pain experience: an ecological momentary assessment. Pain Rep 2024; 9:e1172. [PMID: 39015820 PMCID: PMC11249513 DOI: 10.1097/pr9.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/27/2024] [Accepted: 05/27/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction Psychological, social, and lifestyle factors contribute to the knee osteoarthritis (OA) pain experience. These factors could be measured more accurately using smartphone ecological momentary assessment (EMA). Objectives The objective of this study was to characterise the pain experiences of those with knee OA by a smartphone EMA survey and explain how momentary psychological and social states influence knee OA pain experiences. Methods A smartphone EMA survey was designed and piloted. Eligible participants completed smartphone EMA assessing the knee OA pain experience 3 times daily for 2 weeks. Descriptive statistics were used to characterise factors involved in knee OA pain followed by the development of mixed-effects location scale models to explore heterogeneity and relationships between symptoms involved in the knee OA pain experience. Results Eighty-six community-dwelling volunteers with knee OA were recruited. Pain, psychosocial, and lifestyle factors involved in knee OA pain experience were heterogeneous and variable. Those with greater variability in pain, fatigue, negative affect, and stress had worse levels of these symptoms overall. In addition, fatigue, negative affect, stress, anxiety, loneliness, and joint stiffness demonstrated within-person relationships with knee OA pain outcomes. Conclusions Knee OA pain is a heterogeneous biopsychosocial condition. Momentary experiences of psychological, social, fatigue, and joint stiffness explain individual and between-individual differences in momentary knee OA pain experiences. Addressing these momentary factors could improve pain and functional outcomes in those with knee OA. Validation studies, including individuals with more severe knee OA presentations, are required to support findings and guide clinical interventions to improve outcomes for those with knee OA.
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Affiliation(s)
- Mark Overton
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Nicola Swain
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Carrie Falling
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - David Gwynne-Jones
- Department of Surgical Sciences, Otago School of Medicine, University of Otago, Dunedin, New Zealand
| | - Roger Fillingim
- Pain Research and Intervention Center of Excellence (PRICE), Department of Community Dentistry and Behavioural Science, University of Florida, Gainesville, FL, USA
| | - Ramakrishnan Mani
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
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Wang Q, Runhaar J, Kloppenburg M, Boers M, Bijlsma JWJ, Bierma-Zeinstra SMA. Evaluation of the Diagnostic Performance of American College of Rheumatology, EULAR, and National Institute for Health and Clinical Excellence Criteria Against Clinically Relevant Knee Osteoarthritis: Data From the CHECK Cohort. Arthritis Care Res (Hoboken) 2024; 76:511-516. [PMID: 37933434 DOI: 10.1002/acr.25270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 10/17/2023] [Accepted: 11/02/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Our objective was to evaluate the diagnostic performance of the EULAR, American College of Rheumatology (ACR), and National Institute for Health and Care Excellence (NICE) criteria by using clinical experts' diagnosis of clinically relevant knee osteoarthritis (OA) as the outcome of interest. METHODS In a previous study, we recruited clinical experts to evaluate longitudinal (5-, 8-, and 10-year follow-up) clinical and radiographic data of symptomatic knees from the Cohort Hip and Cohort Knee (CHECK) study for the presence or absence of clinically relevant OA. In the current study, ACR, EULAR, and NICE criteria were applied to the same 5-, 8-, and 10-year follow-up data; then a knee was diagnosed with OA if fulfilling the criteria at one of the three time points (F1), two of the time points (F2), or at all three time points (F3). Using clinically relevant OA as the reference standard, the sensitivity, specificity, and positive and negative predictive values for the three criteria were assessed. RESULTS A total of 539 participants for a total of 833 examined knees were included. Thirty-six percent of knees were diagnosed with clinically relevant OA by experts. Sixty-seven percent to 74% of the knees received the same diagnosis (OA or non-OA) by the three criteria sets for the different definitions (F1 to F3). EULAR consistently (F1 through F3) had the highest specificity, and NICE consistently had the highest sensitivity. CONCLUSION The diagnoses only moderately overlapped among the three criteria sets. The EULAR criteria seemed to be more suitable for study enrollment (when aimed at recruiting clinically relevant OA knees), given the highest specificities. The NICE criteria, given the highest sensitivities, could be more useful for an initial diagnosis in clinical practice.
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Affiliation(s)
- Qiuke Wang
- Erasmus MC University Center Rotterdam, Rotterdam, The Netherlands, and Shanghai Sixth People's Hospital, Shanghai, China
| | - Jos Runhaar
- Erasmus MC University Center Rotterdam, Rotterdam, The Netherlands
| | | | - Maarten Boers
- Amsterdam University Medical Center, Amsterdam, The Netherlands
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Holzer KJ, Todorovic MS, Wilson EA, Steinberg A, Avidan MS, Haroutounian S. Cognitive flexibility training for chronic pain: a randomized clinical study. Pain Rep 2024; 9:e1120. [PMID: 38352025 PMCID: PMC10863938 DOI: 10.1097/pr9.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 09/12/2023] [Accepted: 10/09/2023] [Indexed: 02/16/2024] Open
Abstract
Introduction Previous studies suggest an association between cognitive flexibility and development of chronic pain after surgery. It is not known whether cognitive flexibility can be improved in patients with chronic pain. Objectives This study tested whether a neurocognitive training program results in improved cognitive flexibility and pain in patients with chronic pain. Methods We conducted a single-center, prospective, randomized study investigating 5-week daily neurocognitive training in patients with chronic pain. Participants (n = 145) were randomized into neurocognitive training or care as usual, and they completed assessments at baseline, posttreatment, and 3 months. The treatment group was asked to spend 35 minutes daily completing a program with tasks on cognitive flexibility, memory, attention, and speed. The primary outcome was performance on the neurocognitive performance test (NCPT). Secondary outcomes included levels of pain interference and severity. Results At 5 weeks, the treatment group showed greater improvements on NCPT compared with the control group (d = 0.37); effect size was smaller at 3 months (d = 0.18). The treatment group reported lower pain severity at 5 weeks (d = 0.16) and 3 months (d = 0.39) than the control group, but pain interference was only lower at 3 months (d = 0.20). Conclusions Outcomes suggest that using neurocognitive training to modify cognitive flexibility in patients with chronic pain may improve pain severity. This study provided effect size estimates to inform sample size calculations for randomized controlled trials to test the effectiveness of neurocognitive interventions for the prevention and treatment of chronic pain.
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Affiliation(s)
- Katherine J. Holzer
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Marko S. Todorovic
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Elizabeth A. Wilson
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Aaron Steinberg
- Emergency Department, SSM Health St. Mary's Hospital, St. Louis, MO, USA
| | - Michael S. Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Queiroga F, Cross M, Thomas MJ, March L, Epstein J, Guillemin F. A scoping review of patient self-report measures of flare in knee and hip osteoarthritis (OA): A report from the OMERACT flares in OA working group. Semin Arthritis Rheum 2023; 63:152281. [PMID: 37948937 DOI: 10.1016/j.semarthrit.2023.152281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE We aimed to analyze the content validity/domain match and feasibility of self-report instruments that could measure flare in osteoarthritis (OA), by extending our 2017 literature review on the definition of flare in knee and hip OA. METHOD We searched PubMed (Medline), Web of Science and PsycInfo (Ebsco Host) databases for original articles reporting research about flare (or synonyms) in humans with knee and hip OA, between 2017 and 2023. Four experts worked independently, checking the records, and assessing content validity and feasibility, writing justification for exclusion. RESULTS At literature review phase, 575 papers were filtered. After experts' analysis, 59 studies were included, and 44 instruments associated with flare in OA were identified. Most were studies about pain in knee or hip OA (35 %), cultural adaptation of a measure (33 %) or studies investigating psychometric properties of full (16 %) or short form (4 %) instruments. The assessment of domain match and feasibility revealed that 15 instruments were assigned a label of 'yes' or 'uncertain' as to whether or not there was a good match with the domain concept or whether the instrument was considered feasible to use. DISCUSSION Most identified instruments considered different aspects of pain and the associated discomfort in performing daily activities but did not include the central aspects of flare in OA, i.e. the change of state, nor the additional Outcome Measures in Rheumatology (OMERACT) endorsed domains for OA flare namely stiffness, swelling, psychological aspects, impact of symptoms including fatigue and sleep disturbance. Although it is possible that the period specified to conduct this literature review may have led to some recognized instruments being excluded, this review demonstrates the need for the research community to reach consensus on the best way to measure self-reported flares in future clinical trials and observational studies.
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Affiliation(s)
| | | | - Martin J Thomas
- Keele University, School of Medicine, Keele, Staffordshire, UK; Haywood Academic Rheumatology Centre, Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Staffordshire, UK
| | - Lyn March
- Institute of Bone and Joint Research - Kolling Institute, University of Sydney, and Rheumatology Department, Royal North Shore, Hospital, Sydney, Australia
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Ruder MC, Masood Z, Kobsar D. Reliability of waveforms and gait metrics from multiple outdoor wearable inertial sensors collections in adults with knee osteoarthritis. J Biomech 2023; 160:111818. [PMID: 37793202 DOI: 10.1016/j.jbiomech.2023.111818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/06/2023]
Abstract
Wearable sensors may allow research to move outside of controlled laboratory settings to be able to collect real-world data in clinical populations, such as older adults with osteoarthritis. However, the reliability of these sensors must be established across multiple out-of-lab data collections. Nine older adults with symptomatic knee arthritis wore wearable inertial sensors on their proximal tibias during an outdoor 6-minute walk test outside of a controlled laboratory setting as part of a pilot study. Reliability of the underlying waveforms, discrete peak outcomes, and spatiotemporal outcomes were assessed over four separate data collections, each approximately 1 week apart. Reliability at a different number of included strides was also assessed at 10, 20, 50, and 100 strides. The underlying waveforms and discrete peak outcome measures had good-to-excellent reliability for all axes, with lower reliability in frontal plane angular velocity axis. Spatiotemporal outcomes demonstrated excellent reliability. The inclusion of additional strides had little to no effect on reliability in most axes, but the confidence intervals generally became smaller across all axes. However, there was improvement in axes with lower (i.e., good) reliability. These data were collected in an out-of-lab setting, and the results are generally consistent with previous in-lab data collections, likely due to its semi-controlled nature. Additional out-of-laboratory research is required to investigate if these trends continue during truly free-living collections. This study provides support for increasing research conducted in out-of-lab data collections, as demonstrated by the good-to-excellent reliability of all axes.
