Pain and disability in osteoarthritis: a review of biobehavioral mechanisms

Post-Traumatic Stress Disorder as a Risk Factor for Adverse Outcomes in Total Knee Arthroplasty

BACKGROUND

There is a scarcity of literature concerning individuals who have existing post-traumatic stress disorder (PTSD) and their outcomes after primary total knee arthroplasty (TKA). This study compared outcomes in patients undergoing primary TKA who have a previous history of PTSD.

METHODS

An electronic health care database was used to identify patients diagnosed with PTSD undergoing TKA. Through 1:1 ratio propensity matching, these patients were matched with a cohort of non-PTSD (NPTSD) individuals. Postoperative parameters, including health care visits and prescriptions, were assessed within a 1-month time frame following surgery. Complications and revision rates were evaluated after one month, 6 months, one year, 2 years, and 5 years. A total of 646,186 patients undergoing primary TKA were identified. Ultimately, 7,381 patients who had PTSD were propensity matched to 7,381 NPTSD patients.

RESULTS

Patients who had PTSD presented to the emergency department at a higher rate than NPTSD patients within 7 days (OR [odds ratio]: 1.5; CI [confidence interval]: 1.0 to 2.4) postoperative. Within one month, cohorts were prescribed opioid analgesics at similar rates (OR: 0.9; CI: 0.8 to 1.1). Patients who had PTSD were found to have a higher number of infections within one month (OR: 1.7; CI: 1.2 to 2.6) and 5 years (OR: 1.2; CI: 1.0 to 1.5), periprosthetic fractures at 6 months (OR: 2.1; CI: 1.0 to 4.5) and one year (OR: 2.1; CI: 1. to 4.0), and higher revision rates at all time points.

CONCLUSIONS

Patients diagnosed with PTSD exhibited higher rates of periprosthetic infections at one month and 5 years and increased periprosthetic fracture rates at 6 months and one year after TKA compared to NPTSD patients. These findings underscore the importance of tailored early postoperative education and understanding outcomes for patients who have PTSD in contrast to those who do not have a diagnosis of PTSD.

Central aspects of pain associated with physical activity: results from the Investigating Musculoskeletal Health and Wellbeing cohort

Background

Knee pain reduces activity, while inactivity can increase pain. The central nervous system modulates both pain and activity. The 8-item Central Aspects of Pain (CAP) questionnaire measures self-reported symptoms associated with current and future knee pain severity and psychophysical evidence of central pain sensitivity. The objective was to explore associations between CAP and physical inactivity in people with knee pain.

Methods

Participants from the Investigating Musculoskeletal Health and Wellbeing cohort who reported their knee as their most troublesome joint with numerical rating scale pain severity ≥1/10 completed questionnaires at baseline and 12 months addressing demographic and clinical characteristics, CAP questionnaire, and physical inactivity (Frail Non-Disabled questionnaire item). Chi-squared, correlations and multivariable logistic regression were performed.

Results

Seven hundred twenty-two participants provided baseline data and 404 longitudinal data. Higher baseline CAP scores were associated with higher baseline pain severity {OR: 1.25 (95% confidence interval [CI]: 1.02-1.53); P = 0.032} and physical inactivity (OR: 1.18 [95% CI: 1.11-1.25]; P < 0.001). Increasing CAP scores over 12 months were associated with becoming physically inactive (OR: 1.16 [95% CI: 1.01-1.32]; P = 0.032). The effects of CAP on physical inactivity were not fully explained by pain severity nor by any single characteristic of widespread pain distribution, emotional or cognitive factors, sleep disturbance, or fatigue.

Conclusion

Central aspects of pain questionnaire displays cross-sectional and longitudinal associations with physical inactivity. Central nervous system manifestations of pain appear to link pain with physical activity and may be more important than pain severity.

Effects of Walking Aids on Knee Adduction Moment After Total Knee Arthroplasty: A Gait Analysis Study

BACKGROUND

Total knee arthroplasty (TKA) is a common intervention for treating end-stage knee osteoarthritis (OA). Postoperatively, altered biomechanics may increase the risk of OA progression in the contralateral knee. Knee adduction moment (KAM) is a key indicator of medial knee joint loading and is associated with OA progression. Walking aids are often prescribed to reduce joint stress during walking; however, their comparative effects on KAM in patients undergoing TKA remain unclear. This study aimed to evaluate the effects of different walking aids (double canes [D-canes], rollators without forearm support [rollators], and rollators with forearm support [F-rollators]) on KAM peak and impulse in both the operated and contralateral knees of patients after TKA using gait analysis.

METHODOLOGY

A cross-sectional study was conducted on eight women who underwent unilateral TKA. Participants walked under four conditions: no aid, D-canes, rollators, and F-rollators. A three-dimensional motion capture system measured the lower limb kinematics and kinetics. The primary outcomes were KAM peak and impulse for both knees. Secondary outcomes included ground reaction force in the vertical direction (GRF Z), forward trunk tilt angle, and lower limb joint angles. A two-way repeated-measures measures analysis of variance (ANOVA) was used for statistical comparisons.

RESULTS

Walking aids significantly reduced the KAM peak and impulse in both the operated and contralateral knees compared with unaided walking (P < 0.001). In the operated knee, the KAM peak decreased by approximately 20% with all aids, whereas in the contralateral knee, reductions were 6% for D-canes, 16% for rollators, and 24% for F-rollators. Rollators and F-rollators more effectively reduced contralateral knee loading than D-canes (P < 0.001). A significant negative correlation was found between trunk forward tilt angle and GRF Z (ρ= -0.74, P < 0.001), suggesting that increased forward lean with rollators and F-rollators enhanced lower limb offloading. No significant changes were observed in knee varus angle or walking speed across conditions.

CONCLUSIONS

Walking aids, particularly F-rollators, effectively reduce KAM and offload the contralateral knee in patients after TKA. These findings suggest potential benefits for patients at risk of OA progression in non-operated knees.

The Effect of Single-Session Stimulating Massage on the Knee Joint Position Sense in Healthy Older Adult Men: A Randomized Crossover Trial

Background

Proprioception is critical for older adults to maintain their balance and prevent falling. However, massage is a convenient intervention that its beneficial effect on the proprioception is suggested.

Purpose

This study aimed to determine whether one session of stimulating massage of the muscles around the knee joint improves position sense in older adult men.

Methods

Twenty healthy older adults participated in this blind, randomized, crossover trial. The two treatment phases were massage and rest. The washout period between interventions was a 1-week interval. The massage protocol was as follows: deep effleurage, petrissage, and tapotement for 5 minutes for the anterior (tensor fascia lata, quadriceps, sartorius, and gracilis) and posterior (hamstrings) muscles of the knee (10 minutes in total).

Results

Outcome measures were absolute, constant, and variable errors (AE, CE, and VE). Participants were assessed immediately before and after the intervention by a blinded investigator. Independent t-tests were used for statistical analyses. Massage reduced absolute error (2.77°, p = 0.01).

Conclusion

The finding of this study confirms the beneficial impact of the massage on the joint position sense in healthy older adult men.

Prospective validity of a clinical prediction rule for response to non-surgical multidisciplinary management of knee osteoarthritis in tertiary care: a multisite prospective longitudinal study

OBJECTIVES

We tested a previously developed clinical prediction tool-a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological degeneration) that were related to poor response to non-surgical management of knee osteoarthritis. This study sought to prospectively evaluate the predictive validity of this nomogram to identify patients most likely to respond poorly to non-surgical management of knee osteoarthritis.

DESIGN

Multisite prospective longitudinal study.

SETTING

Advanced practice physiotherapist-led multidisciplinary service across six tertiary hospitals.

PARTICIPANTS

Participants with knee osteoarthritis deemed appropriate for trial of non-surgical management following an initial assessment from an advanced practice physiotherapist were eligible for inclusion.

INTERVENTIONS

Baseline clinical nomogram scores were collected before a trial of individualised non-surgical management commenced.

