Arthritis Burden and Impact are Greater among U.S. Women than Men: Intervention Opportunities

Economic impact of informal caring for a person with arthritis in Australia from 2015 to 2030: a microsimulation approach using national survey data

OBJECTIVES

To estimate the economic burden of informal caregivers not in the labour force (NILF) due to caring for a person with arthritis in Australia, with projections of these costs from 2015 to 2030.

DESIGN

Static microsimulation modelling using national survey data.

SETTING

Australia nationwide survey.

PARTICIPANTS

Participants include respondents to the Survey of Disability, Ageing and Carers who are informal carers of a person who has arthritis as their main chronic condition and non-carers.

OUTCOME MEASURES

Estimating the economic impact and national aggregated costs of informal carers NILF to care for a person with arthritis and projecting these costs from 2015 to 2030 in 5-year intervals.

RESULTS

On a per-person basis, when adjusted for age, sex and highest education attained, the difference in average weekly total income between informal carers and non-carers employed in the labour force is $A1051 (95% CI: $A927 to $A1204) in 2015 and projected to increase by up to 22% by 2030. When aggregated, the total national annual loss of income to informal carers NILF is estimated at $A388.2 million (95% CI: $A324.3 to $A461.9 million) in 2015, increasing to $A576.9 million (95% CI: $A489.2 to $A681.8 million) by 2030. The national annual tax revenue lost to the government of the informal carers NILF is estimated at $A99 million (95% CI: $A77.9 to $A126.4 million) in 2015 and is projected to increase 49% by 2030.

CONCLUSION

Informal carers NILF are economically worse off than employed non-carers, and the aggregated national annual costs are substantial. The future economic impact of informal carers NILF to care for a person with arthritis in Australia is projected to increase, with the estimated differences in income between informal carers and employed non-carers increasing by 22% from 2015 to 2030.

Trends and Racial/Ethnic Differences in Health Care Spending Stratified by Gender among Adults with Arthritis in the United States 2011-2019

The purpose of this study was to determine if there were racial/ethnic differences and patterns for individual office-based visit expenditures by gender among a nationally representative sample of adults with arthritis. We retrospectively analyzed pooled data from the 2011 to 2019 Medical Expenditure Panel Survey of adults who self-reported an arthritis diagnosis, stratified by gender (men = 13,378; women = 33,261). Our dependent variable was office-based visit expenditures. Our independent variables were survey year (categorized as 2011-2013, 2014-2016, 2017-2019) and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, non-Hispanic other/multiracial). We conducted trends analysis to assess for changes in expenditures over time. We utilized a two-part model to assess differences in office-based expenditures among participants who had any office-based expenditure and then calculated the average marginal effects. The unadjusted office-based visit expenditures increased significantly across the study period for both men and women with arthritis, as well as for some racial and ethnic groups depending on gender. Differing racial and ethnic patterns of expenditures by gender remained after accounting for socio-demographic, healthcare access, and health status factors. Delaying care was an independent driver of higher office-based expenditures for women with arthritis but not men. Our findings reinforce the escalating burden of healthcare costs among U.S. adults with arthritis across genders and certain racial and ethnic groups.

Integration of mental health comorbidity in medical specialty programs in 20 countries

METHODS

A systematic analysis was performed of the medical specialization academic programs of 20 different countries to establish which medical specialties take into account mental health issues in the specialty curricular design and which mental health content these programs address. The criteria that were explored in the educational programs include: 1) name of the medical specialties that take into account mental health content in curriculum design, 2) name of the mental health issues addressed by these programs. After independent review and data extraction, paired investigators compared the findings and reached consensus on all discrepancies before the final presentation of the data. Descriptive statistics evaluated the frequency of the data presented.

RESULTS

Internal medicine, family medicine, neurology, pediatrics and geriatrics were the specialties that included mental health topics in their programs. In four countries: Bangladesh, Serbia, the Netherlands and France, 50%of all graduate specialty training programs include mental health content. In ten countries: Germany, Sweden, the United Kingdom, Mexico, Belgium, India, Russia, Canada, Israel and Spain, between 20% and 49% of all graduate specialty training programs include mental health content. In six countries - Brazil, Chile, Colombia, Croatia, Kenya, and the United States-less than 20% of all graduate specialty training programs include mental health content.

DISCUSSION

The proposal that we have made in this article should be taken into account by decision-makers, in order to complement the different postgraduate training programs with mental health issues that are frequently present with other physical symptoms. It is not our intention that the different specialists know how to treat psychiatric comorbidities, but rather pay attention to their existence and implications in the diagnosis, evolution and prognosis of many other diseases. The current fragmentation of medicine into ever finer specialties makes the management of comorbidity ever more difficult: a reorientation of post- graduate training might improve the situation.

Frailty in Korean patients with chronic obstructive pulmonary disease, using data from the Korea National Health and Nutrition Examination Survey, 2015 and 2016

AIM

To describe frailty, to identify its determinants, and to examine how it affected functioning in Korean patients with chronic obstructive pulmonary disease (COPD). This analysis was based on datasets from the Korea National Health and Nutrition Examination Survey (KNHANES).

BACKGROUND

Most of what is known about the prevalence and determinants of frailty in patients with COPD has come from countries other than Korea. Examining this issue with a representative sample of COPD patients in Korea will shed light on frailty in this population.

METHODS

This cross-sectional study, a secondary data analysis, used datasets from the KNHANES VI (2015) and VII (2016) to understand frailty in 417 patients with COPD (mean age = 65.36; FEV1%predicted value = 78.91). Demographic and clinical data, symptoms, self-rated health, frailty, and functioning were collected in health interviews and health examinations. Descriptive and inferential statistics were used to analyze the data.

RESULTS

One hundred forty-eight participants (35.5%) were frail, 156 (37.4%) were pre-frail, and 113 (27.1%) exhibited no frailty. Multivariate logistic regression showed that self-rated health, stage of COPD based on the Global Initiative for Chronic Obstructive Lung Disease, pain/discomfort, and arthritis were significant predictors of frailty. Multivariate logistic regression also showed that frail participants were more likely to experience limitations in usual activities, after controlling for other covariates.

CONCLUSION

Health care providers who know the determinants of frailty and its relationship with poor functioning will be better prepared to identify at-risk patients with COPD who might benefit from pulmonary rehabilitation.

Trajectory of excess healthcare consultations, medication use, and work disability in newly diagnosed knee osteoarthritis: a matched longitudinal register-based study

PURPOSE

To estimate the excess healthcare use and work disability attributable to knee osteoarthritis (OA) in the first 5 years following diagnosis.

METHODS

Among individual aged 40-80 years who resided in Skåne on 31^st December 2008, we identified those with a main diagnosis of knee OA during 2009-2014 and no previous diagnosis of any OA from 1998 (n = 16,888). We created a comparison cohort matched (1:1) by sex, age, and municipality from individuals with no OA diagnosis (at any site) during 1998-2016. We compared healthcare use and net disability days for 60 months following diagnosis between the two groups. We applied a survival-adjusted regression technique controlling for sociodemographic characteristics as well as pre-diagnosis outcome and comorbidity.

