Knee pain is the commonest pain complaint amongst older adults in general practice. General Practitioners (GPs) may use x rays when managing knee pain, but little information exists regarding this process. Our objectives, therefore, were to describe the information GPs provide when ordering knee radiographs in older people, to assess the association between a clinical diagnosis of osteoarthritis (OA) and the presence of radiographic knee OA, and to investigate the clinical content of the corresponding radiologists' report.
A cross sectional study of GP requests for knee radiographs and their matched radiologists' reports from a local radiology department. Cases, aged over 40, were identified during an 11-week period. The clinical content of the GPs' requests and radiologists' reports was analysed. Associations of radiologists' reporting of i) osteoarthritis, ii) degenerative disease and iii) individual radiographic features of OA, with patient characteristics and clinical details on the GPs' requests, were assessed.
The study identified 136 cases with x ray requests from 79 GPs and 11 reporting radiologists. OA was identified clinically in 19 (14%) of the requests, and queried in another 31 (23%). The main clinical descriptor was pain in 119 cases (88%). Radiologists' reported OA in 22% of cases, and the features of OA were mentioned in 63%. Variation in reporting existed between radiologists. The commonest description was joint space narrowing in 52 reports (38%). There was an apparent although non significant increase in the reporting of knee OA when the GP had diagnosed or queried it (OR 1.95; 95% CI 0.76, 5.00).
The features of radiographic OA are commonly reported in those patients over 40 whom GPs send for x ray. If OA is clinically suspected, radiologists appear to be more likely to report its presence. Further research into alternative models of referral and reporting might identify a more appropriate imaging policy in knee disorders for primary care.
Traditionally the management of any chronic condition starts with its diagnosis. The labelling of disease can be beneficial in terms of defining appropriate treatment such as in coronary artery disease. However, sometimes it may be detrimental such as when x-rays are used to diagnose lumbar spondylosis leading to patients inappropriately limiting their activity. Chronic knee pain in the elderly is another example where applying labels is problematical. A common diagnosis in this situation is osteoarthritis, but this label can be applied in two ways: as a radiological diagnosis, or as a clinical one. The x-ray diagnosis, however, does not equate with the clinical syndrome, and vice versa. In addition, diagnosing knee pain as osteoarthritis does not necessarily help in management, since a patient's debility is more dependent upon their clinical signs and symptoms than the presence of radiographic osteoarthritis, and by the same token its clinical counterpart. GPs are consistent in their management of knee pain, but in attempting to diagnose the pain as osteoarthritis, these plans can alter and become more dependent on the actual diagnosis than the clinical picture. As a result management may well diverge from what the current best evidence supports. Diagnosis for diagnosis sake, should therefore be discouraged, and chronic knee pain gives us one example of why this is the case. GPs would be better placed to manage this condition if it was considered more as a regional pain syndrome, perhaps defining it simply as ‘chronic knee pain in older people’. This example suggests that there is a pressing need in primary care to carefully consider in chronic disease when it is appropriate to be definitive in diagnosis such that when using disease specific labels, there is definite benefit for the patient and doctor.
chronic disease; diagnosis; knee osteoarthritis; radiography
BACKGROUND: In Canada, primary care physicians manage most musculoskeletal problems. However, their training in this area is limited, and some aspects of management may be suboptimal. This study was conducted to examine primary care physicians' management of 3 common musculoskeletal problems, ascertain the determinants of management and compare management with that recommended by a current practice panel. METHODS: A stratified computer-generated random sample of 798 Ontario members of the College of Family Physicians of Canada received a self-administered questionnaire by mail. Respondents selected various items in the management of 3 hypothetical patients: a 77-year-old woman with a shoulder problem, a 64-year-old man with osteoarthritis of the knee and a 30-year-old man with an acutely hot, swollen knee. Scores reflecting the proportion of recommended investigations, interventions and referrals selected for each scenario were calculated and examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). For the shoulder problem, all of the recommended items were chosen by the majority of respondents. However, of the items not recommended, ordering blood tests was selected by almost half (242 [45.7%]) as was prescribing an NSAID (236 [44.7%]). For the knee osteoarthritis the majority of respondents chose the recommended items except exercise (selected by only 175 [33.1%]). Of the items not recommended, tests were chosen by about half of the respondents and inappropriate referrals (chiefly for orthopedic surgery) were chosen by a quarter. For the acutely hot knee, the majority of physicians chose all of the recommended items except use of ice or heat (selected by only 188 [35.6%]). Although most (415 [78.5%]) of the respondents selected the recommended joint aspiration for this scenario, 84 (15.9%) omitted this investigation or referral to a specialist. The selection of recommended items was strongly associated with training in musculoskeletal specialties during medical school and residency. INTERPRETATION: Primary care physicians' management of 3 common musculoskeletal problems was for the most part in accord with panel recommendations. However, the unnecessary use of diagnostic tests, inappropriate prescribing of NSAIDs, low use of patient-centred options such as exercise, and lack of diagnostic suspicion of infectious arthritis are cause for concern. The results point to the need for increased exposure to musculoskeletal problems during undergraduate and residency training and in continuing medical education.
