"You don't put it down to arthritis": A qualitative study of the first symptoms recalled by individuals with knee osteoarthritis

Objective

As part of the first phase of the OARSI Early-stage Symptomatic Knee Osteoarthritis (EsSKOA) initiative, we explored the first symptoms and experiences recalled by individuals with knee osteoarthritis (OA).

Design

This qualitative study, informed by qualitative description, was a secondary analysis of focus groups (n ​= ​17 groups) and one-on-one interviews (n ​= ​3) conducted in 91 individuals living with knee OA as part of an international study to better understand the OA pain experience. In each focus group or interview, participants were asked to describe their first symptoms of knee OA. We inductively coded these transcripts and conducted thematic analysis.

Results

Mean age of participants was 70 years (range 47-92) and 68 ​% were female. We developed four overarching themes: Insidious and Episodic Onset, Diverse Early Symptoms, Must be Something Else, and Adjustments. Participants described the gradual and intermittent way in which symptoms of knee OA developed over many years; many could not identify a specific starting point. Participants described diverse initial knee symptoms, including activity-exacerbated joint pain, stiffness and crepitus. Most participants dismissed early symptoms or rationalized their presence, employing various strategies to enable continued participation in recreational and daily activities. Few sought medical attention until physical functioning was demonstrably impacted.

Conclusions

The earliest symptoms of knee OA are frequently insidious in onset, episodic and present long before individuals present to health professionals. These results highlight challenges to identifying people with knee OA early and support the development of specific classification criteria for EsSKOA to capture individuals at an early stage.

Fundamentals of osteoarthritis: outcome evaluation with patient-reported measures and functional tests

Evaluating outcome in osteoarthritis (OA) clinical research and practice requires reliable, valid and responsive patient-reported outcome measures (PROMs) and functional tests that reflect important problems experienced by people with OA. The goal of this work is to provide information to start to guide the reader in selecting measures for people with OA. In this narrative review, we begin by providing an overview of measurement properties that can help clinicians and researchers in making decisions about whether a measure might be appropriate for use in their research or clinical context. We then report evidence supporting the use of measures of pain (e.g., Pain Visual Analogue (VAS), Numeric Pain Rating Scale (NPRS), Intermittent and Constant Osteoarthritis Pain, PROMIS Pain Interference, and, for screening in research, the painDETECT and the Self-report Leeds Assessment of Neuropathic Symptoms and Signs) and fatigue (e.g., PROMIS-Fatigue) at a group level in clinical research. Several multi-dimensional joint-specific measures (e.g., Western Ontario McMaster Universities' Osteoarthritis Outcomes Scale, Knee/Hip Injury and Osteoarthritis Outcome Score, Oxford Hip/Knee Scale) also have evidence for group-level use. Functional tests (e.g., timed walk tests, 30 Second Chair Stand, Timed Up and Go, etc.) have measurement properties supporting their use at the group level in clinical research and at the individual patient level as do the pain VAS and NPRS. Other generic and disease-specific PROMs have been used in or could be used in OA studies but their measurement properties require further evaluation in people with OA.

The longitudinal relationship between hand, hip and knee osteoarthritis and cardiovascular events: a population-based cohort study

OBJECTIVE

In this population-based cohort study, we examined the association between the presence of symptomatic osteoarthritis (OA) and risk for cardiovascular (CV) events.

METHOD

A cohort aged ≥55 years recruited from 1996 to 98 was followed through provincial health administrative data to 2014. Demographics, joint complaints and functional limitations were collected. Hip, knee and hand OA were defined using a validated definition. Using Cox-regressions, the relationship between OA and a composite CV outcome (myocardial infarction (MI), stroke, angina, heart failure, revascularization) was assessed controlling for age, body mass index (BMI), sex, pre-existing metabolic factors, comorbidities, income status, primary care exposure and functional limitations.

RESULTS

18,490 participants were included: median age was 68 years, 60.3% were female; 24.4% met criteria for OA (10.0% hip, 15.3% knee, 16.0% hand), 16.3% self-reported limitation in grip and 25.4% in walking. Over a median 13.4 years, 31.9% experienced a CV event. Controlling for all but walking limitation, a dose-response relationship was observed between number of joints affected by knee/hip OA and CV risk (HR 2 hips/knees vs none: 1.13, 95% CI 1.03-1.23; 3+ hips/knees: 1.22, 95% CI 1.09-1.36). This relationship became non-significant additionally controlling for difficulty walking. Self-reported difficulty walking was associated with a 30% increased hazard for CV events. The effect of hand OA was not significant.

CONCLUSION

In a large population cohort, a greater burden of hip/knee OA was associated with higher CV risk; the relationship was explained by OA-related difficulty walking. Increased attention to management of OA with a view to improving mobility has potential to reduce CV events.

Osteoarthritis-related difficulty walking and risk for diabetes complications

OBJECTIVES

To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA.

DESIGN

A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events.

RESULTS

Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04).

