The Association between Symptoms, Pain Coping Strategies, and Physical Activity Among People with Symptomatic Knee and Hip Osteoarthritis

Relationship Between Patient-reported Outcome Measures and Accelerometer-measured Physical Activity and Sleep in Patients With Postherpetic Neuralgia

OBJECTIVE

Available treatment for chronic neuropathic pain is still limited, and the positive effects are modest. Thus, clinicians aim to improve activity and quality of life despite pain. The objective monitoring of activity is attracting attention in chronic pain assessments. Therefore, we objectively evaluated daytime activity and sleep in patients with postherpetic neuralgia (PHN), using actigraphy to determine risk factors for decreased activity.

METHODS

Participants with PHN wore an actigraph (a wristwatch-like accelerometer) on the nondominant hand. The actigraph measured day-time activity and sleep, which were compared with participant-reported subjective pain and sleep assessments.

RESULTS

Fifty-four individuals with PHN who visited our outpatient clinic completed questionnaires and a week of actigraph monitoring. Subjective scores of pain intensity, neuropathic pain, disability in daily life, pain-catastrophizing thoughts, and insomnia were all well correlated. However, the actigraph-monitored activity levels, using 2 equations, and sleep quality were not associated with any pain or sleep-related subjective scores.

CONCLUSION

The discrepancy between the subjective and objective scores in this study may be due to (1) features of PHN, an archetype of peripheral neuropathic pain affecting no motor nerves, (2) actigraph measurement limitations regarding the sedentary life of the elderly, or (3) activity misperception, a new proposition explaining the discrepancy between subjective and objective measures of activity, similar to the sleep state misperception. In patients with PHN, high pain intensity may be reported in those with highly maintained activity, in which treatment must be selected cautiously to prevent interruption of their physical abilities.

Understanding the biopsychosocial knee osteoarthritis pain experience: an ecological momentary assessment

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.

Prevalence and Risk Factors of Osteoarthritis in Korea: A Cross-Sectional Study

Background and Objectives: The goal of this study is to determine the prevalence of knee osteoarthritis (OA) and risk factors for the disease in Korean adults over the age of 50, as well as to provide basic data for OA prevention through management. Materials and Methods: Based on 2010-2013 data from the Korean National Health and Nutrition Survey, 7962 adults over the age of 50 who participated in radiological tests and health surveys for the diagnosis of osteoarthritis were chosen as participants. Results: The risk factors for OA occurrence were investigated using complex sample multiple logistic regression analysis. According to the findings, the prevalence of knee OA in Korea was 33.3% in this study, with the risk of OA being higher in women, the elderly, people with a lower education level, and people with obesity. Conclusions: To reduce the incidence of OA, interventions and lifestyle changes are needed to prevent the onset of disease in participants with risk factors for OA, such as older women, low education levels, and obesity.

The relationship between experience of knee pain and physical activity participation: A scoping review of quantitative studies

Objectives

Physical activity (PA) in people with knee pain can help to relieve pain and prevent health problems. However, engaging in regular PA is challenging for them due to chronic musculoskeletal pain. An understanding of how the experience of knee pain affects PA is important to minimize the negative effects of knee pain on participation in PA among this population. We examined the quantitative evidence describing the relationship between the experience of knee pain and participation in PA.

Methods

We conducted a scoping review based on the PRISMA-ScR process across 27 items and Peters' methodological framework. Searches using keywords were performed in Medline, PsycINFO, CINAHL and Scopus.

Results

Nine studies were included in this review. While one study clearly showed that increased knee pain increased PA, four studies indicated that knee pain decreased PA among individuals with knee pain. One study revealed that increased knee pain decreased moderate PA, but no significant difference with light intensity PA. Three studies showed that knee pain had no impact on PA. Moreover, psychological factors (catastrophizing and pain-related activity interference) and certain activities of daily living were risk factors for insufficient PA among people with knee pain.

Conclusions

The limited quantitative evidence on the relationship between the experience of knee pain and PA participation highlights a gap in the knowledge base. The review findings found mixed results, with a negative, positive or no relationship between knee pain and levels of PA among individuals with knee pain. The findings also suggest that the relationship can be affected by psychological factors and different levels and types of PA. Therefore, practitioners should consider multi-component interventions which aim to increase PA levels of individuals with knee pain, after considering the above mediating factors.

Objectively measured physical activity levels and adherence to physical activity guidelines in people with multimorbidity-A systematic review and meta-analysis

Objective

To determine levels of objectively measured physical activity (PA) and the proportion of adults with multimorbidity that adheres to PA guidelines.

Methods

All studies, where PA was measured at baseline using an activity monitor in an adult (≥18 years) multimorbid (≥80% of the population had ≥2 chronic conditions) population. A systematic literature search was performed in Medline, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov, opengrey.eu and google.com from inception up until 18^th of January 2022. Risk of bias was assessed with a modified version of the Quality Assessment Tool for Quantitative Studies. A random-effects meta-analyses was performed to estimate daily minutes of sedentary behavior (SB), light PA (LPA), moderate PA (MPA), moderate to vigorous PA (MVPA) and steps. Proportions adhering to PA guidelines was narratively synthesized. Certainty of evidence was determined using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Fifteen studies (2,172 participants) were included. The most frequent combination of conditions were type 2 diabetes and hypertension (six studies). Participants spent a daily average of 500.5 (95% CI: 407.1 to 593.9) minutes in SB, 325.6 (95% CI: 246.4 to 404.7 minutes in LPA and 32.7 (95% CI: 20.2 to 45.3) minutes in MVPA. The mean daily number of steps was 5,145 (95% CI: 4264 to 6026) for people in free-living conditions. The proportion adhering to PA guidelines ranged widely (7.4% to 43%). All studies were rated as at high risk of bias and the certainty of evidence was very low.