A recent study of adults aged ≥50 years reporting knee pain found an excess of radiographic knee osteoarthritis (knee ROA) in symptomatic males compared to females. This was independent of age, BMI and other clinical signs and symptoms. Since this finding contradicts many previous studies, our objective was to explore four possible explanations for this gender difference: X-ray views, selection, occupation and non-articular conditions.
A community-based prospective study. 819 adults aged ≥50 years reporting knee pain in the previous 12 months were recruited by postal questionnaires to a research clinic involving plain radiography (weight-bearing posteroanterior semiflexed, supine skyline and lateral views), clinical interview and physical examination. Any knee ROA, ROA severity, tibiofemoral joint osteoarthritis (TJOA) and patellofemoral joint osteoarthritis (PJOA) were defined using all three radiographic views. Occupational class was derived from current or last job title. Proportions of each gender with symptomatic knee ROA were expressed as percentages, stratified by age; differences between genders were expressed as percentage differences with 95% confidence intervals.
745 symptomatic participants were eligible and had complete X-ray data. Males had a higher occurrence (77%) of any knee ROA than females (61%). In 50–64 year olds, the excess in men was mild knee OA (particularly PJOA); in ≥65 year olds, the excess was both mild and moderate/severe knee OA (particularly combined TJOA/PJOA). This male excess persisted when using the posteroanterior view only (64% vs. 52%). The lowest level of participation in the clinic was symptomatic females aged 65+. Within each occupational class there were more males with symptomatic knee ROA than females. In those aged 50–64 years, non-articular conditions were equally common in both genders although, in those aged 65+, they occurred more frequently in symptomatic females (41%) than males (31%).
The excess of knee ROA among symptomatic males in this study seems unlikely to be attributable to the use of comprehensive X-ray views. Although prior occupational exposures and the presence of non-articular conditions cannot be fully excluded, selective non-participation bias seems the most likely explanation. This has implications for future study design.
Studies have suggested that the symptoms of knee osteoarthritis (OA) are rather weakly associated with radiographic findings and vice versa. Our objectives were to identify estimates of the prevalence of radiographic knee OA in adults with knee pain and of knee pain in adults with radiographic knee OA, and determine if the definitions of x ray osteoarthritis and symptoms, and variation in demographic factors influence these estimates.
A systematic literature search identifying population studies which combined x rays, diagnosis, clinical signs and symptoms in knee OA. Estimates of the prevalence of radiographic OA in people with knee pain were determined and vice versa. In addition the effects of influencing factors were scrutinised.
The proportion of those with knee pain found to have radiographic osteoarthritis ranged from 15–76%, and in those with radiographic knee OA the proportion with pain ranged from 15% – 81%. Considerable variation occurred with x ray view, pain definition, OA grading and demographic factors
Knee pain is an imprecise marker of radiographic knee osteoarthritis but this depends on the extent of radiographic views used. Radiographic knee osteoarthritis is likewise an imprecise guide to the likelihood that knee pain or disability will be present. Both associations are affected by the definition of pain used and the nature of the study group. The results of knee x rays should not be used in isolation when assessing individual patients with knee pain.
Obesity is linked to knee osteoarthritis (OA) and knee pain. These are disabling problems that are more prevalent in older adults. No prospective study has estimated the impact of excess weight avoidance on the occurrence of knee pain in the general older population. The aim of this study was to investigate the influence of overweight and obesity on the onset and progression of knee pain and disability in older adults living in the community.
A prospective cohort study of people aged 50 and over registered with three general practices in North Staffordshire, UK. 5784 people who had responded to a survey in March 2000 were mailed a follow-up questionnaire in March 2003. The main outcome measures were self-reported knee pain and severe knee pain and disability at 3 years measured by the Western Ontario and McMaster Universities Osteoarthritis index.
Adjusted response to follow-up was 75%. Among responders with no knee pain at baseline, obesity predicted onset of severe knee pain (relative risk 2.8; 95% CI 1.8, 4.5 compared to normal body mass index (BMI) category). Considering overweight and obese categories together, 19% of new cases of severe knee pain over a 3-year period could potentially be avoided by a one-category shift downwards in BMI; this includes almost half of the new cases that arose in the obese group.