PRIMARY OUTCOME MEASURE

Clinical outcome (Global Rating of Change) was collected 6 months following commencement of non-surgical management and dichotomised to responder (a little better to a very great deal better) or poor responder (almost the same to a very great deal worse). Clinical nomogram accuracy was evaluated from receiver operating characteristics curve analysis and area under the curve, and sensitivity/specificity and positive/negative likelihood ratios were calculated.

RESULTS

A total of 242 participants enrolled. Follow-up scores were obtained from 210 participants (87% response rate). The clinical nomogram demonstrated an area under the curve of 0.70 (p<0.001), with greatest combined sensitivity 0.65 and specificity 0.64. The positive likelihood ratio was 1.81 (95% CI 1.32 to 2.36) and negative likelihood ratio 0.55 (95% CI 0.41 to 0.75).

CONCLUSIONS

The knee osteoarthritis clinical nomogram prediction tool may have capacity to identify patients at risk of poor response to non-surgical management. Further work is required to determine the implications for service delivery, feasibility and impact of implementing the nomogram in clinical practice.

Accelerometer-derived physical activity analysis of elderly osteoarthritis patients

BACKGROUND

Because disability in Osteoarthritis (OA) may change physical activity (PA), which might affect the disease progression, it is important to measure a patient's daily PA to study the relationship between a patient's PA and disease progression.

OBJECTIVE

The objective of the present study was to investigate the relationship between PA and patients with OA and people without OA using data from the Korea National Health and Nutrition Examination Survey (KNHANES).

METHODS

Demographic study was conducted to obtain data of comorbidities of participants. PA was compared between the group with OA (OA group) and the group without OA (non-OA group). In addition, PAs of OA patients with comorbidities and those without comorbidities were compared. The cut-off of moderate to vigorous physical activity (MVPA) was obtained through a receiver operating characteristic (ROC) curve.

RESULTS

In the demographic study, there were significantly more educated participants in the OA group (p < .001). Actigraph data showed a significant decrease in MVPA (p < .001) but a significant increase in light activity (p = .002) in the OA group. In addition, the OA group showed significantly lower light PA but significantly higher MVPA in ≥10 min bout length. OA patients with comorbidities showed higher MVPA than OA patients without comorbidities (p = .044). The cut-off point of MVPA was 7.071 min/day when ROC curve was conducted.

CONCLUSIONS

The present study suggests that patients with OA and low activity need a certain level of physical activity and a cut-off point for MVPA is presented which accounts for comorbidities in OA patients.

Dynamic Alginate Hydrogel as an Antioxidative Bioink for Bioprinting

3D bioprinting holds great potential for use in tissue engineering to treat degenerative joint disorders, such as osteoarthritis. However, there is a lack of multifunctional bioinks that can not only support cell growth and differentiation, but also offer protection to cells against injuries caused by the elevated oxidative stress; this conditions is a common characteristic of the microenvironment of the osteoarthritis disease. To mitigate oxidative stress-induced cellular phenotype change and malfunction, an anti-oxidative bioink derived from an alginate dynamic hydrogel was developed in this study. The alginate dynamic hydrogel gelated quickly via the dynamic covalent bond between the phenylboronic acid modified alginate (Alg-PBA) and poly (vinyl alcohol) (PVA). It presented good self-healing and shear-thinning abilities because of the dynamic feature. The dynamic hydrogel supported long-term growth of mouse fibroblasts after stabilization with a secondary ionic crosslinking between introduced calcium ions and the carboxylate group in the alginate backbone. In addition, the dynamic hydrogel showed good printability, resulting in the fabrication of scaffolds with cylindrical and grid structures with good structural fidelity. Encapsulated mouse chondrocytes maintained high viability for at least 7 days in the bioprinted hydrogel after ionic crosslinking. Most importantly, in vitro studies implied that the bioprinted scaffold could reduce the intracellular oxidative stress for embedded chondrocytes under H₂O₂ exposure; it could also protect the chondrocytes from H₂O₂-induced downregulation of extracellular matrix (ECM) relevant anabolic genes (ACAN and COL2) and upregulation of a catabolic gene (MMP13). In summary, the results suggest that the dynamic alginate hydrogel can be applied as a versatile bioink for the fabrication of 3D bioprinted scaffolds with an innate antioxidative ability; this technique is expected to improve the regenerative efficacy of cartilage tissues for the treatment of joint disorders.

Localized Multi-Site Knee Bioimpedance as a Predictor for Knee Osteoarthritis Associated Pain Within Older Adults During Free-Living

The drastic increase in the aging population has increased the prevalence of osteoarthritis in the United States. The ability to monitor symptoms of osteoarthritis (such as pain) within a free-living environment could improve understanding of each person's experiences with this disease and provide opportunities to personalize treatments specific to each person and their experience. In this work, localized knee tissue bioimpedance and self-reports of knee pain were collected from older adults ([Formula: see text]) with and without knee osteoarthritis over 7 days of free-living to evaluate if knee tissue bioimpedance is associated with persons' knee pain experience. Within the group of persons' with knee osteoarthritis increases in 128 kHz per-length resistance and decreases in 40 kHz per-length reactance were associated with increased probability of persons having active knee pain ([Formula: see text] and [Formula: see text]).

Dynamic hyaluronic acid hydrogel with covalent linked gelatin as an anti-oxidative bioink for cartilage tissue engineering

In the past decade, cartilage tissue engineering has arisen as a promising therapeutic option for degenerative joint diseases, such as osteoarthritis, in the hope of restoring the structure and physiological functions. Hydrogels are promising biomaterials for developing engineered scaffolds for cartilage regeneration. However, hydrogel-delivered mesenchymal stem cells or chondrocytes could be exposed to elevated levels of reactive oxygen species (ROS) in the inflammatory microenvironment after being implanted into injured joints, which may affect their phenotype and normal functions and thereby hinder the regeneration efficacy. To attenuate ROS induced side effects, a multifunctional hydrogel with an innate anti-oxidative ability was produced in this study. The hydrogel was rapidly formed through a dynamic covalent bond between phenylboronic acid grafted hyaluronic acid (HA-PBA) and poly(vinyl alcohol) and was further stabilized through a secondary crosslinking between the acrylate moiety on HA-PBA and the free thiol group from thiolated gelatin. The hydrogel is cyto-compatible and injectable and can be used as a bioink for 3D bioprinting. The viscoelastic properties of the hydrogels could be modulated through the hydrogel precursor concentration. The presence of dynamic covalent linkages contributed to its shear-thinning property and thus good printability of the hydrogel, resulting in the fabrication of a porous grid construct and a meniscus like scaffold at high structural fidelity. The bioprinted hydrogel promoted cell adhesion and chondrogenic differentiation of encapsulated rabbit adipose derived mesenchymal stem cells. Meanwhile, the hydrogel supported robust deposition of extracellular matrix components, including glycosaminoglycans and type II collagen, by embedded mouse chondrocytesin vitro. Most importantly, the hydrogel could protect encapsulated chondrocytes from ROS induced downregulation of cartilage-specific anabolic genes (ACAN and COL2) and upregulation of a catabolic gene (MMP13) after incubation with H₂O₂. Furthermore, intra-articular injection of the hydrogel in mice revealed adequate stability and good biocompatibilityin vivo. These results demonstrate that this hydrogel can be used as a novel bioink for the generation of 3D bioprinted constructs with anti-ROS ability to potentially enhance cartilage tissue regeneration in a chronic inflammatory and elevated ROS microenvironment.

The Relationship Between Psychological Aspects and Trajectories of Symptoms in Total Knee Arthroplasty and Total Hip Arthroplasty

BACKGROUND

This study aimed to examine different trajectories of physical symptoms in hip and knee arthroplasty patients from presurgery to 1 year postsurgery and relate this to preoperative anxiety and depressive symptoms.