RESULTS

The estimated 5-year incremental effects of knee OA per-patient were 16.8 (95% CI: 15.8, 17.7) healthcare consultations, 0.7 (0.4, 1.1) inpatient days, 420 (372, 490) defined daily dose of prescribed medications, and 21.8 (15.2, 30.0) net disability days. Primary care consultations constituted about 73% of the excess healthcare consultations. Most of these incremental effects occurred in the first year after diagnosis. Better survival in the knee OA group accounted for 0.7 (95% CI: 0.5, 0.8) and 1.4 (0.7, 2.6) of the excess healthcare consultations and net disability days, respectively. Both estimated total and incremental resources use were generally greater for women than men with knee OA.

CONCLUSION

Knee OA was associated with considerable excess healthcare use and work disability independent of pre-diagnosis resources use, comorbidity, and sociodemographic characteristics.

Macrophage regulator of G-protein signaling 12 contributes to inflammatory pain hypersensitivity

Background

Pain is a predominant symptom in rheumatoid arthritis (RA) patients that results from joint inflammation and is augmented by central sensitization. Regulator of G-protein signaling 12 (RGS12) is the largest protein in the RGS protein family and plays a key role in the development of inflammation. This study investigated the regulation of RGS12 in inflammatory pain and explored the underlying mechanisms and potential RA pain targets.

Methods

Macrophage-specific RGS12-deficient (LysM-Cre⁺;RGS12^fl/fl) mice were generated by mating RGS12^fl/fl mice with LysM-Cre⁺ transgenic mice. Collagen antibody-induced arthritis (CAIA) models were induced in LysM-Cre⁺;RGS12^fl/fl mice by the administration of a cocktail of five monoclonal antibodies and LPS. Mouse nociception was examined using the von Frey and heat plate tests. Primary macrophages and RAW264.7 cells were used to analyze the regulatory function and mechanism of RGS12 in vitro. The expression and function of RGS12 and COX2 (cyclooxygenase 2) were determined by real-time PCR, ELISA, and luciferase assays.

Results

Ablation of RGS12 in macrophages decreased pain-related phenotypes, such as paw swelling, the clinical score, and the inflammatory score, in the CAIA model. LysM-Cre⁺;RGS12^fl/fl mice displayed increased resistance to thermal and mechanical stimulation from day 3 to day 9 during CAIA, indicating the inhibition of inflammatory pain. Overexpression of COX2 and PGE2 in macrophages enhanced RGS12 expression, and PGE2 regulated RGS12 expression through the G-protein-coupled receptors EP2 and EP4. Furthermore, RGS12 or the RGS12 PTB domain strengthened the transcriptional regulation of COX2 by NF-κB, whereas inhibiting NF-κB suppressed RGS12-mediated regulation of COX2 in macrophages.

Conclusions

Our results demonstrate that the deletion of RGS12 in macrophages attenuates inflammatory pain, which is likely due to impaired regulation of the COX2/PGE2 signaling pathway.

Associations of Arthritis-Attributable Interference with Routine Life Activities: A Modifiable Source of Compromised Quality-of-Life

OBJECTIVE

Arthritis patients experience the impact of disease beyond routinely assessed clinical measures. We characterized arthritis-attributable interference in four important routine life domains: 1) recreation/leisure/hobbies; 2) household chores; 3) errands/shopping; and 4) social activities.

METHODS

Participants were from the Arthritis Conditions Health Effects Survey (2005-2006), a cross-sectional survey of noninstitutionalized US adults 45 years or older with doctor-diagnosed arthritis (n = 1793). We estimated the prevalence of "a lot" of arthritis-attributable interference and quantified the associations between sociodemographic, clinical, and psychological characteristics and "a lot" of arthritis-attributable interference (vs "a little" or "none") in each domain using prevalence ratios (PRs) in multivariable (MV)-adjusted logistic regression models.

RESULTS

An estimated 1 in 5 to 1 in 4 adults with arthritis reported "a lot" of arthritis-attributable interference in recreation/leisure/hobbies (27%), household chores (25%), errands/shopping (22%), and social activities (18%). The highest prevalence of "a lot" of arthritis-attributable interference was for those unable to work/disabled or reporting severe arthritis symptoms (pain, stiffness, fatigue), anxiety, depression, or no/low confidence in ability to manage arthritis, across domains. In MV-adjusted models, those unable to work/disabled, currently seeing a doctor, or reporting fair/poor self-rated health, severe joint pain, anxiety, or no/low confidence in ability to manage arthritis were more likely to report arthritis-attributable interference than their respective counterparts. Magnitudes varied by domain but were consistently strongest for those unable to work/disabled (MV PR range = 1.8-2.5) and with fair/poor health (MV PR range = 1.7-2.7).

CONCLUSION

Many characteristics associated with arthritis-attributable interference in routine life activities are potentially modifiable, suggesting unmet need for use of existing evidence-based interventions that address these characteristics and reduce interferences to improve quality of life.

Which one? What kind? How many? Types, causes, and prevalence of disability among U.S. adults

BACKGROUND

Quantifying the number of people with and types of disabilities is helpful for medical, policy, and public health planning.

OBJECTIVE/HYPOTHESIS

To update prior estimates on types, prevalence, and main causes of disability among U.S. adults using the Survey of Income and Program Participation (SIPP) data.

METHODS

We used cross-sectional data from the SIPP 2008 Panel Wave 6 interviews collected May-August 2010. Analyses were restricted to non-institutionalized adults ages ≥18 years (n = 66,410). Disability was ascertained via five non-mutually exclusive components: 1) specific activity difficulties, 2) selected impairments, 3) use of an assistive aid, 4) household work limitations, and 5) paid work limitations. Prioritized main cause of disability was established for the 95% of respondents with a disability type eligible for health condition questions. We generated weighted population estimates (number and percentage, with 95% confidence intervals (CIs)), accounting for the complex sample survey design.

RESULTS

50 million U.S. adults (21.8%) experienced a disability in 2010. Mobility-related activity limitations were the most prevalent disabilities across all five components. The most common main causes of disability were arthritis/rheumatism, 9.1 million (19.2%, 95% CI = 18.4-20.0) and back or spine problems, 8.9 million (18.6%, 95% CI = 17.9-19.3).

CONCLUSIONS

A growing population with disabilities has the potential to put considerable and unsustainable demand on medical, public health, and senior service systems. Strengthening clinical community linkages and expanding the availability of existing evidence-based public health interventions to prevent, delay, and mitigate the effects of disability could improve health and outcomes for people with disabilities.