Conclusions

PA levels and adherence varied from low to above guideline recommended levels for adults with chronic conditions, depending on PA intensity. The very low certainty of evidence calls for high quality studies focusing on detailed descriptions of PA behavior in people with multimorbidity.

PROSPERO registration number

CRD42020172456.

Objectively-assessed physical activity and self-reported activity pacing in adults with multiple sclerosis: A pilot study

OBJECTIVE

To examine the association between self-reported activity pacing (a strategy to manage fatigue symptoms) and objectively-measured physical activity behaviours in adults with multiple sclerosis.

DESIGN

Single cross-sectional study.

SETTING

Multiple sclerosis rehabilitation centre in Colchester, United Kingdom.

SUBJECTS

Twenty-one adults (59 ± 9 years) with multiple sclerosis.

MAIN MEASURES

Physical activity behaviours (activity level: activity counts per minute; activity variability: highest activity counts per minute each day divided by activity counts per minute on that day) were measured with accelerometers. Self-reported activity pacing (Activity Pacing and Risk of Overactivity Questionnaire), fatigue severity (Fatigue Severity Scale) and health-related quality of life (RAND-12-Item Short-Form Health Survey) were measured. Scatter plots were used to explore associations between measures.

RESULTS

Activity level was 258 ± 133 counts per minutes, activity variability was 4 ± 1, self-reported activity pacing was 3 ± 1, fatigue severity was 5 ± 2 and health-related quality of life was 43 ± 8. Increased self-reported activity pacing was associated with lower activity levels and less variability in daily activities.

CONCLUSION

This investigation suggests that people with multiple sclerosis who have low physical activity levels could be inappropriately using activity pacing as a reactionary response to their multiple sclerosis symptoms.

Assessment of Activity Pacing in Relation to Physical Activity and Health-Related Quality of Life in Adults with Multiple Sclerosis: A Foundation for Further Intervention Development

BACKGROUND

Activity pacing is a behavioral strategy for coping with fatigue, optimizing physical activity (PA) levels, and achieving a paced approach to lifestyle and sustainable self-regulated exercise practice to optimize health and well-being. Yet little is known about how activity pacing affects PA and health-related quality of life (HRQOL) while controlling for fatigue and demographic characteristics over time in adults with multiple sclerosis (MS). This study examined the natural use of activity pacing and how it is associated with PA and HRQOL over time in adults with MS.

METHODS

Sixty-eight adults with MS (mean ± SD age, 45.2 ± 10.9 years) completed questionnaires on their activity pacing, fatigue, PA, and HRQOL 14, 33, and 52 weeks after rehabilitation. Associations between the variables were examined using multilevel models.

RESULTS

No associations were found between activity pacing and PA (β = -0.01, P = .89) or between activity pacing and HRQOL (β = -0.15, P = .09).

CONCLUSIONS

This study provides an initial understanding of how activity pacing relates to PA and HRQOL in people with MS over time and indicates that there is no clear strategy among adults with MS that is successful in improving PA and HRQOL in the short or long term. Persons with MS may benefit from goal-directed activity pacing interventions to improve longitudinal engagement in PA, and the present study provides a foundation for further intervention development.

Satisfaction, Usability, and Compliance With the Use of Smartwatches for Ecological Momentary Assessment of Knee Osteoarthritis Symptoms in Older Adults: Usability Study

Background

Smartwatches enable physicians to monitor symptoms in patients with knee osteoarthritis, their behavior, and their environment. Older adults experience fluctuations in their pain and related symptoms (mood, fatigue, and sleep quality) that smartwatches are ideally suited to capture remotely in a convenient manner.

Objective

The aim of this study was to evaluate satisfaction, usability, and compliance using the real-time, online assessment and mobility monitoring (ROAMM) mobile app designed for smartwatches for individuals with knee osteoarthritis.

Methods

Participants (N=28; mean age 73.2, SD 5.5 years; 70% female) with reported knee osteoarthritis were asked to wear a smartwatch with the ROAMM app installed. They were prompted to report their prior night’s sleep quality in the morning, followed by ecological momentary assessments (EMAs) of their pain, fatigue, mood, and activity in the morning, afternoon, and evening. Satisfaction, comfort, and usability were evaluated using a standardized questionnaire. Compliance with regard to answering EMAs was calculated after excluding time when the watch was not being worn for technical reasons (eg, while charging).

Results

A majority of participants reported that the text displayed was large enough to read (22/26, 85%), and all participants found it easy to enter ratings using the smartwatch. Approximately half of the participants found the smartwatch to be comfortable (14/26, 54%) and would consider wearing it as their personal watch (11/24, 46%). Most participants were satisfied with its battery charging system (20/26, 77%). A majority of participants (19/26, 73%) expressed their willingness to use the ROAMM app for a 1-year research study. The overall EMA compliance rate was 83% (2505/3036 responses). The compliance rate was lower among those not regularly wearing a wristwatch (10/26, 88% vs 16/26, 71%) and among those who found the text too small to read (4/26, 86% vs 22/26, 60%).

Conclusions

Older adults with knee osteoarthritis positively rated the ROAMM smartwatch app and were generally satisfied with the device. The high compliance rates coupled with the willingness to participate in a long-term study suggest that the ROAMM app is a viable approach to remotely collecting health symptoms and behaviors for both research and clinical endeavors.

The impact of mental and somatic stressors on physical activity and sedentary behaviour in adults with type 2 diabetes mellitus: a diary study

Background

Adopting an active lifestyle is key in the management of type 2 diabetes mellitus (T2DM). Nevertheless, the majority of individuals with T2DM fails to do so. Additionally, individuals with T2DM are likely to experience mental (e.g., stress) and somatic (e.g., pain) stressors. Research investigating the link between these stressors and activity levels within this group is largely lacking. Therefore, current research aimed to investigate how daily fluctuations in mental and somatic stressors predict daily levels of physical activity (PA) and sedentary behaviour among adults with T2DM.