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Affiliation(s)
- Matthew C Ruder
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada.
| | - Zaryan Masood
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada
| | - Dylan Kobsar
- Department of Kinesiology, McMaster University, Hamilton, ON, Canada
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6
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Parry E, Walker C, Thomas MJ. Recognising and managing osteoarthritis flares in primary care. BMJ 2023; 383:e076455. [PMID: 37813436 DOI: 10.1136/bmj-2023-076455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Affiliation(s)
- Emma Parry
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Staffordshire, UK
| | - Christine Walker
- Research User Group, Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire, UK (patient author)
| | - Martin J Thomas
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Staffordshire, UK
- Haywood Academic Rheumatology Centre, Midlands Partnership University NHS Foundation Trust, Haywood Hospital, Staffordshire, UK
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Crawford LS, Mills EP, Peek A, Macefield VG, Keay KA, Henderson LA. Function and biochemistry of the dorsolateral prefrontal cortex during placebo analgesia: how the certainty of prior experiences shapes endogenous pain relief. Cereb Cortex 2023; 33:9822-9834. [PMID: 37415068 PMCID: PMC10472490 DOI: 10.1093/cercor/bhad247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/08/2023] Open
Abstract
Prior experiences, conditioning cues, and expectations of improvement are essential for placebo analgesia expression. The dorsolateral prefrontal cortex is considered a key region for converting these factors into placebo responses. Since dorsolateral prefrontal cortex neuromodulation can attenuate or amplify placebo, we sought to investigate dorsolateral prefrontal cortex biochemistry and function in 38 healthy individuals during placebo analgesia. After conditioning participants to expect pain relief from a placebo "lidocaine" cream, we collected baseline magnetic resonance spectroscopy (1H-MRS) at 7 Tesla over the right dorsolateral prefrontal cortex. Following this, functional magnetic resonance imaging scans were collected during which identical noxious heat stimuli were delivered to the control and placebo-treated forearm sites. There was no significant difference in the concentration of gamma-aminobutyric acid, glutamate, Myo-inositol, or N-acetylaspartate at the level of the right dorsolateral prefrontal cortex between placebo responders and nonresponders. However, we identified a significant inverse relationship between the excitatory neurotransmitter glutamate and pain rating variability during conditioning. Moreover, we found placebo-related activation within the right dorsolateral prefrontal cortex and altered functional magnetic resonance imaging coupling between the dorsolateral prefrontal cortex and the midbrain periaqueductal gray, which also correlated with dorsolateral prefrontal cortex glutamate. These data suggest that the dorsolateral prefrontal cortex formulates stimulus-response relationships during conditioning, which are then translated to altered cortico-brainstem functional relationships and placebo analgesia expression.
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Affiliation(s)
- Lewis S Crawford
- School of Medical Sciences (Neuroscience), Brain and Mind Centre, University of Sydney, Sydney 2006, Australia
| | - Emily P Mills
- School of Medical Sciences (Neuroscience), Brain and Mind Centre, University of Sydney, Sydney 2006, Australia
| | - A Peek
- School of Medical Sciences (Neuroscience), Brain and Mind Centre, University of Sydney, Sydney 2006, Australia
| | | | - Kevin A Keay
- School of Medical Sciences (Neuroscience), Brain and Mind Centre, University of Sydney, Sydney 2006, Australia
| | - Luke A Henderson
- School of Medical Sciences (Neuroscience), Brain and Mind Centre, University of Sydney, Sydney 2006, Australia
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8
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Thirumaran AJ, Deveza LA, Atukorala I, Hunter DJ. Assessment of Pain in Osteoarthritis of the Knee. J Pers Med 2023; 13:1139. [PMID: 37511752 PMCID: PMC10381750 DOI: 10.3390/jpm13071139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Knee osteoarthritis (KOA) pain is a subjective and personal experience, making it challenging to characterise patients' experiences and assess their pain. In addition, there is no global standard for the assessment of pain in KOA. Therefore, this article examines the possible methods of assessing and characterising pain in patients with KOA using clinical symptoms, pain assessment tools, and imaging. We examine the current methods of assessment of pain in KOA and their application in clinical practice and clinical trials. Furthermore, we explore the possibility of creating individualised pain management plans to focus on different pain characteristics. With better evaluation and standardisation of pain assessment in these patients, it is hoped that patients would benefit from improved quality of life. At the same time, improvement in pain assessment would enable better data collection regarding symptom response in clinical trials for the treatment of osteoarthritis.
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Affiliation(s)
- Aricia Jieqi Thirumaran
- Nepean Hospital, Kingswood, NSW 2747, Australia
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
| | - Leticia Alle Deveza
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
- Rheumatology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Inoshi Atukorala
- Senior Lecturer in Clinical Medicine & Consultant Rheumatologist, University Medical Unit, National Hospital Sri Lanka, Colombo 00700, Sri Lanka
- Faculty of Medicine, University of Colombo, Colombo 00800, Sri Lanka
| | - David J Hunter
- Sydney Musculoskeletal Health, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, St Leonards, NSW 2065, Australia
- Rheumatology Department, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
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9
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Huang Y, Lascarides P, Ngai W, Steele K, Hummer CD. Three Weekly Intra-Articular Injections of Hylan G-F 20 vs Arthrocentesis in Patients with Chronic Idiopathic Knee Osteoarthritis: A Multicenter, Evaluator- and Patient-Blinded, Randomized Controlled Trial. CURRENT THERAPEUTIC RESEARCH 2023; 99:100707. [PMID: 37408828 PMCID: PMC10319210 DOI: 10.1016/j.curtheres.2023.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/22/2023] [Indexed: 07/07/2023]
Abstract
Background Knee osteoarthritis is a leading cause of disability worldwide. Symptoms can vary over time, leading to episodes of worsened symptoms known as flares. Intra-articular injection of hyaluronic acid has demonstrated long-term symptomatic relief in the broader knee osteoarthritis population, although its use in the flare population has not been extensively examined. Objective To assess the efficacy and safety of 3 once-weekly intra-articular injections of hylan G-F 20 (as single and repeat courses) in patients with chronic knee osteoarthritis, including a subpopulation that experienced flare. Methods Prospective randomized controlled, evaluator- and patient-blinded, multicenter trial with 2 phases: hylan G-F 20 vs arthrocentesis only (control) and 2 courses vs single-course hylan G-F 20. Primary outcomes were visual analog scale (0-100 mm) pain scores. Secondary outcomes included safety and synovial fluid analysis. Results Ninety-four patients (104 knees) were enrolled in Phase I, with 31 knees representing flare patients. Seventy-six patients (82 knees) were enrolled in Phase II. Long-term follow-up was 26 to 34 weeks. In flare patients, hylan G-F 20 showed significantly more improvement than the controls for all primary outcomes except pain at night (P = 0.063). Both 1 and 2 courses of hylan G-F 20 showed significant improvements from baseline for primary outcomes with no differences in efficacy between groups in the intention-to-treat population at the end of Phase II. Two courses of hylan G-F 20 showed better improvement in pain with motion (P = 0.0471) at long-term follow-up. No general side effects were reported, and local reactions (pain/swelling of the injected joint) resolved within 1 to 2 weeks. Hylan G-F 20 was also associated with reduced effusion volume and protein concentration. Conclusions Hylan G-F 20 significantly improves pain scores vs arthrocentesis in flare patients with no safety concerns. A repeat course of hylan G-F 20 was found to be well tolerated and efficacious.
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Affiliation(s)
- Yili Huang
- Zucker School of Medicine at Hofstra/Northwell, Northwell Phelps Hospital, Sleepy Hollow, New York
| | - Peter Lascarides
- Northwell Health, Northern Westchester Hospital, Mount Kisco, New York
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10
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Collins JE, Yang YH, Opare-Addo MB, Losina E. Quantifying sustained pain worsening in knee osteoarthritis. Osteoarthritis Cartilage 2023; 31:802-808. [PMID: 37024069 PMCID: PMC10200767 DOI: 10.1016/j.joca.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/10/2023] [Accepted: 03/04/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE Recent work suggests that many persons with knee osteoarthritis (OA) experience stable symptoms over time. Whether patients experience periods of symptom exacerbation or flare which interrupt this stable course, and how long such periods last, has received little study. Our objective is to describe the frequency and duration of episodes of pain worsening in persons with knee OA. METHODS We selected participants from the Osteoarthritis Initiative with radiographic, symptomatic knee OA. We defined a clinically relevant increase in knee pain as an increase in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain of ≥9 points. We defined sustained worsening as maintaining at least 80% of the initial increase. We used Poisson regression to estimate the incidence rate (IR) of episodes of pain worsening. RESULTS 1093 participants were included in the analysis. Eighty-eight percent had ≥1 increase in WOMAC pain ≥9 points (IR: 26.3 per 100 person years (95% CI: 25.2, 27.4)). Forty-eight percent had ≥1 episode of sustained worsening (IR: 9.7 per 100 person-years (95% CI: 8.9, 10.5)). Elevated pain was maintained an average of 2.4 years after the initial increase. CONCLUSION Most participants with knee OA reported at least one clinically relevant increase in WOMAC pain, but fewer than half experienced an episode of sustained pain worsening. These individual-level data portray a more nuanced and fluctuating course of OA pain than suggested by trajectory studies. These data could be useful in shared decision-making regarding prognosis and treatment choices in persons affected by symptomatic knee OA.
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Affiliation(s)
- J E Collins
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Y H Yang
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
| | - M B Opare-Addo
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, United States of America
| | - E Losina
- Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and Policy and Innovation EValuation in Orthopaedic Treatments (PIVOT) Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States of America
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11
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Thomas MJ. Expanding and explaining symptoms in knee osteoarthritis trajectories: fluctuations, flares, and future directions. Osteoarthritis Cartilage 2023; 31:725-726. [PMID: 37024070 DOI: 10.1016/j.joca.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Affiliation(s)
- Martin J Thomas
- Centre for Musculoskeletal Health Research, School of Medicine, Keele University, Staffordshire, ST5 5BG, UK; Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Haywood Hospital, Staffordshire ST6 7AG, UK.
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12
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Vivekanantham A, Selby D, Lunt M, Sergeant JC, Parkes MJ, O'Neill TW, Dixon W. Day-to-day variability of knee pain and the relationship with physical activity in people with knee osteoarthritis: an observational, feasibility study using consumer smartwatches. BMJ Open 2023; 13:e062801. [PMID: 36914192 PMCID: PMC10016308 DOI: 10.1136/bmjopen-2022-062801] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To assess the feasibility of using smartwatches in people with knee osteoarthritis (OA) to determine the day-to-day variability of pain and the relationship between daily pain and step count. DESIGN Observational, feasibility study. SETTING In July 2017, the study was advertised in newspapers, magazines and, on social media. Participants had to be living/willing to travel to Manchester. Recruitment was in September 2017 and data collection was completed in January 2018. PARTICIPANTS 26 participants aged>50 years with self-diagnosed symptomatic knee OA were recruited. OUTCOME MEASURES Participants were provided with a consumer cellular smartwatch with a bespoke app that triggered a series of daily questions including two times per day questions about level of knee pain and one time per month question from the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire. The smartwatch also recorded daily step counts. RESULTS Of the 25 participants, 13 were men and their mean age was 65 years (standard deviation (SD) 8 years). The smartwatch app was successful in simultaneously assessing and recording data on knee pain and step count in real time. Knee pain was categorised into sustained high/low or fluctuating levels, but there was considerable day-to-day variation within these categories. Levels of knee pain in general correlated with pain assessed by KOOS. Those with sustained high/low levels of pain had a similar daily step count average (mean 3754 (SD 2524)/4307 (SD 2992)), but those with fluctuating pain had much lower step count levels (mean 2064 (SD 1716)). CONCLUSIONS Smartwatches can be used to assess pain and physical activity in knee OA. Larger studies may help inform a better understanding of causal links between physical activity patterns and pain. In time, this could inform development of personalised physical activity recommendations for people with knee OA.
