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Although pain is common in osteoarthritis, most people fail to achieve adequate analgesia. Increasing acknowledgement of the contribution of pain sensitisation has resulted in the investigation of medications affecting pain processing with central effects. Antidepressants contribute to pain management in other conditions where pain sensitisation is present.To assess the benefits and harms of antidepressants for the treatment of symptomatic knee and hip osteoarthritis in adults.We used standard, extensive Cochrane search methods. The latest search was January 2021.We included randomised controlled trials of adults with osteoarthritis that compared use of antidepressants to placebo or alternative comparator. We included trials that focused on efficacy (pain and function), treatment-related adverse effects and had documentation regarding discontinuation of participants. We excluded trials of less than six weeks of duration or had participants with concurrent mental health disorders.We used standard Cochrane methods. Major outcomes were pain; responder rate; physical function; quality of life; and proportion of participants who withdrew due to adverse events, experienced any adverse events or had serious adverse events. Minor outcomes were proportion meeting the OARSI (Osteoarthritis Research Society International) Response Criteria, radiographic joint structure changes and proportion of participants who dropped out of the study for any reason. We used GRADE to assess certainty of evidence.Nine trials (2122 participants) met the inclusion criteria. Seven trials examined only knee osteoarthritis. Two also included participants with hip osteoarthritis. All trials compared antidepressants to placebo, with or without non-steroidal anti-inflammatory drugs. Trial sizes were 36 to 388 participants. Most participants were female, with mean ages of 54.5 to 65.9 years. Trial durations were 8 to 16 weeks. Six trials examined duloxetine. We combined data from nine trials in meta-analyses for knee and hip osteoarthritis. One trial was at low risk of bias in all domains. Five trials were at risk of attrition and reporting bias. High-certainty evidence found that antidepressants resulted in a clinically unimportant improvement in pain compared to placebo. Mean reduction in pain (0 to 10 scale, 0 = no pain) was 1.7 points with placebo and 2.3 points with antidepressants (mean difference (MD) -0.59, 95% confidence interval (CI) -0.88 to -0.31; 9 trials, 2122 participants). Clinical response was defined as achieving a 50% or greater reduction in 24-hour mean pain. High-certainty evidence demonstrated that 45% of participants receiving antidepressants had a clinical response compared to 28.6% receiving placebo (RR 1.55, 95% CI 1.32 to 1.82; 6 RCTs, 1904 participants). This corresponded to an absolute improvement in pain of 16% more responders with antidepressants (8.9% more to 26% more) and a number needed to treat for an additional beneficial effect (NNTB) of 6 (95% CI 4 to 11). High-certainty evidence showed that the mean improvement in function (on 0 to 100 Western Ontario and McMaster Universities Arthritis Index, 0 = best function) was 10.51 points with placebo and 16.16 points with antidepressants (MD -5.65 points, 95% CI -7.08 to -4.23; 6 RCTs, 1909 participants). This demonstrates a small, clinically unimportant response. Moderate-certainty evidence (downgraded for imprecision) showed that quality of life measured using the EuroQol 5-Dimension scale (-0.11 to 1.0, 1.0 = perfect health) improved by 0.07 points with placebo and 0.11 points with antidepressants (MD 0.04, 95% CI 0.01 to 0.07; 3 RCTs, 815 participants). This is clinically unimportant. High-certainty evidence showed that total adverse events increased in the antidepressant group (64%) compared to the placebo group (49%) (RR 1.27, 95% CI 1.15 to 1.41; 9 RCTs, 2102 participants). The number needed to treat for an additional harmful outcome (NNTH) was 7 (95% CI 5 to 11). Low-certainty evidence (downgraded twice for imprecision for very low numbers of events) found no evidence of a difference in serious adverse events between groups (RR 0.94, 95% CI 0.46 to 1.94; 9 RCTs, 2101 participants). The NNTH was 1000. Moderate-certainty evidence (downgraded for imprecision) showed that 11% of participants receiving antidepressants withdrew from trials due to an adverse event compared to 5% receiving placebo (RR 2.15, 95% CI 1.56 to 2.97; 6 RCTs, 1977 participants). The NNTH was 17 (95% CI 10 to 35).There is high-certainty evidence that use of antidepressants for knee osteoarthritis leads to a non-clinically important improvement in mean pain and function. However, a small number of people will have a 50% or greater important improvement in pain and function. This finding was consistent across all trials. Pain in osteoarthritis may be due to a variety of causes that differ between individuals. It may be that the cause of pain that responds to this therapy is only present in a small number of people. There is moderate-certainty evidence that antidepressants have a small positive effect on quality of life with heterogeneity between trials. High-certainty evidence indicates antidepressants result in more adverse events and moderate-certainty evidence indicates more withdrawal due to adverse events. There was little to no difference in serious adverse events (low-certainty evidence due to low numbers of events). This suggests that if antidepressants were being considered, there needs to be careful patient selection to optimise clinical benefit given the known propensity for adverse events with antidepressant use. Future trials should include alternative antidepressant agents or phenotyping of pain in people with osteoarthritis, or both.

