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Objective: Musculoskeletal (MSK) disorders affect ~50% of US adults and 75% of those over the age of 65, representing a sizable economic and disability burden. Outcome measures, both objective and subjective, help clinicians and investigators determine whether interventions to treat MSK conditions are effective. This narrative review qualitatively compared the responsiveness of different types of outcome measures, a key measurement characteristic that assesses an outcome measure's ability to detect change in patient status. Methods: We evaluated elective orthopedic interventions as a model for assessing responsiveness because the great majority of patients improves following surgery. We searched for articles reporting responsiveness (quantified as effect size [ES]) of subjective and objective outcome measures after orthopedic surgery and included 16 articles reporting 17 interventions in this review. Results: In 14 of 17 interventions, subjective function measures had an ES 10% greater than that of objective function measures. Two reported a difference in ES of <10%. The sole intervention that demonstrated higher ES of objective function used a composite measure. Sixteen interventions reported measures of subjective pain and/or mixed measures and subjective function. In nine interventions, subjective pain had a higher ES than subjective function by >10%, in three, subjective function had a higher ES than subjective pain by >10%, and in the remaining four, the difference between pain and function was <10%. Conclusion: These findings reinforce the clinical observation that subjective pain generally changes more than function following elective orthopedic surgery. They also suggest that subjective function measures are more responsive than objective function measures, and composite scores may be more responsive than individual performance tests. [ABSTRACT FROM AUTHOR]

Objective: Patients with axial spondyloarthritis (axSpA) often experience significant delay between symptom onset and diagnosis for reasons that are incompletely understood. We investigated associations between demographic, medical, and socioeconomic factors and axSpA diagnostic delay. Methods: We identified patients meeting modified New York criteria for ankylosing spondylitis (AS) or 2009 Assessment of Spondyloarthritis International Society criteria for axSpA in the Mass General Brigham health care system between December 1990 and October 2021. We determined the duration of diagnostic delay, defined as the duration of back pain symptoms reported at diagnosis, as well as disease manifestations and specialty care prior to diagnosis from the electronic health record. We obtained each patient's Social Vulnerability Index (SVI) by mapping their address to the US Centers for Disease Control SVI Atlas. We examined associations among disease manifestations, SVI, and diagnostic delay using ordinal logistic regression. Results: Among 554 patients with axSpA who had a median diagnostic delay of 3.8 years (interquartile range 1.1–10), peripheral arthritis (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.45–0.93) and older age at symptom onset (OR 0.83, 95% CI 0.78–0.88 per five years) were associated with shorter delay. AS at diagnosis (OR 1.85, 95% CI 1.30–2.63), a history of uveitis prior to diagnosis (OR 2.77, 95% CI 1.73–4.52), and higher social vulnerability (defined as national SVI 80th to 99th percentiles; OR 1.99, 95% CI 1.06–3.84) were associated with longer diagnostic delay. Conclusion: Older age at back pain onset and peripheral arthritis were associated with shorter delay, whereas uveitis was associated with longer diagnostic delay. Patients with higher socioeconomic vulnerability had longer diagnostic delay independent of clinical factors. [ABSTRACT FROM AUTHOR]

Objective: Class III obesity (body mass index >40 kg/m2) is associated with higher complications following total knee replacement (TKR), and weight loss is recommended. We aimed to establish the cost‐effectiveness of Roux‐en‐Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and lifestyle nonsurgical weight loss (LNSWL) interventions in knee osteoarthritis patients with class III obesity considering TKR. Methods: Using the Osteoarthritis Policy model and data from published literature to derive model inputs for RYGB, LSG, LNSWL, and TKR, we assessed the long‐term clinical benefits, costs, and cost‐effectiveness of weight‐loss interventions for patients with class III obesity considering TKR. We assessed the following strategies with a health care sector perspective: 1) no weight loss/no TKR, 2) immediate TKR, 3) LNSWL, 4) LSG, and 5) RYGB. Each weight‐loss strategy was followed by annual TKR reevaluation. Primary outcomes were cost, quality‐adjusted life expectancy (QALE), and incremental cost‐effectiveness ratios (ICERs), discounted at 3% per year. We conducted deterministic and probabilistic sensitivity analyses to examine the robustness of conclusions to input uncertainty. Results: LSG increased QALE by 1.64 quality‐adjusted life‐years (QALYs) and lifetime medical costs by $17,347 compared to no intervention, leading to an ICER of $10,600/QALY. RYGB increased QALE by 0.22 and costs by $4,607 beyond LSG, resulting in an ICER of $20,500/QALY. Relative to immediate TKR, LSG and RYGB delayed and decreased TKR utilization. In the probabilistic sensitivity analysis, RYGB was cost‐effective in 67% of iterations at a willingness‐to‐pay threshold of $50,000/QALY. Conclusion: For patients with class III obesity considering TKR, RYGB provides good value while immediate TKR without weight loss is not economically efficient. [ABSTRACT FROM AUTHOR]