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Affiliation(s)
- Arani Vivekanantham
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Rheumatology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David Selby
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Mark Lunt
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Jamie C Sergeant
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Matthew J Parkes
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Terence W O'Neill
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Will Dixon
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Department of Rheumatology, Salford Royal NHS Foundation Trust, Salford, UK
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Li S, Cao P, Chen T, Ding C. Latest insights in disease-modifying osteoarthritis drugs development. Ther Adv Musculoskelet Dis 2023; 15:1759720X231169839. [PMID: 37197024 PMCID: PMC10184265 DOI: 10.1177/1759720x231169839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 03/29/2023] [Indexed: 05/19/2023] Open
Abstract
Osteoarthritis (OA) is a prevalent and severely debilitating disease with an unmet medical need. In order to alleviate OA symptoms or prevent structural progression of OA, new drugs, particularly disease-modifying osteoarthritis drugs (DMOADs), are required. Several drugs have been reported to attenuate cartilage loss or reduce subchondral bone lesions in OA and thus potentially be DMOADs. Most biologics (including interleukin-1 (IL-1) and tumor necrosis factor (TNF) inhibitors), sprifermin, and bisphosphonates failed to yield satisfactory results when treating OA. OA clinical heterogeneity is one of the primary reasons for the failure of these clinical trials, which can require different therapeutic approaches based on different phenotypes. This review describes the latest insights into the development of DMOADs. We summarize in this review the efficacy and safety profiles of various DMOADs targeting cartilage, synovitis, and subchondral bone endotypes in phase 2 and 3 clinical trials. To conclude, we summarize the reasons for clinical trial failures in OA and suggest possible solutions.
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Affiliation(s)
| | | | - Tianyu Chen
- Clinical Research Center, Zhujiang Hospital, Southern Medical University, Guangzhou, China
- Department of Orthopedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
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The impact of waiting time for orthopaedic consultation on pain levels in individuals with osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage 2022; 30:1561-1574. [PMID: 35961505 DOI: 10.1016/j.joca.2022.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/30/2022] [Accepted: 07/27/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Time spent waiting for access to orthopaedic specialist health services has been suggested to result in increased pain in individuals with osteoarthritis (OA). We assessed whether time spent on an orthopaedic waiting list resulted in a detrimental effect on pain levels in patients with knee or hip OA. METHODS We searched Ovid MEDLINE, EMBASE and EBSCOhost databases from inception until September 2021. Eligible articles included individuals with OA on an orthopaedic waitlist and not receiving active treatment, and reported pain measures at two or more time points. Random-effects meta-analysis was used to estimate the pooled effect of waiting time on pain levels. Meta-regression was used to determine predictors of effect size. RESULTS Thirty-three articles were included (n = 2,490 participants, 67 ± 3 years and 62% female). The range of waiting time was 2 weeks to 2 years (20.8 ± 18.8 weeks). There was no significant change in pain over time (effect size = 0.082, 95% CI = -0.009, 0.172), nor was the length of time associated with longitudinal changes in pain over time (β = 0.004, 95% CI = -0.005, 0.012). Body mass index was a significant predictor of pain (β = -0.043, 95% CI = -0.079, 0.006), whereas age and sex were not. CONCLUSIONS Pain remained stable for up to 1 year in patients with OA on an orthopaedic waitlist. Future research is required to understand whether pain increases in patients waiting longer than 1 year.
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15
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van Berkel AC, Schiphof D, Waarsing JH, Runhaar J, van Ochten JM, Bindels PJE, Bierma-Zeinstra SMA. Course of pain and fluctuations in pain related to suspected early hip osteoarthritis: the CHECK study. Fam Pract 2022; 39:1041-1048. [PMID: 35365995 PMCID: PMC9680658 DOI: 10.1093/fampra/cmac030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Annemaria C van Berkel
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Dieuwke Schiphof
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jan H Waarsing
- Department of Orthopaedics, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jos Runhaar
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - John M van Ochten
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Patrick J E Bindels
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sita M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Orthopaedics, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Johnson AJ, Buchanan T, Laffitte Nodarse C, Valdes Hernandez PA, Huo Z, Cole JH, Buford TW, Fillingim RB, Cruz-Almeida Y. Cross-Sectional Brain-Predicted Age Differences in Community-Dwelling Middle-Aged and Older Adults with High Impact Knee Pain. J Pain Res 2022; 15:3575-3587. [PMID: 36415658 PMCID: PMC9676000 DOI: 10.2147/jpr.s384229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose Knee OA-related pain varies in impact across individuals and may relate to central nervous system alterations like accelerated brain aging processes. We previously reported that older adults with chronic musculoskeletal pain had a significantly greater brain-predicted age, compared to pain-free controls, indicating an "older" appearing brain. Yet this association is not well understood. This cross-sectional study examines brain-predicted age differences associated with chronic knee osteoarthritis pain, in a larger, more demographically diverse sample with consideration for pain's impact. Patients and Methods Participants (mean age = 57.8 ± 8.0 years) with/without knee OA-related pain were classified according to pain's impact on daily function (ie, impact): low-impact (n=111), and high-impact (n=60) pain, and pain-free controls (n=31). Participants completed demographic, pain, and psychosocial assessments, and T1-weighted magnetic resonance imaging. Brain-predicted age difference (brain-PAD) was compared across groups using analysis of covariance. Partial correlations examined associations of brain-PAD with pain and psychosocial variables. Results Individuals with high-impact chronic knee pain had significantly "older" brains for their age compared to individuals with low-impact knee pain (p < 0.05). Brain-PAD was also significantly associated with clinical pain, negative affect, passive coping, and pain catastrophizing (p's<0.05). Conclusion Our findings suggest that high impact chronic knee pain is associated with an older appearing brain on MRI. Future studies are needed to determine the impact of pain-related interference and pain management on somatosensory processing and brain aging biomarkers for high-risk populations and effective intervention strategies.
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Affiliation(s)
- Alisa J Johnson
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, FL, USA,Department of Community Dentistry & Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Taylor Buchanan
- Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - Chavier Laffitte Nodarse
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, FL, USA,Department of Community Dentistry & Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Pedro A Valdes Hernandez
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, FL, USA,Department of Community Dentistry & Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA
| | - Zhiguang Huo
- Department of Biostatistics, College of Public Health & Health Professions College of Medicine, University of Florida, Gainesville, FL, USA
| | - James H Cole
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK,Dementia Research Centre, Institute of Neurology, University College London, London, UK
| | - Thomas W Buford
- Department of Medicine, University of Alabama, Birmingham, AL, USA
| | - Roger B Fillingim
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, FL, USA,Department of Community Dentistry & Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA,Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yenisel Cruz-Almeida
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, FL, USA,Department of Community Dentistry & Behavioral Science, College of Dentistry, University of Florida, Gainesville, FL, USA,Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA,Correspondence: Yenisel Cruz-Almeida, University of Florida, PO Box 103628, 1329 SW 16th Street, Ste 5180, Gainesville, FL, 32608, USA, Tel +1 352-294-8584, Fax +1 352-273-5985, Email
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Abstract
The phenomenon of flares is a common feature in the daily life of people with osteoarthritis (OA). Characterized by episodes of sudden-onset increases in signs and symptoms, their impact can often be distressing and disabling. Despite their potential to have both short-term and long-term consequences for patients across the whole course of the condition, their occurrence and optimal management are not fully understood. This article provides a contemporary perspective on defining OA flares and their potential triggers, and offers suggestions for how health professionals might explore flare patterns with patients in clinical practice and frame timely best-practice treatment approaches.
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Affiliation(s)
- Martin J Thomas
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Staffordshire ST5 5BG, UK; Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Haywood Hospital, Burslem, Staffordshire ST6 7AG, UK.
| | | | - Tuhina Neogi
- Department of Medicine, Section of Rheumatology, Boston University School of Medicine, 650 Albany Street, Suite X-200, Boston, MA 02118, USA
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18
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Temporomandibular disorders cases with high-impact pain are more likely to experience short-term pain fluctuations. Sci Rep 2022; 12:1657. [PMID: 35102207 PMCID: PMC8803984 DOI: 10.1038/s41598-022-05598-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 01/11/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractTemporomandibular disorders (TMD) patients can present clinically significant jaw pain fluctuations which can be debilitating and lead to poor global health. The Graded Chronic Pain Scale evaluates pain-related disability and its dichotomous grading (high/low impact pain) can determine patient care pathways and in general high-impact pain patients have worse treatment outcomes. Individuals with low-impact TMD pain are thought to have better psychosocial functioning, more favorable disease course, and better ability to control pain, while individuals with high-impact pain can present with higher levels of physical and psychological symptoms. Thereby, there is reason to believe that individuals with low- and high-impact TMD pain could experience different pain trajectories over time. Our primary objective was to determine if short-term jaw pain fluctuations serve as a clinical marker for the impact status of TMD pain. To this end, we estimated the association between high/low impact pain status and jaw pain fluctuations over three visits (≤ 21-day-period) in 30 TMD cases. Secondarily, we measured the association between jaw pain intensity and pressure pain thresholds (PPT) over the face and hand, the latter measurements compared to matched pain-free controls (n = 17). Jaw pain fluctuations were more frequent among high-impact pain cases (n = 15) than low-impact pain cases (n = 15) (OR 5.5; 95% CI 1.2, 26.4; p value = 0.033). Jaw pain ratings were not associated with PPT ratings (p value > 0.220), suggesting different mechanisms for clinical versus experimental pain. Results from this proof-of-concept study suggest that targeted treatments to reduce short-term pain fluctuations in high-impact TMD pain is a potential strategy to achieve improved patient perception of clinical pain management outcomes.