ObjectiveTo systematically review the evidence for the efficacy of mesenchymal stem cell (MSC) injections in improving osteoarthritis (OA)-related structural outcomes.MethodsOvid Medline and EMBASE were searched from their inceptions to April 2020 using MeSH terms and key words. Independent reviewers extracted data and assessed methodological quality. Qualitative evidence synthesis was performed due to the heterogeneity of interventions and outcome measures.ResultsThirteen randomized controlled trials (phase I or II) were identified: 10 in OA populations and 3 in populations at risk of OA, with low (n = 9), moderate (n = 3), or high (n = 1) risk of bias. Seven studies used allogeneic MSCs (4 bone marrow, 1 umbilical cord, 1 placenta, 1 adipose tissue), 6 studies used autologous MSCs (3 adipose tissue, 2 bone marrow, 1 peripheral blood). Among the 11 studies examining cartilage outcomes, 10 found a benefit of MSCs on cartilage volume, morphology, quality, regeneration, and repair, assessed by magnetic resonance imaging, arthroscopy, or histology. The evidence for subchondral bone was consistent in all 3 studies in populations at risk of OA, showing beneficial effects. Sixteen unpublished, eligible trials were identified by searching trial registries, including 8 with actual or estimated completion dates before 2016.ConclusionOur systematic review of early-phase clinical trials demonstrated consistent evidence of a beneficial effect of intraarticular MSC injections on articular cartilage and subchondral bone. Due to the heterogeneity of MSCs, modest sample sizes, methodological limitations, and potential for publication bias, further work is needed before this therapy is recommended in the management of OA.

Objectives Chronic inflammation increases the production of cytokines and activates proinflammatory pathways which may lead to nonspecific low back pain (LBP). We systematically reviewed the literature to investigate whether inflammatory biomarkers are associated with nonspecific LBP. Materials and methods CINAHL, Medline, and Embase were searched between January 1946 and May 2018. MeSH terms and key words were used to identify studies examining the association between inflammatory biomarkers and LBP. Two reviewers performed the risk of bias assessment and 3 reviewers extracted data independently. Qualitative evidence synthesis was performed. Results Thirteen studies, ranging from fair to low quality, were included. Five studies examined the association between C-reactive protein (CRP)/high-sensitivity CRP and LBP; 6 studies assessed tumor necrosis factors (TNFs); 8 studies assessed interleukins (ILs); and 2 studies assessed fibrinogen. There was evidence for an association of elevated levels of CRP, TNFs, and IL-6 with LBP. There was conflicting evidence for an association between IL-1β, fibrinogen, and LBP. Discussion Our findings support the notion of a positive association between inflammatory biomarkers and nonspecific LBP, specifically for CRP, TNFs, and IL-6. Although further high quality longitudinal studies are needed to confirm these findings and evaluate the magnitude of these associations, our findings suggest a role of inflammation in the pathogenesis of nonspecific LBP.