METHODS

Patients (N = 345) completed the Hip injury and Osteoarthritis Outcome Score or the Knee injury and Osteoarthritis Outcome Score to examine their preoperative and postoperative pain, stiffness, and function, presurgery, and 3, 6, and 12 months postsurgery. Presurgery anxiety and depressive symptoms were assessed using the 7-item Generalized Anxiety Disorder Scale and the 9-item Patient Health Questionnaire. Latent trajectory analysis was used to identify different subgroups in trajectories. The step-3 method was used to assess subgroup characteristics.

RESULTS

The effect of time on pain, function, and stiffness was different between subgroups of patients. Knee patients belonged mainly to classes with least improvement. Least improvement in pain was characterized by a combination of high levels of both anxiety and depressive symptoms. Anxiety and depressive symptoms were independently related to less reduction in stiffness while little improvement in function was characterized by higher depressive symptoms.

CONCLUSION

The results of this study indicate that anxiety and depressive symptoms were significantly, but differently, related to the distinct physical symptoms examined.

Disability and functioning in primary and secondary hip osteoarthritis in Benin

Background

In Africa, primary hip osteoarthritis seems to be less frequent than in Europe. Sickle cell disease is responsible for aseptic osteonecrosis of the femoral head associated with secondary hip osteoarthritis. Very little evidence is available on the influence of aetiology (primary and secondary) and radiographic status on pain and disability in a Beninese population with hip osteoarthritis.

Objectives

The aim of this study was to compare the impacts of aetiology and radiographic status on pain, disability and quality of life in a Beninese population with hip osteoarthritis.

Method

This was a descriptive cross-sectional study, including participants recruited in the Clinic of Physical Medicine and Rehabilitation at the National Teaching Hospital in Cotonou.

Assessment was based on the International Classification of Functioning, Disability and Health model. The main outcomes were severity of osteoarthritis, pain, range of motion, muscle strength, gait speed and quality of life. Statistical comparisons between the aetiologies were performed using a t-test or rank sum test. One-way analysis of variance was used to test the effect of radiographic status.

Results

Forty-nine participants (26 women and 23 men; mean age [standard deviation] 40.5 [17.9] years) were recruited. According to the aetiology (59.2% and 40.8% of primary and secondary osteoarthritis, respectively), there were no significant differences for any of the outcomes. Grades I, II, III and IV osteoarthritis were observed in 22.4%, 14.3%, 26.5% and 36.7% of the participants, respectively. Participants with grade IV osteoarthritis were more affected than those with grades I, II and III based on the Kellgren and Lawrence classification.

Conclusion

Aetiology did not influence pain, gait speed or quality of life. Participants with grade IV osteoarthritis had more pain, were more limited in walking and had a more impaired quality of life.

The Impact of Self-Efficacy on Activity Limitations in Patients With Hip Osteoarthritis: Results From a Cross-Sectional Study

Objective

Pain and activity limitations are the main health complaints in osteoarthritis. We explored pathways between pain and activity limitations in a chain mediation model that involved self‐efficacy, physical activity behavior, and muscle function in patients with hip osteoarthritis not awaiting hip replacement.

Methods

We used cross‐sectional, baseline data from a randomized controlled trial on 152 patients with clinical hip osteoarthritis according to the American College of Rheumatology not awaiting hip replacement. The associations between pain, self‐efficacy, self‐reported physical activity, muscle function (leg extensor power), and activity limitations (performance‐based and self‐reported activity limitation outcomes) were modeled using structural equation models.

Results

The effect of pain on performance‐based activity limitation was fully mediated by self‐efficacy, physical activity, and muscle function. Of the total effect of self‐efficacy on performance‐based activity limitation, the direct effect accounted for 63% (95% CI: 45%‐82%), whereas the indirect effect via physical activity constituted 16% (95% CI: 1%‐30%) and the indirect effect via muscle function constituted 21% (95% CI: 9%‐32%). In contrast, physical activity and muscle function had no effect on self‐reported activity limitations, whereas pain had a direct effect and an indirect effect mediated by self‐efficacy.

Conclusion

Our results suggest that self‐efficacy should be taken into consideration in prevention and treatment of activity limitations in patients with hip osteoarthritis not awaiting hip replacement. Coupling exercise with programs of self‐efficacy enhancement could potentially increase the positive effects of exercise.

Short-term Effects of Mulligan's Mobilization With Movement on Pain, Function, and Emotional Aspects in Individuals With Knee Osteoarthritis: A Prospective Case Series

OBJECTIVE

To evaluate the short-term effects of Mulligan's mobilization with movement (MWM) on pain, physical function, emotional aspects, and proprioceptive acuity after a 2-week treatment period and throughout a 3-week follow-up period.

METHODS

A single group of 30 participants (60.96 ± 5.16 years) with symptomatic knee osteoarthritis (KOA) was evaluated. The protocol involved 5 evaluations moments, before (baseline) and after 2 weeks of intervention (24 hours after the last session), and at 3-week follow-up. The intervention included 3 Mulligan's MWM techniques. The variables evaluated were pain (pressure pain threshold and Visual Numeric Scale), physical function (range of motion, proprioceptive acuity, and the Western Ontario and McMaster Universities Osteoarthritis Index) and emotional aspects (Beck Depression Inventory). Analysis of variance for repeated measures was used considering a significance level of 5%.

RESULTS

At the second evaluation (after intervention), the pressure pain threshold presented higher values for rectus femoris, tibialis anterior, and patellar tendon sites and reduced values for the Visual Numeric Scale, Beck Depression Inventory, and Western Ontario and McMaster Universities Osteoarthritis Index compared with baseline. Also, during the follow-up period, all variables returned close to baseline levels. Proprioceptive acuity and range of motion did not present significant changes.

CONCLUSION

Scores for pain relief, physical function, and emotional aspects improved after a course of MWM in this single group of individuals with KOA. Mobilization with movement had limited outcome during follow-up. It suggests that future clinical trials on the use of MWM for KOA should be considered.

Tai Chi Is Safe and Effective for the Hip Joint: A Biomechanical Perspective

There is little research related to the biomechanical effects of Tai Chi on the hip joint. This study was aimed to analyze the biomechanical characteristic of a typical Tai Chi movement, Brush Knee and Twist Step. A total of 12 experienced older men voluntarily participated in this study. Each participant was requested to perform standard Brush Knee and Twist Step and normal walking. The scaled-generic musculoskeletal model of each participant was developed. A finite element model of the hip joint and pelvis was established and validated. Data from each trail were input to the model for simulation, and the biomechanics were compared between Brush Knee and Twist Step and walking. Compared with walking, Tai Chi may have better improvement in the range of motion of the hip joint and the coordination of the neuromuscular system under safer condition. It is suitable for patients with hip osteoarthritis and the older adults with severe muscle loss, and clinical studies are required to confirm it further.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Does resiliency mediate the association of psychological adaptability with disability and pain in patients with an upper extremity injury or illness?

OBJECTIVE

Symptom intensity and magnitude of limitations are highly variable for a given nociception and pathophysiology. As psychological determinants are of great influence to physical wellbeing, we assessed the influence of the protective factor measured and labelled as resilience in upper extremity illness.

METHODS

One hundred and six patients completed a survey of demographics, the Brief Resilience Scale (BRS), the Psychological Adaptation Scale (PAS), an 11-point ordinal measure of pain intensity, and the PROMIS Physical Function (PROMIS PF) Computer Adaptive Test (CAT). Measures of pain intensity and PROMIS PF were repeated 3 months later. We created mediation models using structural equation modeling (SEM) to assess the mediation effect of BRS on the association of PAS and other confounding variables with disability and pain at initial assessment and 3 months later.

RESULTS

Resiliency does not mediate the association of psychological adaptability with physical limitations and pain intensity at baseline (P = .89 and .82 respectively) or 3 months after enrollment (P = .65 and .72 respectively).