Methods

Individuals with T2DM (N = 54) were instructed to complete a morning diary assessing mental and somatic stressors and to wear an accelerometer for 10 consecutive days. The associations between the mental and somatic stressors and participants’ levels of PA and sedentary behaviour were examined using (generalized) linear mixed effect models.

Results

Valid data were provided by 38 participants. We found no evidence that intra-individual increases in mental and somatic stressors detrimentally affected participants’ activity levels. Similarly, levels of sedentary behaviour nor levels of PA were predicted by inter-individual differences in the mental and somatic stressors.

Aerobic capacity and fatigability are associated with activity levels in women with hip osteoarthritis

Physical activity is important for physical function and pain relief in people with lower extremity osteoarthritis (OA). Unfortunately, people with OA are not as active as their peers without OA. The objective of this study was to determine whether aerobic capacity and fatigability are associated with physical activity in women with hip OA. We conducted a cross-sectional analysis of 36 women with hip OA. We assessed aerobic fitness as predicted VO₂ max from a 6-min walk test. We assessed fatigability using a treadmill test. Finally, we assessed self-reported physical activity using the UCLA activity scale and quantified steps per day and activity intensity using accelerometers. We used Pearson correlations to determine associations. We used regression analysis to determine whether fatigability mediated the association between aerobic fitness and physical activity. On average, subjects were moderately active via the UCLA score (5.2 ± 1.3 out of 10). Aerobic fitness (R = 0.582, p < .001) and fatigability (R = 0.516, p =.003) were significantly correlated with UCLA scores. However, aerobic fitness was the best predictor of UCLA scores, as well as sedentary time, and time spent in light activity. Fatigability was not a mediator between aerobic fitness and UCLA scores. Aerobic fitness and fatigability may be modifiable barriers to physical activity in people with OA. Future interventional studies should examine whether improving aerobic fitness improves physical activity or fatigability.

Developing guidelines to support injured workers who live and work with chronic pain

BACKGROUND

Living and working with chronic pain requires persons to alter lifestyles and have the knowledge as well as support to manage unforeseen challenges. Knowledge for persons living with pain who want to participate in meaningful paid and unpaid work is not easily accessible. While there is literature on chronic pain management, work transitions and return to work, less emphasis has been placed on the complexity of living and working with chronic pain. The Creating a Way Forward Project was envisioned to address this gap and to identify the informational needs of workers with pain, health/helping professionals (workers' advisors, return to work specialists, legal representatives), and stakeholders. The overarching aim of the project was to use evidence and experiential knowledge to inform the development of a foundation for educational guides and toolkits to support workers with pain to achieve their outcomes for remaining at work.

METHODS

Phase one of the project involved a scoping review of chronic pain and work. Phase two involved stakeholder consultations, a focus group and knowledge integration of the literature and experiential insights. Knowledge synthesis drew on a Template Analysis of multiple sources of data.

RESULTS

Knowledge domains and key components were identified for persons with pain and for the health/helping professions.

CONCLUSION

These domains reflect a foundation for knowledge in practical training and the development of curriculum for education in self-management program and in inter professional health profession education. These knowledge domains provide a basis for future research in integrated approaches and knowledge use toward improving transitions for persons living with chronic pain who want to participate in productive paid and unpaid work. Ongoing research in knowledge domains that health providers and persons with pain need will expand the potential for improving health outcomes in living with and managing pain.

Preoperative risk factors associated with chronic pain profiles following total knee arthroplasty

Background

One in five patients experience chronic pain 12 months following total knee arthroplasty (TKA). This longitudinal study used a person‐centred approach to identify subgroups of patients with distinct chronic pain profiles following TKA and identified preoperative characteristics associated with these profiles.

Methods

On the day before surgery, 202 patients completed questionnaires that assessed pain, interference with functioning, fatigue, anxiety, depression and illness perceptions. Average and worst pain were assessed prior to surgery, on postoperative day 4, at 6 week and at 3 and 12 months following surgery. Using growth mixture modelling, two subgroups with distinct average and worst pain profiles were identified.

Results

Patients in the “lower average” and “lower worst” pain classes had moderate preoperative pain scores that decreased over the remaining 9 months following TKA. Patients in the “higher average” and “higher worst” pain classes had relatively higher preoperative pain scores that increased during the first three months and then decreased slightly over the remaining 9 months. Patients in the higher pain classes had higher interference with function scores; used opioids prior to surgery more often, were more likely to receive a continuous nerve block and ketamine; had higher preoperative fatigue severity and interference scores; and had worse perceptions of illness than patients in the lower pain classes.

Conclusions

These risk factors may be used to identify subgroups of patients at higher risk for more severe pain after TKA. Future studies should test whether modifying these risk factors can improve patients’ outcomes after TKA.

Significance statement

The present study provides a novel and original analysis of pain profiles following total knee arthroplasty that may contribute to our understanding of the transition from acute to chronic pain. Our results may be used to identify patients at higher risk for poorer outcomes based on preoperative risk factors.

Associations between Activity Pacing, Fatigue, and Physical Activity in Adults with Multiple Sclerosis: A Cross Sectional Study

Fatigue is common in people with multiple sclerosis (MS). Activity pacing is a behavioral way to cope with fatigue and limited energy resources. However, little is known about how people with MS naturally pace activities to manage their fatigue and optimize daily activities. This study explored how activity pacing relates to fatigue and physical activity in people with MS. Participants were 80 individuals (60 females, 20 males) with a diagnosis of MS. The participants filled in questionnaires on their activity pacing, fatigue, physical activity, and health-related quality of life, 3-6 weeks before discharge from rehabilitation. The relationships between the variables were examined using hierarchical regression. After controlling for demographics, health-related quality of life, and perceived risk of overactivity, no associations were found between activity pacing and fatigue (β = 0.20; t = 1.43, p = 0.16) or between activity pacing and physical activity (β = -0.24; t = -1.61, p = 0.12). The lack of significant associations between activity pacing and fatigue or physical activity suggests that without interventions, there appears to be no clear strategy amongst people with MS to manage fatigue and improve physical activity. People with MS may benefit from interventions to manage fatigue and optimize engagement in physical activity.