Stiff knee gait may increase risk of second total knee arthroplasty

Osteoarthritis (OA) progression in the contralateral limb after unilateral total knee arthroplasty (TKA) may be related to altered and asymmetrical movement patterns that overload the contralateral joints. The purpose of this study was to determine if biomechanical factors after unilateral TKA were associated with future contralateral TKA. One hundred and fifty-eight individuals who underwent unilateral TKA completed three dimensional motion analysis 6-24 months after unilateral TKA (baseline). Subjects were re-contacted for follow-up (mean 5.89 years after baseline testing) to determine if they had undergone a contralateral TKA. Biomechanical variables from gait at baseline were compared between those who did and did not undergo contralateral TKA at follow-up using one-way ANOVAs. Odds ratios were calculated for variables found to be significant in the ANOVA models. Individuals who underwent contralateral TKA had less knee flexion excursion (10.5° vs. 12.1°; p = 0.032) and less knee extension excursion (8.2° vs. 9.6°; p = 0.035) at baseline on the operated side during walking. Individuals who underwent contralateral TKA also had less knee flexion excursion on the contralateral limb at baseline (11.9° vs. 14.0°; p = 0.017). For every additional degree of knee flexion excursion on the contralateral knee at baseline, there was a 9.1% reduction in risk of future contralateral TKA. Individuals who walked with stiffer gait patterns were more likely to undergo future contralateral TKA. Clinical Significance: Altered movement patterns after surgery may increase the risk for contralateral TKA. Knee excursion is an important metric to include in outcome studies and may serve as a target of rehabilitation after TKA. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:397-402, 2019.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Operation Change: A New Paradigm Addressing Behavior Change and Musculoskeletal Health Disparities

BACKGROUND

In this study, we examined the implementation and efficacy of Operation Change, a community-based, culturally sensitive program to stimulate behavioral changes in activity level and improve musculoskeletal health in African-American (AA) and Hispanic/Latina (H/L) women with obesity and early-stage osteoarthritis.

METHODS

Sixty-two women (32 AA and 30 H/L), 40-75 years old, with nontraumatic knee pain and body mass index values > 30, participated in a 12-week program of presentations, motivational interviewing, goal setting, and physical activities. Assessments (at 0, 6, and 12 weeks) included a demographic questionnaire, physical assessment, timed 50-ft walking test, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Short Form-36 Health Survey (SF-36), 8-Item Physical Health Questionnaire (PHQ-8), and motivational interview assessment.

RESULTS

Walking time improved significantly for H/L women (P < 0.0001) but not AA women (P = 0.0759). Both groups had significant mean weight loss (P < 0.05) with high variability among individuals. WOMAC scores for both groups indicated decreased pain (P < 0.0001) and stiffness (P < 0.0001) and improved physical functioning (P < 0.0001) by 12 weeks. SF-36 results were comparable to those of the WOMAC. PHQ-8 results improved significantly for H/L women (P < 0.0001) but not AA women (P = 0.077). Participants scored the motivational interviewing component of the program favorably.

CONCLUSIONS

Participation in Operation Change increased physical activity, resulting in improvements in pain and function scores. This supports a new paradigm for behavioral modification that helps AA and H/L women take an active role in living with osteoarthritis.

Current Trends in the Use of Shoulder Arthroplasty in the United States

Reverse total shoulder arthroplasty (rTSA) has become increasingly popular since its introduction to the United States. The purpose of this study was to assess the current trends and use of rTSA, anatomic total shoulder arthroplasty (aTSA), and hemiarthroplasty (HA) from 2011 to 2014. Shoulder arthroplasty data from the National (Nationwide) Inpatient Sample database were analyzed for the years 2011 to 2014 using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. For each procedure, use and patient and hospital characteristics were identified. Shoulder arthroplasties increased by 24% between 2011 and 2014, to 79,105 procedures. The proportion of arthroplasties that were aTSA did not change substantially (44% for both years; P=.0585), while the proportion that were rTSA surpassed aTSA in 2014, increasing from 33% to 46% (P<.0001). Use of rTSA topped use of aTSA by 2013 for Medicare patients. The proportion that were HA procedures declined from 23% to 11% (P<.0001). The use of rTSA for fracture increased from 26% to 58% (P<.0001) of all arthroplasties for this indication, while the use of HA for fracture decreased from 69% to 40% (P<.0001). Orthopedists performed rTSA more often than aTSA for Medicare patients by 2013 and the general population by 2014. The use of rTSA for fracture has grown significantly, with rTSA being performed more frequently than HA for this indication. [Orthopedics. 2018; 41(3):e416-e423.].

Determinants of physical functioning in women with knee osteoarthritis

BACKGROUND

Knee osteoarthritis (OA) is an important health problem with its high prevalence and association with pain and functional disability in physical tasks and activities especially in women.

AIMS

To explore the impacts of widely seen demographic, pathological, psychological, and impairment factors on physical functioning in women with knee OA using the performance-based and self-reported measures.

METHODS

One hundred and ten women with knee OA participated in this study. Performance-based measures included the 10-m walk test, timed up and go (TUG) test, and a stair test. Self-reported physical functioning was measured using the Western Ontario and McMasters Universities OA Index. Knee muscle strength, pain intensity, flexion range of motion (ROM), body mass index (BMI), radiographic severity, and anxious and depressive symptoms were measured. Age, disease duration, and comorbidities were recorded. Correlation and linear regression analyses were used to assess the associations.

RESULTS

In the linear regression models, knee muscle weakness, limited knee flexion ROM, pain intensity, and older age contributed to 65% of variance in physical performance measures mostly explained by knee muscle weakness. Knee pain intensity, BMI, anxiety, and knee muscle weakness contributed to 60% of variance in WOMAC physical function score mostly explained by pain. Radiologic severity, depression, comorbidities, and disease duration did not have a significant association (P < 0.05). Performance-based measures had significant but moderate correlations with WOMAC physical function score (r range 0.51-0.57, P < 0.05).

CONCLUSION

In women with knee OA, knee muscle strength was the main determinant of performance-based physical functioning together with knee flexion ROM, knee pain, and age. Knee pain was the main determinant of self-reported physical functioning. BMI, anxiety, and knee muscle strength had some contributions as well. Performance-based and self-reported measures had moderate relations and evaluate different aspects of physical functioning. In the management of women with knee OA strengthening of weak knee muscles, improving limited flexion ROM, pain management, weight loss, and improving anxiety should be considered as a priority and performance-based and self-reported measures should be used together for a comprehensive evaluation of physical functioning.

Back Stiffness Is Associated with Physical Health and Low Back Pain-Related Disability in Community-Dwelling Older Adults

Objective

Back stiffness is a common complaint among older adults with low back pain. Nonetheless, self-reported back stiffness has received little exploration in this patient population. The purpose of this study was to examine the associations of self-reported low back stiffness with physical health and low back pain-related disability among older adults with low back pain.

Design

Cross-sectional analysis.

Subjects

Data included in this study were obtained from the Retirement Community Back Pain Study, a population-based survey of older adults.

Methods

Participants completed the Medical Outcomes Survey Short-Form 36 and the modified Oswestry Low Back Pain Questionnaire. Physical health, derived from the Short Form-36, was represented by the physical component summary score. Back stiffness was rated on a 0-10 scale, where 0 indicated "no back stiffness."

Results

Covariates-that is, intensity and duration of low back pain, age, sex, weight, education level, and comorbidities-explained 27% of the variance in physical health ( P  < 0.0001) and 38% of the variance in low back pain-related disability ( P  = 0.0002). Self-reported stiffness explained an additional 6% of the variance in physical health ( P  < 0.0001) and 10% of the variance in low back pain-related disability ( P  < 0.0001).