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19
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Pagé MG, Gauvin L, Sylvestre MP, Nitulescu R, Dyachenko A, Choinière M. An Ecological Momentary Assessment Study of Pain Intensity Variability: Ascertaining Extent, Predictors, and Associations With Quality of Life, Interference and Health Care Utilization Among Individuals Living With Chronic Low Back Pain. THE JOURNAL OF PAIN 2022; 23:1151-1166. [PMID: 35074499 DOI: 10.1016/j.jpain.2022.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/16/2022]
Abstract
This ecological momentary assessment (EMA) study examined the extent of pain intensity variability among 140 individuals with chronic low back pain and explored predictors of such variability and psychosocial and health care utilization outcomes. Individuals completed momentary pain intensity reports (0-10 numeric rating scale) several times daily for two periods of seven consecutive days, one month apart. Participants also completed online questionnaires at baseline which tapped into pain characteristics, pain-related catastrophization, kinesiophobia, activity patterns, and depression and anxiety symptoms. Questionnaires assessing quality of life and health care utilization were administered online one month after completion of the last EMA report. Data were analyzed using linear hierarchical location-scale models. Results showed that pain intensity fluctuated over the course of a week as shown by an average standard deviation of 1.2. The extent of variability in pain intensity scores was heterogeneous across participants but stable over assessment periods. Patients' baseline characteristics along with psychosocial and health care utilization outcomes were not significantly associated with pain intensity variability. We conclude that pain intensity variability differs across patients yet correlates remain elusive. There is an important gap in our knowledge of what affects this variability. Future EMA studies should replicate and extend current findings. PERSPECTIVE: This study provides evidence indicating that there is substantial variability in momentary reports of pain intensity among individuals living with chronic low back pain. However, risk and protective factors for greater lability of pain are elusive as is evidence that greater pain intensity variability results in differential health care utilization.
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Affiliation(s)
- M Gabrielle Pagé
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
| | - Lise Gauvin
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Social and Preventive Medicine, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Marie-Pierre Sylvestre
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Social and Preventive Medicine, École de santé publique de l'Université de Montréal, Montreal, Quebec, Canada
| | - Roy Nitulescu
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Centre d'intégration et d'analyse en données médicales du Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Alina Dyachenko
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Centre d'intégration et d'analyse en données médicales du Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal & Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
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20
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Oo WM, Little C, Duong V, Hunter DJ. The Development of Disease-Modifying Therapies for Osteoarthritis (DMOADs): The Evidence to Date. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:2921-2945. [PMID: 34262259 PMCID: PMC8273751 DOI: 10.2147/dddt.s295224] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 12/16/2022]
Abstract
Osteoarthritis (OA) is a complex heterogeneous articular disease with multiple joint tissue involvement of varying severity and no regulatory-agency-approved disease-modifying drugs (DMOADs). In this review, we discuss the reasons necessitating the development of DMOADs for OA management, the classifications of clinical phenotypes or molecular/mechanistic endotypes from the viewpoint of targeted drug discovery, and then summarize the efficacy and safety profile of a range of targeted drugs in Phase 2 and 3 clinical trials directed to cartilage-driven, bone-driven, and inflammation-driven endotypes. Finally, we briefly put forward the reasons for failures in OA clinical trials and possible steps to overcome these barriers.
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Affiliation(s)
- Win Min Oo
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar
| | - Christopher Little
- Raymond Purves Bone and Joint Research Laboratories, Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Vicky Duong
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David J Hunter
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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21
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Bowden JL, Kobayashi S, Hunter DJ, Mills K, Peat G, Guillemin F, Parry E, Thomas MJ, Eyles JP. Best-practice clinical management of flares in people with osteoarthritis: A scoping review of behavioral, lifestyle and adjunctive treatments. Semin Arthritis Rheum 2021; 51:749-760. [PMID: 34144385 DOI: 10.1016/j.semarthrit.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/19/2021] [Accepted: 04/27/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Transient episodes of increased pain, stiffness or swelling are common in people with osteoarthritis (OA). Yet, evidence-based management strategies for lessening the impact of OA flares are rarely covered in clinical guidelines and have been identified as a gap by clinicians delivering OA care. We aimed to identify evidence on behavioral, lifestyle or other adjunctive flare management strategies that could be used by clinicians or consumers. MATERIALS AND METHODS A literature search between 1990-2020 was performed in three databases using a scoping methodology. We included qualitative or quantitative studies, and reviews that examined OA flare management, or that reported OA flare outcomes at timepoints ≤2 weeks post-intervention. Outcomes included any physical or psychological OA outcome treatable with a therapeutic intervention. RESULTS We included 9 studies, all of which examined the relationship between therapeutic exercise/ physical activity and OA flares. All studies reported pain outcomes at the knee. Two also included the hip. Only two studies examined specific management strategies for OA flares. Both favorably reported the benefits of undertaking an exercise program modified accordingly during an episode, but the quality of the evidence was low. DISCUSSION This scoping review highlights the paucity of evidence available on non-pharmacological treatments of OA flare management that could influence clinical practice. At present, there is no robust evidence to support or reject any specific therapies for OA flare management in clinical practice. Future work is needed, particularly around outcomes beyond pain, trajectories of symptom improvement, and for joints other than the knee.
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Affiliation(s)
- Jocelyn L Bowden
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, Australia.
| | - Sarah Kobayashi
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia
| | - David J Hunter
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, Australia
| | | | - George Peat
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | | | - Emma Parry
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK
| | - Martin J Thomas
- Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele, UK; Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Staffordshire, UK
| | - Jillian P Eyles
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, Sydney, Australia
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22
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Zhang C, Wang Y, Sun K, Yu D, Tian S. Effects of Melatonin on Osteogenic Differentiation of Bone Marrow Mesenchymal Stem Cells in Inflammatory Environment by Regulating Mammalian Target of Rapamycin/Phosphatidylinositol 3-Kinase/Protein Kinase B Signaling. J BIOMATER TISS ENG 2021. [DOI: 10.1166/jbt.2021.2579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Human bone marrow mesenchymal stem cells (BMSCs) differentiation into special cell types is affected by inflammation. Melatonin has various effects such as anti-oxidation and immune regulation. However, melatonin’s effect on BMSCs osteogenic differentiation during inflammation
has not been elucidated. Rat BMSCs were isolated and assigned into control group, inflammation group (1 μg/ml lipopolysaccharide, LPS) and melatonin group (100 μM melatonin was added to LPSstimulated BMSCs cells) followed by analysis of BMSCs proliferation by MTT assay, Caspase 3 and
ALP activity, expression of Runx2 and OP by Real time PCR, ROS content and SOD activity, TNF-α and IL-1β secretion by ELISA and mTOR/PI3K/AKT signaling protein level by Western blot. LPS action on BMSCs significantly inhibits BMSCs proliferation, promotes Caspase 3 activity, inhibits
ALP activity, decreases Runx2 and OP expression and SOD activity, increases ROS content and TNF-α and IL-1β secretion as well as reduced mTOR and p-PI3K level (P <0.05). Melatonin addition significantly reversed the above changes (P <0.05). Melatonin can regulate oxidative
stress, inhibit inflammation, and promote BMSCs proliferation and osteogenic differentiation in inflammatory environment by activating mTOR/PI3K/AKT signaling pathway.
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Affiliation(s)
- Chi Zhang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266555, China
| | - Yuanhe Wang
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266555, China
| | - Kang Sun
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266555, China
| | - Dingzhu Yu
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266555, China
| | - Shaoqi Tian
- Department of Orthopaedic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266555, China
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Prego-Domínguez J, Khazaeipour Z, Mallah N, Takkouche B. Socioeconomic status and occurrence of chronic pain: a meta-analysis. Rheumatology (Oxford) 2021; 60:1091-1105. [PMID: 33276382 DOI: 10.1093/rheumatology/keaa758] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/10/2020] [Accepted: 10/07/2020] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To examine the association between socioeconomic status (SES) and the occurrence of chronic pain, defined as pain that persists or recurs for >3 months. METHODS We performed a structured search in Medline, Embase, WHO Global Index Medicus and Conference Proceedings Citation Index-Science databases to identify cohort and case-control studies on chronic pain and SES and its subgroups (SES combined index, educational level, income and occupational status). We extracted study characteristics, outcome measures and measures of association and their 95% CIs. Literature search, data extraction and risk of bias assessment were conducted by two independent researchers. We performed main and subgroup meta-analyses using random-effects model, and formally assessed heterogeneity and publication bias. RESULTS A total of 45 studies, covering a population of ∼175 000 individuals, were meta-analysed, yielding a pooled Odds Ratio (OR) of 1.32 (95% CI: 1.21, 1.44) and 1.16 (95% CI: 1.09, 1.23) for low and medium SES levels, respectively, compared with high level. We obtained similar results in all the subgroup analyses. Heterogeneity was generally moderate to high across strata, and some evidence of publication bias for low socioeconomic status was found. CONCLUSION Our results support a moderate increase in the risk of chronic pain for low and medium SES when compared with high SES, a feature that remained constant in all measures of exposure or outcome used. Further prospective research on populations from developing countries are needed to confirm our findings as the studies available for this meta-analysis were carried out exclusively in developed countries.
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Affiliation(s)
- Jesús Prego-Domínguez
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Zahra Khazaeipour
- Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Narmeen Mallah
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain
| | - Bahi Takkouche
- Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBER-ESP), Madrid, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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24
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Meng F, Shuai J, Li G, Weng J, Zeng H. Effect of Down-Regulation of Long-Chain Non-Coding RNAs Myocardial Infarction Associated Transcript 2 Expression on Osteoarthritis Chondrocytes. J BIOMATER TISS ENG 2021. [DOI: 10.1166/jbt.2021.2546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Osteoarthritis (OA) is featured as articular cartilage degradation. LncRNA Mirt2 involves in inflammation, but its role in osteoarthritis is unclear. Our study intends to assess LncRNA Mirt2’s role in OA chondrocytes. The chondrocytes of OA patients (OA group) and healthy controls
(control group) were isolated to measure LncRNA Mirt2 expression by Real time PCR. Chondrocytes were assigned into control group, LPS group, LPS + si-NC group, LPS + Mirt2 siRNA group followed by analysis of LncRNA Mirt2 level by real time PCR, cell proliferation by MTT assay, cell apoptosis
by flow cytometry, expression of COL2A1, MMP13, ADAMTS-5, MEK1/2, Erk1/2 and phosphorylated Erk1/2 by western blot. LncRNA Mirt2 level was increased in OA chondrocytes. Under LPS stim-ulation, Mirt2 expression was significantly increased in chondrocytes and chondrocyte proliferation was decreased,
along with significantly increased apoptosis and upregulated COL2A1, MMP13, ADAMTS-5, MEK1/2 and Erk1/2 and phosphorylated Erk1/2 (P < 0.05). Transfection of Mirt2 siRNA down-regulated its expression in chondrocytes stimulated by LPS, which significantly reversed the above changes
(P < 0.05). LncRNA Mirt2 expression is increased in OA chondrocytes. Downregulation of LncRNA Mirt2 can regulate COL2A1, MMP13 and ADAMTS-5 level via MAPK/ERK signaling pathway, promote OA chondrocytes proliferation and inhibit apoptosis.
