Alex N. Bastick

Prognostic factors for progression of clinical osteoarthritis of the knee: a systematic review of observational studies

IntroductionWe performed a systematic review of prognostic factors for the progression of symptomatic knee osteoarthritis (OA), defined as increase in pain, decline in physical function or total joint replacement.MethodWe searched for available observational studies up to January 2015 in Medline and Embase according to a specified search strategy. Studies that fulfilled our initial inclusion criteria were assessed for methodological quality. Data were extracted and the results were pooled, or if necessary summarized according to a best evidence synthesis.ResultsOf 1,392 articles identified, 30 met the inclusion criteria and 38 determinants were investigated. Pooling was not possible due to large heterogeneity between studies. The best evidence synthesis showed strong evidence that age, ethnicity, body mass index, co-morbidity count, magnetic resonance imaging (MRI)-detected infrapatellar synovitis, joint effusion and baseline OA severity (both radiographic and clinical) are associated with clinical knee OA progression. There was moderate evidence showing that education level, vitality, pain-coping subscale resting, MRI-detected medial femorotibial cartilage loss and general bone marrow lesions are associated with clinical knee OA progression. However, evidence for the majority of determinants was limited (including knee range of motion or markers) or conflicting (including age, gender and joint line tenderness).ConclusionStrong evidence was found for multiple prognostic factors for progression of clinical knee OA. A large variety in definitions of clinical knee OA (progression) remains, which makes it impossible to summarize the evidence through meta-analyses. More research on prognostic factors for knee OA is needed using symptom progression as an outcome measure. Remarkably, only few studies have been performed using pain progression as an outcome measure. The pathophysiology of radiographic factors and their relation with symptoms should be further explored.

What Are the Prognostic Factors for Radiographic Progression of Knee Osteoarthritis? A Meta-analysis

BackgroundA previous systematic review on prognostic factors for knee osteoarthritis (OA) progression showed associations for generalized OA and hyaluronic acid levels. Knee pain, radiographic severity, sex, quadriceps strength, knee injury, and regular sport activities were not associated. It has been a decade since the literature search of that review and many studies have been performed since then investigating prognostic factors for radiographic knee OA progression.Questions/purposesThe purpose of this study is to provide an updated systematic review of available evidence regarding prognostic factors for radiographic knee OA progression.MethodsWe searched for observational studies in MEDLINE and EMBASE. Key words were: knee, osteoarthritis (or arthritis, or arthrosis, or degenerative joint disease), progression (or prognosis, or precipitate, or predictive), and case-control (or cohort, or longitudinal, or follow-up). Studies fulfilling the inclusion criteria were assessed for methodologic quality according to established criteria for reviews on prognostic factors in musculoskeletal disorders. Data were extracted and results were pooled if possible or summarized according to a best-evidence synthesis. A total of 1912 additional articles were identified; 43 met our inclusion criteria. The previous review contained 36 articles, thus providing a new total of 79 articles. Seventy-two of the included articles were scored high quality, the remaining seven were low quality.ResultsThe pooled odds ratio (OR) of two determinants showed associations with knee OA progression: baseline knee pain (OR, 2.38 [95% CI, 1.74–3.27) and Heberden nodes (OR, 2.66 [95% CI, 1.46–8.84]). Our best-evidence synthesis showed strong evidence that varus alignment, serum hyaluronic acid, and tumor necrosis factor-α are associated with knee OA progression. There is strong evidence that sex, former knee injury, quadriceps strength, smoking, running, and regular performance of sports are not associated with knee OA progression. Evidence for the majority of determined associations, however, was limited, conflicting, or inconclusive.ConclusionsBaseline knee pain, presence of Heberden nodes, varus alignment, and high levels of serum markers hyaluronic acid and tumor necrosis factor-α predict knee OA progression. Sex, knee injury, and quadriceps strength, among others, did not predict knee OA progression. Large variation remains in definitions of knee OA and knee OA progression. Clinical studies should use more consistent definitions of these factors to facilitate data pooling by future meta-analyses.

Identifying trajectories of pain severity in early symptomatic knee osteoarthritis : A 5-year followup of the cohort hip and cohort knee (CHECK) study