Conclusions

Back stiffness in older, community-dwelling adults with low back pain may help explain physical health and low back pain-related disability, above and beyond demographics and pain. Future longitudinal research is needed to evaluate low back stiffness as a predictor of physical health and disability. Ultimately, assessment and treatment of back stiffness in older adults with low back pain may improve patient outcomes.

Effects of a Community-Based Exercise Program on Older Adults’ Physical Function, Activities of Daily Living, and Exercise Self-Efficacy: Feeling Fit Club

Community-based exercise programs have demonstrated feasibility, yet many lack controlled studies examining their efficacy. This study examined the efficacy of a community-based exercise program, using a controlled design. Participants ( N = 262, Mage = 74.0 years, SD = 8.4) were women (77%) and men recruited from senior centers served by the county Area Agency on Aging. Intervention participants ( n = 133) were newly enrolled in classes. Controls ( n = 129) were recruited from matched sites not offering classes. Validated measures of physical function, exercise self-efficacy, balance, and activities of daily living (ADL) confidence were administered at baseline and 3 months. Significant improvements in upper and lower body strength, aerobic endurance, mobility, exercise self-efficacy, and balance were found in the exercisers but not controls. No changes in ADL confidence occurred in exercisers, while significant decreases occurred in controls. Findings support the efficacy of the county-wide program. Building an evidence base for community-delivered programs should provide impetus for increased dissemination through state and national agencies thereby increasing program impact.

Within-Person Pain Variability and Mental Health in Older Adults With Osteoarthritis: An Analysis Across 6 European Cohorts

Pain is a key symptom of osteoarthritis (OA) and has been linked to poor mental health. Pain fluctuates over time within individuals, but a paucity of studies have considered day-to-day fluctuations of joint pain in relation to affective symptoms in older persons with OA. This study investigated the relationship of pain severity as well as within-person pain variability with anxiety and depression symptoms in 832 older adults with OA who participated in the European Project on OSteoArthritis (EPOSA): a 6-country cohort study. Affective symptoms were examined with the Hospital Anxiety and Depression Scale, pain severity was assessed with the Western Ontario and McMaster Universities OA Index and the Australian/Canadian Hand Osteoarthritis Index, and intraindividual pain variability was measured using pain calendars assessed at baseline, 6, and 12 to 18 months. Age-stratified multiple linear regression analyses adjusted for relevant confounders showed that more pain was associated with more affective symptoms in older-old participants (74.1-85 years). Moreover, older-old participants experienced fewer symptoms of anxiety (ratio = .85, 95% confidence interval [CI], .77-.94), depression (ratio = .90, 95% CI, .82-.98), and total affective symptoms (ratio = .87, 95% CI, .79-.94) if their pain fluctuated more. No such association was evident in younger-old participants (65-74.0 years). These findings imply that stable pain levels are more detrimental to mental health than fluctuating pain levels in older persons.

PERSPECTIVE

This study showed that more severe and stable joint pain levels were associated with anxiety and depressive symptoms in older persons with OA. These findings emphasize the importance of measuring pain in OA at multiple time points, because joint pain fluctuations may be an indicator for the presence of affective symptoms.

Radiographic Analysis of Simulated First Dorsal Interosseous and Opponens Pollicis Loading Upon Thumb CMC Joint Subluxation: A Cadaver Study

BACKGROUND

Therapy programs to treat thumb carpometacarpal (CMC) arthritis may engage selective activation and reeducation of thenar muscles, particularly the first dorsal interosseous (FDI) and opponens pollicis (OP) to reduce subluxation of the joint. We describe the effect of simulated selective activation of the FDI and OP muscles upon radiographic subluxation of the thumb CMC joint.

METHODS

In a cadaver model of CMC subluxation, loads were applied to the FDI, the OP, and then concomitantly at 0%, 25%, 50%, 75%, and 100% maximal loads and radial subluxation of the joint and reduction in subluxation was measured.

RESULTS

Selective activation of the OP, alone, improved the subluxation ratio (SR) in a dose-dependent manner. Selective activation of FDI, alone, demonstrated minimal effects on SR. Concomitant activation of OP and FDI improved the SR across all loading states, and activation of 75% and greater, when compared with FDI activation alone, resulted in a statistically significant improvement in SR to within 10% of the presubluxed joint.

CONCLUSIONS

Concomitant activation of the FDI and OP acts to reduce subluxation of the thumb CMC joint in a dose-dependent fashion. The OP is likely the predominant reducing force. Hand therapy programs that focus on selective strengthening programs likely function in part to encourage patients to activate the easily palpable and easily understood FDI. Concomitant coactivation of the OP may be the major reducing force to elicit clinical and radiographic reduction of subluxation, improved thumb positioning, and reduction of pain and arthritic symptoms.

Understanding Occupation, Sick Leave, and Disability Pension Due to Knee and Hip Osteoarthritis From a Sex Perspective

OBJECTIVE

To investigate the association between occupation and risk for sick leave or disability pension due to knee or hip osteoarthritis (OA) from a sex perspective.

METHODS

We conducted a population-based study including residents ages 40-70 years in the Skåne region, Sweden (2007) and working in the included job sectors (n = 165,179). We retrieved data on cause-specific sick leave and disability pension (2007-2012) and linked to individual information on occupation and education (2007). Occupations were classified into job sectors. We calculated sex-specific, age-adjusted odds ratios (ORs) of sick leave and disability pension due to OA in traditionally female-dominated job sectors (health care, child care, and cleaning) and traditionally male-dominated job sectors (construction, farming, metal work, or transportation) compared to business and administration.

RESULTS

Of all eligible subjects, 2,445 had sick leave or disability pension due to knee or hip OA. Adjusted for age, the risk of sick leave due to knee OA was increased for women working in health care, with an OR of 3.3 (95% confidence interval [95% CI] 2.6-4.2), child care OR 2.9 (95% CI 2.2-3.8), and cleaning OR 3.0 (95% CI 2.2-4.1), as was the risk for disability pension. The risk was increased also for persons working in occupations with higher educational requirements. The risk was similarly increased in male-dominated sectors. In female-dominated job sectors the risk of sick leave and disability pension due to knee OA, but not hip OA, was higher than that for other musculoskeletal diseases.

CONCLUSION

Traditionally female-dominated occupational sectors are associated with an increased risk of sick leave and disability pension due to knee OA.

Sex Variations in the Effects of Arthritis and Activity Limitation on First Heart Disease Event Occurrence in the Canadian General Population: Results From the Longitudinal National Population Health Survey

OBJECTIVE

To estimate sex-specific effects of arthritis and activity limitation on incident heart disease in a nationally representative, Canadian longitudinal population-based survey.

METHODS

Information on sociodemographic variables, self-reported physician-diagnosed chronic conditions (including arthritis and heart disease), activity limitations, and traditional risk factors was collected every 2 years from 1994-1995 through 2010-2011 as part of the longitudinal Canadian National Population Health Survey. Deaths due to ischemic heart disease (International Classification of Diseases, Tenth Revision [ICD-10] codes I20-I25) and heart failure (ICD-10 codes I50.0-I50.9) were confirmed against the Canadian Vital Statistics Database. Discrete-time survival analysis stratified by sex was used to estimate effects of arthritis and activity limitation on first heart disease event occurrence.