Question: What health information needs are perceived by people with low back pain? Design: Systematic review of publications examining perceived health information needs related to low back pain identified through Medline, EMBASE, CINAHL and PsycINFO (1990 to 2018). Participants: Adults with low back pain of any duration. Data extraction and analysis: Two reviewers independently extracted descriptive data regarding study design and methodology, and assessed risk of bias. Aggregated findings of the perceived needs of people with low back pain regarding health information were meta-synthesised. Results: Forty-one studies (34 qualitative, four quantitative and three mixed-methods) were identified. Two major areas of perceived health information needs for low back pain emerged. The first major area was needs related to information content: general information related to low back pain, its cause and underlying pathology; strong desire for diagnosis and imaging; prognosis, future disability and effect on work capacity; precipitants and management of flares; general management approaches; self-management strategies; prevention; and support services. The second major area of needs related to how the information was delivered. People with low back pain wanted clear, consistent information delivered in suitable tone and understandable language. Conclusion: Available data suggest that the information needs of people with low back pain are centred around their desire for a diagnosis, potentially contributing to expectations for and overuse of imaging. People with low back pain expressed a strong desire for clear, consistent and personalised information on prognosis, treatment options and self-management strategies, related to healthcare and occupational issues. To correct unhelpful beliefs and optimise delivery of evidence-based therapy, patient and healthcare professional education (potentially by an integrated public health approach) may be warranted. Key words: Health information, Low back pain, Need, Patient perspective, Preference, Systematic review

Objective.Vascular pathology (changes in blood vessels) and osteoarthritis (OA) are both common chronic conditions associated with aging and obesity, but whether vascular pathology is a risk factor for OA is unclear. The aim of this study was to systematically review the evidence for an association between vascular pathology and risk of joint-specific OA.Methods.Scopus, Ovid Medline, and EMBASE were searched from inception to February 2019. MeSH terms and keywords were used to identify studies examining the association between vascular pathology and OA. Two reviewers independently extracted the data and assessed the methodological quality. Qualitative evidence synthesis was performed.Results.Fifteen studies with high (n = 3), fair (n = 3), or low (n = 9) quality were included. Features of vascular pathology included atherosclerosis, vascular stiffness, and endothelial dysfunction in different vascular beds. There was evidence for an association between vascular pathology and risk of hand OA in women but not men, and between vascular pathology and risk of knee OA in both men and women. Only 2 studies examined hip OA showing no association between vascular pathology and risk of hip OA.Conclusion.There is evidence suggesting an association between vascular pathology and risk of hand and knee OA, with a potential causal relationship for knee OA. Based on the limited evidence, it is hard to conclude an association for hip OA. Further stronger evidence is needed to determine whether there is a causal relationship.

Objectives To identify the breadth of the literature regarding patients’ perceived health information needs related to inflammatory arthritis care. Methods A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO was performed to identify relevant articles (1990 -2016) examining patients’ perceived needs relating to health information in inflammatory arthritis. Data and themes were identified and categorised and risk of bias assessed. Results Twenty nine studies (11 quantitative, 14 qualitative and 4 mixed methods) from 4121 identified articles were relevant for inclusion. Most focussed on rheumatoid arthritis. Key findings included: (1) Reasons for seeking health information often focussed on gaining ownership over their condition and facilitating self-management. (2) Demographic differences in information needs were inconsistent, but women and younger patients generally reported more needs. (3) Desired information content was broad, and included targeted and practical information covering disease treatment and psychosocial wellbeing. (4) Preferred information delivery method was consultation with a Rheumatologist; however group sessions had advantages for psychosocial issues while written information provided useful supplementation. (5) Barriers to meeting health information needs were around timely access. Conclusions Patients with inflammatory arthritis have high information needs, desiring practical and individualised information. When developing strategies to meet patients’ information needs, aligning patient expectations with delivery methods that are accessible, cost-effective and flexible may help to optimize patient outcomes.

Background Arthritis, regardless of cause, has significant physical, social and psychological impacts on patients. We aimed to identify the non-healthcare needs perceived by patients with inflammatory arthritis (IA) and osteoarthritis (OA), and to determine if these differ. Methods We electronically searched MEDLINE, PsycINFO, EMBASE and CINAHL (1990–2020) systematically to identify non-healthcare-related needs of people with IA or OA. All citations were screened and quality appraised by two reviewers. Data was extracted by a single reviewer. Results The search identified 7853 citations, with 31 studies included (12 for OA, 20 for IA). Six areas of need emerged and these were similar in both group These were: 1) Assistance with activities of daily living especially related to a lack of independence; 2) Social connectedness: need for social participation; 3) Financial security: worry about financial security and increased costs of health-seeking behaviours; 4) Occupational needs: desire to continue work for financial and social reasons, facilitated by flexibility of workplace conditions/environment; 5) Exercise and leisure: including limitation due to pain; 6) Transportation: limitations in ability to drive and take public transport due to mobility concerns. Many areas of need were linked; e.g. loss of employment and requiring support from family was associated with a sense of “failure” and loss of identity, as social isolation. Conclusions This review highlights the pervasive impact of arthritis on peoples’ lives, regardless of aetiology, albeit with a limited evidence base. Improved identification and targeting of non-healthcare needs of people with arthritis is likely to improve person-centred care.