Objective. To identify subgroups of pain trajectories in patients with symptomatic knee osteoarthritis (OA), and to explain these different trajectories by patient characteristics, lifestyle, and coping factors, as well as radiographic features. Methods. Longitudinal data of pain severity (0–10) from 5 years of followup of the CHECK (Cohort Hip and Cohort Knee) study was used. Latent class growth analysis identified homogeneous subgroups with distinct trajectories of pain. Multinomial regression analysis was used to examine different lifestyle and coping characteristics between the trajectories. Results. In longitudinal pain data of 5 years of followup in 705 participants, 3 pain trajectories were identified: marginal, mild, and moderate pain trajectories. Compared with the marginal pain trajectory, the mild and moderate pain trajectories can be characterized by the following baseline variables: body mass index (BMI) > 25, additional hip pain, low education level, using the coping strategy “worrying,” and having ≥ 3 comorbidities. Moderate pain trajectory can be supplemented with the Kellgren-Lawrence grading scale grade ≥ 2 radiological change. Conclusion. Three trajectories of pain were identified. Participants with a BMI > 25, secondary school as highest education level, having at least 3 comorbidities, additional hip pain, and/or whose coping style is worrying are more likely to develop a moderate or mild pain trajectory compared with those without these characteristics. In the management of knee pain in people with early symptomatic OA, attention should also be given to additional factors such as hip pain, other comorbidities, passive coping strategy, and obesity.

Defining hip pain trajectories in early symptomatic hip osteoarthritis – 5 year results from a nationwide prospective cohort study (CHECK)

OBJECTIVE To define distinct hip pain trajectories in individuals with early symptomatic hip osteoarthritis (OA) and to determine risk factors for these pain trajectories. METHOD Data were obtained from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study. Participants with hip pain or stiffness and a completed 5-year follow-up were included. Baseline demographic, anamnestic, physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale (NRS) for pain. Pain trajectories were retrieved by latent class growth analysis (LCGA). Multinomial logistic regression was used to calculate risk ratios. RESULTS 545 participants were included. Four distinct pain trajectories were uncovered by LCGA. We found significant differences in baseline characteristics, including body mass index (BMI); symptom severity; pain coping strategies and in criteria for clinical hip OA (American College of Rheumatology (ACR)). Lower education, higher activity limitation scores, frequent use of pain transformation as coping strategy and painful internal hip rotation were more often associated with trajectories characterized by more severe pain. No association was found for baseline radiographic features. CONCLUSION We defined four distinct pain trajectories over 5 years follow-up in individuals with early symptomatic hip OA, suggesting there are differences in symptomatic progression of hip OA. Baseline radiographic severity was not associated with the pain trajectories. Future research should be aimed at measuring symptomatic progression of hip OA with even more frequent symptom assessment.

Characteristics associated with joint replacement in early symptomatic knee or hip osteoarthritis: 6-year results from a nationwide prospective cohort study (CHECK)

BACKGROUND Many patients with osteoarthritis (OA) of the knee and/or hip undergo total joint replacement (TJR) because of severely progressed symptoms. AIM To determine patient and disease characteristics associated with undergoing TJR in participants with recent-onset knee and/or hip OA. DESIGN AND SETTING Participants with hip or knee pain from the nationwide prospective Cohort Hip and Cohort Knee (CHECK) study were included. METHOD The outcome measure was total hip arthroplasty (THA) or total knee arthroplasty (TKA) during 6 years of follow-up. Joint-dependent characteristics were compared using generalised estimating equations (GEE). Multivariable models were built for both subgroups. Differences in symptomatic and radiographic progression were determined between baseline and 2-year follow-up (T2). RESULTS The knee subgroup included 751 participants (1502 knees), and there were 538 participants in the hip subgroup (1076 hips). Nineteen participants (22 knees) underwent TKA and 53 participants (62 hips) THA. Participants who underwent TKA had higher baseline body mass index, painful knee flexion, and higher Kellgren and Lawrence scores. Participants who underwent THA had painful internal hip rotation and showed more severe radiographic OA features. Participants who underwent TKA or THA showed more rapid symptomatic and radiographic OA progression at T2. CONCLUSION In patients with recent-onset knee or hip pain, radiographic OA features already exist and a substantial number of patients fulfil existing criteria for knee and hip OA. A trend was observed in rapid progression of radiographic and symptomatic OA severity among patients with TKA and THA. Early detection of OA by the GP is important in managing knee and hip OA.

OP0292 Different Pain Trajectories in Early Symptomatic Knee OA; 5 Year Follow-Up of Check (Cohort Hip & Cohort Knee) Study