RESULTS

The study included 12,591 participants with no prior history of heart disease and 1,783 incident heart disease events. After adjusting for common risk factors, arthritis was associated with a significant increased risk of incident heart disease in women (adjusted odds ratio [OR] 1.58, 95% confidence interval [95% CI] 1.23-2.02). Even higher risks were reported in women with arthritis and activity limitation (OR 2.19, 95% CI 1.61-2.97). Arthritis was not associated with incident heart disease in men, except for when also reported with activity limitation (OR 1.60, 95% CI 1.14-2.26).

CONCLUSION

Women with arthritis, and men with arthritis and activity limitation, have significant excess risks for developing heart disease in the general population. These findings point to the need for improved access to arthritis care, cardiovascular prevention strategies, particularly in women with arthritis, and directed interventions toward prevention of activity limitation.

Effects of quadriceps functional exercise with isometric contraction in the treatment of knee osteoarthritis

OBJECTIVE

This study aims to investigate the effects of a quadriceps isometric contraction exercise method in the treatment of knee osteoarthritis (OA).

METHODS

A total of 250 patients with a confirmed diagnosis of knee OA were enrolled. The patients were randomly divided into an exercise treatment test group (128 patients) and a traditional treatment control group (122 patients). Quadriceps isometric contraction exercise was used in the test group, and local physiotherapy and oral nonsteroidal anti-inflammatory drugs were used in the control group. Knee joint function was evaluated with a visual analog scale (VAS) score and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire before treatment, and 1 and 3 months after treatment.

RESULTS

VAS scoring and the WOMAC questionnaire showed significant relief in pain 1 month after treatment in the test group (P < 0.05), but minimal relief in the control group; at 1 month, there was also minimal joint function improvement in the test group (P > 0.05), but significant improvement in the control group (P < 0.05). However, 3 months after treatment, pain relief and knee joint function were more improved in the test group than in the control group, with a significant difference (P < 0.05).

CONCLUSION

Through our short-term observation, joint pain was effectively relieved and knee joint function was improved with systematic quadriceps isometric contraction exercise.

The Utilization of Health Services and Self-Care by Older Women With Sleeping Problems: Results From a Nationally Representative Sample of 9,110 Women

OBJECTIVE

This research aims to investigate the health service use-including complementary and alternative medicine (CAM)-and self-care by women aged 62 to 67 with sleeping problems.

METHOD

In total, 9,110 participants (99.6%) responded to questions about sleeping problems, health service utilization and self-care (e.g., herbal medicines and vitamins), demographics, and chronic illnesses.

RESULTS

In all, 48.2% ( n = 4,394) women indicated that they had a sleeping problem. Women with sleeping problems consulted a general practitioner (GP) more frequently (odds ratio [OR] = 1.72; 95% confidence interval [CI] = [1.36, 2.17]; p < .005) and were more likely to be using herbal medicines (OR = 1.24; 95% CI = [1.13, 1.36]; p < .005) than women without sleeping problems.

DISCUSSION

Health professionals, particularly GPs, may need to actively inquire with older patients in their care with sleeping problems about the use of herbal medicines, to ensure their sleeping problems are being directly and effectively treated, particularly in light of increased risks associated with sleeping problems for this age cohort.

Discordance between self-reported arthritis and musculoskeletal signs and symptoms in older women

BACKGROUND

Arthritis is a gendered disease where women have a higher prevalence and more disability than men with arthritis of the same age. Health survey data is a major source of information for monitoring of the burden of arthritis. The validity of self-reported arthritis and the determinants of its accuracy among women have not been thoroughly studied. The objectives of this study were to: 1) examine the agreement between self-report diagnosed arthritis and musculoskeletal signs and symptoms in community-living older women; 2) estimate the sensitivity, specificity, and predictive values of self-reported arthritis; and 3) assess the factors associated with the disagreement.

METHODS

A cross-sectional survey of women was undertaken in 2012-13. The health survey asked women about diagnosed arthritis and musculoskeletal signs and symptoms. Agreement between self-reported arthritis and musculoskeletal signs symptoms was measured by Cohen's kappa. Sensitivity, specificity, and predictive values of self-reported arthritis were estimated using musculoskeletal signs and symptoms as the reference standard. Factors associated with disagreement between self-reported arthritis and the reference standard were examined using multiple logistic regression.

RESULTS

There were 223 participants self-reported arthritis and 347 did not. A greater number of participants who self-reported arthritis were obese compared to those who did not report arthritis. Those who reported arthritis had worse health, physical functioning, and arthritis symptom measures. Among the 570 participants, 198 had musculoskeletal signs and symptoms suggesting arthritis (the reference standard). Agreement between self-reported arthritis and the reference standard was moderate (kappa = 0.41). Sensitivity, specificity, and positive and negative predictive values of self-reported arthritis in older women were 66.7, 75.5, 59.2, and 81.0% respectively. Regression analysis results indicated that false-positive is associated with better health measured by the Short Form 36 physical summary score, the Health Assessment Questionnaire disability index, or the Western Ontario and McMaster University Osteoarthritis Index total score; whereas false-negative is negatively associated with these variables.

CONCLUSION

While some women who reported diagnosed arthritis did not have recent musculoskeletal signs or symptoms, others with the signs and symptoms did not report diagnosed arthritis. Researchers should use caution when employing self-reported arthritis as the case-definition in epidemiological studies.

Anxiety and depression in patients with osteoarthritis: impact and management challenges

Background

Anxiety and depression are common psychological comorbidities that impact the quality of life (QoL) of patients. In this systematic review, we 1) determined the impact of anxiety and depression on outcomes in patients with osteoarthritis (OA) and 2) summarized unique challenges these comorbidities present to current OA management.

Patients and methods

A systematic literature search was performed using the OVID Medline and EMBASE databases until April 2016. Full-text research articles published in English from the year 2000 onward with a sample size of >100 were included in this review. Eligible research articles were reviewed and the following data were extracted: study author(s), year of publication, study design, and key findings.

Results

A total of 38 studies were included in the present review. The present study found that both anxiety and/or depression were highly prevalent among patients with OA. Patients with OA diagnosed with these comorbidities experienced more pain, had frequent hospital visits, took more medication, and reported less optimal outcomes. Management strategies in the form of self-care, telephone support, audio/video education programs, and new pharmacotherapies were reported with favorable results.

Conclusion

Anxiety and depression adversely impact the QoL of patients with OA. Physicians/caregivers are highly recommended to consider these comorbidities in patients with OA. Ultimately, a holistic individualized management approach is necessary to improve patient outcomes.

Effectiveness of a Scaled-Up Arthritis Self-Management Program in Oregon: Walk With Ease

OBJECTIVES

To evaluate the effectiveness of Walk With Ease (WWE), an evidence-based arthritis self-management program that was scaled up in Oregon in 2012 to 2014.

METHODS

Guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, we collected participant surveys and attendance records and conducted observations. Preprogram and postprogram, participants self-reported pain and fatigue (scale: 0-10 points; high scores indicate more pain and fatigue) and estimated episodes of physical activity per week in the last month.