Objectives Allied health and complementary and alternative medicines (CAM) are therapeutic therapies commonly accessed by consumers to manage low back pain (LBP). We aimed to identify the literature regarding patients' perceived needs for physiotherapy, chiropractic therapy and CAM for the management of LBP. Methods A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO (1990‐2016) was conducted to identify studies examining patients' perceived needs for allied health and CAM for LBP. Data regarding study design and methodology were extracted. Areas of patients' perceived need for allied health and CAM were aggregated. Results Forty‐four studies from 2202 were included: 25 qualitative, 18 quantitative and 1 mixed‐methods study. Three areas of need emerged: (i) physiotherapy was viewed as important, particularly when individually tailored. However, patients had concerns about adherence, adverse outcomes and correct exercise technique. (ii) Chiropractic therapy was perceived to be effective and needed by some patients, but others were concerned about adverse outcomes. (iii) An inconsistent need for CAM was identified with some patients perceiving a need, while others questioning the legitimacy and short‐term duration of these therapies. Conclusions Our findings regarding patients' perceived needs for allied health and CAM for LBP may assist in informing development of more patient‐centred guidelines and service models for LBP. Understanding patients' concerns regarding active‐based physiotherapy, which is recommended in most guidelines, and issues surrounding chiropractic and CAM, which are generally not, may help inform management that better aligns patient's perceived needs with effective treatments, to improve outcomes for both patients and the health‐care system.

Background Care that is patient-centred is more likely to be sustainable and associated with improved health outcomes. This approach to care requires an understanding of patients' health service needs, yet few studies have directly investigated the perceived health service needs of people with inflammatory arthritis. Objectives To systematically identify the existing literature relating to patient perceived health service needs for inflammatory arthritis. Methods A systematic review of MEDLINE, EMBASE, CINAHL and PsycINFO was conducted (1990–2016). Studies examining patients' perceived needs relating to health services for inflammatory arthritis were identified. Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Findings were collated and categorized thematically. Results 28 of 1405 (16 qualitative, 10 quantitative and 2 mixed-methods) studies were relevant. The main areas of perceived need related to 1) Communication: consumers wanted clear, empathic communication and to be involved with decision-making. 2) Characteristics of ongoing care: adequate consultation length with continuity and timely care were valued. 3) Factors influencing care-seeking included individual attitudes, disease severity, finances and family expectations. 4) Allied health and complementary and alternative medicines (CAM) were perceived as useful by many. The reporting of CAM use to doctors was variable, with several factors contributing to under-reporting. Conclusions This review identified patients' perceived needs for better communication with their health providers, the heterogeneity of influences determining when care is sought and preferences regarding non-pharmacologic therapies. Aligning patients' perceived needs with evidence based therapy for people with inflammatory arthritis will be important in optimizing patient outcomes.

Background Context Optimal management of low back pain (LBP) involves patients' active participation in care, facilitated by positive interactions with their health care provider(s) (HCP). An understanding of patients' perceived needs regarding their HCP is, therefore, necessary to achieve such outcomes. Therefore, the aim of the present study is to review the existing literature regarding patients' perceived needs of HCP managing LBP. Methods A systematic scoping review of publications in MEDLINE, EMBASE, CINAHL, and PsycINFO (1990–2016) was performed. Descriptive data regarding study design and methodology were extracted, and risk of bias was assessed. Aggregates of patients' perceived needs of HCP for LBP were categorized. Results Forty-three studies (30 qualitative, 12 quantitative, and 1 mixed methods) from 1,829 were relevant. Four areas of perceived need emerged: (1) there are several characteristics of HCP that patients desire, such as good communication and shared decision-making; (2) patients wanted HCP to provide information, including a cause of their LBP and legitimization of their symptoms; (3) patients' valued holistic, individualized care, and continuity of care; and (4) patients perceived long waiting times, difficulties with access to treatment, cost, and personal effort to be obstacles to care. Conclusions Patients with LBP want patient-centered care, to be actively involved, and they have identified characteristics of HCP that foster a good provider-patient relationship. They noted areas of dissatisfaction with HCP and perceived obstacles to care. Given limited health care resources, HCP and policy makers need to implement novel methods of health care delivery that address these issues to facilitate improved patient satisfaction and achieve better patient and health system outcomes.