Obesity accounts for a substantial proportion of severe disabling knee pain. As knee pain is a common disabling condition in older adults living in the community, effective public health interventions about avoidance of excess weight could have a major impact on future lower limb disability in older adults.
In longitudinal studies across a range of regional musculoskeletal pain syndromes, certain prognostic factors consistently emerge. They are “generic” in the sense that they appear to apply regardless of the particular anatomical site or underlying cause of the pain.
To investigate the value of generic indicators of poor functional outcome for knee pain and osteoarthritis in the community.
We conducted a population‐based cohort study of adults aged ⩾50 years with knee pain as part of the Clinical Assessment Study (Knee) (CAS(K)). At baseline, participants completed a postal questionnaire and attended a research clinic where they completed a further questionnaire and underwent structured physical examination and x rays. The 18‐month follow‐up was via a self‐completed questionnaire. Risk ratios were calculated using Cox regression with a fixed time period assigned to each participant.
In total, 60% of participants experienced a poor outcome at 18 months. Twelve univariate associations were associated with poor outcome, with four variables remaining in the multivariate model (older age, being overweight or obese, having possible or probable anxiety, and more severe pain).Using a simple unweighted additive risk score (1 point each for age ⩾60 years, body mass index ⩾25 kg/m2, possible or probable anxiety, Chronic Pain Grade II–IV), 90% of participants with all four generic indicators were correctly classified.
This study has demonstrated that generic prognostic indicators can be used to determine the prognosis of older people in the community with knee pain.
epidemiology; knee pain; prognosis; osteoarthritis
The extent and factors associated with knee pain fluctuation are not well-known. We evaluated the prevalence, correlates, and association with function of consistency of knee pain.
Participants of The Multicenter Osteoarthritis (MOST) Study, a cohort of individuals with or at high risk of knee osteoarthritis (OA) had baseline knee x-rays, questionnaires, and a question about frequent knee pain (FKnP) (pain on most of the past 30 days) at two time points: a telephone screen and a later clinic visit. We computed the prevalence of inconsistent knee pain (positive answer to FKnP question at only one time point) and consistent knee pain (positive answer to FKnP question at both time points). We evaluated the association of consistency of FKnP with a number of sociodemographic factors, pain severity, and function.
There were 2940 participants with complete data (5867 knees) (mean age 62, mean BMI 30.7, 60% female). Of those, 2977 knees had pain, with 43% having inconsistent and 57% having consistent knee pain. Those with radiographic OA (OR 0.46), depressive symptoms (OR 0.73), and widespread pain (OR 0.68) (all p<0.05) were less likely to have inconsistent compared with consistent knee pain. Pain, function, and strength were significantly better in persons with 2 knees that had inconsistent compared with consistent pain.
A substantial proportion of persons with knee pain have inconsistent knee pain, associated with better physical function and strength (adjusting for pain severity). Such pain may be suggestive of an earlier stage of disease.
Osteoarthritis; Knee pain; Temporal pattern; function
Psychological models predict behaviour in a wide range of settings. The aim of this study was to explore the usefulness of a range of psychological models to predict the health professional behaviour 'referral for lumbar spine x-ray in patients presenting with low back pain' by UK primary care physicians.
Psychological measures were collected by postal questionnaire survey from a random sample of primary care physicians in Scotland and north England. The outcome measures were clinical behaviour (referral rates for lumbar spine x-rays), behavioural simulation (lumbar spine x-ray referral decisions based upon scenarios), and behavioural intention (general intention to refer for lumbar spine x-rays in patients with low back pain). Explanatory variables were the constructs within the Theory of Planned Behaviour (TPB), Social Cognitive Theory (SCT), Common Sense Self-Regulation Model (CS-SRM), Operant Learning Theory (OLT), Implementation Intention (II), Weinstein's Stage Model termed the Precaution Adoption Process (PAP), and knowledge. For each of the outcome measures, a generalised linear model was used to examine the predictive value of each theory individually. Linear regression was used for the intention and simulation outcomes, and negative binomial regression was used for the behaviour outcome. Following this 'theory level' analysis, a 'cross-theoretical construct' analysis was conducted to investigate the combined predictive value of all individual constructs across theories.