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Affiliation(s)
- Fanbin Meng
- Hand and Microsurgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, 518036, China
| | - Jun Shuai
- Department of Dermatology, Shenzhen Futian Center for Chronic Disease Control, Shenzhen, Guangdong, 518046, China
| | - Guoqing Li
- Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, 518036, China
| | - Jian Weng
- Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, 518036, China
| | - Hui Zeng
- Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, 518036, China
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Chen L, Hu J, Zhou B, Li Y, Wei K, Wang J, Lv H, Zeng F. Effect of Integrin-Linked Kinase on Osteogenesis of Bone Marrow Mesenchymal Stem Cells in Inflammatory Environment via Regulating Mitogen Activated Protein Kinase/Protein Kinase B Signaling Pathway. J BIOMATER TISS ENG 2021. [DOI: 10.1166/jbt.2021.2559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Osteoarthritis (OA) pathogenesis involves inflammation, age, weight and other factors. Integrin-linked kinase (ILK) regulates cell apoptosis, metastasis, and growth. However, whether ILK affects bone formation of bone marrow mesenchymal stem cells in an inflammatory environment has
not been elucidated. Rat BMSCs were isolated and assigned into control group, inflammation group (lipopolysaccharide was added to cells); and si-ILK group (ILK siRNA was transfected into the inflammation group BMSCs) followed by analysis of cell proliferation by MTT assay, expression of ILK,
Runx2 and OP by real time PCR, ALp activity, TNF-α and IL-6 secretion by ELISA and MAPK/AKT signaling protein expression by western blot. Compared to control, ILK in BMSCs cells in inflammatory environment was significantly upregulated, resulting in inhibition of cell proliferation,
decreased ALP activity, reduced expression of osteogenic genes Runx2 and OP, increased secretion of TNF-α and IL-6, and downregulated p-AKT (P < 0.05); transfection of ILK siRNA down-regulated ILK in inflammatory environment BMSCs, which significantly increased BMSCs
cell proliferation, increased ALP activity and expression of Runx2 and OP, decreased TNF-α and IL-6 secretion and increased p-AKT expression (P < 0.05). ILK expression is increased in BMSCs in an inflammatory environment. Down-regulation of ILK in BMSCs cells in an inflammatory
environment can regulate MAPK/AKT signaling, inhibit inflammatory factors secretion, thereby promoting BMSCs proliferation and osteogenesis differentiation.
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Affiliation(s)
- Liyuan Chen
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Jieliang Hu
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Baojun Zhou
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Yan Li
- Department of Electrophysiology, People’s Hospital of Xingguo County, Ganzhou, Jiangxi, 342400, China
| | - Kongxing Wei
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Jinglei Wang
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Hongyan Lv
- Second Department of Orthopedics, The Third Affiliated Hospital of Gansu University of Traditional Chinese Medicine (First People’s Hospital of Baiyin City), Baiyin, Gansu, 730900, China
| | - Fanyun Zeng
- Emergency Traumatic Surgery, The Affiliated Ganzhou Hospital of Nanchang University (Ganzhou People’s Hospital), Ganzhou, Jiangxi, 341000, China
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Atukorala I, Pathmeswaran A, Makovey J, Metcalf B, Bennell KL, March L, Chang T, Zhang Y, Hunter DJ. Can pain flares in knee osteoarthritis be predicted? Scand J Rheumatol 2021; 50:198-205. [PMID: 33467963 DOI: 10.1080/03009742.2020.1829035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objectives: This study examined whether risk factors for knee osteoarthritis (KOA) pain such as age, gender, body mass index (BMI), baseline pain, and other putative risk factors for knee osteoarthritis pain flares (KOAF) (e.g. knee buckling, injury, mood/stress/social support scores, and footwear) could predict KOAF.Method: People with KOA and previous history of KOAF were selected from a 3 month web-based longitudinal study. KOAF was defined as an increase of ≥ 2 points on a numeric rating scale (compared with background pain) which resolved within 20 days. Predictors assessed at baseline were gender, age, duration of KOA, BMI, pain, knee injury (7 days before), knee buckling (2 days before), Lubben Social Support, Knee Injury and Osteoarthritis Outcome Score, Intermittent and Constant Osteoarthritis Pain score (ICOAP), Positive/Negative Affect Score, and footwear stability/heel height. Outcome was occurrence of any KOAF during the ensuing 30 days. The combined ability of the above variables to predict occurrence of any KOAF was evaluated by multiple logistic regression with a 10-fold cross-validation method to build and internally validate the model. Variables that assessed similar domains were eliminated using receiver operating characteristics curve assessment for best fit.Results: Complete data were available for 313 people (66.6% female, mean ± sd age 62.3 ± 8.2 years, BMI 29.7 ± 6.5 kg/m2). Increasing age, years of osteoarthritis, BMI, background/worst levels of pain, knee injury, knee buckling, ICOAP, and footwear category/heel height significantly predicted the occurrence of KOAF during the following 30 days, with an area under the curve of 0.73 (95% confidence interval 0.67-0.80).Conclusion: A combination of risk factors assessed at baseline, including exposures with potential to vary, successfully predicts the KOAF in the ensuing 30 days.
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Affiliation(s)
- I Atukorala
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - A Pathmeswaran
- Department of Public Health, University of Kelaniya, Ragama, Sri Lanka
| | - J Makovey
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia
| | - B Metcalf
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - K L Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - L March
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia.,Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - T Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Y Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - D J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia.,Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
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27
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Atukorala I, Pathmeswaran A, Batuwita N, Rajapaksha N, Ratnasiri V, Wijayaratne L, De Silva M, Chang T, Zhang Y, Hunter DJ. Is being barefoot, wearing shoes and physical activity associated with knee osteoarthritis pain flares? Data from a usually barefoot Sri Lankan cohort. Int J Rheum Dis 2020; 24:96-105. [PMID: 33200581 DOI: 10.1111/1756-185x.14024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/18/2020] [Accepted: 10/15/2020] [Indexed: 01/13/2023]
Abstract
AIM To identify the association between hours of being barefoot/wearing footwear, physical activity (PA) and knee osteoarthritis pain flares (KOAF). METHODS Persons with a diagnosis of knee osteoarthritis, who reported previous KOAF, were followed up in a 3 months long telephone-based case-crossover study. Exposures to risk factors were assessed every 10 days and whenever the participants experienced a KOAF. Conditional logistic regression examined associations of KOAF with following: hours of being barefoot/using footwear and PA performed (P < .05). RESULTS There were 260 persons recruited, of whom 183 continued longitudinal follow up. Of them, 120 persons had at least one valid KOAF and control period. Participants were female (90%) with mean (SD) age and body mass index of 59.9 (7.0) years, 28.0 (5.0) kg/m2 respectively. Participants were barefoot for a mean duration of 12.7 hours (SD 4.6) and used footwear for 5.1 (SD 4.7) hours daily; 99% wore heel heights <2.5 cm. Duration of being barefoot, 1 and 2 days before, demonstrated reduced multivariate odds of KOAF (odds ratio [OR] = 0.85; 95% CI 0.80-0.90). Moderate PA performed 1, 2 days prior was associated with a significantly increased risk of KOAF (multivariate OR 4.29; 2.52-7.30 and OR 3.36; 2.01-5.61). Similarly, hours of using footwear 1 and 2 days before flare demonstrated increased odds of KOAF (OR 1.15; 1.07-1.23 and 1.10; 1.03-1.18). CONCLUSIONS Increased duration of being barefoot 1 to 2 days before is associated with reduced risk of KOAF. Performing moderate PA 1 to 2 days before was associated with an increased risk of KOAF.
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Affiliation(s)
- Inoshi Atukorala
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | | | - Nishamani Batuwita
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Nimesha Rajapaksha
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Vishmi Ratnasiri
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Lalith Wijayaratne
- Department of Rheumatology and Rehabilitation (General), National Hospital Sri Lanka, Colombo, Sri Lanka
| | - Monika De Silva
- Department of Rheumatology and Rehabilitation (General), National Hospital Sri Lanka, Colombo, Sri Lanka
| | - Thashi Chang
- Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David John Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney, Sydney, Australia.,Rheumatology Department, Royal North Shore Hospital, Sydney, NSW, Australia
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Prevalence, Severity, and Correlates of Pain Flares in Response to a Repeated Sit-to-Stand Activity: A Cross-sectional Study of 14 902 Patients With Knee and Hip Osteoarthritis in Primary Care. J Orthop Sports Phys Ther 2020; 50:309-318. [PMID: 31492080 DOI: 10.2519/jospt.2019.9125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine prevalence, severity, and clinical correlates of pain flares in response to a repeated sit-to-stand activity. DESIGN Cross-sectional. METHODS The analyses included 11 013 patients with knee osteoarthritis (OA) and 3889 patients with hip OA who completed a 30-second chair-stand test before starting the Good Life with osteoArthritis in Denmark treatment program. Prevalence and severity of pain flares were evaluated by change in self-reported joint pain intensity on an 11-point numeric rating scale after the test. Correlates with pain flares (an increase on the numeric rating scale of 2 points or greater) were assessed using regression analyses. RESULTS One out of 3 patients with knee OA and 1 out of 5 patients with hip OA experienced pain flares (numeric rating scale of 2 or greater). Low knee/hip confidence, 3 or more painful body sites, fewer than 12 chair stands in 30 seconds, and body mass index of 30 kg/m2 or greater were associated with pain flares in response to the 30-second chair-stand test in patients with knee and hip OA. Low self-efficacy and joint stiffness were associated with pain flares in patients with knee OA. Using pain medication was associated with pain flares in patients with hip OA. CONCLUSION Pain flares in response to a repeated sit-to-stand activity were common in patients with knee and hip OA. The clinical correlates associated with pain flares included joint confidence, functional performance, and body mass index, and are potentially modifiable with patient education, exercise therapy, and weight loss, respectively. J Orthop Sports Phys Ther 2020;50(6):309-318. Epub 6 Sep 2019. doi:10.2519/jospt.2019.9125.
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Cuyul-Vásquez I, Leiva-Sepúlveda A, Catalán-Medalla O, Araya-Quintanilla F, Gutiérrez-Espinoza H. The addition of blood flow restriction to resistance exercise in individuals with knee pain: a systematic review and meta-analysis. Braz J Phys Ther 2020; 24:465-478. [PMID: 32198025 DOI: 10.1016/j.bjpt.2020.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 02/04/2020] [Accepted: 03/03/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Blood flow restriction (BFR) is an effective clinical intervention used to increase strength in healthy individuals. However, its effects on pain and function in individuals with knee pain are unknown. OBJECTIVE To determine the effectiveness of adding BFR to resistance exercise for pain relief and improvement of function in patients with knee pain. METHODS Systematic review with meta-analysis of randomized clinical trials. Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases were searched from inception to May 2019. Randomized clinical trials that compared resistance exercise with or without BFR to treat knee pain and function in individuals older than 18 years of age with knee pain were included. RESULTS Eight randomized clinical trials met the eligibility criteria and for the quantitative synthesis, five studies were included. The pooled standardized mean difference (SMD) estimate showed that resistance exercises with BFR was not more effective than resistance exercises for reducing pain (SMD: -0.37cm, 95% CI=-0.93, 0.19) and improving knee function (SMD=-0.23 points, 95% CI=-0.71, 0.26) in patients with knee pain. CONCLUSION In the short term, there is low quality of evidence that resistance exercise with BFR does not provide significant differences in pain relief and knee function compared to resistance exercises in patients with knee pain. PROSPERO registration number: CRD42018102839.