CONCLUSIONS

Positive and protective factors promote beneficial resilience mechanisms that strengthen coping responses to pain and disability. In future studies we should either include more patients to improve power and provide more information about the health benefits of resilience or focus more on mood and self-efficacy on symptoms and limitations in patients with musculoskeletal illness.

LEVEL OF EVIDENCE

Prospective, longitudinal cohort study; Level II.

Effects of a finger exercise program on hand function in automobile workers with hand osteoarthritis: A randomized controlled trial

Hand osteoarthritis reduces a person's ability to perform work activities and return to their occupation. We investigated the effects of a finger exercise program on hand grip strength, pain, physical function, and stiffness in automobile manufacturing workers with hand osteoarthritis. This randomized controlled trial was conducted on 29 subjects. Fifteen experimental subjects received a finger exercise program with paraffin baths, while 14 control subjects received only paraffin baths. Hand grip strength, pain, physical function, and stiffness were assessed at baseline and 8 weeks later. In the experimental group, hand grip strength (P < 0.001) and Australian/Canadian osteoarthritis hand index (AUSCAN) scores (pain, P < 0.001; stiffness, P < 0.001; physical function, P < 0.001) were significantly improved by 3.52 ± 2.03, 21.6 ± 8.3 (pain), 16.8 ± 10.21 (stiffness), and 13.86 ± 4.54 (physical function) compared with preintervention values. In the control group, hand grip strength (P = 0.004) and AUSCAN scores (pain, P < 0.001; stiffness, P = 0.019; physical function, P < 0.001) were significantly improved by 0.57 ± 0.62, 7.85 ± 5.46 (pain) 11.42 ± 7.18 (stiffness), and 10.28 ± 14.41 (physical function) compared with preintervention values. Significant differences between groups were found for postintervention hand grip strength (P = 0.015) and AUSCAN index subscale scores (pain, P < 0.001; physical function, P = 0.020). A combined finger exercise and paraffin bath program is effective in reducing pain, improving physical function, and increasing hand grip strength in workers with hand osteoarthritis.

Physical activity status by pain severity in patients with knee osteoarthritis: a nationwide study in Korea

Backgrounds

Few reports have explored the extent to which physical activity is affected by pain severity in knee osteoarthritis (KOA) patients. We used national representative data to investigate the physical activity of KOA patients compared to the general population to determine what proportion of patients met physical activity recommendations and to explore how the proportion changes with pain severity.

Methods

We used data from the fifth Korean National Health and Nutrition Examination Survey (KNHANES V; 2010–2012). In total, 1279 participants aged ≥50 years who had radiographic KOA and who evaluated knee pain on a numerical rating scale were selected. KOA was assessed using the Kellgren–Lawrence system. The Korean short version of the International Physical Activity Questionnaire was used to measure physical activity status. We used the physical activity recommendations of the American College of Rheumatology Work Group Panel when evaluating the extent of activity in KOA patients.

Results

Only 18.6% of KOA patients met the osteoarthritis expert panel recommendations, lower than in the general population (23.2%; p = 0.003). The percentages that met the recommendations in the none to mild pain group, moderate pain group, and severe pain group were 23.4%, 17.6%, and 18.3%, respectively (p = 0.341). In terms of flexibility, a somewhat higher percentage of those with moderate pain engaged in physical activity compared to those with little or no pain (17.1% vs. 12.3%), but the difference was not significant (p = 0.585).

Conclusions

Regardless of pain severity, overall physical activity was suboptimal in Korean KOA patients. It is important to emphasize to osteoarthritis patients in clinical settings the need for physical activity, and a policy-based effort is required to facilitate appropriate exercise.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2301-6) contains supplementary material, which is available to authorized users.

Effectiveness of home-based physiotherapy on pain and disability in participants with osteoarthritis of knee: an observational study

[Purpose] The objective of this observational study was to examine the effect of home physiotherapy on pain and disability in participants with knee osteoarthritis. [Participants and Methods] From January 2017 to December 2017, 139 participants who were recipients of HealthCare atHome physiotherapy services across various locations were included in the main analysis. The mean treatment cycle duration was 31.5 days (mean number of sessions delivered, 19.7). Physiotherapy was performed for approximately 45–50 min in the form of electrotherapy, exercise therapy, and manual therapy. Visual analog scale (VAS) scores were documented after each visit, whereas The Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC) as an outcome were recorded weekly. [Results] Statistically significant improvement in the visual analog scale and Western Ontario and Mcmaster Universities Osteoarthritis Index scores were observed, with overall % improvement of 52% and 43%, respectively. [Conclusion] The average scores in pain and disability were reduced after home based physiotherapy.

Is muscle strength in a painful limb affected by knee pain status of the contralateral limb? - Data from the Osteoarthritis Initiative

Contralateral knee pain has been suggested to be associated with muscle weakness in a pain-free knee, potentially through a mechanism of central nervous inhibition. Whether contralateral knee pain also affects muscle strength in a painful knee, however, is unknown. Here we study the extent to which isometric muscle strength differs between matched painful limbs of people with unilateral knee pain vs. matched painful limbs people with bilateral knee pain. To that end, 163 participants with unilateral knee pain were identified from the Osteoarthritis Initiative. Unilaterally painful (UP) limbs were defined as having numerical rating scale (NRS) ≥4/10, infrequent/frequent pain in the painful limb, while contralateral pain-free limbs were defined by NRS=0-1, no/infrequent pain and Western Ontario and McMaster Universities Arthritis Index (WOMAC) ≤1. The comparator group were matched bilaterally painful (BP) limbs. Maximum isometric muscle strength (N) was compared between 1:1 matched BP and UP limbs. Extensor strength was found to be lower in BP limbs than in UP limbs, (-2.9%; p=0.39) but this difference was not statistically significant. Extensor strength was significantly lower in the UP vs. contralateral pain-free limbs (-6.2%; p<0.001). No differences were observed between BP and contralateral painful limbs (0.6%; p=0.87). In conclusion, the current results identify a slight reduction of maximum knee extensor strength in a painful limb, when the contralateral knee is also painful. In contrast to pain-free limbs, this effect did not reach statistical significance, but the overall findings support the concept of central nervous inhibition of muscle strength by contralateral knee pain.

Exercise interventions and patient beliefs for people with hip, knee or hip and knee osteoarthritis: a mixed methods review

BACKGROUND

Chronic peripheral joint pain due to osteoarthritis (OA) is extremely prevalent and a major cause of physical dysfunction and psychosocial distress. Exercise is recommended to reduce joint pain and improve physical function, but the effect of exercise on psychosocial function (health beliefs, depression, anxiety and quality of life) in this population is unknown.

OBJECTIVES

To improve our understanding of the complex inter-relationship between pain, psychosocial effects, physical function and exercise.

SEARCH METHODS

Review authors searched 23 clinical, public health, psychology and social care databases and 25 other relevant resources including trials registers up to March 2016. We checked reference lists of included studies for relevant studies. We contacted key experts about unpublished studies.

SELECTION CRITERIA

To be included in the quantitative synthesis, studies had to be randomised controlled trials of land- or water-based exercise programmes compared with a control group consisting of no treatment or non-exercise intervention (such as medication, patient education) that measured either pain or function and at least one psychosocial outcome (self-efficacy, depression, anxiety, quality of life). Participants had to be aged 45 years or older, with a clinical diagnosis of OA (as defined by the study) or self-reported chronic hip or knee (or both) pain (defined as more than six months' duration).To be included in the qualitative synthesis, studies had to have reported people's opinions and experiences of exercise-based programmes (e.g. their views, understanding, experiences and beliefs about the utility of exercise in the management of chronic pain/OA).

DATA COLLECTION AND ANALYSIS

We used standard methodology recommended by Cochrane for the quantitative analysis. For the qualitative analysis, we extracted verbatim quotes from study participants and synthesised studies of patients' views using framework synthesis. We then conducted an integrative review, synthesising the quantitative and qualitative data together.