Constructs from TPB, SCT, CS-SRM, and OLT predicted behaviour; however, the theoretical models did not fit the data well. When predicting behavioural simulation, the proportion of variance explained by individual theories was TPB 11.6%, SCT 12.1%, OLT 8.1%, and II 1.5% of the variance, and in the cross-theory analysis constructs from TPB, CS-SRM and II explained 16.5% of the variance in simulated behaviours. When predicting intention, the proportion of variance explained by individual theories was TPB 25.0%, SCT 21.5%, CS-SRM 11.3%, OLT 26.3%, PAP 2.6%, and knowledge 2.3%, and in the cross-theory analysis constructs from TPB, SCT, CS-SRM, and OLT explained 33.5% variance in intention. Together these results suggest that physicians' beliefs about consequences and beliefs about capabilities are likely determinants of lumbar spine x-ray referrals.
The study provides evidence that taking a theory-based approach enables the creation of a replicable methodology for identifying factors that predict clinical behaviour. However, a number of conceptual and methodological challenges remain.
BACKGROUND—Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care.
AIM—To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom.
METHOD—A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. Findings from UK studies were summarised with reference to European and international studies.
RESULTS—During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled.
CONCLUSION—Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.
OBJECTIVES: To evaluate the influences of radiographic severity, quadriceps strength, knee pain, age, and gender on functional ability in patients with osteoarthritis of the knee. METHODS: Equal numbers of knee pain positive and negative respondents to a survey of registrants aged more than 55 years at a general practice were invited to attend for knee radiographs and quadriceps femoris isometric strength estimations. Disability was measured using the Stanford Health Assessment Questionnaire. RESULTS: Complete data were available on 70 men (mean age 72.7 years) and 89 women (mean age 68.1 years); 44% reported knee pain, 48% had radiographic features of osteoarthritis, and 32% reported some degree of disability. Significant correlations were observed between disability and radiographic score, quadriceps strength, and knee pain. Logistic regression analysis, however, showed significant independent contributions from quadriceps strength (odds ratio 0.84 kgF), knee pain (odds ratio 1.67), and age (odds ratio 1.06 per year) only; the radiographic score had no influence on the model. These results were not influenced by confining the analysis to the group with radiographic features of osteoarthritis. CONCLUSIONS: Quadriceps strength, knee pain, and age are more important determinants of functional impairment in elderly subjects than the severity of knee osteoarthritis as assessed radiographically. Strategies designed to optimise muscle strength may have the potential to reduce a vast burden of disability, dependency, and cost.
Background and purpose
Primary spontaneous osteonecrosis of the knee is a painful lesion in the elderly without any known cause. The onset of pain is usually acute. The prognosis is poor with high frequency of osteoarthritis, joint surface collapse, and subsequent knee surgery. In the present study, we determined whether bisphosphonates can prevent the joint surface collapse by delaying the post-necrotic remodeling.
Patients and methods
Between 2006 and 2009, 17 consecutive patients (mean age 68 years) with clinical and radiographic signs of knee osteonecrosis were identified and given alendronate, 70 mg perorally, once a week for a minimum of 6 months. The patients were followed clinically, radiographically, and by MRI.
10 of the 17 patients did not develop osteoarthritis (group A), 4 patients developed mild osteoarthritis but no knee joint surface collapse (group B), and 3 patients had a joint surface collapse (group C). 2 of the 3 patients in group C—as compared to none in the other groups—stopped medication prematurely, due to side effects.
Compared to a previous, untreated series of osteonecrosis patients at our hospital, the clinical results in the present series appeared better. 59% of the patients had a complete radiographic recovery, as compared to 25% in the original study. 12% were failures regarding need to undergo surgery when bisphosphonates were given, as compared to 32% in the previous untreated series. An anticatabolic drug delaying the remodeling might be an effective treatment in osteonecrosis of the knee but further (preferably randomized) studies are necessary.
Background: No consistent relationship between the severity of symptoms of knee osteoarthritis (OA) and radiographic change has been demonstrated.
Objectives: To determine the relationship between symptoms of knee OA and tibial cartilage volume, whether pain predicts loss of cartilage in knee OA, and whether change in cartilage volume over time relates to change in symptoms over the same period.
Method: 132 subjects with symptomatic, early (mild to moderate) knee OA were studied. At baseline and 2 years later, participants had MRI scans of their knee and completed questionnaires quantifying symptoms of knee OA (knee-specific WOMAC: pain, stiffness, function) and general physical and mental health (SF-36). Tibial cartilage volume was determined from the MRI images.
Results: Complete data were available for 117 (89%) subjects. A weak association was found between tibial cartilage volume and symptoms at baseline. The severity of the symptoms of knee OA at baseline did not predict subsequent tibial cartilage loss. However, weak associations were seen between worsening of symptoms of OA and increased cartilage loss: pain (rs = 0.28, p = 0.002), stiffness (rs = 0.17, p = 0.07), and deterioration in function (rs = 0.21, p = 0.02).