RESULTS

Recruitment successfully reached the targeted population-sedentary adults with arthritis (n = 598). Participants reported significant reduction in pain (-0.47 points; P = .006) and fatigue (-0.58 points; P = .021) and increased physical activity (0.86 days/week; P < .001). WWE was adopted by workplaces and medical, community, faith, and retirement centers. Most WWE programs were delivered with high fidelity; average attendance was 47%.

CONCLUSIONS

WWE is suitable for implementation by diverse organizations. Effect sizes for pain and fatigue were less than those in the original WWE studies, but this is to be expected for a large-scale implementation. Public Health Implications. WWE can be effectively translated to diverse, real-world contexts to help sedentary adults increase physical activity and reduce pain and fatigue.

Dietary Phytochemicals: Natural Swords Combating Inflammation and Oxidation-Mediated Degenerative Diseases

Cumulatively, degenerative disease is one of the most fatal groups of diseases, and it contributes to the mortality and poor quality of life in the world while increasing the economic burden of the sufferers. Oxidative stress and inflammation are the major pathogenic causes of degenerative diseases such as rheumatoid arthritis (RA), diabetes mellitus (DM), and cardiovascular disease (CVD). Although a number of synthetic medications are used to treat these diseases, none of the current regimens are completely safe. Phytochemicals (polyphenols, carotenoids, anthocyanins, alkaloids, glycosides, saponins, and terpenes) from natural products such as dietary fruits, vegetables, and spices are potential sources of alternative medications to attenuate the oxidative stress and inflammation associated with degenerative diseases. Based on in vitro, in vivo, and clinical trials, some of these active compounds have shown good promise for development into novel agents for treating RA, DM, and CVD by targeting oxidative stress and inflammation. In this review, phytochemicals from natural products with the potential of ameliorating degenerative disease involving the bone, metabolism, and the heart are described.

First dorsal interosseous muscle contraction results in radiographic reduction of healthy thumb carpometacarpal joint

INTRODUCTION

Hand therapists selectively strengthen the first dorsal interosseus (FDI) to stabilize arthritic joints yet the role of the FDI has not yet been radiographically validated.

PURPOSE

To determine if FDI contraction reduces radial subluxation (RS) of the thumb metacarpal (MC).

METHODS

Fluoroscopy was used to obtain true anterior-posterior radiographs of non-arthritic CMC joints: 1) at rest, 2) while stressed and 3) while stressed with maximal FDI contraction. Maximal FDI strength during CMC stress and thumb MC RS and trapezial articular width were measured. The ratio of RS to the articular width was calculated.

RESULTS

Seventeen participants (5 male, 12 female) participated. Subluxation of a stressed CMC significantly reduced and the subluxation to articular width ratio significantly improved after FDI activation.

CONCLUSIONS

Contraction of the FDI appears to radiographically reduce subluxation of the healthy thumb CMC joint. Further exploration on the FDI's reducibility and its carry-over effects in arthritic thumbs is needed.

LEVEL OF EVIDENCE

4.

Women's Experiences of Undergoing Total Knee Joint Replacement Surgery

PURPOSE

The purpose of the study was to describe women's experiences of undergoing total knee joint replacement surgery.

DESIGN

A qualitative approach was used.

METHOD

A content analysis of the text from interviews with five women was conducted.

FINDINGS

The time before surgery was marked by the experience of constant pain, which affected the women negatively in their everyday lives. During surgery, the information provided by the staff gave each woman a sense of security; the women handed over responsibility to the staff and experienced a sensation of relief. The postoperative period was characterized by a feeling of joy when the surgery was over, although a rough and tedious rehabilitation phase then began. Challenges in everyday life were a factor for motivation and confidence, although postoperative pain was experienced as discouraging.

CONCLUSION

Support from health care staff is an important factor for coping with everyday life during the preoperative, perioperative and postoperative phases of undergoing knee joint replacement.

Characterization of osteoarthritic human knees indicates potential sex differences

BACKGROUND

The prevalence of osteoarthritis is higher in women than in men in every age group, and overall prevalence increases with advancing age. Sex-specific differences in the properties of osteoarthritic joint tissues may permit the development of sex-specific therapies. Sex hormones regulate cartilage and bone development and homeostasis in a sex-dependent manner. Recent in vitro studies show that the vitamin D3 metabolite 1α,25-dihydroxyvitamin D3 [1α,25(OH)2D3] also has sex-specific effects on musculoskeletal cells, suggesting that vitamin D3 metabolites may play a role in osteoarthritis-related sex-specific differences. The purpose of this study was to determine if sex-specific differences exist in synovial fluid and knee tissues isolated from male and female patients with severe knee osteoarthritis. We determined the presence of vitamin D3 metabolites, inflammatory cytokines, growth factors, and matrix metalloproteinases (MMPs) in synovial fluid and assessed responses of articular chondrocytes and subchondral osteoblasts to 17β-estradiol, dihydrotestosterone, and 1α,25(OH)2D3.

METHODS

Samples from knee joints of 10 Caucasian male and 10 Caucasian female patients with advanced osteoarthritis aged 65 to 75 years were obtained from total knee arthroplasty. Vitamin D metabolites, cytokines, MMPs, and growth factors in the synovial fluid were measured. Primary cultures of chondrocytes were isolated from fibrillated articular cartilage adjacent to osteoarthritis lesions and minimally affected cartilage distal to the lesion. Osteoblasts were isolated from the subchondral bone. Expression of receptors for 17β-estradiol and 1α,25(OH)2D3 was assessed by real-time PCR. Chondrocytes and osteoblasts were treated with 10(-8) M 17β-estradiol, dihydrotestosterone, or 1α,25(OH)2D3 and effects on gene expression and protein synthesis determined.

RESULTS

Histology of the articular cartilage confirmed advanced osteoarthritis. Sex differences were found in synovial fluid levels of vitamin D metabolites, cytokines, and metalloproteinases as well as in the cellular expression of receptors for 17β-estradiol and 1α,25(OH)2D3. Male cells were more responsive to 1α,25(OH)2D3 and dihydrotestosterone, whereas 17β-estradiol-affected female cells.

CONCLUSIONS

These results demonstrate that there are underlying sex differences in knee tissues affected by osteoarthritis. Our findings do not address osteoarthritis etiology but have implications for different prevention methods and treatments for men and women. Further research is needed to better understand these sex-based differences.

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.

