Kelli D. Allen

A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative

PURPOSE Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers. METHODS A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data. RESULTS Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin. CONCLUSIONS The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs.

Association of ALS with head injury, cigarette smoking and APOE genotypes

OBJECTIVE An increased risk of ALS has been reported for US veterans, but the cause is unknown. Since head injury and cigarette smoking are two previously implicated environmental risk factors that are more common in military than civilian study populations, we tested their association with ALS in a US veteran study population. METHODS We used logistic regression to examine the association of ALS with head injury and cigarette smoking in 241 incident cases and 597 controls. Since APOE is a plausible ALS candidate gene, we also tested its main effect and its statistical interaction with these environmental exposures. RESULTS Cigarette smoking was not associated with ALS in this predominantly male and Caucasian population. Veterans who had experienced head injuries during the last 15years before the reference date had an adjusted odds ratio of 2.33 (95% confidence interval 1.18-4.61), relative to veterans without any head injuries. This association was strongest in APOE-4 carriers. CONCLUSIONS Our results add to the body of evidence suggesting that head injuries may be a risk factor for multiple neurodegenerative diseases, including ALS. We hypothesize that the strength of association between head injuries and ALS may depend upon APOE genotype.

Association Between Blood Lead and the Risk of Amyotrophic Lateral Sclerosis

The authors conducted a 2003-2007 case-control study including 184 cases and 194 controls to examine the association between blood lead and the risk of amyotrophic lateral sclerosis (ALS) among US veterans and to explore the influence on this association of bone turnover and genetic factors related to lead toxicokinetics. Blood lead, plasma biomarkers of bone formation (procollagen type 1 amino-terminal peptide (PINP)) and resorption (C-terminal telopeptides of type 1 collagen (CTX)), and the K59N polymorphism in the delta-aminolevulinic acid dehydratase gene, ALAD, were measured. Odds ratios and 95% confidence intervals for the association of blood lead with ALS were estimated with unconditional logistic regression after adjustment for age and bone turnover. Blood lead levels were higher among cases compared with controls (P < 0.0001, age adjusted). A doubling of blood lead was associated with a 1.9-fold increased risk of ALS (95% confidence interval: 1.3, 2.7) after adjustment for age and CTX. Additional adjustment for PINP did not alter the results. Significant lead-ALS associations were observed in substrata of PINP and CTX levels. The K59N polymorphism in the ALAD gene did not modify the lead-ALS association (P = 0.32). These results extend earlier findings by accounting for bone turnover in confirming the association between elevated blood lead level and higher risk of ALS.

State of the evidence.

Purpose of reviewThis review focuses on recent studies of osteoarthritis epidemiology, including research on prevalence, incidence, and a broad array of potential risk factors at the person level and joint level. Recent findingsStudies continue to illustrate the high impact of osteoarthritis worldwide, with increasing incidence. Person-level risk factors with strong evidence regarding osteoarthritis incidence and/or progression include age, sex, socioeconomic status, family history, and obesity. Joint-level risk factors with strong evidence for incident osteoarthritis risk include injury and occupational joint loading; the associations of injury and joint alignment with osteoarthritis progression are compelling. Moderate levels of physical activity have not been linked to increased osteoarthritis risk. Some topics of high recent interest or emerging evidence for association with osteoarthritis include metabolic pathways, vitamins, joint shape, bone density, limb length inequality, muscle strength and mass, and early structural damage. SummaryOsteoarthritis is a complex, multifactorial disease, and there is still much to learn regarding mechanisms underlying incidence and progression. However, there are several known modifiable and preventable risk factors, including obesity and joint injury; efforts to mitigate these risks can help to lessen the impact of osteoarthritis.

Amyotrophic Lateral Sclerosis among 1991 Gulf War Veterans: Evidence for a Time-Limited Outbreak

Background: In follow-up to recent reports of an elevated risk of amyotrophic lateral sclerosis (ALS) among 1991 Gulf War veterans, we analyzed the distribution of disease onset times to determine whether the excess risk was time limited. Methods: This secondary analysis used data from a population-based series of ALS cases identified between 1991 and 2001 among the 2.5 million military personnel who were on active duty during the 1991 Gulf War. Annual standardized incidence ratios (SIR) were calculated for all cases and for those with disease onset before age 45 years. Results: Forty-eight of 124 cases occurred among those deployed to the Persian Gulf region during the war. The annual SIR for deployed military personnel did not demonstrate a monotonically increasing trend for either all cases (χ2 = 0.11, d.f. = 1, p = 0.74) or for cases under 45 years of age at onset (χ2 = 2.41, d.f. = 1, p = 0.12). The highest risk was observed in 1996, declining thereafter. Among military personnel who were not deployed to the Gulf region, the level of risk remained fairly constant during the 11-year period. Conclusions: The excess risk of ALS among 1991 Gulf War veterans was limited to the decade following the war.