Conclusion: Tibial cartilage volume is weakly associated with symptoms in knee OA. There is a weak association between loss of tibial cartilage and worsening of symptoms. This suggests that although cartilage is not a major determinant of symptoms in knee OA, it does relate to symptoms.
Selective non-participation at baseline (due to non-response and non-consent) and loss to follow-up are important concerns for longitudinal observational research. We investigated these matters in the context of baseline recruitment and retention at 18 months of participants for a prospective observational cohort study of knee pain and knee osteoarthritis in the general population.
Participants were recruited to the Knee Clinical Assessment Study – CAS(K) – by a multi-stage process involving response to two postal questionnaires, consent to further contact and medical record review (optional), and attendance at a research clinic. Follow-up at 18-months was by postal questionnaire. The characteristics of responders/consenters were described for each stage in the recruitment process to identify patterns of selective non-participation and loss to follow-up. The external validity of findings from the clinic attenders was tested by comparing the distribution of WOMAC scores and the association between physical function and obesity with the same parameters measured directly in the target population as whole.
3106 adults aged 50 years and over reporting knee pain in the previous 12 months were identified from the first baseline questionnaire. Of these, 819 consented to further contact, responded to the second questionnaire, and attended the research clinics. 776 were successfully followed up at 18 months. There was evidence of selective non-participation during recruitment (aged 80 years and over, lower socioeconomic group, currently in employment, experiencing anxiety or depression, brief episode of knee pain within the previous year). This did not cause significant bias in either the distribution of WOMAC scores or the association between physical function and obesity.
Despite recruiting a minority of the target population to the research clinics and some evidence of selective non-participation, this appears not to have resulted in significant bias of cross-sectional estimates. The main effect of non-participation in the current cohort is likely to be a loss of precision in stratum-specific estimates e.g. in those aged 80 years and over. The subgroup of individuals who attended the research clinics and who make up the CAS(K) cohort can be used to accurately estimate parameters in the reference population as a whole. The potential for selection bias, however, remains an important consideration in each subsequent analysis.
Background: Hospital based studies of occupational risk factors for knee disorders are complicated by the possibility of selective referral to hospital of people whose work is made difficult by their symptoms.
Aims: To explore the extent of such bias and to assess the association of meniscal injury with occupational activities.
Methods: A questionnaire was mailed to a community sample of 2806 men aged 20–59 years in southern England. This asked about lifetime occupational and sporting activities, and any history of knee symptoms lasting 24 hours or longer. Rates of hospital referral were compared in symptomatic men according to their occupational activities. In a nested case-control investigation, the occupational activities of 67 men who reported meniscectomy were compared with those of 335 controls.
Results: Among 1404 men who responded to the questionnaire, the lifetime prevalence of knee symptoms was 54%, and in 70% of cases the symptoms had started suddenly, usually while playing sport. Symptomatic men whose work entailed kneeling or squatting were more likely to be referred to an orthopaedic surgeon than the average (28% and 31% versus 24%), especially if they experienced locking of the knee (69% and 73% versus 43%). In the nested case-control study, meniscectomy was associated with playing soccer and work that involved regular kneeling or squatting.
Conclusions: Results suggest that hospital referral for knee symptoms is influenced to some extent by patients' occupational activities. Playing soccer is confirmed as a strong risk factor for knee cartilage injury.
To examine whether the consistency or persistence of knee pain, in addition to its severity, predicts incident total knee replacement (TKR).
The Multicenter Osteoarthritis Study (MOST) is a longitudinal study of persons aged 50 to 79 years with symptomatic knee osteoarthritis or at high risk of disease. Subjects were queried about the presence of knee pain on most days of the previous 30 days (i.e., frequent knee pain; FKP) at 2 timepoints: a telephone screen followed by a clinic visit (median separation 4 weeks). We defined a knee as having “consistent pain” if the subject answered positively to the FKP question at both timepoints, “inconsistent pain” if FKP was positive at only one timepoint, or as “no FKP” if negative at both. We examined the association between consistent FKP and risk of TKR using multiple binomial regression with generalized estimating equations.
In 3026 persons (mean age 63 yrs, mean body mass index 30.4), 2979 knees (50%) had no FKP at baseline, 1279 knees (21.5%) had inconsistent FKP, and 1696 knees (28.5%) had consistent FKP. Risk of TKR over 30 months was 0.8%, 2.6%, and 8.8% for knees with no, inconsistent, and consistent FKP, respectively. Relative risks of TKR over 30 months were 1.2 (95% CI 0.6–2.3) and 2.3 (95% CI 1.2–4.4) for knees with inconsistent and consistent FKP, compared with those without FKP. This association was consistent across each level of pain severity on the Western Ontario and McMaster Universities Osteoarthritis Index.