Impact of Race and Gender on Utilization Rate of Total Shoulder Arthroplasty

Marked underutilization rates of total joint arthroplasty in minorities compared with nonminorities exist, with a paucity of literature surrounding inequities related to total shoulder arthroplasty (TSA). Using the Statewide Planning and Research Cooperative System database, patients who underwent elective TSA in New York State (NYS) were identified and characterized by age, race, gender, medical comorbidities, and payor status. Patients were stratified into 4 separate 5-year periods from 1990 to 2009. Comorbidity severity was defined using the Elixhauser criteria. A total of 10,538 elective TSAs were identified, with half of the procedures occurring in the most recent time quartile. Whites accounted for 70% of the procedures, whereas blacks accounted for 5%. During the 20-year period, the age-adjusted incidence of TSA in white men and women increased by 417% and 421%, respectively, whereas the incidence for black men and women increased by 378% and 329%, respectively. Black men had the lowest utilization rate among all subgroups, and overall disparity between races continued to widen over time. Blacks had significantly more comorbid conditions (P<.001) than whites when undergoing TSA. Blacks were more likely to have Medicaid insurance and less participation in Medicare (P<.001). Racial and gender disparities clearly exist in TSA utilization rates in NYS and may be worsening. Although reasons for these disparities are likely multifactorial, a deeper understanding of the factors involved in patient selection and access to care is necessary to appropriately address these disparities and effect change at a system-wide patient and provider level. [Orthopedics. 2016; 39(3):e538-e544.].

Home-administered pre-surgical psychological intervention for knee osteoarthritis (HAPPiKNEES): study protocol for a randomised controlled trial

BACKGROUND

Knee replacement surgery reduces pain for many people with osteoarthritis (OA). However, surgical outcomes are partly dependent on patients' moods, and those with depression or anxiety have worse outcomes. Approximately one-third of people with OA have mood problems. Cognitive behavioural therapy (CBT), a psychological therapy, is recommended by the National Institute for Health and Care Excellence for improving mood. However, evidence for the effectiveness of CBT before knee surgery in improving pain, mood, and quality of life following this surgery for people with knee OA is lacking.

METHODS/DESIGN

This is a multi-centre, mixed-methods feasibility randomised controlled trial to compare treatment as usual (TAU) plus a brief CBT-based intervention with a TAU-only control, for people with knee OA. We will recruit 50 patients with knee OA, listed for knee replacement surgery, with high levels of distress (assessed using a mood questionnaire), and who consent to take part. Participants will be randomly allocated to receive TAU plus intervention or TAU. Up to 10 sessions of CBT will be offered on an individual basis by a psychologist. The assessments and interventions will be completed before surgery. Repeat assessments at 4 and 6 months after randomisation will be sent and received by post. Two patient-partners will conduct feedback interviews with some participants to assess what aspects of the intervention were helpful or unhelpful, the acceptability of randomisation, the experience of being in a control group, and the appropriateness of the measures used. Interviews will be audio-recorded, transcribed, and analysed using the framework approach. We will examine the feasibility and acceptability of patient-partners conducting the interviews by also interviewing the patient-partners.

DISCUSSION

Findings from this study will be used to design a definitive study that will examine the clinical and cost-effectiveness of the CBT intervention in improving patient outcomes following knee surgery.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN80222865; Date: 19 June 2014.

Automated Internet-based pain coping skills training to manage osteoarthritis pain: a randomized controlled trial

Osteoarthritis (OA) places a significant burden on worldwide public health because of the large and growing number of people affected by OA and its associated pain and disability. Pain coping skills training (PCST) is an evidence-based intervention targeting OA pain and disability. To reduce barriers that currently limit access to PCST, we developed an 8-week, automated, Internet-based PCST program called PainCOACH and evaluated its potential efficacy and acceptability in a small-scale, 2-arm randomized controlled feasibility trial. Participants were 113 men and women with clinically confirmed hip or knee OA and associated pain. They were randomized to a group completing PainCOACH or an assessment-only control group. Osteoarthritis pain, pain-related interference with functioning, pain-related anxiety, self-efficacy for pain management, and positive and negative affect were measured before intervention, midway through the intervention, and after intervention. Findings indicated high acceptability and adherence: 91% of participants randomized to complete PainCOACH finished all 8 modules over 8 to 10 weeks. Linear mixed models showed that, after treatment, women who received the PainCOACH intervention reported significantly lower pain than that in women in the control group (Cohen d = 0.33). Intervention effects could not be tested in men because of their low pain and small sample size. Additionally, both men and women demonstrated increases in self-efficacy from baseline to after intervention compared with the control group (d = 0.43). Smaller effects were observed for pain-related anxiety (d = 0.20), pain-related interference with functioning (d = 0.13), negative affect (d = 0.10), and positive affect (d = 0.24). Findings underscore the value of continuing to develop an automated Internet-based approach to disseminate this empirically supported intervention.

Factors associated with higher healthcare costs in individuals living with arthritis: evidence from the quantile regression approach

OBJECTIVE

To examine the factors associated with higher healthcare cost in women with arthritis, using generalized linear models (GLMs) and quantile regression (QR).

METHODS

This is a cross-sectional healthcare cost study of individuals with arthritis that focused on older Australian women. Cost data were drawn from the Medicare Australia datasets.

RESULTS

GLM results show that healthcare cost was significantly associated with various socio-demographic and health factors. Although QR analysis results show the same direction of association between these factors and healthcare cost as in the GLMs, they indicate progressively increased effect sizes at the 50th, 75th, 90th and 95th percentiles.

CONCLUSION

Findings suggest traditional regression models such as GLMs that assume a single rate of change to accurately describe the relationships between explanatory variables and healthcare costs across the entire distribution of cost can produce biased results. QR should be considered in future healthcare cost research.

Gait metric profile and gender differences in hip osteoarthritis patients. A case-controlled study

PURPOSE

Hip osteoarthritis (OA) is a slowly progressive destructive disease that results in alterations in joint loads and biomechanics to which patients adapt compensatory alterations and abnormal gait patterns. This prospective cross-sectional, case-controlled study examined these alterations in gait metrics and evaluated gender differences in gait spatiotemporal parameters. Correlations between function and gait metrics were also investigated.

BASIC PROCEDURES

Hip OA patients (138 females and 122 males) and healthy controls (14 females and 26 males) matched for age and gender underwent the same investigative protocol consisting of a spatiotemporal gait analysis followed by functional evaluations using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the SF-36 Health Survey (SF-36).

MAIN FINDINGS

Differences between the patient and the control groups were significant in all the spatiotemporal parameters. There were significant gender differences within the hip OA group in all parameters except for cadence and single limb support percentage. WOMAC and SF-36 scores revealed significant differences between the study and control groups in most components. Significantly higher scores in the three components of the WOMAC as well as in six SF-36 score components were found among males compared to females in the patient group.

PRINCIPAL CONCLUSIONS

Gait, WOMAC and SF-36 were effective objective and subjective tools for evaluating a large cohort of patients with hip OA, and can be highly useful for supplementing the assessment of hip OA severity and enhancing treatment efficacy during the course of the disease.

The Effect of Male Sex on Survival in Systemic Sclerosis

Objective.

Systemic sclerosis (SSc) has a female predominance, however, little is understood about the effect of sex on SSc manifestations and survival. The objectives of our study were to evaluate differences in disease manifestations, and survival rates between males and females with SSc.

Methods.

A retrospective cohort study of the Toronto Scleroderma Program was conducted to evaluate sex-based differences in disease manifestations and survival. A relative survival analysis compared SSc survival to the general population.

Results.