MAIN RESULTS

Twenty-one trials (2372 participants) met the inclusion criteria for quantitative synthesis. There were large variations in the exercise programme's content, mode of delivery, frequency and duration, participant's symptoms, duration of symptoms, outcomes measured, methodological quality and reporting. Comparator groups were varied and included normal care; education; and attention controls such as home visits, sham gel and wait list controls. Risk of bias was high in one and unclear risk in five studies regarding the randomisation process, high for 11 studies regarding allocation concealment, high for all 21 studies regarding blinding, and high for three studies and unclear for five studies regarding attrition. Studies did not provide information on adverse effects.There was moderate quality evidence that exercise reduced pain by an absolute percent reduction of 6% (95% confidence interval (CI) -9% to -4%, (9 studies, 1058 participants), equivalent to reducing (improving) pain by 1.25 points from 6.5 to 5.3 on a 0 to 20 scale and moderate quality evidence that exercise improved physical function by an absolute percent of 5.6% (95% CI -7.6% to 2.0%; standardised mean difference (SMD) -0.27, 95% CI -0.37 to -0.17, equivalent to reducing (improving) WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function on a 0 to 100 scale from 49.9 to 44.3) (13 studies, 1599 participants)). Self-efficacy was increased by an absolute percent of 1.66% (95% CI 1.08% to 2.20%), although evidence was low quality (SMD 0.46, 95% CI 0.34 to 0.58, equivalent to improving the ExBeliefs score on a 17 to 85 scale from 64.3 to 65.4), with small benefits for depression from moderate quality evidence indicating an absolute percent reduction of 2.4% (95% CI -0.47% to 0.5%) (SMD -0.16, 95% CI -0.29 to -0.02, equivalent to improving depression measured using HADS (Hospital Anxiety and Depression Scale) on a 0 to 21 scale from 3.5 to 3.0) but no clinically or statistically significant effect on anxiety (SMD -0.11, 95% CI -0.26 to 0.05, 2% absolute improvement, 95% CI -5% to 1% equivalent to improving HADS anxiety on a 0 to 21 scale from 5.8 to 5.4; moderate quality evidence). Five studies measured the effect of exercise on health-related quality of life using the 36-item Short Form (SF-36) with statistically significant benefits for social function, increasing it by an absolute percent of 7.9% (95% CI 4.1% to 11.6%), equivalent to increasing SF-36 social function on a 0 to 100 scale from 73.6 to 81.5, although the evidence was low quality. Evidence was downgraded due to heterogeneity of measures, limitations with blinding and lack of detail regarding interventions. For 20/21 studies, there was a high risk of bias with blinding as participants self-reported and were not blinded to their participation in an exercise intervention.Twelve studies (with 6 to 29 participants) met inclusion criteria for qualitative synthesis. Their methodological rigour and quality was generally good. From the patients' perspectives, ways to improve the delivery of exercise interventions included: provide better information and advice about the safety and value of exercise; provide exercise tailored to individual's preferences, abilities and needs; challenge inappropriate health beliefs and provide better support.An integrative review, which compared the findings from quantitative trials with low risk of bias and the implications derived from the high-quality studies in the qualitative synthesis, confirmed the importance of these implications.

AUTHORS' CONCLUSIONS

Chronic hip and knee pain affects all domains of people's lives. People's beliefs about chronic pain shape their attitudes and behaviours about how to manage their pain. People are confused about the cause of their pain, and bewildered by its variability and randomness. Without adequate information and advice from healthcare professionals, people do not know what they should and should not do, and, as a consequence, avoid activity for fear of causing harm. Participation in exercise programmes may slightly improve physical function, depression and pain. It may slightly improve self-efficacy and social function, although there is probably little or no difference in anxiety. Providing reassurance and clear advice about the value of exercise in controlling symptoms, and opportunities to participate in exercise programmes that people regard as enjoyable and relevant, may encourage greater exercise participation, which brings a range of health benefits to a large population of people.

Barriers and facilitators of physical activity in knee and hip osteoarthritis: a systematic review of qualitative evidence

Physical activity (PA), including engagement in structured exercise, has a key role in the management of hip and knee osteoarthritis (OA). However, maintaining a physically active lifestyle is a challenge for people with OA. PA determinants in this population need to be understood better so that they can be optimised by public health or healthcare interventions and social policy changes.

OBJECTIVES

The primary aim of this study is to conduct a systematic review of the existing qualitative evidence on barriers and facilitators of PA for patients with hip or knee OA. Secondary objective is to explore differences in barriers and facilitators between (1) lifestyle PA and exercise and (2) PA uptake and maintenance.

METHODS

Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, Grey literature and qualitative journals were searched. Critical Appraisal Skills Programme-Qualitative checklist and Lincoln and Guba's criteria were used for quality appraisal. Thematic synthesis was applied.

FINDINGS

Ten studies were included, seven focusing on exercise regimes, three on overall PA. The findings showed a good fit with the biopsychosocial model of health. Aiming at symptom relief and mobility, positive exercise experiences and beliefs, knowledge, a 'keep going' attitude, adjusting and prioritising PA, having healthcare professionals' and social support emerged as PA facilitators. Pain and physical limitations; non-positive PA experiences, beliefs and information; OA-related distress; a resigned attitude; lack of motivation, behavioural regulation, professional support and negative social comparison with coexercisers were PA barriers. All themes were supported by high and medium quality studies. Paucity of data did not allow for the secondary objectives to be explored.

CONCLUSION

Our findings reveal a complex interplay among physical, personal including psychological and social-environmental factors corresponding to the facilitation and hindrance of PA, particularly exercise, engagement. Further research on the efficacy of individualised patient education, psychological interventions or social policy change to promote exercise engagement and lifestyle PA in individuals with lower limb OA is required.

TRIAL REGISTRATION NUMBER

CRD42016030024.

Decreased muscle mass is independently associated with knee pain in female patients with radiographically mild osteoarthritis: a nationwide cross-sectional study (KNHANES 2010-2011)

To evaluate the association between muscle mass and knee pain in relation to radiographic severity of knee osteoarthritis. We consulted nationwide health examination and survey records collected from 2010 to 2011 and extracted data regarding female patients aged > 50 years and diagnosed with knee osteoarthritis. Radiographic severity was assessed on plain radiographs using the Kellgren-Lawrence system, whereas appendicular skeletal mass was obtained from dual-energy X-ray absorptiometry data. We performed multivariate logistic regression to evaluate the association between knee pain and muscle mass index (appendicular skeletal muscle mass divided by body weight in percentile) in patient groups stratified by radiographic severity of knee osteoarthritis. Among 17,476 participants of the national survey, 2013 female knee osteoarthritis patients were identified and stratified by radiographic severity (grade ≤ 1, n = 1136; grade 2, n = 240; grade 3, n = 379; and grade 4, n = 258). For mild osteoarthritis (Kellgren-Lawrence grade 2), muscle mass index was significantly lower in patients with knee pain than in those without knee pain (24.9 ± 3.9 vs 26.5 ± 6.3%, P = 0.023), whereas no such difference was noted for severe osteoarthritis (Kellgren-Lawrence grade > 2). After adjusting for clinical variables by multivariate logistic regression, decreased muscle mass index remained significantly associated with knee pain in patients with mild osteoarthritis but not in those with severe osteoarthritis (regression coefficient 0.915, 95% confidence interval 0.854-0.981, P = 0.012). Lower muscle mass may be a risk factor for knee pain in patients with radiographically mild knee osteoarthritis but not in those with radiographically severe osteoarthritis.

A walking program for people with severe knee osteoarthritis did not reduce pain but may have benefits for cardiovascular health: a phase II randomised controlled trial

OBJECTIVE

The primary aim was to evaluate the effect of a dosed walking program on knee pain for patients with severe knee osteoarthritis (OA). Secondary aims evaluated the effects on cardiovascular health, function and quality of life.