Consistency of frequent knee pain is associated with an increased risk of TKR independently of knee pain severity. (First Release April 15 2011; J Rheumatol 2011;38:1390–5; doi:10.3899/jrheum.100743)
OSTEOARTHRITIS; PAIN; JOINT REPLACEMENT; KNEE
Self-management (SM) programs are effective for some chronic conditions, however the evidence for arthritis SM is inconclusive. The aim of this case series project was to determine whether a newly developed specific self-management program for people with osteoarthritis of the knee (OAK), implemented by health professionals could achieve and maintain clinically meaningful improvements.
Participants: 79 participants enrolled; mean age 66, with established osteoarthritis of the knee. People with coexisting inflammatory joint disease or serious co-morbidities were excluded.
Intervention: 6-week disease (OA) and site (knee) specific self-management education program that included disease education, exercise advice, information on healthy lifestyle and relevant information within the constructs of self-management. This program was conducted in a community health care setting and was delivered by health professionals thereby utilising their knowledge and expertise.
Measurements: Pain, physical function and mental health scales were assessed at baseline, 8 weeks, 6 and 12 months using WOMAC and SF-36 questionnaires. Changes in pain during the 8-week intervention phase were monitored with VAS.
Pain improved during the intervention phase: mean (95% CI) change 15 (8 to 22) mm. Improvements (0.3 to 0.5 standard deviation units) in indices of pain, mental health and physical functioning, assessed by SF-36 and WOMAC questionnaires were demonstrated from baseline to 12 months.
This disease and site-specific self-management education program improved health status of people with osteoarthritis of the knee in the short and medium term.
To develop a sensitive and specific screening tool for knee and hip osteoarthritis in the general population of elderly people.
The Knee and Hip OsteoArthritis Screening Questionnaire (KHOA-SQ) was developed based on previous studies and observed data and sent to 11,002 people aged 60 to 90 years, stratified by age and gender, who were selected by random sampling. Algorithms of the KHOA-SQ were created. Respondents positive for knee or hip OA on the KHOA-SQ were invited to be evaluated by an orthopedic surgeon. A sample of 300 individuals negative for knee or hip OA on the KHOA-SQ were also invited for evaluation. Sensitivity and specificity were determined for the KHOA-SQ, as well as for KHOA-SQ questions. Classification and Regression Tree analysis was used to find alternative screening algorithms from the questionnaire.
Of 11,002 individuals contacted, 7,577 completed the KHOA-SQ. Of 1,115 positive for knee OA, on the KHOA-SQ, 710 (63.6%) were diagnosed with it. For hip OA, 339 of the 772 who screened positive (43.9%) were diagnosed it. Sensitivity for the hip algorithm was 87.4% and specificity 59.8%; for the knee, sensitivity was 94.5% and specificity 43.8%. Two alternative algorithms provided lower specificity.
The KHOA-SQ offers high sensitivity and moderate specificity. Although this tool correctly identifies individuals with knee or hip OA, the high false positive rate could pose problems. Based on our questions, no better algorithm was found.
Large variations in pain and function are seen over time in subjects at risk for and with radiographic knee osteoarthritis (OA). We hypothesized that this variation may be related not only to knee OA but also to patient characteristics. The objective of this study was to investigate the influence of age, gender, and body mass index (BMI) on clinically relevant change in pain and function over two years in subjects at high risk for or with knee OA.
We assessed 143 individuals (16% women, mean age 50 years [range 27–83]) twice; 14 and 16 years after isolated meniscectomy. Subjects completed one disease-specific questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS) and one generic measure, the SF-36. Individuals with a BMI between 25 and 29.9 were considered overweight, while individuals with a BMI of 30 or more were considered obese.
Subjects aged 46–56 (the middle tertile) were more likely to change (≥10 points on a 0–100 scale) in the KOOS subscale Activities of Daily Living (ADL) than younger subjects (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 1.5–13.0). Essentially the same result was obtained after adjusting for baseline values. Overweight or obesity was a risk factor for clinically relevant change for knee pain (OR 2.4, 95% CI 1.0 – 5.8, OR 4.0, 95% CI 1.2 – 13.6) and obesity for change in ADL (OR 4.3, 95% CI 1.2 – 15.4). The results did not remain significant when adjusted for the respective baseline value. Being symptomatic was strongly associated with increased variation in pain and function while presence or absence of radiographic changes did not influence change over two years in this cohort.