Objective: Class III obesity (body mass index [BMI] ≥40 kg/m2) is associated with worse knee pain and total knee replacement (TKR) outcomes. Because bariatric surgery yields sustainable weight loss for individuals with BMI ≥40 kg/m2, our objective was to establish the value of Roux‐en‐Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) in conjunction with usual care for knee osteoarthritis (OA) patients with BMI ≥40 kg/m2. Methods: We used the Osteoarthritis Policy model to assess long‐term clinical benefits, costs, and cost‐effectiveness of RYGB and LSG. We derived model inputs for efficacy, costs, and complications associated with these treatments from published data. Primary outcomes included quality‐adjusted life‐years (QALYs), lifetime costs, and incremental cost‐effectiveness ratios (ICERs), all discounted at 3%/year. This analysis was conducted from a health care sector perspective. We performed sensitivity analyses to evaluate uncertainty in input parameters. Results: The usual care + RYGB strategy increased the quality‐adjusted life expectancy by 1.35 years and lifetime costs by $7,209, compared to usual care alone (ICER = $5,300/QALY). The usual care + LSG strategy yielded less benefit than usual care + RYGB and was dominated. Relative to usual care alone, both usual care + RYGB and usual care + LSG reduced opioid use from 13% to 4%, and increased TKR usage from 30% to 50% and 41%, respectively. For cohorts with BMI between 38 and 41 kg/m2, usual care + LSG dominated usual care + RYGB. In the probabilistic sensitivity analysis, at a willingness‐to‐pay threshold of $50,000/QALY, usual care + RYGB and usual care + LSG were cost‐effective in 70% and 30% of iterations, respectively. Conclusion: RYGB offers good value among knee OA patients with BMI ≥40 kg/m2, while LSG may provide good value among those with BMI between 35 and 41 kg/m2. [ABSTRACT FROM AUTHOR]

Objective: To examine impact of pre‐existing and incident problematic musculoskeletal (MSK) areas after total knee replacement (TKR) on postoperative 60‐month Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain/function scores. Methods: Using data from a randomized controlled trial of subjects undergoing TKR for osteoarthritis, we assessed problematic MSK areas in six body regions before TKR and 12, 24, 36, and 48 months after TKR. We defined the following two variables: 1) density count (number of problematic MSK areas occurring after TKR; range 0‐24) and 2) cumulative density count (problematic MSK areas both before and after TKR, categorized into four levels: no preoperative areas and density count of 0‐1 [reference group]; no preoperative areas and density count of 2 or more; one or more preoperative areas and density count of 0‐1; and one or more preoperative areas and density count of 2 or greater). We evaluated the associations between categorized 60‐month WOMAC and cumulative density count by ordinal logistic regression. Results: Among 230 subjects, 24% reported one or more preoperative problematic MSK area. After TKR, 75% reported a density count of 0 to 1; 25% reported a density count of 2 or more. Compared with the reference group, each cumulative density count category was associated with an increased odds of having a higher category of 60‐month WOMAC pain score, as follows: 2.97 (95% confidence interval [CI], 1.48‐5.98) for no preoperative problematic areas and density count of 2 or greater, 3.31 (95% CI, 1.64‐6.66) for one or more preoperative problematic areas and density count of 0 to 1, and 2.85 (95% CI, 0.97‐8.39) for one or more preoperative problematic areas and density count of 2 or greater. Similar associations were observed with 60‐month WOMAC function score. Conclusion: In TKR recipients, the presence of problematic musculoskeletal areas beyond the index knee—preoperatively and/or postoperatively—was associated with worse 60‐month WOMAC pain/function score. [ABSTRACT FROM AUTHOR]

Objective: Pain catastrophizing and widespread pain are predictors of pain chronicity/severity. Gaps remain in our understanding of the extent to which each is a stable (trait) or dynamic (state) variable. We undertook this study to assess the stability of each variable from before to after total knee replacement (TKR) and whether changes are explained by pain improvements.Methods: We used data from a prospective study of TKR recipients ages ≥40 years. Questionnaires included body pain diagrams assessing widespread pain, the Pain Catastrophizing Scale (PCS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale. We divided subjects into widespread pain groups (0 versus 1-2 versus ≥3 pain regions) and into low and high PCS score groups (<16 versus ≥16). We assessed changes in group membership from pre-TKR to 12 months post-TKR, then compared these changes between subjects with most and least WOMAC pain improvement.Results: A total of 176 subjects completed scales at both time points; 64% were female, the mean age was 66 years, and baseline median WOMAC pain score was 40. In all, 71% of subjects in the high PCS score group improved to join the low PCS score group at follow-up. While 73 subjects (41%) changed widespread pain group, they were similarly likely to worsen and to improve. We found a statistically significant positive association of improvement in WOMAC pain score with improvement in PCS score (r = 0.31), but not widespread pain (r = -0.004).Conclusion: The PCS score reflects state-like aspects of catastrophizing that diminish along with pain. In contrast, widespread pain scores worsened and improved equally often, regardless of knee pain relief. The findings urge caution in interpreting PCS score and widespread pain as trait measures in musculoskeletal research. [ABSTRACT FROM AUTHOR]