Association of Pain and Steps Per Day in Persons With Mild-to-Moderate, Symptomatic Knee Osteoarthritis: A Mixed-Effects Models Analysis of Multiple Measurements Over Three Years

OBJECTIVE

Pain is a consistently reported barrier to physical activity by persons with knee osteoarthritis (OA). Nonetheless, few studies of knee OA have investigated the association of pain with daily walking levels. The current study assessed the relationship of 2 distinct measures of knee pain with objectively measured physical activity in adults with knee OA.

METHODS

This was a longitudinal, observational investigation of 59 individuals (48 women; mean ± SD age 61.1 ± 6.4 years, mean ± SD body mass index 28.1 ± 5.6 kg/m² ) with clinical knee OA. Data were collected every 3 months for up to 3 years. Physical activity was characterized as the average steps per day taken over at least 3 days, mea-sured by accelerometry. Pain was measured using 2 patient-administered questionnaires: the pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS-pain) and the P4 pain scale (P4-pain). Mixed-effects models determined the association between pain and physical activity levels (over covariates) among adults with knee OA (α = 0.05).

RESULTS

All covariates (age [β = -3.65, P < 0.001], body mass index [β = -3.06, P < 0.001], season [spring/fall β = -6.91, P = 0.002; winter β = -14.92, P < 0.001]) were predictors of physical activity. Neither the inverted KOOS-pain (β = 0.04, P = 0.717) nor P4-pain (β = -0.37, P = 0.264) was associated with physical activity.

CONCLUSION

Knee pain is not associated with daily walking levels in persons with mild-to-moderate, symptomatic knee OA. While pain management remains an important target of interventions, strategies to increase steps per day in this population should focus on overcoming potentially more crucial barriers to activity participation.

Association of Systemic Inflammation and Fatigue in Osteoarthritis: 2007-2010 National Health and Nutrition Examination Survey

BACKGROUND/PURPOSE

Mechanistic insight into osteoarthritis fatigue is needed as clinical management of this condition is nonspecific. Systemic inflammation is associated with fatigue in other chronic diseases. The purpose of this study was to explore the relationship between systemic inflammation and fatigue in osteoarthritis, while controlling for covariates.

METHOD

This secondary analysis with a cross-sectional, multiyear retrospective design used data from the 2007-2010 National Health and Nutrition Examination Survey. Adults with self-reported osteoarthritis who participated in an examination at a mobile center and had no comorbidities associated with fatigue or systemic inflammation were included (n = 296). Complex sample analysis, independent samples t tests, and χ² tests of independence were used to explore differences between nonfatigued and fatigued adults with osteoarthritis. Adjusted hierarchical logistic regression models were used to calculate odds of fatigue as a function of two systemic inflammatory markers, C-reactive protein (CRP), and white blood cell (WBC) count.

RESULTS

Fatigued adults with osteoarthritis had significantly higher CRP levels and WBC counts compared to nonfatigued adults with osteoarthritis. In adjusted logistic regression models, increased CRP was associated with higher odds of fatigue when controlling for age, days affected by pain, depressive symptoms, sleep quantity, and body mass index (Odds ratio [OR] = 3.38, 95% CI [1.18, 9.69]). WBC count was not associated with higher odds of fatigue when controlling for these variables (OR = 1.10, 95% CI [0.92, 1.32]).

CONCLUSION

Systemic inflammation may have a relationship with fatigue in osteoarthritis. Future work is necessary to replicate these findings in more robust studies.

Measuring Physical Activity in Spinal Cord Injury Using Wrist-Worn Accelerometers

OBJECTIVE

Our objective was to evaluate interunit agreement and construct validity of two activity monitors (Actiwatch Score and PRO-Diary) in people with and without spinal cord injury.

METHOD

Thirty-eight participants (19 with spinal cord injury; 19 age- and sex-matched controls; mean age = 49 yr) wore both monitors and completed tasks during one visit ranging in physical intensity. To compare activity by group and monitor, we conducted t tests. We assessed interunit agreement using intraclass correlations and Bland-Altman plots.

RESULTS

Both monitors demonstrated significantly different increasing physical activity levels with higher intensity tasks. Participants with spinal cord injury had similar activity counts within tasks compared with controls except for walking-wheeling. Agreement was high between monitors across tasks (interclass correlation coefficients = .78-.97).

CONCLUSION

Both monitors demonstrated good construct validity for measuring physical activity across activities and high agreement. Either monitor is appropriate to examine physical activity patterns in people with spinal cord injury.

Sarcopenia in osteoarthritis and rheumatoid arthritis: The association with self-reported fatigue, physical function and obesity

AIM

To determine if there is an association between sarcopenia, physical function and self-reported fatigue in osteoarthritis (OA) and rheumatoid arthritis (RA).

METHODS

A cross-sectional analysis of measurements from a cohort of 157 participants with OA or RA was performed. The relationship between muscle mass (appendicular muscle index (AMI)), physical function (timed up and go, 30-seconds sit-to-stand test, 40-meter fast-paced walk test and grip-strength) and two fatigue measures (Multidimensional Assessment of Fatigue (MAF) and a fatigue Visual Analogue Scale (VAS)) was explored using hierarchical linear regression or logistic regression with established AMI cut-offs for sarcopenia.