In a population highly enriched in early-stage and established knee OA, symptomatic, middle-aged, and overweight or obese subjects were more likely to vary in their knee function and pain over two years. The natural course of knee pain and function may be associated with subject characteristics such as age and BMI.
The Intermittent and Constant Osteoarthritis Pain (ICOAP) questionnaire was developed to assess two forms of pain reported by people with osteoarthritis: intermittent and constant pain. Studies examining its measurement qualities have provided some support for its use as separate and total scales. However, it has not been previously evaluated using Rasch analysis. The current study examined the fit between data obtained from the ICOAP questionnaire and the Rasch model to determine whether it meets the requirements of interval-level measurement.
ICOAP responses from 175 participants with knee osteoarthritis were collected in a cross-sectional questionnaire study. Participants were recruited from hospital clinics and a group who had taken part in previous research. The questionnaires were completed at home and returned by pre-paid envelope and the data were analysed using RUMM2020.
Fit to the Rasch model was achieved for both the Constant and Intermittent subscales following removal of a small number of items. The Total scale initially resulted in substantial misfit to the model, but fit was improved by removing four items that misfit the model. However, several participants presented with high fit residuals, which is consistent with misfit.
The results support the use of Constant and Intermittent subscales as unidimensional measures of pain. The Total scale can be adapted to improve fit to the Rasch model, but there are concerns over participant misfit.
Rasch analysis; Osteoarthritis; Pain; Outcome assessment
To evaluate whether the ongoing debate over diagnostic problems and treatment choices for acute rhinosinusitis has had any influence on the management of the disease.
We randomly selected 300 Danish general practitioners (GPs) from the files of the Research Unit for General Practice at Aarhus University. Invitations to participate and a questionnaire were sent to the GPs by mail.
A total of 149 (49%) GPs answered the questionnaire. When asked about symptoms, the highest priority was given to sinus pain and signs of tenderness. The most frequent examinations were objective examination of the ear-nose-throat (ENT), palpation of the maxillofacial area, and C-reactive protein point-of-care testing (or CRP rapid test). Nearly all GPs prescribed local vasoconstrictors, and in 70% of cases, antibiotics were prescribed. Phenoxymethyl-penicillin was the preferred antibiotic. Use of the CRP rapid test, years in practice, or employment in an ENT department did not have a significant impact on the diagnostic certainty and antibiotic prescribing rate.
The clinical diagnoses are based on a few symptoms, signs, and the CRP rapid test. Other examinations, including imaging techniques, are seldom used. Phenoxymethylpenicillin is the preferred antibiotic, and the GPs’ diagnostic certainty was 70%.
general practice; acute rhinosinusitis; diagnosis; treatment; antibiotic
Although the severity of knee osteoarthritis (OA) usually is assessed using different measures of joint structure, function, and pain, the relationships between these measures are unclear.
Therefore, we: (1) examined the relationships between the measures of knee structure (flexion-extension range of motion, radiographic tibiofemoral angle, and medial joint space), function (Knee Osteoarthritis Outcome Scores [KOOS], peak adduction angle, and moment), and pain (visual analog scale [VAS]); and (2) identified variables that best predicted knee pain.
We assessed 15 patients with medial knee OA using VAS pain, KOOS questionnaire, 3-D gait analysis, and radiographic examination. Parameter relationships were assessed using Pearson correlation, and variables most predictive of knee pain were determined using a stepwise multiple regression.
Subjective measurements correlated (|r| ≥ 0.54) with one another, as did most of the objective measurements (|r| ≥ 0.56) except for adduction moment which did not correlate with any variable. All variables correlated (|r| > 0.54) with VAS knee pain except peak adduction moment. Medial joint space and peak adduction angle best predicted knee pain, accounting for approximately three-quarters of the model variance (r2 = 0.73).
Medial joint space and peak adduction angle may be useful for predicting knee pain in patients with medial knee OA. Therapies that target these structural and functional variables may reduce knee pain in this population.
Increasing the medial joint space and limiting the peak knee adduction angle may be critical in achieving effective pain relief in patients with varus knee OA.
Objectives. To compare patient self-report of knee flexion, extension, range of motion (ROM) and American Knee Society (AKS) Pain, Knee and Functional scores with a clinician assessment.
Methods. A total of 239 consecutive total knee arthroplasty (TKA) patients (290 knees) were mailed surveys with an AKS questionnaire and lateral knee photographs that showed knee ROM in 10° increments to compare their operated knee(s) ROM. Patients were subsequently seen in clinic and their ROM, AKS Pain, Knee and Functional scores were measured. Patient- and physician-reported measures were compared using independent sample t-test and correlated using Spearman's correlation coefficient. A priori rules for comparisons were based on previously published reports.