Objective: The present study was undertaken to evaluate changes in knee magnetic resonance imaging (MRI) findings over the course of 18 months in subjects with osteoarthritic change and meniscal tear treated with arthroscopic partial meniscectomy (APM) or nonoperatively with physical therapy (PT). Methods: We used 18‐month follow‐up data from the Meniscal Tear in Osteoarthritis Research Trial. MRI results were read with reference to the MRI Osteoarthritis Knee Score. We focused on 18‐month change in bone marrow lesions (BMLs), cartilage thickness, cartilage surface area, osteophyte size, effusion‐synovitis, and Hoffa‐synovitis. We used multinomial logistic regression to assess associations between MRI‐based changes in each feature and treatment type. Results: A total of 351 subjects were randomized, and 225 had both baseline and 18‐month MRI results. In both treatment groups, patients experienced substantial changes in several MRI‐based markers. In 60% of the APM group, versus 33% of the PT group, cartilage surface area damage advanced in ≥2 subregions (adjusted odds ratio 4.2 [95% confidence interval 2.0–9.0). Patients who underwent APM also had greater advancement in scores for osteophytes and effusion‐synovitis. We did not find significant associations between treatment type and change in cartilage thickness, BMLs, or Hoffa‐synovitis. Conclusion: This cohort of patients with meniscal tear and osteoarthritis showed marked advancement in MRI‐based features over 18 months. Patients treated with APM showed more advancement in some features compared to those treated nonoperatively. The clinical relevance of these early findings is unknown and requires further study. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to measure cumulative incidence and incidence rate and identify factors associated with new musculoskeletal (MSK) symptomatic areas after total knee replacement (TKR) for osteoarthritis (OA). Methods: Using data from a randomized controlled trial of patients undergoing elective TKR for OA, we assessed for MSK symptomatic areas by region (neck, hands/wrists/arms/shoulders, back, hips, nonindex knee, and ankles/feet) at baseline (pre‐TKR), and at 3, 6, 12, 24, 36, and 48 months post‐TKR. Cumulative incidence and incidence rates were calculated for each region. Factors associated with incident MSK symptomatic areas were identified using generalized linear mixed models. Time to incident symptomatic area was assessed using Cox proportional hazards regression. Results: Among 293 subjects, the cumulative incidence of any new MSK symptomatic area over 4 years was 45%; the incidence rate was 19.2 per 100 person‐years. Body site–specific cumulative incidence and incidence rates were highest for nonindex knee and back. Predictors of incident MSK symptomatic areas included female sex (relative risk [RR] 1.64; 95% confidence interval [CI] 1.15‐2.34), body mass index of 35 or higher (RR 1.27; 95% CI 0.88‐1.85), Charlson Comorbidity Index 2 or more (RR 1.28; 95% CI 0.92‐1.78), baseline index knee Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score greater than 40 (RR 1.39; 95% CI 0.99‐1.95), and anxiety/depression (measured by the five‐item Mental Health Index) (RR 1.70; 95% CI 1.20‐2.40). Conclusion: Incident MSK symptomatic areas occurred in roughly half of recipients of TKR in the 4 years after the operation. Further study is needed to examine the long‐term impact of MSK symptomatic areas on postoperative pain, function, and quality of life. [ABSTRACT FROM AUTHOR]