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Affiliation(s)
- Iván Cuyul-Vásquez
- Faculty of Health, Therapeutic Process Department, Temuco Catholic University, Temuco, Chile
| | | | - Oscar Catalán-Medalla
- Faculty of Health, Therapeutic Process Department, Temuco Catholic University, Temuco, Chile
| | - Felipe Araya-Quintanilla
- Rehabilitation and Health Research Center (CIRES), Universidad de las Américas, Santiago, Chile; Faculty of Health Sciences, Universidad SEK, Santiago, Chile
| | - Hector Gutiérrez-Espinoza
- Rehabilitation and Health Research Center (CIRES), Universidad de las Américas, Santiago, Chile; Physical Therapy Department, Clinical Hospital San Borja Arriaran, Santiago, Chile.
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30
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Riddle DL. Prevalence of similar or worse symptom and osteoarthritis severity of index and contralateral knees prior to knee arthroplasty: A cross-sectional multicenter cohort study. Knee 2020; 27:485-492. [PMID: 31874821 PMCID: PMC7196028 DOI: 10.1016/j.knee.2019.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/21/2019] [Accepted: 10/28/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients considering knee arthroplasty (KA) and consulting orthopedic surgeons use different criteria to judge surgical appropriateness with surgeons placing high priority on osteoarthritis (OA) severity and age while patients place greatest emphasis on pain severity. In the face of fluctuating symptoms and high rates of bilateral knee OA, selection of the optimal knee for KA surgery can be challenging. This study examined osteoarthritis and symptom severity profiles of index versus contralateral knees of persons preparing for KA. METHODS The nine-year Osteoarthritis Initiative data from 427 participants and five-year Multicenter Osteoarthritis Study data from 377 participants undergoing KA were included. The Western Ontario and McMaster Universities Osteoarthritis Index Pain, Function, and Stiffness Scales for both knees and radiographic readings were obtained at the visit prior to knee arthroplasty. Radar plots illustrated symptom and OA severity. Prevalence estimates of the proportion of contralateral knees with comparable or worse symptoms and OA severity relative to the index knee were reported. RESULTS The prevalence of comparable or worse knee OA on the contralateral knees as compared with index knees is 26% (95% CI = 22%, 30%). Prevalence of the same or worse WOMAC Pain for the contralateral knees relative to the index knees is 17% (95% CI = 14%, 21%). CONCLUSIONS The prevalence of comparable/worse knee OA or symptoms on the contralateral knees relative to index knees of persons undergoing unilateral KA is substantial. Methods for selecting the surgical knee should be reconsidered for this substantial subgroup of patients.
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31
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DUICA L, SZAKÁCS J, SILIȘTEANU Sînziana Călina. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction. Osteoarthritis, which is a cause of chronic pain and disability with manifestation in any joint, with greater frequency in the joints of the lower limbs, upper limbs, but also at the spine level , affects around 250 million people in the entire world. This condition affects around 10% of the global population (18) and has an impressive impact on people, as it is one of the first 5 causes of disability. Material and method. The objectives of the treatment made by the patients diagnosed with knee osteoarthritis were: pain reduction, increased joint amplitude, increased muscle strength, increased muscle tone, increased quality of life and reintegration into the family and social environment. In the study, there were discussed demographic data regarding the patients. In order to assess the pain parameter, the VAS scale was used, as well as WOMAC subscales. To assess the quality of life of patients with knee osteoarthritis, the QOL scale (Quality of Life) was used. Anxiety was assessed with the help of a test that comprises the evaluation of symptoms at the cognitive, behavioral and physical level. Results and discussions. The pain was evaluated on the VAS scale, having a statistically significant evolution for the evaluation moments. Also with the help of the WOMAC index, two other parameters were evaluated, namely joint rigidity and functional capacity, the results being statistically significant in the 3 evaluation moments. The patients’ anxiety was evaluated with the help of the anxiety test; the results obtained were statistically significant at the 3 evaluation moments. Conclusions. It is vital that the recovery treatment in osteoarthritis be individualized and adapted to the age group. In our group, it enabled the reduction of pain and anxiety, the increase of the functional capacity and the quality of the patients’ lives.Taking into account the fact that the most affected group in the study group was the active professional one, we can evaluate the size of the recovery and the social, family and professional integration for these patients.
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Affiliation(s)
- Lavinia DUICA
- 1 Lucian Blaga University of Sibiu, Faculty of Medicine, Sibiu, România 2 Hospital of Psychiatry „Doctor Gheorghe Preda” Sibiu, Romania
| | - Juliánna SZAKÁCS
- 3George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Faculty of Medicine, Department of Biophysics
| | - SILIȘTEANU Sînziana Călina
- 4 Railway Hospital Iasi - Specialty Ambulatory of Suceava 5 "Stefan cel Mare" University of Suceava FEFS-DSDU
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32
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Abram SGF, Judge A, Khan T, Beard DJ, Price AJ. Rates of knee arthroplasty in anterior cruciate ligament reconstructed patients: a longitudinal cohort study of 111,212 procedures over 20 years. Acta Orthop 2019; 90:568-574. [PMID: 31288595 PMCID: PMC6844427 DOI: 10.1080/17453674.2019.1639360] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Long-term rates of knee arthroplasty in patients with anterior cruciate ligament (ACL) injury who undergo ligament reconstruction (ACLr) are unclear. We determined this risk of arthroplasty through comparison with the general population.Patients and methods - All patients undergoing an ACLr in England, 1997-2017, were identified from national hospital statistics. Patients subsequently undergoing a knee arthroplasty were identified and survival analysis was performed (survival without undergoing knee arthroplasty). A Cox proportional hazards model was used to identify factors associated with knee arthroplasty. Relative risk of knee arthroplasty (total or partial) in comparison with the general population was determined.Results - 111,212 ACLr patients were eligible for analysis (mean age 29; 77% male). Overall, 0.46% (95% confidence interval [CI] 0.40-0.52) ACLr patients underwent knee arthroplasty within 5 years, 0.97% (CI 0.82-1.2) within 10 years, and 1.8% (CI 1.4-2.3) within 15 years. Knee arthroplasty risk was greater in older age groups and women. In comparison with the general population, the relative risk of undergoing arthroplasty at a younger age (at time of arthroplasty) was elevated: at 30-39 years (risk ratio [RR] 20; CI 11-35), 40-49 years (RR 7.5; CI 5.5-10), and 50-59 years (RR 2.5; CI 1.8-3.5), but not 60-69 years (RR 1.7; CI 0.93-3.2).Interpretation - Patients sustaining an ACL injury who undergo ACLr are at elevated risk of subsequent knee arthroplasty in comparison with the general population. Although the absolute rate of arthroplasty is low, the risk of arthroplasty at a younger age is particularly elevated. When the outcome of shared decision-making is ACLr, this data will help inform patients and clinicians about the long-term risk of requiring knee arthroplasty.
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Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; ,NIHR Biomedical Research Centre, Oxford; ,Correspondence:
| | | | - Tanvir Khan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; ,NIHR Biomedical Research Centre, Oxford; ,Faculty of Medicine & Health Sciences, University of Nottingham, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; ,NIHR Biomedical Research Centre, Oxford;
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, UK; ,NIHR Biomedical Research Centre, Oxford;
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Rice D, McNair P, Huysmans E, Letzen J, Finan P. Best Evidence Rehabilitation for Chronic Pain Part 5: Osteoarthritis. J Clin Med 2019; 8:jcm8111769. [PMID: 31652929 PMCID: PMC6912819 DOI: 10.3390/jcm8111769] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 09/30/2019] [Indexed: 02/06/2023] Open
Abstract
Osteoarthritis (OA) is a leading cause of chronic pain and disability in older adults, which most commonly affects the joints of the knee, hip, and hand. To date, there are no established disease modifying interventions that can halt or reverse OA progression. Therefore, treatment is focused on alleviating pain and maintaining or improving physical and psychological function. Rehabilitation is widely recommended as first-line treatment for OA as, in many cases, it is safer and more effective than the best-established pharmacological interventions. In this article, we describe the presentation of OA pain and give an overview of its peripheral and central mechanisms. We then provide a state-of-the-art review of rehabilitation for OA pain—including self-management programs, exercise, weight loss, cognitive behavioral therapy, adjunct therapies, and the use of aids and devices. Next, we explore several promising directions for clinical practice, including novel education strategies to target unhelpful illness and treatment beliefs, methods to enhance the efficacy of exercise interventions, and innovative, brain-directed treatments. Finally, we discuss potential future research in areas, such as treatment adherence and personalized rehabilitation for OA pain.
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Affiliation(s)
- David Rice
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 1142, New Zealand.
- Waitemata Pain Service, Department of Anaesthesiology and Perioperative Medicine, Waitemata District Health Board, Auckland 1142, New Zealand.
| | - Peter McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland 1142, New Zealand.
| | - Eva Huysmans
- Pain in Motion International Research Group.
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, 1090 Brussel, Belgium.
- Department of Public Health (GEWE), Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1090 Brussels, Belgium.
- I-CHER, Interuniversity Center for Health Economics Research, 1090 Brussels, Belgium.
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, 1090 Brussels, Belgium.
| | - Janelle Letzen
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21287, USA.
| | - Patrick Finan
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University, Baltimore, MD 21287, USA.
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Schiphof D, Runhaar J, Waarsing JH, van Spil WE, van Middelkoop M, Bierma-Zeinstra SMA. The clinical and radiographic course of early knee and hip osteoarthritis over 10 years in CHECK (Cohort Hip and Cohort Knee). Osteoarthritis Cartilage 2019; 27:1491-1500. [PMID: 31202721 DOI: 10.1016/j.joca.2019.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 05/29/2019] [Accepted: 06/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the radiographic and symptomatic course in subjects with hip or knee complaints suspected of early osteoarthritis (OA). DESIGN CHECK (Cohort Hip and Cohort Knee) is a multicenter, prospective observational cohort study of 1,002 subjects with first complaints in knee(s) and/or hip(s) (age 56 ± 5 years; 79% female; body mass index (BMI) 26 ± 4 kg/m2). Visits took place at baseline and at 2, 5, 8, and 10 year follow-up. At each visit, questionnaires were administered, physical examination performed, and X-ray images obtained. Clinical OA was defined according to the clinical American College of Rheumatism (ACR) criteria. Radiographic OA (ROA) was defined as Kellgren and Lawrence score (K&L) ≥2. RESULTS 83% of the subjects reported knee pain, 59% hip pain, and 42% reported both hip and knee pain at baseline. 85% of the subjects completed 10-year follow-up. Pain scores remained rather stable over time, although individual scores fluctuated. A total of 138 subjects never fulfilled the clinical American College of Rheumatology (ACR) criteria. 60% (n = 601) had ROA in one or both knees, and 51% (n = 513) had ROA in one or both hips at 10 years. Only 13.5% of the subjects did not develop ROA after 10 years. Most joint replacements (n = 52 (57%)) took place in subjects with multiple affected joints. CONCLUSIONS The symptomatic course in subjects with hip or knee complaints suspected of OA remained fairly stable on population level, though individual scores fluctuated. The radiological course was progressive, with joint replacements particularly in subjects with both hip and knee OA.