OBJECTIVE The aim of this study was to describe the correlation between changes in structural abnormalities assessed on magnetic resonance imaging (MRI) and change in radiographic osteoarthritis (OA) over 10 years in a midlife cohort. METHODS A total of 211 participants (mean age 45 years [range 26-61 years], 57% female) were studied at baseline, 2 years, and 10 years. Approximately one-half were adult offspring of subjects who had undergone knee replacement for OA and the remainders were randomly selected controls. Joint space narrowing (JSN) and osteophytes were assessed from radiographs, while cartilage volume, cartilage defects, and meniscal tears/extrusion were assessed from MRI. Spearman ranked correlation analysis was used to describe the correlation between structural changes assessed on MRI and radiographs. Only medial tibiofemoral compartment results are presented, as the lateral compartment had limited change. RESULTS Over 10 years, change in meniscal tears showed a moderate independent correlation with change in both JSN (ρ = +0.37, P

Background Optimal management of osteoarthritis requires active patient participation. Understanding patients’ perceived health information needs is important in order to optimize health service delivery and health outcomes in osteoarthritis. We aimed to review the existing literature regarding patients’ perceived health information needs for OA. Methods A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990–2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients’ perceived needs of osteoarthritis health information were categorized. Results 30 studies from 2876 were included: 16 qualitative, 11 quantitative and 3 mixed-methods studies. Three areas of perceived need emerged: (1) Need for clear communication: terms used were misunderstood or had unintended connotations. Patients wanted clear explanations. (2) Need for information from various sources: patients wanted accessible health professionals with specialist knowledge of arthritis. The Internet, whilst a source of information, was acknowledged to have dubious reliability. Print media, television, support groups, family and friends were utilised to fulfil diverse information needs. (3) Needs of information content: patients desired more information about diagnosis, prognosis, management and prevention. Conclusions Patients desire more information regarding the diagnosis of osteoarthritis, its impact on daily life and its long-term prognosis. They want more information not only about pharmacological management options, but also non-pharmacological options to help them manage their symptoms. Also, patients wanted this information to be delivered in a clear manner from multiple sources of health information. To address these gaps, more effective communication strategies are required. The use of a variety of sources and modes of delivery may enable the provision of complementary material to provide information more successfully, resulting in better patient adherence to guidelines and improved health outcomes.

Health service planners, administrators and providers need to understand the patients' perspective of health services related to osteoporosis to optimise health outcomes. The aims of this study were to systematically identify and review the literature regarding patients' perceived health service needs relating to osteoporosis and osteopenia. A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoporosis health services were categorised. Thirty-three studies (19 quantitative and 14 qualitative) from 1027 were relevant. The following areas of perceived need emerged: (1) patients sought healthcare from doctors to obtain information and initiate management. They were dissatisfied with poor communication, lack of time and poor continuity of care. (2) Patients perceived a role for osteoporosis pharmacotherapy but were concerned about medication administration and adverse effects. (3) Patients believed that exercise and vitamin supplementation were important, but there is a lack of data examining the needs for other non-pharmacological measures such as smoking cessation and alcohol. (4) Patients wanted diagnostic evaluation and ongoing surveillance of their bone health. This review identified patients' needs for better communication with their healthcare providers. It also showed that a number of important cornerstones of therapy for osteoporosis, such as pharmacotherapy and exercise, are identified as important by patients, as well as ongoing surveillance of bone health. Understanding patients' perceived needs and aligning them with responsive and evidence-informed service models are likely to optimise patient outcomes.