RESULTS

There were no significant differences for perceived fatigue-related variables between OA or RA sarcopenic or non-sarcopenic participants. Participants with OA had worse physical function (TUG; P = 0.029, STS; P = 0.004, WS; P = 0.003), but participants with RA had lower grip strength (P<0.001). The RA group had higher CRP (P = 0.006), were more likely to receive glucocorticoids (P<0.001), and experienced worse fatigue (P = 0.050). The hierarchical multiple regression showed that self-reported fatigue (VAS/MAF-distress) had a significant but weak association with AMI in RA. Participants with higher percentage body fat had a significantly stronger association with sarcopenia in both OA and RA.

CONCLUSION

Sarcopenia, when assessed by AMI, does not appear to be strongly associated with self-reported fatigue or physical function in participants with either OA or RA. Higher body fat had a moderately strong association with sarcopenia in this cross-sectional study, suggesting that body composition may be an important factor in the health of patients with longstanding OA or RA.

Within-person pain variability and physical activity in older adults with osteoarthritis from six European countries

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.

Ecological Momentary Assessment Methodology in Chronic Pain Research: A Systematic Review

Self-reported pain intensity assessments are central to chronic pain research. Ecological momentary assessment (EMA) methodologies are uniquely positioned to collect these data, and are indeed being used in the field. However, EMA protocols are complex, and many decisions are necessary in the design of EMA research studies. A systematic literature review identified 105 articles drawing from 62 quantitative EMA research projects examining pain intensity in adult chronic pain patients. Study characteristics were tabulated to summarize and describe the use of EMA, with an emphasis placed on various dimensions of decision-making involved in executing EMA methodologies. Most identified studies considered within-person relationships between pain and other variables, and a few examined interventions on chronic pain. There was a trend toward the use of smartphones as EMA data collection devices more recently, and completion rates were not reported in nearly one third of studies. Pain intensity items varied widely with respect to number of scale points, anchor labels, and length of reporting period; most used numeric rating scales. Recommendations are provided for reporting to improve reproducibility, comparability, and interpretation of results, and for opportunities to clarify the importance of design decisions.

PERSPECTIVE

Studies that use EMA methodologies to assess pain intensity are heterogeneous. Aspects of protocol design, including data input modality and pain item construction, have the potential to influence the data collected. Thorough reporting on design features and completion rates therefore facilitates reproducibility, comparability, and interpretation of study results.

Understanding knee osteoarthritis from the patients' perspective: a qualitative study

BACKGROUND

No studies of Health Coach Interventions for knee OA sufferers that include patients' perspectives have been published. The study assesses current clinical practice and primary care professionals' advice from the patients' perspective, in order to obtain a participative design for a complex intervention based on coaching psychology. Moreover, wants to analyse the experiences, perceptions, cognitive evaluation, values, emotions, beliefs and coping strategies of patients with knee osteoarthritis, and secondly the impact of these factors in the Self-management of this condition.

METHODS

It is an interpretative qualitative study. The study included patients with diagnosis of knee osteoarthritis (OA) from 4 primary health care centres in Barcelona. A theoretical sampling based on a prior definition of participants' characteristics was carried out. Ten semi-structured interviews with knee OA patients were carried out. A content thematic analysis was performed following a mixed-strategy text codification in Lazarus framework and in emerging codes from the data.

RESULTS

The results are structured in two blocks: Experiences and perceptions of informants and Experiences of knee osteoarthritis according to the Lazarus model. Regarding experiences and perceptions of informants: Some participants reported that the information was mostly provided by health professionals. Informants know which food they should eat to lose weight and the benefits of weight loss. Moreover, participants explained that they like walking but that sometimes it is difficult to put into practice. Regarding experiences of knee osteoarthritis according Lazarus model: Cognitive evaluation is influenced by cognitive distortions such as obligation, guilt, dramatization and catastrophism.

VALUES

Family is the value most associated with wellbeing. Helping others is another recurring value. Emotions: Most participants explain that they feel anxiety, irritability or sadness. Beliefs: To some, physiotherapy helps them feel less pain. However, others explain that it is of no use to them. Participants are aware of the association overweight- pain. Coping strategies: The strategies for coping with emotions aim to reduce psychological distress (anxiety, sadness, anger) and some are more active than others.

CONCLUSIONS

The study highlights that patients with knee osteoarthritis require a person-centered approach that provides them with strategies to overcome the psychological distress caused by this condition.

Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/OMERACT recommendations

Although pain reduction is commonly the primary outcome in chronic pain clinical trials, physical functioning is also important. A challenge in designing chronic pain trials to determine efficacy and effectiveness of therapies is obtaining appropriate information about the impact of an intervention on physical function. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) and Outcome Measures in Rheumatology (OMERACT) convened a meeting to consider assessment of physical functioning and participation in research on chronic pain. The primary purpose of this article is to synthesize evidence on the scope of physical functioning to inform work on refining physical function outcome measurement. We address issues in assessing this broad construct and provide examples of frequently used measures of relevant concepts. Investigators can assess physical functioning using patient-reported outcome (PRO), performance-based, and objective measures of activity. This article aims to provide support for the use of these measures, covering broad aspects of functioning, including work participation, social participation, and caregiver burden, which researchers should consider when designing chronic pain clinical trials. Investigators should consider the inclusion of both PROs and performance-based measures as they provide different but also important complementary information. The development and use of reliable and valid PROs and performance-based measures of physical functioning may expedite development of treatments, and standardization of these measures has the potential to facilitate comparison across studies. We provide recommendations regarding important domains to stimulate research to develop tools that are more robust, address consistency and standardization, and engage patients early in tool development.