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Affiliation(s)
- D Schiphof
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - J Runhaar
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - J H Waarsing
- Department of Orthopedics, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - W E van Spil
- Department of Rheumatology & Clinical Immunology, UMC Utrecht, Utrecht, the Netherlands
| | - M van Middelkoop
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - S M A Bierma-Zeinstra
- Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Orthopedics, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Abram SGF, Judge A, Beard DJ, Carr AJ, Price AJ. Long-term rates of knee arthroplasty in a cohort of 834 393 patients with a history of arthroscopic partial meniscectomy. Bone Joint J 2019; 101-B:1071-1080. [DOI: 10.1302/0301-620x.101b9.bjj-2019-0335.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Aims The aim of this study was to determine the long-term risk of undergoing knee arthroplasty in a cohort of patients with meniscal tears who had undergone arthroscopic partial meniscectomy (APM). Patients and Methods A retrospective national cohort of patients with a history of isolated APM was identified over a 20-year period. Patients with prior surgery to the same knee were excluded. The primary outcome was knee arthroplasty. Hazard ratios (HRs) were adjusted by patient age, sex, year of APM, Charlson comorbidity index, regional deprivation, rurality, and ethnicity. Risk of arthroplasty in the index knee was compared with the patient’s contralateral knee (with vs without a history of APM). A total of 834 393 patients were included (mean age 50 years; 37% female). Results Of those with at least 15 years of follow-up, 13.49% (16 256/120 493; 95% confidence interval (CI) 13.30 to 13.69) underwent subsequent arthroplasty within this time. In women, 22.07% (95% CI 21.64 to 22.51) underwent arthroplasty within 15 years compared with 9.91% of men (95% CI 9.71 to 10.12), corresponding to a risk ratio (RR) of 2.23 (95% CI 2.16 to 2.29). Relative to the general population, patients with a history of APM were over ten times more likely (RR 10.27; 95% CI 10.07 to 10.47) to undergo arthroplasty rising to almost 40 times more likely (RR 39.62; 95% CI 27.68 to 56.70) at a younger age (30 to 39 years). In patients with a history of APM in only one knee, the risk of arthroplasty in that knee was greatly elevated in comparison with the contralateral knee (no APM; HR 2.99; 95% CI 2.95 to 3.02). Conclusion Patients developing a meniscal tear undergoing APM are at greater risk of knee arthroplasty than the general population. This risk is three-times greater in the patient’s affected knee than in the contralateral knee. Women in the cohort were at double the risk of progressing to knee arthroplasty compared with men. These important new reference data will inform shared decision making and enhance approaches to treatment, prevention, and clinical surveillance. Cite this article: Bone Joint J 2019;101-B:1071–1080.
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Affiliation(s)
- Simon G. F. Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
- Musculoskeletal Research Unit, University of Bristol, Bristol, UK
- NIHR Biomedical Research Centre, Bristol, UK
| | - David J. Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
| | - Andrew J. Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
| | - Andrew J. Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
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Delineating conditions and subtypes in chronic pain using neuroimaging. Pain Rep 2019; 4:e768. [PMID: 31579859 PMCID: PMC6727994 DOI: 10.1097/pr9.0000000000000768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/22/2019] [Accepted: 05/25/2019] [Indexed: 12/19/2022] Open
Abstract
Differentiating subtypes of chronic pain still remains a challenge—both from a subjective and objective point of view. Personalized medicine is the current goal of modern medical care and is limited by the subjective nature of patient self-reporting of symptoms and behavioral evaluation. Physiology-focused techniques such as genome and epigenetic analyses inform the delineation of pain groups; however, except under rare circumstances, they have diluted effects that again, share a common reliance on behavioral evaluation. The application of structural neuroimaging towards distinguishing pain subtypes is a growing field and may inform pain-group classification through the analysis of brain regions showing hypertrophic and atrophic changes in the presence of pain. Analytical techniques such as machine-learning classifiers have the capacity to process large volumes of data and delineate diagnostically relevant information from neuroimaging analysis. The issue of defining a “brain type” is an emerging field aimed at interpreting observed brain changes and delineating their clinical identity/significance. In this review, 2 chronic pain conditions (migraine and irritable bowel syndrome) with similar clinical phenotypes are compared in terms of their structural neuroimaging findings. Independent investigations are compared with findings from application of machine-learning algorithms. Findings are discussed in terms of differentiating patient subgroups using neuroimaging data in patients with chronic pain and how they may be applied towards defining a personalized pain signature that helps segregate patient subgroups (eg, migraine with and without aura, with or without nausea; irritable bowel syndrome vs other functional gastrointestinal disorders).
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Investigating intraindividual pain variability: methods, applications, issues, and directions. Pain 2019; 160:2415-2429. [DOI: 10.1097/j.pain.0000000000001626] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Thomas MJ, Rathod-Mistry T, Harper S, Parry EL, Pope C, Neogi T, Peat G. Acute Flares of Knee Osteoarthritis (the ACT-FLARE Study): Protocol for a Web-Based Case-Crossover Study in Community-Dwelling Adults. JMIR Res Protoc 2019; 8:e13428. [PMID: 31008709 PMCID: PMC6658279 DOI: 10.2196/13428] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 01/22/2023] Open
Abstract
Background The cardinal feature of osteoarthritis (OA) is pain. Although heterogeneity in pain and function have been demonstrated in the long-term course of OA, the more proximate determinants of acute flare-ups remain less clear. How short-term intermittent or transient exposures trigger acute flare-ups has important implications for effective and sustainable self-management strategies. Objective The primary objective of this study is to identify potential triggers of acute flares in knee OA. Secondary objectives are to determine their course and consequences and describe high-risk participant profiles. Methods We carried out a Web-based case-crossover study. This study aims to recruit 620 community-dwelling adults aged ≥40 years, resident in England, and who have knee pain, with or without a recorded diagnosis of knee OA, and no preexisting diagnosis of inflammatory arthropathy. Participants will be recruited via 3 routes: (1) general practice registers, (2) offline community advertisement, and (3) online social media advertisement. By using questionnaires comparing periods before participants’ self-reported flare-up episodes (hazard periods) with periods during the study when their knee OA symptoms are stable (control periods), triggers preceding flare-ups will be identified and examined using conditional logistic regression. Time-to-resolution of flare-up will be examined by monitoring people’s daily pain, bothersomeness, and medication usage until the participant reports when their flare-up episode ends. Rates of flare-ups will be examined across different participant and flare characteristics using regression models to identify high-risk participant profiles. A study-specific Patient Advisory Group (PAG) is providing suggestion, input, and ongoing support for all stages of the research process. Results Participant recruitment opened in July 2018 and is anticipated to continue for 6 months. The study results will be disseminated through a number of channels, including relevant national or international conferences and peer-reviewed publication in a medical journal, via advocacy or charity organizations, such as Versus Arthritis and across social media. Findings will be fed back to members of our PAG, study participants, and clinicians from participating primary care general practices. The PAG will also take an active role in the overall dissemination strategy. Conclusions This study will provide empirical evidence to help patients identify common knee OA flare triggers and provide health care professionals with questions to identify patients at most risk of frequent flare-ups. International Registered Report Identifier (IRRID) DERR1-10.2196/13428
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Affiliation(s)
- Martin J Thomas
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom.,Haywood Academic Rheumatology Centre, Haywood Hospital, Midlands Partnership NHS Foundation Trust, Staffordshire, United Kingdom
| | - Trishna Rathod-Mistry
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom.,Keele Clinical Trials Unit, Keele University, Staffordshire, United Kingdom
| | - Stephen Harper
- Keele Clinical Trials Unit, Keele University, Staffordshire, United Kingdom
| | - Emma L Parry
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Christopher Pope
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Tuhina Neogi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - George Peat
- Primary Care Centre Versus Arthritis, Research Institute for Primary Care and Health Sciences, Keele University, Staffordshire, United Kingdom
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Timmermans EJ, de Koning EJ, van Schoor NM, van der Pas S, Denkinger MD, Dennison EM, Maggi S, Pedersen NL, Otero Á, Peter R, Cooper C, Siviero P, Castell MV, Herbolsheimer F, Edwards M, Limongi F, Deeg DJH, Schaap LA. Within-person pain variability and physical activity in older adults with osteoarthritis from six European countries. BMC Musculoskelet Disord 2019; 20:12. [PMID: 30611248 PMCID: PMC6320627 DOI: 10.1186/s12891-018-2392-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/21/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This study examines the association of both pain severity and within-person pain variability with physical activity (PA) in older adults with osteoarthritis (OA). METHODS Data from the European Project on OSteoArthritis were used. At baseline, clinical classification criteria of the American College of Rheumatology were used to diagnose OA in older adults (65-85 years). At baseline and 12-18 months follow-up, frequency and duration of participation in the activities walking, cycling, gardening, light and heavy household tasks, and sports activities were assessed with the Longitudinal Aging Study Amsterdam Physical Activity Questionnaire. Physical activity was calculated in kcal/day, based on frequency, duration, body weight and the metabolic equivalent of each activity performed. At baseline and 12-18 months follow-up, pain severity was assessed using the pain subscales of the Western Ontario and McMaster Universities OA Index and the Australian/Canadian Hand OA Index. Within-person pain variability was assessed using two-week pain calendars that were completed at baseline, 6 months follow-up and 12-18 months follow-up. RESULTS Of all 669 participants, 70.0% were women. Sex-stratified multiple linear regression analyses showed that greater pain severity at baseline was cross-sectionally associated with less PA in women (Ratio = 0.95, 95% CI = 0.90-0.99), but not in men (Ratio = 0.99, 95% CI = 0.85-1.15). The longitudinal analyses showed a statistically significant inverse association between pain severity at baseline and PA at follow-up in women (Ratio = 0.94, 95% CI = 0.89-0.99), but not in men (Ratio = 1.00, 95% CI = 0.87-1.11). Greater pain variability over 12-18 months was associated with more PA at follow-up in men (Ratio = 1.18, 95% CI = 1.01-1.38), but not in women (Ratio = 0.94, 95% CI = 0.86-1.03). CONCLUSIONS Greater pain severity and less pain variability are associated with less PA in older adults with OA. These associations are different for men and women. The observed sex differences in the various associations should be studied in more detail and need replication in future research.