Question: What needs of non-biomedical services are perceived by people with low back pain? Design: Systematic review of qualitative and quantitative studies examining perceived needs of non-biomedical services for low back pain, identified through searching of MEDLINE, EMBASE, CINAHL and PsycINFO (1990 to 2016). Participants: Adults with low back pain of any duration. Data extraction and analysis: Descriptive data regarding study design and methodology were extracted. The preferences, expectations and satisfaction with non-biomedical services reported by people with low back pain were identified and categorised within areas of perceived need. Results: Twenty studies (19 qualitative and one quantitative) involving 522 unique participants (total pool of 590) were included in this systematic review. Four areas emerged. Workplace: people with low back pain experience pressure to return to work despite difficulties with the demands of their occupation. They want their employers to be informed about low back pain and they desire workplace accommodations. Financial: people with low back pain want financial support, but have concerns about the inefficiencies of compensation systems and the stigma associated with financial remuneration. Social: people with low back pain report feeling disconnected from social networks and want back-specific social support. Household: people with low back pain report difficulties with household duties; however, there are few data regarding their need for auxiliary devices and domestic help. Conclusion: People with low back pain identified work place, financial and social pressures, and difficulties with household duties as areas of need beyond their healthcare requirements that affect their ability to comply with management of their condition. Consideration of such needs may inform physiotherapists, the wider health system, social networks and the workplace to provide more relevant and effective services. [Chou L, Cicuttini FM, Urquhart DM, Anthony SN, Sullivan K, Seneviwickrama M, Briggs AM, Wluka AE (2018) People with low back pain perceive needs for non-biomedical services in workplace, financial, social and household domains: a systematic review. Journal of Physiotherapy 64: 74–83] Key words: Low back pain, Systematic review, Patients, Health services needs, Health services demand

Summary Objective To identify and synthesise evidence regarding patients' perceived health service needs related to osteoarthritis (OA). Design A comprehensive systematic scoping review of MEDLINE, PsycINFO, EMBASE and CINAHL (1990–2016) was performed to capture information regarding patient perceived health service needs related to OA. Risk of bias and quality of included articles were assessed. Relevant data were extracted and collated to provide a systematic review of the existing literature. Results Of the 1384 identified manuscripts, 21 were relevant to areas of patient perceived need, including needs related to medical care, pharmacologic therapy, physiotherapy and exercise therapy and alternative medicine. Key findings included (1) Symptom control drove the need for both conventional and complementary services. (2) An individualized relationship was sought with a practitioner knowledgeable in OA care and who adopted a holistic approach, whether providing conventional or alternative therapies. (3) Medications were required to obtain symptomatic relief, with use tempered by recognition of potential side effects and financial cost. (4) The need for allied health services was recognised, although patient and system issues were barriers to uptake. (5) Patient's attitudes towards joint replacement, orthoses and physical aids were influenced by patient preferences and previous healthcare experiences. Conclusion Patient perceived needs are similar to those suggested by clinical guideline recommendations. Better aligning patient perceived needs with healthcare requirements may improve OA outcomes and optimise healthcare system utilisation.

The aim of this study was to describe the correlation between changes in structural abnormalities assessed on magnetic resonance imaging (MRI) and change in radiographic osteoarthritis (OA) over 10 years in a midlife cohort.A total of 211 participants (mean age 45 years [range 26-61 years], 57% female) were studied at baseline, 2 years, and 10 years. Approximately one-half were adult offspring of subjects who had undergone knee replacement for OA and the remainders were randomly selected controls. Joint space narrowing (JSN) and osteophytes were assessed from radiographs, while cartilage volume, cartilage defects, and meniscal tears/extrusion were assessed from MRI. Spearman ranked correlation analysis was used to describe the correlation between structural changes assessed on MRI and radiographs. Only medial tibiofemoral compartment results are presented, as the lateral compartment had limited change.Over 10 years, change in meniscal tears showed a moderate independent correlation with change in both JSN (ρ = +0.37, P 0.01) and osteophytes (ρ = +0.31, P 0.01) in the adjusted analysis. Meniscal extrusion (ρ = +0.22, P 0.01) and cartilage defects (ρ = +0.16, P 0.04) showed a slightly weaker independent correlation with JSN in the adjusted analysis, whereas cartilage volume loss showed no significant correlation with either of the 2 radiographic outcomes.Change in JSN is correlated with change in meniscal tears and, to a lesser extent, with meniscal extrusion and cartilage defects. In this sample, change in JSN is a composite measure that does not reflect cartilage volume loss, prompting the review of the use of JSN as an outcome measure in chondro-protective drug trials.