There were 959 patients (791 females, 168 males) identified, with a female:male ratio of 4.7:1. Males more frequently had diffuse SSc [45% vs 30%, relative risk (RR) 1.44, 95% CI 1.18–1.75] and interstitial lung disease (ILD; 41% vs 33%, RR 1.24, 95% CI 1.01–1.52). There were 324 deaths (65 males, 259 females). Males had increased unadjusted mortality compared to females (HR 1.57, 95% CI 1.19–2.06). In an adjusted model including immunosuppressive use, male sex (HR 1.40, 95% CI 1.06–1.85), ILD (HR 1.58, 95% CI 1.26–1.98), and older age at diagnosis (HR 1.05, 95% CI 1.04–1.06) were independently associated with increased mortality, whereas the limited subtype (HR 0.70, 95% CI 0.49–0.77) and anticentromere antibodies (HR 0.70, 95% CI 0.49–0.98) were independently associated with decreased mortality. Male sex was associated with increased risk of mortality (HR 1.16, p = 0.003) in patients with SSc above that observed for males in the general population.

Conclusion.

The differential effect of disease between sexes is small, yet males have decreased survival compared to females with SSc.

Perceived health status of women with knee osteoarthritis: a cross-sectional study of the relationships of age, body mass, pain and walking limitations

Persons with knee osteoarthritis (OA) often experience considerable physical disability. Although some studies suggest women with this condition suffer more than men, few have attempted to characterize the magnitude and that impact of this condition specifically among women with moderate knee osteoarthritis as well as the relationships that exist between their perceived health status and well established physical, emotional and perceptual factors found in this disease. This exploratory study strove to better understand factors that underpin the perceived impact of the condition, and to describe the extent of pain and function among women with mild to moderate knee osteoarthritis, and how this impacts this condition. The records of 20 women with the condition who had undergone multiple tests using a standardized protocols and validated instruments were examined. The primary outcome measure was the perceived impact of the disease using the Arthritis Impact Measurement Scale. Secondary outcome measures included six minute walking distance, fastest walking velocity, self-reported pain, pain and functional self-efficacy, body mass, and depression. The variables were subjected to t-tests, and correlational analyses. Results demonstrated pain is the clinical factor most consistently impacting the disease experience, along with deficiencies in walking ability (p <0.05). Important mediating variables of ambulatory capacity were body mass and pain self-efficacy.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial

A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients' doctors' offices (N=129 patients); the control group received usual care (N=127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.

Economic burden of long-term care of rheumatoid arthritis patients in Hungary

BACKGROUND AND AIM

Long-term care (LTC) in Hungary is provided in four major ways: day care, nursing, chronic care, and rehabilitation. The aim of this study was to explore the financing of LTC in Hungary, with a disease-specific focus on rheumatoid arthritis (RA) patients.

DATA AND METHODS

Data were derived from the National Health Insurance Fund Administration (NHIFA). For 2012, we analyzed the following indicators: number of patients and cases, crude and weighted hospital days, and health insurance expenditure.

RESULTS

The annual health insurance expenditure of LTC was 112.6 million EUR in Hungary in 2012 and covered 209,000 patients (225,000 cases). The NHIFA spent 0.69 million EUR for the LTC of 976 patients with RA. The annual health insurance cost per patient was significantly (by 32%) higher for patients with RA (710 EUR) than the average cost of all patients (538 EUR). The average length of stay was also higher for patients with RA (19.7 days) than for the general LTC population (17.4 days).

CONCLUSIONS

The cost of LTC of patients with RA is higher than the average cost of the general LTC patient population. Early treatment of RA patients could contribute to decreasing LTC expenditure. More generally, health technology assessment can inform future LTC funding debates in Central and Eastern European countries by putting more emphasis on LTC utilization and costs.

Central pain processing in osteoarthritis: implications for treatment

SUMMARY Osteoarthritis (OA) is a major cause of pain and is characterized by loss of articular cartilage integrity, synovitis and remodeling of subchondral bone. However, OA pain mechanisms remain incompletely understood. Pain severity does not always correlate with the extent of joint damage. Furthermore, many people with OA continue to experience pain despite optimal use of standard therapies that target the joints, including joint-replacement surgery. There is compelling evidence that altered central pain processing plays an important role in maintaining pain and increasing pain severity in some people with OA. A key challenge is to identify this subgroup of patients with abnormal central pain processing in order to improve their clinical outcomes by developing and targeting specific analgesic treatments.

Preferences for patient medication information: what do patients want?

This study investigated respondent preferences on how best to display patient medication information (PMI) that accompanies prescription medications to promote comprehension and appropriate usage. The authors identified 30 individuals diagnosed with select immune disorders, 30 with other chronic diseases, and 30 from the general public and had them review one of two PMI handouts that varied by format, organization, and content. The authors explored preferences for the PMI handout using one-on-one interviews. The authors analyzed the qualitative data to identify relevant themes and patterns using NVivo9 qualitative software. The majority of respondents noted that the formats of the two PMI handouts were more informative than those they currently receive from the pharmacist, with a preference for the 2-column, segmented design. However, respondent PMI preferences varied by age, education, and health status. Patients need simpler and more concise drug information to make better decisions about their health. Current PMI handouts are dense and complex, which can be confusing and not reader friendly. To improve PMI understandability and usefulness, the U.S. Food and Drug Administration is working with stakeholders, consumer advocates, and academics. Findings from this study may help inform future development of more user-friendly PMI.

Aromatase inhibitor associated musculoskeletal symptoms are associated with reduced physical activity among breast cancer survivors

Physical activity (PA) has numerous health benefits for breast cancer survivors. Recent data suggest that some breast cancer survivors treated with aromatase inhibitors may experience aromatase inhibitor associated musculoskeletal symptoms. It is unknown whether aromatase inhibitor associated musculoskeletal symptoms are associated with reduced PA and what other risk factors are associated with such PA reductions. We conducted a cross-sectional study at a large university-based breast cancer clinic among breast cancer survivors prescribed an aromatase inhibitor. At routine follow-up, we surveyed participants about aromatase inhibitor associated musculoskeletal symptoms, as well as pre-aromatase inhibitor, and current, PA levels. Among 300 participants, 90 (30%) reported a reduction of PA since the initiation of aromatase inhibitor therapy. Those with aromatase inhibitor associated musculoskeletal symptoms were more likely to report decreased PA (62% versus 38%, p = 0.001) compared with those without aromatase inhibitor associated musculoskeletal symptoms. In multivariate analyses, aromatase inhibitor associated musculoskeletal symptoms (odds ratio [OR] = 2.29 [95% confidence interval [CI]: 1.36-3.86]), and body mass index (OR = 1.06 [95% CI: 1.02-1.12]) were associated with reductions in PA. In subgroup analysis among breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms, self-reported lower extremity joint pain (OR = 1.23 [95% CI: 1.00-1.50]) and impaired lower extremity physical function (OR = 1.07 [95% CI: 1.01-1.14]) were associated with reductions in PA. Breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms were more likely to report reductions in PA since initiating aromatase inhibitor therapy compared with those without aromatase inhibitor associated musculoskeletal symptoms. Our findings suggest that tailored interventions targeting lower extremity functional limitations are needed to enable breast cancer survivors with aromatase inhibitor associated musculoskeletal symptoms to participate in PA.