Objectives Knee pain is often the first sign of knee OA and it is known that its course can be very different between patients over time. This study identifies distinct groups of patients with different trajectories of pain due to symptomatic knee OA, and describes lifestyle and coping characteristics for each trajectory of pain. Lifestyle factors might be important elements for prevention, since they are modifiable in nature. Yet de role of lifestyle factors in different pain trajectories in early OA is unclear. Methods Longitudinal data of five years follow-up of the CHECK study was used. Participants had pain of knee or hip, were aged 45-65 years, and had not yet consulted their physician for these symptoms or the consultation occurred within 6 months before inclusion. Pain severity was measured with numeric scale (0-10). Latent class growth analysis identified homogenous subgroups with distinct trajectories of pain. Multinomial regression analysis was used to examine different lifestyle and coping characteristics between the trajectories Results Longitudinal data of 5 years follow-up of 705 participants with symptomatic knee OA was analyzed. Three pain trajectories were identified based on their outcome: good, moderate and poor outcome. Participants with good outcome trajectory (n=222) had over time a slight decrease in pain severity and ended up with a low pain severity. Participants with moderate outcome trajectory (n=294) had a stable course of moderate pain over time. The poor outcome trajectory participants (n=189) had an increase of pain severity over time and ended up with severe pain. Compared to the good outcome group, participants in the moderate and poor outcome group were characterized by higher BMI (both OR’s 1.1; p=0.01), smokers (moderate outcome group OR=1.8, p=0.08; poor outcome group OR= 2.5, p=0.01) used passive coping strategies worrying (moderate outcome group OR= 2.2, p=0.01; poor outcome group OR=3.5, p<0.001) and resting (moderate outcome group OR= 1.6, p=0.09; poor outcome group OR=2.4, p=0.004). The passive coping strategy ‘retreating’ reduced the chance of belonging to the poor outcome group (moderate outcome group OR= 0.6, p=0.04; poor outcome group OR=0.5, p=0.009). Conclusions This study identified 3 trajectories of pain: good, moderate and poor outcome. Unhealthy lifestyle characteristics (high BMI and smoking) and passive coping strategies (worrying and resting) characterized the poor outcome group. Distinguishing different trajectories could have implications for the treatment. Treatment for each pain trajectory in early OA might be tailored to lifestyle and coping characteristics. Acknowledgements CHECK-cohort study is initiated by the Dutch Arthritis Association and performed within; Erasmus Medical Center Rotterdam; Kennemer Gasthuis Haarlem; Leiden University Medical Center; Maastricht University Medical Center; Martini Hospital Groningen /Allied Health Care Center for Rheum. and Rehabilitation Groningen; Medical Spectrum Twente Enschede /Ziekenhuisgroep Twente Almelo; Reade, formerly Jan van Breemen Institute/ VU Medical Center Amsterdam; St.Maartens-kliniek Nijmegen; University Medical Center Utrecht and Wilhelmina Hospital Assen Disclosure of Interest None Declared

OP0188-PC Pain trajectories in hip osteoarthritis: Results of the dutch cohort hip and cohort knee (CHECK)

Background Pain is the most important complaint reported in osteoarthritis (OA). In hip OA, a recent study showed five distinctive trajectories of pain over a two year follow-up period.[1] The next step is to validate these finding in another study population with a longer follow-up period. Objectives To identify long term trajectories of persons with hip pain due to OA over a 5-year follow-up period. Methods Data from the inception cohort CHECK[2] was used to investigate the course of pain. For this study 208 participants were included who fulfilled the clinical and/or radiographic American College of Rheumatology (ACR) criteria for hip OA. Participants filled out yearly questionnaires during the 5-year follow-up period. Pain severity was measured by an 11-point numeric rating scale (0=no pain;10=unbearable). Latent class growth analysis (LCGA) was used to determine the number of different trajectories of participants with hip pain due to OA. Multinomial regression analysis was used to predict the effect of baseline characteristics of the participants and the probability of membership to a one of the trajectories. Results Analyses yielded 4 distinctive trajectories of pain during the five year follow-up instead of five trajectories in another study sample over two years of follow-up. Participants within trajectory 1 (“mild pain”; n=78) fluctuated slightly within ranges of mild pain. Trajectory 2 (“moderate pain”; n=76) consists of participants who slowly increased within ranges of moderate pain over the 5-year period. Trajectory 3 (“decreasing pain”; n=22) comprised participants who started with severe pain at baseline, but after 5-years their pain decreased. Participants within trajectory 4 (“always pain”; n=32) had constant levels of severe pain. Compared with the “mild pain” group, participants in the “moderate pain” group have a higher body mass index (BMI), more often have morning stiffness of the hip, a decreased hip flexion, and concurrent knee complaints. Participants in the “always pain” group are more likely to be women. Conclusions LCGA identified 4 distinct trajectories in 208 participants with clinically and/or radiographic determined hip OA. Predictors for membership to the “moderate pain” group were BMI, morning stiffness of the hip, decreased hip flexion, and concurrent knee pain. For the “always pain” group this was gender. References Verkleij SPJ, Hoekstra T, Rozendaal RM, Waarsing JH, Koes BW, Luijsterburg PAJ, Bierma-Zeinstra SMA. Defining discriminative pain trajectories in hip osteoarthritis over a two-year time period. Ann Rheum Dis 2012. Wesseling J et al. CHECK (Cohort Hip and Cohort Knee): similarities and differences with the Osteoarthritis Initiative. Ann Rheum Dis 2009;68:1413-9. Disclosure of Interest None Declared