Telephone-based self-management of osteoarthritis: A randomized trial.

BACKGROUND Osteoarthritis is a leading cause of pain and disability, and self-management behaviors for osteoarthritis are underutilized. OBJECTIVE To examine the effectiveness of a telephone-based self-management intervention for hip or knee osteoarthritis in a primary care setting. DESIGN Randomized clinical trial with equal assignment to osteoarthritis self-management, health education (attention control), and usual care control groups. (ClinicalTrials.gov registration number: NCT00288912) SETTING Primary care clinics in a Veterans Affairs Medical Center. PATIENTS 515 patients with symptomatic hip or knee osteoarthritis. INTERVENTION The osteoarthritis self-management intervention involved educational materials and 12 monthly telephone calls to support individualized goals and action plans. The health education intervention involved nonosteoarthritis educational materials and 12 monthly telephone calls related to general health screening topics. MEASUREMENTS The primary outcome was score on the Arthritis Impact Measurement Scales-2 pain subscale (range, 0 to 10). Pain was also assessed with a 10-cm visual analog scale. Measurements were collected at baseline and 12 months. RESULTS 461 participants (90%) completed the 12-month assessment. The mean Arthritis Impact Measurement Scales-2 pain score in the osteoarthritis self-management group was 0.4 point lower (95% CI, -0.8 to 0.1 point; P = 0.105) than in the usual care group and 0.6 point lower (CI, -1.0 to -0.2 point; P = 0.007) than in the health education group at 12 months. The mean visual analog scale pain score in the osteoarthritis self-management group was 1.1 points lower (CI, -1.6 to -0.6 point; P < 0.001) than in the usual care group and 1.0 point lower (CI, -1.5 to -0.5 point; P < 0.001) than in the health education group. Health care use did not differ across the groups. LIMITATION The study was conducted at 1 Veterans Affairs Medical Center, and the sample consisted primarily of men. CONCLUSION A telephone-based osteoarthritis self-management program produced moderate improvements in pain, particularly compared with a health education control group. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs Health Services Research and Development Service.

Racial differences in osteoarthritis pain and function: potential explanatory factors

OBJECTIVE This study examined factors underlying racial differences in pain and function among patients with hip and/or knee osteoarthritis (OA). METHODS Participants were n=491 African Americans and Caucasians enrolled in a clinical trial of telephone-based OA self-management. Arthritis Impact Measurement Scales-2 (AIMS2) pain and function subscales were obtained at baseline. Potential explanatory variables included arthritis self-efficacy, AIMS2 affect subscale, problem- and emotion-focused pain coping, demographic characteristics, body mass index, self-reported health, joint(s) with OA, symptom duration, pain medication use, current exercise, and AIMS2 pain subscale (in models of function). Variables associated with both race and pain or function, and which reduced the association of race with pain or function by >or=10%, were included in final multivariable models. RESULTS In simple linear regression models, African Americans had worse scores than Caucasians on AIMS2 pain (B=0.65, P=0.001) and function (B=0.59, P<0.001) subscales. In multivariable models race was no longer associated with pain (B=0.03, P=0.874) or function (B=0.07, P=0.509), indicating these associations were accounted for by other covariates. Variables associated with worse AIMS2 pain and function were: worse AIMS2 affect scores, greater emotion-focused coping, lower arthritis self-efficacy, and fair or poor self-reported health. AIMS2 pain scores were also significantly associated with AIMS2 function. CONCLUSION Factors explaining racial differences in pain and function were largely psychological, including arthritis self-efficacy, affect, and use of emotion-focused coping. Self-management and psychological interventions can influence these factors, and greater dissemination among African Americans may be a key step toward reducing racial disparities in pain and function.