NHMRC: 299831, 628582, 1074979, 1011975, 1063574, 1073284 Arthritis Foundation Deakin University

To the Editor: Legionella species are significant pathogens with most infections being caused by Legionella pneumoniae and presenting as Legionnaire disease or Pontiac fever1. Extrapulmonary legionellosis is uncommon and is often thought to arise from hematogenous spread after primary pulmonary infection2. To date, the extrapulmonary sites of infections that have been reported in the literature include spleen, kidneys, liver3, infective endocarditis4, myositis5, cellulitis, and cutaneous abscesses5. The majority of extrapulmonary Legionella infections have been described in immunocompromised patients. A 69-year-old female florist presented to hospital with 1 week of worsening pain and swelling of the right hand, having been treated in the community for presumed seronegative arthritis for the preceding 6 months. Her presentation 6 months earlier was with pain and swelling in her right hand and mild, transient symptoms in the left hand. Clinical examination at that time found synovitis in multiple proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints and palmar tenosynovitis in the right hand. Otherwise, joint examination was normal. The tenosynovitis was confirmed on ultrasound (US). She was treated with ceftriaxone, but failed to improve. … Address correspondence to Dr. L. Chou, Department of Rheumatology, Royal Melbourne Hospital, 300 Grattan St., Parkville, Melbourne, Australia 3050. E-mail: louisa.chou{at}monash.edu

Background Low back pain (LBP), a major public health problem, is the leading cause of disability worldwide (1). Current management recommendations include medical, psychological and physical treatments, complementary and alternative medicines (2,3). Initiatives to improve the management of LBP have been largely based on outcomes determined by health professionals. The relative success and requirement for health care interventions may differ from the patient9s perspective. Objectives To systematically review the literature about consumer perceived needs of allied health and complementary and alternative therapies (CAM) relating to LBP. Methods A comprehensive systematic review of MEDLINE, EMBASE, CINAHL and PsycINFO was conducted to identify studies examining consumer perceived needs relating to allied health and CAM services in managing LBP (1990 - May 2015). Data regarding study design and methods were extracted. Emergent themes were identified and aggregated to provide a systematic review of the current literature. Results 1779 manuscripts were identified, of which 39 were found to be relevant (figure 1). Of these, 25 used qualitative, 14 used quantitative and 1 used mixed methods. The quality of the literature was variable. Few studies directly addressed the review question. Many results were consistent, with the following main themes emerging from at least 2 studies: 1) CAM elicited conflicting views from consumers, with some willing to try CAM, believing it to be beneficial and CAM practitioners perceived to be more empathetic and understanding. Other consumers questioned the legitimacy of CAM and believed it offered only transitory benefits. 2) Chiropractic therapy was perceived to be effective by some consumers, but not others, who had concerns about side effects and were disappointed with the temporary effects. 3) Physiotherapy and exercise therapy were often preferred by patients for LBP. Consumers believed these to help with pain relief, prevent worsening of back pain and to improve mobility and function. Consumers strongly preferred physiotherapy to be individually tailored to their health needs and abilities. This review identified a paucity of data examining LBP consumers9 perceived needs of allied health and CAM in males, geriatric populations and patients from developing countries or non-English speaking backgrounds. Conclusions Consumers with LBP perceive a role for physiotherapy but have inconsistent beliefs regarding CAM and chiropractic therapy. This review has highlighted significant gaps in the literature relating to consumers9 needs of allied health and CAM for LBP. Health care practitioners need to understand consumers9 beliefs regarding the multiple modes of therapy used by consumers to manage their LBP, to better align care provision. Incorporating this into care has the potential to improve outcomes for both consumers and the health system. References Hoy D et al. Best Pract Res Clin Rheumatol. 2010 Chou R et al. Ann Intern Med 2007. Airaksinen O et al. Eur Spine J. 2006 Acknowledgement This work was supported by Arthritis and Osteoporosis Victoria. D Urqhuart and A Wluka are recipients of an NHMRC Career Development Fellowship (Clinical level 2). Disclosure of Interest None declared