DESIGN

Participants with severe knee OA and increased cardiovascular risk were randomly assigned to a 12-week walking program of 70 min/week of at least moderate intensity, or to usual care. The primary outcome was knee pain (0-10). Secondary outcomes were of cardiovascular risk including physical activity, blood pressure, blood lipid and glucose levels, body mass index and waist circumference; WOMAC Index scores; physical function; and quality of life.

RESULTS

Forty-six participants (23 each group) were recruited. Sixteen participants (70%) adhered to the walking program. Intention to treat analysis showed no between-group difference in knee pain. The walking group had increased odds of achieving a healthy systolic blood pressure (OR = 5.7, 95% CI 1.2-26.9), and a faster walking speed (Mean Difference (MD) = 0.12 m/s, 95% CI 0.02-0.23). Per protocol analysis based on participant adherence showed the walking group had more daily steps (MD = 1345 steps, 95% CI 365-2325); more time walking (MD = 18 min/day, 95% CI 5-31); reduced waist circumference (MD = -5.3 cm, 95% CI -10.5 to -0.03); and increased knee stiffness (MD = 0.9 units, 95% CI 0.07-1.8).

CONCLUSIONS

Patients with severe knee OA prescribed a 12-week walking program of 70 min/week may have had cardiovascular benefits without decreasing knee pain. Australian New Zealand Clinical Trials Registry ACTRN12615000015549.

Muscle contributions to knee extension in the early stance phase in patients with knee osteoarthritis

The aim of this study was to analyze individual muscle contributions to knee angular acceleration using a musculoskeletal simulation analysis and evaluate knee extension mechanics in the early stance phase in patients with knee osteoarthritis (OA). The subjects comprised 15 patients with medial knee OA and 14 healthy elderly individuals. All participants underwent gait performance test using 8 infrared cameras and two force plates to measure the kinetic and kinematic data. The simulation was driven by 92 Hill-type muscle-tendon units of the lower extremities and a trunk with 23° of freedom. We analyzed each muscle contribution to knee angular acceleration in the 5%-15% and 15%-25% periods of the stance phase (% SP) using an induced acceleration analysis. We compared accelerations by individual muscles between the two groups using an analysis of covariance for controlling gait speed. Patients with knee OA had a significantly lesser knee extension acceleration by the vasti muscles and higher knee acceleration by hip adductors than those in controls in 5-15% SP. In addition, knee OA resulted in significantly lesser knee extension acceleration by the vasti muscles in 15-25% SP. These results indicate that patients with knee OA have decreased dependency on the vasti muscles to control knee movements during early stance phase. Hip adductor muscles, which mainly control mediolateral motion, partly compensate for the weak knee extension by the vasti muscles in patients with knee OA.

Identifying factors of psychological distress on the experience of pain and symptom management among cancer patients

Background

Epidemiological evidence suggests the impact psychological distress has on symptomatic outcomes (pain) among cancer patients. While studies have examined distress across various medical illnesses, few have examined the relationship of psychological distress and pain among patients diagnosed with cancer. This study aimed to examine the impact psychological distress-related symptoms has on pain frequency, presence of pain, and pain-related distress among oncology patients.

Methods

Data were collected from a sample of White and Black adults (N = 232) receiving outpatient services from a comprehensive cancer center. Participants were surveyed on questions assessing psychological distress (i.e., worry, feeling sad, difficulty sleeping), and health (pain presence, pain frequency, comorbidities, physical functioning), behavioral (pain-related distress), and demographic characteristics.

Results

Patients reporting functional limitations were more likely to report pain. Specifically, those reporting difficulty sleeping and feeling irritable were similarly likely to report pain. Data further showed age and feeling irritable as significant indicators of pain-related distress, with younger adults reporting more distress.

Conclusions

It must be recognized that psychological distress and experiences of pain frequency are contingent upon a myriad of factors that are not exclusive, but rather coexisting determinants of health. Further assessment of identified predictors such as age, race, socioeconomic status, and other physical and behavioral indicators are necessary, thus allowing for an expansive understanding of the daily challenges and concerns of individuals diagnosed with cancer, while providing the resources for clinicians, researchers, and policy makers to better meet the needs of this patient population.

Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: a pragmatic randomized controlled trial

OBJECTIVE

To assess the effectiveness of exercise therapy added to general practitioner (GP) care compared with GP care alone, in patients with hip osteoarthritis (OA) during 12 months follow-up.

METHODS

We performed a multi-center parallel pragmatic randomized controlled trial in 120 general practices in the Netherlands. 203 patients, aged ≥45 years, with a new episode of hip complaints, complying with the ACR criteria for hip OA were randomized to the intervention group (n = 101; GP care with additional exercise therapy) or the control group (n = 102; GP care only). GP care was given by patient's own GP. The intervention group received, in addition, a maximum of 12 exercise therapy sessions in the first 3 months and hereafter three booster sessions. Blinding was not possible. Primary outcomes were hip pain and hip-related function measured with the HOOS questionnaire (score 0-100).

RESULTS

The overall estimates on hip pain and function during the 12-month follow-up showed no between-group difference (intention-to-treat). At 3-months follow-up there was a statistically significant between-group difference for HOOS pain -3.7 (95% CI: -7.3; -0.2), effect size -0.23 and HOOS function -5.3 (95% CI: -8.9; -1.6), effect size -0.31. No adverse events were reported.

CONCLUSIONS

No differences were found during 12-months follow-up on pain and function. At 3-months follow-up, pain and function scores differed in favor of patients allocated to the additional exercise therapy compared with GP care alone.

TRIAL REGISTRATION

The Netherlands Trial Registry NTR1462.

Multivariate Radiological-Based Models for the Prediction of Future Knee Pain: Data from the OAI

In this work, the potential of X-ray based multivariate prognostic models to predict the onset of chronic knee pain is presented. Using X-rays quantitative image assessments of joint-space-width (JSW) and paired semiquantitative central X-ray scores from the Osteoarthritis Initiative (OAI), a case-control study is presented. The pain assessments of the right knee at the baseline and the 60-month visits were used to screen for case/control subjects. Scores were analyzed at the time of pain incidence (T-0), the year prior incidence (T-1), and two years before pain incidence (T-2). Multivariate models were created by a cross validated elastic-net regularized generalized linear models feature selection tool. Univariate differences between cases and controls were reported by AUC, C-statistics, and ODDs ratios. Univariate analysis indicated that the medial osteophytes were significantly more prevalent in cases than controls: C-stat 0.62, 0.62, and 0.61, at T-0, T-1, and T-2, respectively. The multivariate JSW models significantly predicted pain: AUC = 0.695, 0.623, and 0.620, at T-0, T-1, and T-2, respectively. Semiquantitative multivariate models predicted paint with C-stat = 0.671, 0.648, and 0.645 at T-0, T-1, and T-2, respectively. Multivariate models derived from plain X-ray radiography assessments may be used to predict subjects that are at risk of developing knee pain.

Validation of the Questionnaire to Identify Knee Symptoms (QuIKS) using Rasch analysis

Background

The Questionnaire to Identify Knee Symptoms (QuIKS) was recently developed to promote activity by screening for experiences related to early symptoms in people with emergent chronic knee pain problems, such as osteoarthritis (OA) – like knee pain. The main purpose of the current study was to evaluate measurement properties of the QuIKS using Rasch analysis in a sample of people with knee symptoms consistent with symptomatic knee OA.

Method

This study used cross-sectional data. The sample was 200 subjects along the following knee health continuum: pain-free healthy knees (n = 55) from a university community, knee pain with no knee OA diagnosis (n = 111) from a university-affiliated medical clinic, and patients with surgeon-diagnosed symptomatic knee OA awaiting high tibial osteotomy (n = 34) from a sports medicine surgical clinic. The 13-item QuIKS was evaluated for its factor structure, item- and person-fit, item’s category response structure, differential item functioning by sex and obesity status, local item dependency, unidimensionality, and test precision. Subsequently, the QuIKS underwent known-groups analysis and convergent validity with the Knee injury and Osteoarthritis Outcome Score (KOOS).