Quantifying dimensions of physical behavior in chronic pain conditions

Background

Chronic pain, defined as persistent or recurrent pain lasting longer than 3 months, is a frequent condition affecting an important percent of population worldwide. Pain chronicity can be caused by many different factors and is a frequent component of many neurological disorders. An important aspect for clinical assessment and design of effective treatment and/or rehabilitation strategies is to better understand the impact of pain on domains of functioning in everyday life. The aim of this study was to identify the objectively quantifiable features of physical functioning in daily life and to evaluate their effectiveness to differentiate behavior among subjects with different pain conditions.

Method

Body worn sensors were used to record movement data during five consecutive days in 92 subjects. Sensor data were processed to characterize the physical behavior in terms of type, intensity, duration and temporal pattern of activities, postures and movements performed by subjects in daily life. Metrics quantifying these features were subsequently used to devise composite scores using a factor analysis approach. The severity of clinical condition was assessed using a rating of usual pain intensity on a 10-cm visual analog scale. The relationship between pain intensity and the estimated metrics/composite scores was assessed using multiple regression and discriminant analysis.

Results

According to the factor analysis solution, two composite scores were identified, one integrating the metrics quantifying the amount and duration of activity periods, and the other the metrics quantifying complexity of temporal patterns, i.e., the diversity of body movements and activities, and the manner in which they are organized throughout time. All estimated metrics and composite scores were significantly different between groups of subjects with clinically different pain levels. Moreover, analysis revealed that pain intensity seemed to have a more significant impact on the overall physical behavior, as it was quantified by a global composite score, whereas the type of chronic pain appeared to influence mostly the complexity of the temporal pattern.

Conclusion

The methodology described could be informative for the design of objective outcome measures in chronic pain management/rehabilitation programs.

Functional outcome measures in a surgical model of hip osteoarthritis in dogs

Background

The hip is one of the most common sites of osteoarthritis in the body, second only to the knee in prevalence. However, current animal models of hip osteoarthritis have not been assessed using many of the functional outcome measures used in orthopaedics, a characteristic that could increase their utility in the evaluation of therapeutic interventions. The canine hip shares similarities with the human hip, and functional outcome measures are well documented in veterinary medicine, providing a baseline for pre-clinical evaluation of therapeutic strategies for the treatment of hip osteoarthritis. The purpose of this study was to evaluate a surgical model of hip osteoarthritis in a large laboratory animal model and to evaluate functional and end-point outcome measures.

Methods

Seven dogs were subjected to partial surgical debridement of cartilage from one femoral head. Pre- and postoperative pain and functional scores, gait analysis, radiographs, accelerometry, goniometry and limb circumference were evaluated through a 20-week recovery period, followed by histological evaluation of cartilage and synovium.

Results

Animals developed histological and radiographic evidence of osteoarthritis, which was correlated with measurable functional impairment. For example, Mankin scores in operated limbs were positively correlated to radiographic scores but negatively correlated to range of motion, limb circumference and 20-week peak vertical force.

Conclusions

This study demonstrates that multiple relevant functional outcome measures can be used successfully in a large laboratory animal model of hip osteoarthritis. These measures could be used to evaluate relative efficacy of therapeutic interventions relevant to human clinical care.

Electronic supplementary material

The online version of this article (doi:10.1186/s40634-016-0053-5) contains supplementary material, which is available to authorized users.

Pain, Fatigue, and Physical Activity in Osteoarthritis: The Moderating Effects of Pain- and Fatigue-Related Activity Interference

OBJECTIVE

To examine how self-reported pain- and fatigue-related activity interference relates to symptoms and physical activity (PA) in daily life among people with knee or hip osteoarthritis.

DESIGN

Cross-sectional study with a 7-day repeated-measures assessment period.

SETTING

General community.

PARTICIPANTS

Participants (N=154; mean age, 65y; 60% women [n=92]) with knee or hip osteoarthritis and pain lasting ≥3 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain- or fatigue-related activity interference items on the Brief Pain Inventory or Brief Fatigue Inventory, respectively, from baseline survey, momentary pain and fatigue severity (measured 5times/d for 7d), and PA measured with a wrist-worn accelerometer over 7 days. We hypothesized that perception of pain- and fatigue-related activity interference would moderate the association between symptoms (pain or fatigue) and PA. People with higher pain- or fatigue-related activity interference were thought to have stronger negative associations between momentary ratings of pain and fatigue and PA than did those with lower activity interference.

RESULTS

Pain-related activity interference moderated the association between momentary pain and PA, but only in the first part of the day. Contrary to expectation, during early to midday (from wake-up time through 3 pm), low pain-related interference was associated with stronger positive associations between pain and PA but high pain-related interference was associated with a small negative association between pain and PA. Fatigue-related activity interference did not moderate the relation between fatigue and activity over the course of a day.

CONCLUSIONS

Depending on a person's reported level of pain-related activity interference, associations between pain and PA were different earlier in the day. Only those with high pain-related activity interference had lower levels of PA as pain increased and only in the morning. High pain-related activity interference may be important to address, particularly to maintain PA early in the day despite pain.

Within-Day Variability of Fatigue and Pain Among African Americans and Non-Hispanic Whites With Osteoarthritis of the Knee

OBJECTIVE

Fatigue is common among persons with osteoarthritis (OA), but little is known about racial/ethnic differences in the prevalence, correlates, or dynamics of fatigue in OA. This research therefore used experience sampling methodology (ESM) to examine fatigue and pain at global and momentary levels among African Americans and non-Hispanic whites with OA.

METHODS

Thirty-nine African Americans and 81 non-Hispanic whites with physician-diagnosed knee OA completed a baseline interview and an ESM protocol assessing fatigue, pain, and mood 4 times daily for 7 days. In addition to analyzing basic group differences, multilevel modeling examined within- versus between-subject patterns and correlates of variability in momentary fatigue, controlling for demographics and other potential confounders.