CONCLUSIONS

In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Osteoarthritis year in review 2014: clinical

A systematic search was conducted for the time period April 1 2013 to March 30 2014 using PubMed to identify major osteoarthritis (OA) clinical research themes of the past year. Articles within each theme were selected for inclusion in this review based on study quality and relevance. Two major themes emerged, which relate to the current understanding of OA as a heterogeneous condition with multiple pathogenic mechanisms and clinical manifestations. Theme 1 stems from the role of systemic inflammation in OA pathogenesis, and the concept of 'metabolic OA'. Over the past year, research has examined the effect of OA on incidence and progression of other 'metabolic syndrome'-related conditions, especially cardiovascular disease (CVD) and diabetes and the impact of multi-morbidity on the clinical management of OA. Theme 2 focuses on the concept of personalized medicine as it relates to the treatment of OA. It is hypothesized that the modest efficacy of available OA treatments is a result of inclusion of heterogeneous groups of OA patients in clinical trials. Prognostic studies in the past year have been helpful in identifying 'OA phenotypes' that are more or less likely to respond to treatments--e.g., the presence of synovitis on imaging, central pain sensitization on quantitative sensory testing (QST), or coping efficacy by self-reported patient questionnaire. Their findings are being increasingly used to target interventions to these identified 'OA responder' subgroups with the hopes that treatment effect will be amplified.

The relationship between knee pain characteristics and symptom state acceptability in people with knee osteoarthritis

OBJECTIVE

To examine the association between osteoarthritis (OA) pain characteristics and symptom acceptability.

DESIGN

Using a cross-sectional study design in a knee OA cohort we assessed socio-demographics, knee pain characteristics (Intermittent and Constant Osteoarthritis Pain (ICOAP); higher scores worse), frequency of intermittent pain 'without warning' (unpredictable) or 'after a trigger' (predictable) (never to very often) and the acceptability of knee pain symptoms (yes/no). Using logistic regression, we examined the relationship between pain characteristics and symptom acceptability.

RESULTS

136 cohort members' participated (mean age 74 years, SD 9.5; 54% female). Most (97%) reported intermittent pain (mean ICOAP intermittent score 36.8, SD 19.7) and 62 (46%) reported constant pain (mean ICOAP constant score 46.7, SD 20.2). Of those with intermittent pain, 42% reported frequent (often/very often) predictable pain and 27% frequent unpredictable pain. 35% reported "unacceptable" knee symptoms. In multivariable analysis, the odds of reporting an unacceptable symptom state increased with increasing intermittent knee pain scores and the effect was greater for those with vs without frequent unpredictable intermittent pain (adjusted OR per 10-point increase in ICOAP intermittent score 3.31, 95% confidence interval (CI) 1.38-7.97 vs 1.23, 95%CI 0.88-1.74, respectively; P value for the interaction = 0.03).

CONCLUSION

In a community cohort with symptomatic knee OA, both the severity and predictability of intermittent knee pain contributed to symptom state acceptability. Unpredictable intermittent knee pain was more likely to be associated with an unacceptable symptom state than predictable intermittent pain. Research is warranted to elucidate potentially modifiable determinants of unpredictable intermittent pain in people with knee OA.

Osteoarthritis year 2010 in review: non-pharmacologic therapy

OBJECTIVE

To highlight seminal publications in the past year on the topic of non-pharmacologic management of osteoarthritis (OA).

DESIGN

A systematic search of the PUBMED and Cochrane databases from September 2009 to September 2010 was conducted to identify articles reporting on studies examining the safety or efficacy of non-pharmacologic therapies in the management of OA. Non-pharmacologic therapies were those considered in the 2008 OARSI OA guidelines. Identified articles were reviewed for quality; those of highest quality and deemed to have greatest potential impact on the management of OA were summarized.

RESULTS

The search identified 117 unique articles. Of these, four studies were chosen to highlight. A nested two-stage trial found that traditional Chinese acupuncture (TCA) was not superior to sham acupuncture, but that the providers' style affected both pain reduction and satisfaction with treatment, suggesting that the analgesic benefits of acupuncture may be partially mediated by the acupuncturists' behavior. A systematic review found little evidence of a significant effect for electrostimulation vs sham or no intervention on pain in knee OA. A single-blinded trial of Tai Chi vs attention controls found that 12 weeks of Tai Chi was associated with improvements in symptoms and disability in patients with knee OA. A randomized trial of early ACL reconstructive surgery and rehabilitation vs structured rehabilitation alone in subjects with acute anterior cruciate ligament tears found that, at 24 months following randomization, all study participants had improved, suggesting that a strategy of structured rehabilitation followed acute ACL injury may preclude the need for surgical reconstruction.

CONCLUSIONS

High quality studies of the safety and efficacy of non-pharmacologic agents in the management of OA remain challenging due to difficulties with adequate blinding and appropriate selection of attention controls. High quality studies suggest modest, if any, benefit of many non-pharmacologic therapies over attention control or placebo, but a significant impact of both over no intervention at all.