Objective: Most persons who undergo total knee replacement (TKR) do not increase their physical activity following surgery. We assessed whether financial incentives and health coaching would improve physical activity in persons undergoing TKR.Methods: We designed a factorial randomized controlled trial among persons undergoing TKR for osteoarthritis. Subjects underwent normal perioperative procedures, including postoperative physical therapy, and were assigned to 1 of 4 arms: attention control, telephonic health coaching (THC), financial incentives (FI), or THC + FI. We objectively measured step counts and minutes of physical activity using a commercial accelerometer (Fitbit Zip) and compared the changes from pre-TKR to 6 months post-TKR across the 4 study arms.Results: Of the 202 randomized subjects, 150 (74%) provided both pre-TKR and 6 months post-TKR accelerometer data. Among completers, the mean ± SE daily step count at 6 months ranged from 5,619 ± 381 in the THC arm to 7,152 ± 407 in the THC + FI arm (adjusting for baseline values). Daily step count 6 months post-TKR increased by 680 (95% confidence interval [95% CI] -94, 1,454) in the control arm, 274 (95% CI -473, 1,021) in the THC arm, 826 (95% CI 89, 1,563) in the FI arm, and 1,808 (95% CI 1,010, 2,606) in the THC + FI arm. Weekly physical activity increased by mean ± SE 14 ± 10, 14 ± 10, 16 ± 10, and 39 ± 11 minutes in the control, THC, FI, and THC + FI arms, respectively.Conclusion: A dual THC + FI intervention led to substantial improvements in step count and physical activity following TKR. [ABSTRACT FROM AUTHOR]

To assess the impact of cardiac resynchronization therapy (CRT) with or without atrial overdrive pacing, on sleep-related breathing disorder (SRBD). CRT may have a positive influence on SRBD in patients who qualify for the therapy. Data are inconclusive in patients with obstructive SRBD. Consenting patients eligible for CRT underwent a baseline polysomnography (PSG) 2 weeks after implantation during which pacing was withheld. Patients with an apnea hypopnea index (AHI) ≥15 but <50 were enrolled and randomized to atrial overdrive pacing (DDD) versus atrial synchronous pacing (VDD) with biventricular pacing in both arms. Patients underwent two further PSGs 12 weeks apart. Nineteen men with New York Heart Association class III congestive heart failure participated in the study (age 67.2 ± 7.5, Caucasian 78.9%, ischemic 73.7%). The score on Epworth Sleepiness Score was 7.3 ± 4.0, Pittsburgh Sleep Quality Index 7.4 ± 3.1, and Minnesota Living with Heart Failure Questionnaire 36.9 ± 21.9. There were no differences between the groups. At baseline, patients exhibited poor sleep efficiency (65.3 ± 16.6%) with nadir oxygen saturation of 83.5 ± 5.3% and moderate to severe SRBD (AHI 21.5 ± 15.3) that was mainly obstructive (central apnea index 3.3 ± 6.7/hour). On both follow-up assessments, there was no improvement in indices of SRBD (sleep efficiency [68.3 ± 17.9%], nadir oxygen saturation of 82.8 ± 4.6%, and AHI 24.9 ± 21.9). In a cohort of elderly male CHF patients receiving CRT, CRT had no impact on obstructive SRBD burden with or without atrial overdrive pacing. (PACE 2011; 34:593-603) [ABSTRACT FROM AUTHOR]

Objective: To examine and compare risk factors for various stages of subclinical vascular disease in different vascular beds (carotid and aorta) in women with systemic lupus erythematosus (SLE) who have not yet developed clinical cardiovascular disease., Methods: This cross-sectional study was conducted in 214 women without clinical cardiovascular disease who were enrolled in the Pittsburgh Lupus Registry. B-mode ultrasound was used to measure carotid plaque and intima-media wall thickness (IMT). Doppler probes were used to collect pulse-wave velocity waveforms from the right carotid and femoral arteries as a measure of aortic stiffness. All risk factor data were collected on the day of the ultrasound examinations., Results: The mean +/- SD age of the women was 45.2 +/- 10.5 years and the median SLE disease duration was approximately 9 years. Sixty-eight (32%) of the women had at least 1 focal plaque. The mean +/- SD IMT was 0.71 +/- 0.1 mm, and the mean +/- SD pulse-wave velocity was 5.96 +/- 1.6 meters/second. Using logistic regression, we found that determinants of plaque included older age, higher systolic blood pressure, lower levels of high-density lipoprotein 3, and antidepressant use. Determinants of plaque severity were older age, higher systolic blood pressure, lower levels of albumin, and smoking. Independent determinants of the highest quartile of IMT were older age, higher pulse pressure, lower levels of albumin, elevated C-reactive protein levels, high cholesterol, and higher levels of glucose. Higher aortic stiffness was associated with older age, higher systolic blood pressure, higher C3 levels, lower white blood cell count, higher insulin levels, and renal disease., Conclusion: In women with SLE, the risk factors associated with carotid plaque and IMT are those typically associated with cardiovascular disease in the general population, whereas the risk factors associated with vascular stiffness include SLE-specific variables related to immune dysregulation and complement metabolism. The high prevalence of cardiovascular disease among lupus patients may result from both early adverse effects on vascular stiffening as well as later promotion of wall thickening and plaque through inflammatory-mediated processes. These observations provide clues for future mechanistic studies.