Results

In the QuIKS, each item’s category response structure was modified. No differential item functioning was observed. Local item dependency informed the formation of four testlets. This refined QuIKS obtained summary fit to the Rasch measurement model, unidimensionality, reliability (person separation index = 0.82), and interval-level scoring. Subsequently, the Rasch-validated QuIKS (QuIKS-R) demonstrated excellent known-groups validity and good convergent validity with the KOOS (Spearman’s rho = 0.45 to 0.77).

Conclusions

The QuIKS-R provides interval-level quantification of knee symptoms-related experiences in people with knee symptoms consistent with symptomatic knee OA. Its scores might be useful for clinicians for promoting activity in individuals with early symptoms consistent with symptomatic knee OA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-015-0358-6) contains supplementary material, which is available to authorized users.

Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review

OBJECTIVE

Although physical exercise is the commonly recommended for osteoarthritis (OA) patients, the working mechanism behind the positive effects of physical exercise on pain and function is a black box phenomenon. In the present study we aimed to identify possible mediators in the relation between physical exercise and improvements of pain and function in OA patients.

DESIGN

A systematic search for all studies evaluating the effects of physical exercise in OA patients and select those that additionally reported the change in any physiological factor from pre-to post-exercise.

RESULTS

In total, 94 studies evaluating 112 intervention groups were included. Most included studies evaluated subjects with solely knee OA (96 out of 112 groups). Based on the measured physiological factors within the included studies, 12 categories of possible mediators were formed. Muscle strength and ROM/flexibility were the most measured categories of possible mediators with 61 and 21 intervention groups measuring one or more physiological factors within these categories, respectively. 60% (31 out of 52) of the studies showed a significant increase in knee extensor muscle strength and 71% (22 out of 31) in knee flexor muscle strength over the intervention period. All 5 studies evaluating extension impairments and 10 out of 12 studies (83%) measuring proprioception found a significant change from pre-to post-intervention.

CONCLUSION

An increase of upper leg strength, a decrease of extension impairments and improvement in proprioception were identified as possible mediators in the positive association between physical exercise and OA symptoms.

Back/joint pain, illness perceptions and coping are important predictors of quality of life and work productivity in patients with inflammatory bowel disease: a 12-month longitudinal study

BACKGROUND AND AIMS

Back and joint pain are the most common extraintestinal symptoms reported by patients with inflammatory bowel disease (IBD). We assessed the impact of back/joint pain, illness perceptions, and coping on quality of life (QOL) and work productivity in patients with IBD.

METHODS

Our cohort included 155 IBD patients with and 100 without arthropathy. Arthropathy was defined as daily back pain for ≥3 months and/or peripheral joint pain and/or joint swelling over the last year. At baseline and at 12 months, patients completed questionnaires on the extent of back/joint pain, IBD disease activity, illness perceptions, coping, QOL, and work productivity. The impact of back/joint pain, illness perceptions and coping on QOL and work productivity was determined, using linear mixed models.

RESULTS

In total, 204 IBD patients (72% Crohn's disease, 40% male, mean age 44 ± 14 years) completed questionnaires at both time points. At both time points, IBD patients with back/joint pain reported a significantly lower QOL and work productivity compared with IBD patients without back/joint pain. Predictors of low QOL were back/joint pain (β = -1.04, 95% confidence interval [CI] -1.40, -0.68), stronger beliefs about the illness consequences (β = -0.39, 95% CI -0.59, -0.18) and emotional impact of IBD (β = -0.47, 95% CI -0.66, -0.28), and the coping strategy 'decreasing activity' (β = -0.26, 95% CI -0.48, -0.03). Predictors of work productivity were back/joint pain (β = 0.22, 95% CI 0.07, 0.37) and illness consequences (β = 0.14, 95% CI 0.06, 0.22).

CONCLUSION

Back/joint pain, illness perceptions, and coping are significant predictors of QOL and work productivity, after controlling for disease activity.

Sex differences in patients with different stages of knee osteoarthritis

OBJECTIVE

To quantify the differences in physical impairments and in performance-based measures and patient-reported outcomes in men and women seeking nonoperative management of symptomatic moderate knee osteoarthritis (OA) and those with symptomatic end-stage knee OA scheduled for total knee arthroplasty compared with healthy controls.

DESIGN

Cross-sectional analysis of individuals referred to physical therapy, community participants, and subjects from a 2-year longitudinal study.

SETTING

University research department.

PARTICIPANTS

Cross-sectional analysis of participants (N=289) consisting of a moderate OA group (n=83), a severe OA group (n=143), and a healthy control group (n=63).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Quadriceps strength, timed Up and Go test, stair-climbing test, 6-minute walk test, Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS), and Physical Component Summary (PCS) of the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Women had worse scores than men for physical impairment and performance-based measures (P<.001). In the moderate OA group, women had significantly lower KOS-ADLS (P=.007) and PCS (P=.026) scores than men, with no differences seen between sexes in the other 2 groups for patient-reported measures.

CONCLUSIONS

Differences between women and men with knee OA on physical impairments and performance-based measures are not echoed in the differences seen in patient-reported measures. These measures signal different domains of knee function in patients with knee OA and should be used as part of a comprehensive functional evaluation.

A postal screener for pain and need for treatment in older persons in primary care

OBJECTIVES

To test the Pain intensity, Enjoyment in life, General activity questionnaire (PEG) as a postal screener for pain in older persons.

DESIGN

Population-based survey. Postal screening questionnaires followed by an interview of a sample of participants.

SETTING

Family practices.

PARTICIPANTS

Persons aged 75 and older (N = 243; 95 interviewed).

MEASUREMENTS

Screening included the PEG, a three-item abbreviated version of the Brief Pain Inventory (BPI), plus an additional question on treatment need. Pain severity and related interference was assessed (BPI) during the interview, as was the current (need for) pain treatment.

RESULTS

The median PEG score of the 243 persons participating in the screening (response 76%) was 2.0 (interquartile range 0-4.7). Seventy-nine (35%) had moderate to severe pain (PEG score ≥ 4), of whom 56% reported current pain treatment and 15% stated that they might ask for help. For a PEG score cutoff of 4 or greater, sensitivity was 0.81 and specificity was 0.78 to find scores of 4 or greater on one or both BPI subscales during the interview. For the question on need for treatment, replies on the screener and the interview were not always consistent. Of the 43 interviewed participants with a PEG score of 4 or greater, 60% received treatment. Of the 17 without current pain treatment, 10 still reported pain, three of whom said that they might ask for help.

CONCLUSION

The PEG can be used as a postal screener to detect the presence of pain in older persons, but treatment needs cannot be established using the PEG alone or in combination with a simple additional question.

Synergetic and antagonist muscle strength and activity in women with knee osteoarthritis

BACKGROUND AND PURPOSE

People with knee osteoarthritis (OA) display limitations in daily activities and a lower quality of life. The purpose of this study was to investigate the differences in strength balance and activation during maximum strength efforts between women with knee OA and asymptomatic women.

METHODS

Twelve women with knee OA (age 60.33 ± 6.66 years) and 11 controls (age 56.54 ± 5.46 years) performed maximum isokinetic eccentric and concentric knee extension and flexion tests at 60°/s, 120°/s, and 150°/s. Surface electromyography (EMG) was recorded from the biceps femoris (BF), vastus lateralis (VL), and vastus medialis (VM). Hamstrings-to-quadriceps moment ratios (H/Q), the synergetic (VL/VM), and co-contraction (BF/[VM + VL]) EMG ratios were calculated.

RESULTS

Analysis-of-variance designs showed that women experiencing knee OA had significantly higher H/Q moment ratios and VM/VL EMG ratios than controls (P < 0.05). The co-contraction index was significantly lower in the OA group only during knee flexion (P < 0.05).