Results. A total of 286 knees had both survey and clinic data available and constituted the analytic set. Patient-reported and physician-assessed extension, flexion and ROM were: 3 ± 4.8° vs 1.4 ± 4.3° (P < 0.001), 111.4 ± 14.6° vs 110 ± 12.8° (P = 0.04) and 108.6 ± 16.8 vs 108.6 ± 14.3° (P = 0.98). There was a moderate correlation between patient and physician assessments (extension = 0.31; flexion = 0.44; ROM = 0.42; P ≤ 0.001 for all). Patient-reported and physician-assessed AKS Pain, Knee and Functional scores were: 35.8 ± 15.6 vs 43.9 ± 11.1 (P < 0.001), 79.8 ± 20 vs 88.9 ± 13.3 (P < 0.001) and 57.7 ± 23.1 vs 65.7 ± 26.4 (P < 0.001), respectively. Patient- and physician-assessed AKS Pain, Knee and Functional scores had moderate–high correlation (r = 0.49, 0.49 and 0.70; P ≤ 0.001 for all).
Conclusion. Long-term surveillance of TKA patients may be possible using a self-report AKS, but the average 8- to 10-point difference between patient- and physician-reported AKS scores (patients reporting poorer scores) represents a substantial impact on this outcome instrument. Since patient-reported responses have clear value in global assessment, further evaluation with other validated outcome instruments is warranted.
Long-term surveillance; Total knee arthroplasty; Knee society score; Self-report; Surgeon assessment; Total knee replacement; Pain; Function
Patients with knee osteoarthritis [OA] are commonly treated by physiotherapists in primary care. Measuring physiotherapy performance is important before developing strategies to improve quality. The purpose of this study was to measure physiotherapy performance in patients with knee OA by comparing clinical practice to evidence from systematic reviews.
We developed a data-collection form and invited all private practitioners in Norway [n = 2798] to prospectively collect data on the management of one patient with knee OA through 12 treatment session. Actual practice was compared to findings from an overview of systematic reviews summarising the effect of physiotherapy interventions for knee OA.
A total of 297 physiotherapists reported their management for patients with knee OA. Exercise was the most common treatment used, provided by 98% of the physiotherapists. There is evidence of high quality that exercise reduces pain and improves function in patients with knee OA. Thirty-five percent of physiotherapists used acupuncture, low-level laser therapy or transcutaneous electrical nerve stimulation. There is evidence of moderate quality that these treatments reduce pain in knee OA. Patient education, supported by moderate quality evidence for improving psychological outcomes, was provided by 68%. Physiotherapists used a median of four different treatment modalities for each patient. They offered many treatment modalities based on evidence of low quality or without evidence from systematic reviews, e.g. traction and mobilisation, massage and stretching.
Exercise was used in almost all treatment sessions in the management of knee OA. This practice is desirable since it is supported by high quality evidence. Physiotherapists also provide several other treatment modalities based on evidence of moderate or low quality, or no evidence from systematic reviews. Ways to promote high quality evidence into physiotherapy practice should be identified and evaluated.
The new Musculoskeletal Services Framework outlines the importance of health care needs assessment. Our aim was to provide a model for this for knee pain and disability, describing felt need (individual assessment of a need for health care) and expressed need (demand for health care). This intelligence is required by health care planners in order to implement the new Framework.
A multi-method approach was used. A population survey (n = 5784) was administered to adults aged 50+ registered with 3 general practices. The questionnaire contained a Knee Pain Screening Tool to identify the prevalence of knee pain and health care use in the population, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Survey responders who scored "severe" or "extreme" on at least one item on the pain or physical function scale on the WOMAC were categorised into "severe" groups. Qualitative interviews were undertaken with 22 survey responders to explore in detail the experience of living with knee pain and disability. A sample of interviewees (n = 10) completed an open format patient diary to explore the experience of knee pain in everyday life.
The 12-month period prevalence of knee pain was 49.5%, of which half was severe. Severe difficulties were reported with domestic duties, bending, bathing, climbing stairs and getting in or out of a car. Some self-care is occurring. The majority (53%) of responders with severe pain or disability had not consulted their GP in the last 12 months. The qualitative study revealed reasons for this including a perception that knee pain is part of normal ageing, little effective prevention and treatment is available and the use of medications causes side effects and dependency.
This study adds to previous work by highlighting a gap between felt and expressed need and the reasons for this mismatch. There is evidence of self-management, but also missed opportunities for effective interventions (e.g. lifestyle advice). A targeted and integrated approach between clinicians and health care planners for primary and secondary prevention is required if aspects of the new Musculoskeletal Services Framework are to be successfully implemented.