RESULTS

Both racial groups experienced moderate levels of fatigue; however, there were clear individual differences in both mean fatigue level and variability across momentary assessments. Mean fatigue levels were associated with global pain and depression. Increase in fatigue over the course of the day was much stronger among non-Hispanic whites than African Americans. Momentary fatigue and pain were closely correlated. Mean fatigue predicted variability in mood; at the momentary level, both fatigue and pain were independently associated with mood.

CONCLUSION

Fatigue is a significant factor for both African Americans and non-Hispanic whites with OA, and is negatively related to quality of life. Pain symptoms, at both the momentary level and across individuals, were robust predictors of fatigue. Although overall levels of reported symptoms were similar across these 2 groups, the pattern of fatigue symptoms across the day differed.

Feelings of Usefulness to Others Predict Active Coping With Osteoarthritis Knee Pain

OBJECTIVE

To investigate associations of perceived usefulness to other people with active versus passive coping strategies among adults with knee osteoarthritis (OA). Additional aims explored contributions of personality variables to this dynamic.

METHOD

199 persons (70.3 years ± 10.4) with knee OA reported personality, coping, and psychosocial data using the Big Five Inventory, subscales from the Social Provisions Scale, and the Coping With Illness measure. Regression analyses identified predictors of perceived usefulness and its independent and interactive associations with active versus passive coping and personality variables.

RESULTS

Better subjective health predicted perceived usefulness. Older adults with higher reported perceived usefulness employed more active than passive pain coping strategies. Passive coping was associated with neuroticism and greater functional disability.

DISCUSSION

Usefulness predicted active OA pain coping, suggesting that it may promote well-being among persons with chronic pain. Further study investigating perceived usefulness in promoting positive health behaviors is needed.

Validated Measures of Illness Perception and Behavior in People with Knee Pain and Knee Osteoarthritis: A Scoping Review

OBJECTIVE

To identify validated measures that capture illness perception and behavior and have been used to assess people who have knee pain/osteoarthritis.

METHODS

A scoping review was performed. Nine electronic databases were searched for records from inception through April 19, 2015. Search terms included illness perception, illness behavior, knee, pain, osteoarthritis, and their related terms. This review included English language publications of primary data on people with knee pain/osteoarthritis who were assessed with validated measures capturing any of 4 components of illness perception and behavior: monitor body, define and interpret symptoms, take remedial action, and utilize sources of help. Seventy-one publications included relevant measures. Two reviewers independently coded and analyzed each relevant measure within the 4 components.

RESULTS

Sixteen measures were identified that capture components of illness perception and behavior in the target population. These measures were originally developed to capture constructs that include coping strategies/skills/styles, illness belief, illness perception, self-efficacy, and pain behavior. Coding results indicated that 5, 11, 12, and 5 of these measures included the monitor body, define and interpret symptoms, take remedial action, and utilize sources of help components, respectively.

CONCLUSIONS

Several validated measures were interpreted as capturing some components, and only 1 measure was interpreted as capturing all of the components of illness perception and behavior in the target population. A measure that comprehensively captures illness perception and behavior could be valuable for informing and evaluating therapy for patients along a continuum of symptomatic knee osteoarthritis.

Associations of coping strategies with diary based pain variables among Caucasian and African American patients with osteoarthritis

PURPOSE

The purposes of this study are to examine the associations between pain coping strategies and daily diary-based pain measures and to determine whether these associations differed by race (African American and Caucasian).

METHODS

Primary care patients from the Durham Veterans Affairs and Duke University Medical Centers (N = 153) with hand, hip, or knee osteoarthritis (OA) completed electronic pain diaries on a one-weekend day and one weekday. The maximum, range (maximum minus minimum pain), and area under the curve (AUC) of joint pain ratings were calculated. Pain coping (Coping Strategies Questionnaire (CSQ) coping attempts, catastrophizing, and praying/hoping subscale scores) was assessed prior to diary entries and at the end of each diary day (total, problem-focused, and emotion-focused scores from Stone and Neale's Daily Coping Inventory). Pearson correlations between pain variables and coping measures were examined. Linear mixed models were fit including age, race, weekend/weekday, study enrollment site, education level, pain medication use, self-rated health, Arthritis Impact Measurement Scales affect and function subscales, and interactions of coping measures with race and weekend day/weekday status.

RESULTS

Correlations between coping and pain measures were 0.12-0.45. In adjusted models, maximum pain and pain range were associated with all three diary-based coping measures; maximum pain was associated with CSQ coping attempts; and AUC was associated with CSQ praying/hoping. Interactions were not significant.

CONCLUSIONS

Among participants with OA, pain coping strategies were related to important aspects of the pain experience, particularly pain range and maximum pain. However, race did not modify associations of pain coping strategy use and the pain experience.

Predictors and outcome of pain-related avoidance of activities in persons with early symptomatic knee osteoarthritis: a five-year followup study

OBJECTIVE

It has been hypothesized that pain and low vitality lead to an increase in avoidance of activities in persons with early symptomatic knee osteoarthritis (OA), and that avoidance of activities leads to an increase in activity limitations. The present study aimed to evaluate these hypotheses.

METHODS

Baseline, 2-year, and 5-year followup data of 828 participants from the Cohort Hip and Cohort Knee Study with early symptomatic knee OA were used. Autoregressive generalized estimating equations and linear regression models were used to analyze the longitudinal and cross-sectional associations between self-reported knee pain, vitality, pain-related avoidance of activities, and activity limitations. The models were adjusted for the covariates age, sex, education level, body mass index, comorbidity, radiographic severity, and hip pain.