Racial Differences in Self-Reported Pain and Function among Individuals with Radiographic Hip and Knee Osteoarthritis: The Johnston County Osteoarthritis Project

OBJECTIVE This study compared pain and function among African Americans and Caucasian with radiographic hip and/or knee osteoarthritis (OA), controlling for radiographic severity and other patient characteristics. METHODS Participants were 1368 individuals (32% African American) from the Johnston County Osteoarthritis Project with only knee OA, only hip OA, and both knee and hip OA. Linear regression models examined racial differences in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores and pain and function subscales, adjusting for radiographic severity, age, gender, education, body mass index (BMI), depressive symptoms, and WOMAC pain (last variable in models of function). RESULTS Among those with only knee OA, African Americans had significantly worse mean WOMAC total scores than Caucasian (32.8 vs 24.3, P<0.001), and worse pain and function scores (P<0.001). Racial differences in WOMAC total, pain, and function scores persisted when controlling for radiographic severity and demographic factors but were not significant when also controlling for BMI and depressive symptoms. In models of WOMAC function, pain was the most strongly associated variable and substantially reduced the association of race with function. There were no racial differences in WOMAC scores among those with only hip OA or with both knee and hip OA. CONCLUSION Among participants with knee OA, racial differences in pain and function may be explained by BMI and depressive symptoms, and racial differences in function may also be largely influenced by pain. Improving management of weight and depressive symptoms may be key steps toward reducing racial disparities in knee OA symptoms.

Associations of occupational tasks with knee and hip osteoarthritis: The Johnston County Osteoarthritis Project

Objective. This cross-sectional study examined associations of occupational tasks with radiographic and symptomatic osteoarthritis (OA) in a community-based sample. Methods. Participants from the Johnston County Osteoarthritis Project (n = 2729) self-reported the frequency of performing 10 specific occupational tasks at the longest job ever held (never/seldom/sometimes vs often/always) and lifetime exposure to jobs that required spending > 50% of their time doing 5 specific tasks or lifting 22, 44, or 110 pounds 10 times weekly. Multivariable logistic regression models examined associations of each occupational task separately with radiographic and symptomatic knee and hip OA, controlling for age, race, gender, body mass index, prior knee or hip injury, and smoking. Results. Radiographic hip and knee OA were not significantly associated with any occupational tasks, but several occupational tasks were associated with increased odds of both symptomatic knee and hip OA: lifting > 10 pounds, crawling, and doing heavy work while standing (OR 1.4–2.1). More occupational walking and standing and less sitting were also associated with symptomatic knee OA, and more bending/twisting/reaching was associated with symptomatic hip OA. Exposure to a greater number of physically demanding occupational tasks at the longest job was associated with greater odds of both symptomatic knee and hip OA. Conclusion. Our results confirm an association of physically demanding occupational tasks with both symptomatic knee and hip OA, including several specific activities that increased the odds of OA in both joint groups. These tasks represent possibilities for identifying and targeting at-risk individuals with preventive interventions.

Spatial analysis of the etiology of amyotrophic lateral sclerosis among 1991 Gulf War veterans

BACKGROUND Veterans of the 1991 Gulf War have an increased risk of amyotrophic lateral sclerosis (ALS), but the etiology is unknown. OBJECTIVES This study sought to identify geographic areas with elevated risk for the later development of ALS among military personnel who served in the first Gulf War. METHODS A unified geographic information system (GIS) was constructed to allow analysis of secondary data on troop movements in the 1991 Gulf War theatre in the Persian Gulf region including Iraq, northern Saudi Arabia, and Kuwait. We fit Bayesian Poisson regression models to adjust for potential risk factors, including one relatively discrete environmental exposure, and to identify areas associated with elevated risk of ALS. RESULTS We found that service in particular locations of the Gulf was associated with an elevated risk for later developing ALS, both before and after adjustment for branch of service and potential of exposure to chemical warfare agents in and around Khamisiyah, Iraq. CONCLUSIONS Specific geographic locations of troop units within the 1991 Gulf War theatre are associated with an increased risk for the subsequent development of ALS among members of those units. The identified spatial locations represent the logical starting points in the search for potential etiologic factors of ALS among Gulf War veterans. Of note, for locations where the relative odds of subsequently developing ALS are among the highest, specific risk factors, whether environmental or occupationally related, have not been identified. The results of spatial models can be used to subsequently look for risk factors that follow the spatial pattern of elevated risk.