CONCLUSIONS

Women with knee OA showed a higher H/Q moment ratios probably because of the need for better joint stability or a lower quadriceps capacity. This deficiency was accompanied by a higher VM activation, which probably serves to stabilize the patella upon maximum contraction as well as a higher activation of antagonist muscles.

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.

Self-perceived weather sensitivity and joint pain in older people with osteoarthritis in six European countries: results from the European Project on OSteoArthritis (EPOSA)

Background

People with osteoarthritis (OA) frequently report that their joint pain is influenced by weather conditions. This study aimed to examine whether there are differences in perceived joint pain between older people with OA who reported to be weather-sensitive versus those who did not in six European countries with different climates and to identify characteristics of older persons with OA that are most predictive of perceived weather sensitivity.

Methods

Baseline data from the European Project on OSteoArthritis (EPOSA) were used. ACR classification criteria were used to determine OA. Participants with OA were asked about their perception of weather as influencing their pain. Using a two-week follow-up pain calendar, average self-reported joint pain was assessed (range: 0 (no pain)-10 (greatest pain intensity)). Linear regression analyses, logistic regression analyses and an independent t-test were used. Analyses were adjusted for several confounders.

Results

The majority of participants with OA (67.2%) perceived the weather as affecting their pain. Weather-sensitive participants reported more pain than non-weather-sensitive participants (M = 4.1, SD = 2.4 versus M = 3.1, SD = 2.4; p < 0.001). After adjusting for several confounding factors, the association between self-perceived weather sensitivity and joint pain remained present (B = 0.37, p = 0.03). Logistic regression analyses revealed that women and more anxious people were more likely to report weather sensitivity. Older people with OA from Southern Europe were more likely to indicate themselves as weather-sensitive persons than those from Northern Europe.

Conclusions

Weather (in)stability may have a greater impact on joint structures and pain perception in people from Southern Europe. The results emphasize the importance of considering weather sensitivity in daily life of older people with OA and may help to identify weather-sensitive older people with OA.

Avoidance of activity and limitations in activities in patients with osteoarthritis of the hip or knee: a 5 year follow-up study on the mediating role of reduced muscle strength

OBJECTIVE

To evaluate the mediating role of reduced muscle strength in the relationship between avoidance of activity and limitations in activities in patients with knee or hip osteoarthritis (OA).

METHODS

A longitudinal cohort study with 5 years follow-up was conducted. Patients with knee or hip OA (n = 288) were recruited at rehabilitation centers and hospitals. Self-reported and performance based limitations in activities, avoidance of activity and muscle strength were assessed at baseline, 1, 2, 3 and 5 years follow-up. Generalized Estimating Equations (GEE) analyses were used to evaluate mediation.

RESULTS

In patients with knee OA, reduced knee extensor muscle strength mediated the relationship between avoidance of activity and limitations in activities. In patients with hip OA reduced hip abductor muscle strength mediates the relationship between avoidance of activity and limitations in activities.

CONCLUSION

The results of this longitudinal study support the theory that avoidance of activity leads to deterioration of muscle strength and consequently to more limitations in activities in patients with knee and hip OA.

Short- and long-term clinical outcomes following a standardized protocol of orthopedic manual physical therapy and exercise in individuals with osteoarthritis of the hip: a case series

OBJECTIVES

Describe short- and long-term outcomes observed in individuals with hip osteoarthritis (OA) treated with a pre-selected, standardized set of best-evidence manual therapy and therapeutic exercise interventions.

METHODS

Fifteen consecutive subjects (9 males, 6 females; mean age: 52±7.5 years) with unilateral hip OA received an identical protocol of manual therapy and therapeutic exercise interventions. Subjects attended 10 treatment sessions over an 8-week period for manual therapy interventions and performed the therapeutic exercise as a home program.

RESULTS

Baseline to 8-week follow-up outcomes were as follows: Harris Hip Scale (HHS) scores improved from 60.3(±10.4) to 80.7(±10.5), Numerical Pain Rating Scale (NPRS) scores improved from 4.3(±1.9) to 2.0(±1.9), hip flexion range of motion (ROM) improved from 99 degrees (±10.6) to 127 degrees (±6.3) and hip internal rotation ROM improved from 19 degrees (±9.1) to 31 degrees (±11.5). Improvements in HHS, NPRS, and hip ROM measures reached statistical significance (P<0.05) at 8-weeks and remained significant at the 29-week follow-up. Mean changes in NPRS and HHS scores exceeded the minimal clinically important difference (MCID) at 8-weeks and for the HHS scores alone at 29 weeks. The 8 and 29 week mean Global Rating of Change scores were 5.1(±1.4) and 2.1(±4.2), respectively. Improved outcomes observed following a pre-selected, standardized treatment protocol were similar to those observed in previous studies involving impairment-based manual therapy and therapeutic exercise for hip OA. Future studies might directly compare the two approaches.

Effects of the MWM Technique Accompanied by Trunk Stabilization Exercises on Pain and Physical Dysfunctions Caused by Degenerative Osteoarthritis

[Purpose] This study aimed to identify how treatment with the Mulligan technique of mobilization with movement (MWM) influences pain and physical function of patients with degenerative osteoarthritis. [Subjects] Thirty patients diagnosed with degenerative osteoarthritis were divided into an experimental group (n=15), and a control group (n=15). [Methods] The experimental group was treated with general physical therapy, trunk stabilization exercises, and performed the MWM using the Mulligan technique. The control group was treated with general physical therapy, and then performed trunk stabilization exercises. [Results] Statistically significant differences were found after the intervention in the experimental group in the visual analog scale and Western Ontario and McMaster Universities osteoarthritis index pain, stiffening, and physical function scores. [Conclusion] We consider the treatment of degenerative osteoarthritis patients using the MWM technique is effective for reducing pain and improving physical functions.

Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis

BACKGROUND

The purpose of this study is to explore the relationship between function, pain and stiffness outcomes with individual and community socioeconomic status (SES) measures among individuals with radiographic knee osteoarthritis (rOA).

METHODS

Cross-sectional data from the Johnston County Osteoarthritis Project were analyzed for adults age 45 and older with knee rOA (n = 782) and a subset with both radiographic and symptomatic knee OA (n = 471). Function, pain and stiffness were measured using the Western Ontario and McMasters Universities Index of Osteoarthritis (WOMAC). Individual SES measures included educational attainment (<12 years, ≥12 years) and occupation type (managerial, non-managerial), while community SES was measured using Census block group poverty rate (<12%, 12-25%, ≥25%). SES measures were individually and simultaneously examined in linear regression models adjusting for age, gender, race, body mass index (BMI), occupational physical activity score (PAS), comorbidity count, and presence of hip symptoms.

RESULTS

In analyses among all individuals with rOA, models which included individual SES measures were observed to show that occupation was significantly associated with WOMAC Function (β =2.91, 95% Confidence Interval (CI) = 0.68-5.14), WOMAC Pain (β =0.93, 95% CI = 0.26-1.59) and WOMAC Total scores (β =4.05, 95% CI = 1.04-7.05), and education was significantly associated with WOMAC Function (β =3.57, 95% CI = 1.25-5.90) and WOMAC Total (β =4.56, 95% CI = 1.41-7.70) scores. In multivariable models including all SES measures simultaneously, most associations were attenuated. However, statistically significant results for education remained between WOMAC Function (β =2.83, 95% CI = 0.38-5.28) and WOMAC Total (β =3.48, 95% CI = 0.18-6.78), as well as for the association between occupation and WOMAC Pain (β =0.78, 95% CI = 0.08-1.48). In rOA subgroup analyses restricted to those with symptoms, we observed a significant increase in WOMAC Pain (β =1.36, 95% CI = 0.07-2.66) among individuals living in a block group with poverty rates greater than 25%, an association that remained when all SES measures were considered simultaneously (β =1.35, 95% CI = 0.06-2.64).

CONCLUSIONS

Lower individual and community SES are both associated with worse function and pain among adults with knee rOA.