RESULTS

In longitudinal analyses, knee pain and vitality predicted a subsequent increase in avoidance of activities. Pain-related avoidance of activities predicted a subsequent increase in activity limitations; however, this relationship lost statistical significance (P = 0.089) after adjustment for covariates. Cross-sectional analyses showed strong relationships between knee pain, low vitality, pain-related avoidance of activities, and activity limitations at all time points.

CONCLUSIONS

In persons with early symptomatic knee OA, knee pain and low vitality lead to a subsequent increase in avoidance of activities. Pain-related avoidance of activities is related to activity limitations at inception of symptoms, but also years later. Therefore, it can be recommended to monitor and target avoidance of activities at various stages of the disease.

Activity pacing in daily life: A within-day analysis

Activity pacing is a widely used self-management strategy, but we lack a clear understanding of its nature and usefulness. One source of confusion is a lack of clarity about the use of pacing in everyday life (ie, naturalistic pacing) in people not trained on how to pace activities. It is unknown whether people engage in more pacing when pain is high (pain-contingent) or when fatigue is high (fatigue-contingent). Conversely, it is not known whether naturalistic pacing results in reduced symptoms. We conducted a multilevel daily process study in which participants with osteoarthritis (N=162) reported pain and fatigue severity and frequency of pacing behaviors 5times per day over 5days. We hypothesized that increased pain and fatigue would predict increased pacing and that pacing would have a short-term benefit in terms of decreased pain and fatigue. Multilevel modeling results showed that, as expected, both momentary pain and fatigue were positively associated with subsequent pacing behaviors. Contrary to our hypothesis, increased pacing was associated with higher subsequent levels of pain and fatigue. Naturalistic pacing seems symptom-contingent and not reinforced by symptom reduction. Naturalistic pacing may be distinct from trained or programmatic pacing in terms of outcomes, and further research into naturalistic pacing may provide an important foundation for how best to deliver activity pacing interventions.

Unraveling dynamics of human physical activity patterns in chronic pain conditions

Chronic pain is a complex disabling experience that negatively affects the cognitive, affective and physical functions as well as behavior. Although the interaction between chronic pain and physical functioning is a well-accepted paradigm in clinical research, the understanding of how pain affects individuals' daily life behavior remains a challenging task. Here we develop a methodological framework allowing to objectively document disruptive pain related interferences on real-life physical activity. The results reveal that meaningful information is contained in the temporal dynamics of activity patterns and an analytical model based on the theory of bivariate point processes can be used to describe physical activity behavior. The model parameters capture the dynamic interdependence between periods and events and determine a ‘signature’ of activity pattern. The study is likely to contribute to the clinical understanding of complex pain/disease-related behaviors and establish a unified mathematical framework to quantify the complex dynamics of various human activities.

The avoidance model in knee and hip osteoarthritis: a systematic review of the evidence

The avoidance model in patients with knee and hip osteoarthritis (OA) hypothesizes that pain and psychological distress lead to avoidance of activities, and thereby to muscle weakness and activity limitations. This paper systematically reviews the scientific evidence for the validity of this avoidance model. A qualitative data synthesis was used to identify levels of evidence. Sixty studies were included. In knee OA, strong evidence was found that avoidance of activities is associated with activity limitations via muscle weakness (mediation by muscle weakness), strong evidence was found for an association between muscle weakness and activity limitations, and weak evidence was found that pain and psychological distress are associated with muscle weakness via avoidance of activities (mediation by avoidance). In hip OA, weak evidence was found for mediation by muscle weakness; and strong evidence was found for an association between muscle weakness and activity limitations. More research is needed on the consecutive associations between pain or psychological distress, avoidance of activities and muscle weakness, and to confirm causal relationships.

Impact of chronic musculoskeletal pain on objectively measured daily physical activity: a review of current findings

SUMMARY Chronic pain affects a wide range of outcomes that are typically assessed using self-reported methodologies, which are susceptible to recall biases, current mood and pain intensity. Physical activity (PA) is an important component of the pain experience that can be objectively assessed with accelerometers, which are small, lightweight devices that measure the duration, frequency and intensity of PA over time. Accelerometry provides opportunities to compare actual and perceived PA, to design individually customized treatments, to monitor treatment progress, and to evaluate treatment efficacy. Thus, this technology can provide a more refined understanding of the relationships among symptoms, perceptions, mood, environmental circumstances and PA. The current paper examines patterns of PA in chronic musculoskeletal pain conditions and identifies potential clinical applications for accelerometry.

Relationship between fatigue and subsequent physical activity among older adults with symptomatic osteoarthritis

OBJECTIVE

Although it has been well established that fatigue is common among older adults with osteoarthritis (OA), relatively little is known about how fatigue in daily life affects physical activity. The purposes of this study were to examine the relationship between momentary fatigue and subsequent physical activity among people with OA who reported clinically relevant levels of fatigue and to examine moderators of this relationship.

METHODS

People with knee or hip OA and clinically relevant fatigue participated in physical performance assessments, completed questionnaires, and underwent a home monitoring period in which fatigue severity was measured 5 times/day over 5 days (n = 172). Physical activity was concurrently measured via a wrist-worn accelerometer. Multilevel modeling was used to examine the relationship of momentary fatigue and subsequent activity controlling for other factors (e.g., age, body mass index, pain, and depression).

RESULTS

Fatigue was the strongest predictor of reduced subsequent activity. Only functional mobility (Timed Up and Go) moderated the relationship between fatigue and activity. The relationship between fatigue and activity was strongest for people with high functional mobility.

CONCLUSION

Momentary fatigue is a robust and important variable associated with decreased physical activity. Further, the moderating effect of functional mobility suggests this factor should be considered when intervening on fatigue. While people with better functional mobility may benefit from an activity-based treatment approach (such as learning activity pacing techniques to reduce the impact of fatigue on activity), those with worse functional mobility may benefit from treatment focusing on underlying impairments.