Background Low back pain (LBP) and obesity are both major public health problems. Obesity has been linked with LBP, with recent studies reporting that increased fat but not lean tissue mass is associated with LBP, however previous studies predominantly examined women. The relationship between body composition and LBP in men is unknown. Objectives The aim of this study was to examine the relationship between body composition and LBP and disability in a population-based sample of men. Methods 978 male participants from the Geelong Osteoporosis Study (GOS), a population-based Australian study designed to investigate the epidemiology of osteoporosis among adults, were invited to participate in a follow up study in 2006. Participants completed questionnaires on sociodemographics and health status. LBP was determined using the validated Chronic Back Pain Grade Questionnaire and the presence of mood disorders was assessed using the Hospital Anxiety Depression Scale. Body composition was measured using dual energy x-ray absorptiometry. Independent samples t-tests and chi-square tests were used to compare the baseline characteristics of men with and without LBP and/or disability. Estimated marginal means were used to examine the relationships between obesity measures and body composition in participants with high intensity pain and disability compared to those with no or low pain and disability. Multivariate analyses included adjustments for age, mood disorder, education, mobility and body mass index (BMI). To examine the multivariate associations between body composition and back pain, adjustment was also made for the alternate body composition measure. Interactions between risk factors for LBP and measures of obesity, including measures of body composition were examined. Results Of the 820 respondents (84% response rate), 124 (15%) had high intensity LBP and/or disability. Participants with high intensity pain and/or disability were older, more likely to have a mood disorder, less likely to have completed secondary school and more likely to have poor mobility than those with no or LBP and disability (p 2 , p=0.02) and waist-hip ratio (0.97±0.006 vs 0.96±0.006, p=0.04), with increased tendency towards having a higher fat mass index (8.0 vs 7.6 kg/m 2 , p=0.08), but not fat-free mass index (p=0.68). The associations between LBP and measures of obesity were stronger in those with a mood disorder, particularly for waist-hip ratio (p=0.05 for interaction) and fat mass index (p=0.06 for interaction). Conclusions In a population-based sample of men, high intensity LBP and/or disability were associated with increased levels of obesity, particularly in those with mood disorders. This provides evidence to support a biopsychosocial interaction between mood disorders and obesity with LBP. Acknowledgement S.B: NHMRC Postgraduate Scholarship, S.BO: Alfred Deakin Postdoctoral Fellowship, D.M.U & A.E.W: NHMRC Career Development Fellowships, A.T: NHMRC Early Career Fellowship, JP: NHMRC grants, GOS: NHMRC grants. Disclosure of Interest None declared

Low back pain (LBP) and obesity are major public health problems; however, the relationship between body composition and low back pain in men is unknown. This study aims to examine the association between body composition and LBP and disability in a population-based sample of men, as well as the factors that may affect this relationship. Nine hundred seventy-eight male participants from the Geelong Osteoporosis Study were invited to participate in a follow-up study in 2006. Participants completed questionnaires on sociodemographics and health status. Low back pain was determined using the validated Chronic Back Pain Grade Questionnaire and the presence of an emotional disorder was assessed using the Hospital Anxiety Depression Scale. Body composition was measured using dual energy x-ray absorptiometry. Of the 820 respondents (84% response rate), 124 (15%) had high-intensity low back pain and/or disability (back pain). Low back pain was associated with higher body mass index (28.7 ± 0.4 vs 27.3 ± 0.2 kg/m2, P = 0.02) and waist–hip ratio (0.97 ± 0.006 vs 0.96 ± 0.006, P = 0.04), with increased tendency toward having a higher fat mass index (8.0 vs 7.6 kg/m2, P = 0.08), but not fat-free mass index (P = 0.68). The associations between back pain and measures of obesity were stronger in those with an emotional disorder, particularly for waist–hip ratio (P = 0.05 for interaction) and fat mass index (P = 0.06 for interaction). In a population-based sample of men, high-intensity LBP and/or disability were associated with increased levels of obesity, particularly in those with an emotional disorder. This provides evidence to support a biopsychosocial interaction between emotional disorders and obesity with low back pain.