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Affiliation(s)
- Erik J. Timmermans
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, VU University Medical Center, Amsterdam Public Health Research Institute, De Boelelaan 1089A, 1081HV, Amsterdam, Netherlands
| | - Elisa J. de Koning
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, VU University Medical Center, Amsterdam Public Health Research Institute, De Boelelaan 1089A, 1081HV, Amsterdam, Netherlands
| | - Natasja M. van Schoor
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, VU University Medical Center, Amsterdam Public Health Research Institute, De Boelelaan 1089A, 1081HV, Amsterdam, Netherlands
| | - Suzan van der Pas
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, VU University Medical Center, Amsterdam Public Health Research Institute, De Boelelaan 1089A, 1081HV, Amsterdam, Netherlands
| | - Michael D. Denkinger
- Geriatric Research Unit / Institute of Epidemiology and Medical Biometry, AGAPLESION Bethesda Hospital, Ulm University, Ulm, Germany
| | - Elaine M. Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Stefania Maggi
- National Research Council, Aging Branch, Institute of Neuroscience, Padova, Italy
| | - Nancy L. Pedersen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Ángel Otero
- Department of Preventive Medicine and Public Health, Unit of Primary Care and Family Medicine, Faculty of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Richard Peter
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Paola Siviero
- National Research Council, Aging Branch, Institute of Neuroscience, Padova, Italy
| | - Maria Victoria Castell
- Department of Preventive Medicine and Public Health, Unit of Primary Care and Family Medicine, Faculty of Medicine, Universidad Autonoma de Madrid, Madrid, Spain
| | - Florian Herbolsheimer
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
| | - Mark Edwards
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Federica Limongi
- National Research Council, Aging Branch, Institute of Neuroscience, Padova, Italy
| | - Dorly J. H. Deeg
- Department of Epidemiology and Biostatistics, Amsterdam University Medical Center, VU University Medical Center, Amsterdam Public Health Research Institute, De Boelelaan 1089A, 1081HV, Amsterdam, Netherlands
| | - Laura A. Schaap
- Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Foucher KC, Chmell SJ, Courtney CA. Duration of symptoms is associated with conditioned pain modulation and somatosensory measures in knee osteoarthritis. J Orthop Res 2019; 37:136-142. [PMID: 30325066 DOI: 10.1002/jor.24159] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 09/12/2018] [Indexed: 02/04/2023]
Abstract
Impaired descending pain inhibition has been linked to chronic pain and poorer patient outcomes. Vibration perception threshold (VPT) has also been observed and linked to radiographic stage of OA. However, it is not known how duration of symptoms may influence these neurophysiological measures. Our purpose was to evaluate the relationship between duration of symptoms and conditioned pain modulation (CPM), a measure of descending pain inhibition, and VPT, and to determine whether these relationships differed in men and women seeking orthopedic care. We evaluated 18 men and 27 women with moderate to severe knee OA. We assessed CPM using a submaximal-effort tourniquet test: Pressure pain threshold (PPT) at the symptomatic knee was evaluated before and after a noxious stimulus. CPM impairment was indicated by a ratio of pre-to-post stimulus PPT ≥1. VPT was assessed using a biothesiometer at the medial femoral condyle. We used chi-square, t-tests and Pearson correlations to address study questions. 72% of men, but only 44% of women had CPM impairment. Duration of symptoms was associated with CPM impairment in women (R = 0.566, p = 0.003) but not men (R = 0.366, p = 0.135). Duration of symptoms was also associated with VPT in both men (R = 0.580, p = 0.012) and women (R = 0.406, p = 0.039). These results suggest that longer duration of knee OA may predict more severe pain sensitization and that important sex differences exist in descending pain inhibition in people with chronic knee OA that may affect disease and course of treatment in male and female patients. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Kharma C Foucher
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois
| | - Samuel J Chmell
- Department of Orthopedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Carol A Courtney
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, Illinois
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Parry EL, Thomas MJ, Peat G. Defining acute flares in knee osteoarthritis: a systematic review. BMJ Open 2018; 8:e019804. [PMID: 30030311 PMCID: PMC6059300 DOI: 10.1136/bmjopen-2017-019804] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 04/10/2018] [Accepted: 05/15/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To identify and critically synthesise definitions of acute flares in knee osteoarthritis (OA) reported in the medical literature. DESIGN Systematic review and narrative synthesis. We searched Medline, EMBASE, Web of science and six other electronic databases (inception to July 2017) for original articles and conference abstracts reporting a definition of acute flare (or synonym) in humans with knee OA. There were no restrictions by language or study design (apart from iatrogenic-induced flare-ups, eg, injection-induced). Data extraction comprised: definition, pain scale used, flare duration or withdrawal period, associated symptoms, definition rationale, terminology (eg, exacerbation or flare), baseline OA severity, age, gender, sample size and study design. RESULTS Sixty-nine articles were included (46 flare design trials, 17 observational studies, 6 other designs; sample sizes: 15-6085). Domains used to define flares included: worsening of signs and symptoms (61 studies, 27 different measurement tools), specifically increased pain intensity; minimum pain threshold at baseline (44 studies); minimum duration (7 studies, range 8-48 hours); speed of onset (2 studies, defined as 'sudden' or 'quick'); requirement for increased medication (2 studies). No definitions included activity interference. CONCLUSIONS The concept of OA flare appears in the medical literature but most often in the context of flare design trials (pain increases observed after stopping usual treatment). Key domains, used to define acute events in other chronic conditions, appear relevant to OA flare and could provide the basis for consensus on a single, agreed definition of 'naturally occurring' OA flares for research and clinical application. PROSPERO REGISTRATION NUMBER CRD42014010169.
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Affiliation(s)
- Emma L Parry
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Martin J Thomas
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
| | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, UK
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Trouvin AP, Marty M, Goupille P, Perrot S. Determinants of daily pain trajectories and relationship with pain acceptability in hip and knee osteoarthritis. A national prospective cohort study on 886 patients. Joint Bone Spine 2018; 86:245-250. [PMID: 30025954 DOI: 10.1016/j.jbspin.2018.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/20/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To study daily pain trajectories (DPT) in patients with knee (KOA) and hip osteoarthritis (HOA) over a one-month period and identify relationships with patients characteristics and acceptability. METHODS This prospective, multicenter cohort study was conducted in France by 602 GPs, on outpatients, with painful KOA or HOA. Patients were asked to fill-in a 28-days daily pain diary. DPT were determined by the difference between daily pain and mean pain over 28 days. Pain peaks were defined as an increase of more than 1 point above the mean for up to three consecutive days. The number of pain peaks over the 28 day period allowed classifying the patient's pain trajectory as either "stable" or "unstable". A logistic regression model was used to identify predicting factors associated with stable pain profile. RESULTS Overall, 1645 patients were included and 886 were analyzed, (56% women, 67.8 years, BMI 27.6 kg/m2, pain 6.0, KOA 71.3%). At one month, stable DPT was found in 59.5% of the patients whatever OA location. In HOA, a shorter duration of disease and pain, a greater disability and in KOA, a more recent disease, morning stiffness ≥ 15 minutes and flare-up were independent factors associated with "stable" DPT. At one month, acceptable pain state was more frequent (65.4%) in patients with stable profiles. CONCLUSION In lower limb OA, pain is mostly stable over a 28-days period. Pain is better accepted when stable, with different determining factors according location. DPT should be considered when establishing HOA and KOA management.
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Affiliation(s)
- Anne-Priscille Trouvin
- Inserm U 987, centre d'évaluation et traitement de la douleur, hôpital Cochin, université Paris Descartes, 75014 Paris, France.
| | - Marc Marty
- Service de rhumatologie, centre hospitalier Henri-Mondor, 94010 Créteil, France; Université Paris XII, 94010 Créteil, France
| | - Philippe Goupille
- Service de rhumatologie, CHRU de Tours, 37044 Tours cedex, France; Université de Tours, 37 Tours, 37020 Tours cedex 1, France
| | - Serge Perrot
- Inserm U 987, centre d'évaluation et traitement de la douleur, hôpital Cochin, université Paris Descartes, 75014 Paris, France
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Liu SH, Dubé CE, Eaton CB, Driban JB, McAlindon TE, Lapane KL. Longterm Effectiveness of Intraarticular Injections on Patient-reported Symptoms in Knee Osteoarthritis. J Rheumatol 2018; 45:1316-1324. [PMID: 29907665 DOI: 10.3899/jrheum.171385] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE We examined the longterm effectiveness of corticosteroid or hyaluronic acid injections in relieving symptoms among persons with knee osteoarthritis (OA). METHODS Using Osteoarthritis Initiative data, a new-user design was applied to identify participants initiating corticosteroid or hyaluronic acid injections (n = 412). Knee symptoms (pain, stiffness, function) were measured using The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). We used marginal structural models adjusting for time-varying confounders to estimate the effect on symptoms of newly initiated injection use compared to nonusers over 2 years of followup. RESULTS Among 412 participants initiating injections, 77.2% used corticosteroid injections and 22.8% used hyaluronic acid injections. About 18.9% had additional injection use after initiation, but switching between injection types was common. Compared to nonusers, on average, participants initiating a corticosteroid injection experienced a worsening of pain (yearly worsening: 1.24 points, 95% CI 0.82-1.66), stiffness (yearly worsening: 0.30 points, 95% CI 0.10-0.49), and physical functioning (yearly worsening: 2.62 points, 95% CI 0.94-4.29) after adjusting for potential confounders with marginal structural models. Participants initiating hyaluronic acid injections did not show improvements of WOMAC subscales (pain: 0.50, 95% CI -0.11 to 1.11; stiffness: -0.07, 95% CI -0.38 to 0.24; and functioning: 0.49, 95% CI -1.34 to 2.32). CONCLUSION Although intraarticular injections may support the effectiveness of reducing symptoms in short-term clinical trials, the initiation of corticosteroid or hyaluronic acid injections did not appear to provide sustained symptom relief over 2 years of followup for persons with knee OA.
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Affiliation(s)
- Shao-Hsien Liu
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA. .,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School.
| | - Catherine E Dubé
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA.,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Charles B Eaton
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA.,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Jeffrey B Driban
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA.,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Timothy E McAlindon
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA.,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School
| | - Kate L Lapane
- From the Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, Brown University, Providence; Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island; Division of Rheumatology, Tufts Medical Center, Boston, Massachusetts, USA.,S.H. Liu, PhD, Clinical and Population Health Research Program, Graduate School of Biomedical Sciences, and the Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.E. Dubé, EdD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School; C.B. Eaton, MD, Departments of Family Medicine and Epidemiology, Warren Alpert Medical School and School of Public Health, and Center for Primary Care and Prevention, Memorial Hospital of Rhode Island; J.B. Driban, PhD, Division of Rheumatology, Tufts Medical Center; T.E. McAlindon, MD, Division of Rheumatology, Tufts Medical Center; K.L. Lapane, PhD, Division of Epidemiology of Chronic Diseases and Vulnerable Populations, Department of Quantitative Health Sciences, University of Massachusetts Medical School
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