19Objective: To determine the natural history of flare-ups in knee osteoarthritis and their 20 relation to physical exposures. 21 22 Design: Adults aged ≥45 years with a recent primary care consultation for knee 23 OA/arthralgia completed a daily pen-and-paper diary for up to 3 months, including 24 questions on average knee pain intensity, pain descriptors, other symptoms, activity 25 interference, and selected physical exposures (prolonged kneeling, squatting, climbing 26 stairs, ladders, and moving/lifting heavy objects). Informed by a systematic review, flare-ups 27 were defined a priori. We calculated the rate of flare-ups in the sample, described their 28 nature and duration, and estimated their association with physical exposures in the prior 48 29 hours. 30 31Results: 67 participants completed at least one month of diaries,37 (55%) were female, 32 mean age 62 years (SD 10.6) with a mean body mass index of 24.6 kg/m 2 (SD 5.1). 30 33 participants experienced a total of 54 flare-ups (incidence density 1.09 flare-ups/person-34 days). The median duration of flare-ups was 8 days (range: 2-30). During a flare-up 35 participants were more likely to report sharp, throbbing, stabbing, burning pain, swelling, 36 limping, stiffness, being woken by pain, taking more analgesia, and stopping usual activities. 37 Exposure to one or more physical exposure increased the risk of a flare-up in the 38 subsequent 48 hours (odds ratio 2.19 (95%CI: 1.22, 4.05)). 39 40 Conclusions: Our study with intensive longitudinal data collection suggests acute flare-ups 41 may be experienced by a substantial number of patients. These episodes often last a week 42 108 109 RESULTS 110 111Of the 220 out of 330 responders to the baseline questionnaire, 106 (48%) were eligible and 112 were invited to take part in the diary study, consented to further contact, and were mailed 113 the first diary. Reasons for non-eligibility included; inflammatory disease (41), TKR (27), 114 missing/blank Q (22), no recent knee pain (14), withdrew/died/moved (10). Of the 67 (63%) 115 participants who completed at least one monthly diary, 37 (55%) were female, mean age 62 116 years (SD 10.6) with a mean body mass index of 24.6 kg/m 2 (SD 5.1). Of a possible 5491 117 diary days, 4328 (79%) were fully completed, 1163 (21%) were partially completed, and 111 118 (2%) were missed completely. Comparing responders to non-responders ages were similar 157 158 DISCUSSION 159Our study supports the notion that knee OA, for some people, is characterised by 160 intermittent acute or sudden increases in pain with an associated change in pain quality and 161 knee symptoms. 162 163 Pain intensity in our study was highly variable for some and stable for others. 164 Although not explored in this study, Schneider et al found a link between pain variability in 165 OA and depression 15 . Qualitative studies have highlighted the highly variable nature of pain 166 in OA 2 and when unpredictable can be associated with considerable distress 3 . 167 208 209 All authors were ...
BackgroundWhile knee osteoarthritis (OA) is characterised as a slowly progressive disease, acute flares, episodes of severe pain, and substantial fluctuations in pain intensity appear to be part of the natural history for some patients. We sought to estimate what proportion of symptomatic community-dwelling adults might be affected, and to identify patient and problem characteristics associated with higher risk of such variability in pain.MethodsWe analysed data collected at baseline, 18, 36, 54, and 72 month follow-up of a prospective cohort of symptomatic adults aged over 50 years with current/recent knee pain. At each time point we estimated the proportion of participants reporting 'significant pain variability' (defined as worst pain intensity in the past 6 months ≥5/10 and ≥2 points higher than average pain intensity during the same 6-month period). The associations between significant pain variability and demographic, socioeconomic, lifestyle, clinical, radiographic, and healthcare utilisation factors measured at baseline were estimated by adjusted odds ratios and 95% confidence intervals (aOR; 95%CI) from multivariable discrete-time survival analysis.ResultsSeven hundred and nineteen participants were included in the final analysis. At each time point, 23–32% of participants were classed as reporting significant pain variability. Associated factors included: younger age (aOR (per year): 0.96; 95% CI 0.94, 0.97), higher BMI (per kg/m2:1.03; 1.01, 1.06), higher WOMAC Pain score (per unit: 1.06; 1.03, 1.10), longer time since onset (e.g. 1–5 years vs < 1 year: 1.79; 1.16, 2.75) and morning stiffness (≤30 min vs none: 1.43; 1.10, 1.85). The models accounting for multiple periods of significant symptom variability found similar associations.ConclusionsOur findings are consistent with studies showing that, for some patients OA symptoms are significantly variable over time. Future prospective studies on the nature and frequency of flare ups are needed to help determine triggers and their underlying pathophysiology in order to suggest new avenues for effective episode management of OA to complement long-term behaviour change.Electronic supplementary materialThe online version of this article (doi:10.1186/s12891-017-1434-3) contains supplementary material, which is available to authorized users.
ObjectiveTo identify and critically synthesise definitions of acute flares in knee osteoarthritis (OA) reported in the medical literature.DesignSystematic review and narrative synthesis. We searched Medline, EMBASE, Web of science and six other electronic databases (inception to July 2017) for original articles and conference abstracts reporting a definition of acute flare (or synonym) in humans with knee OA. There were no restrictions by language or study design (apart from iatrogenic-induced flare-ups, eg, injection-induced). Data extraction comprised: definition, pain scale used, flare duration or withdrawal period, associated symptoms, definition rationale, terminology (eg, exacerbation or flare), baseline OA severity, age, gender, sample size and study design.ResultsSixty-nine articles were included (46 flare design trials, 17 observational studies, 6 other designs; sample sizes: 15–6085). Domains used to define flares included: worsening of signs and symptoms (61 studies, 27 different measurement tools), specifically increased pain intensity; minimum pain threshold at baseline (44 studies); minimum duration (7 studies, range 8–48 hours); speed of onset (2 studies, defined as ‘sudden’ or ‘quick’); requirement for increased medication (2 studies). No definitions included activity interference.ConclusionsThe concept of OA flare appears in the medical literature but most often in the context of flare design trials (pain increases observed after stopping usual treatment). Key domains, used to define acute events in other chronic conditions, appear relevant to OA flare and could provide the basis for consensus on a single, agreed definition of ‘naturally occurring’ OA flares for research and clinical application.PROSPERO registration numberCRD42014010169.
BackgroundOsteoarthritis (OA) is a leading cause of persistent pain and disability. Traditionally viewed as a slowly progressive disease, the impact of symptom variability on prognosis remains unclear. ‘Acute-on-chronic’ episodes are a well-recognised feature of many long-term conditions but only recently formally described in OA. This study aimed to develop a web-based data collection platform and establish key methodological design parameters, to develop a larger community-based study investigating acute flares of knee OA in England.MethodsThe study is a 9-week feasibility and pilot web-based observational case-crossover study. Adults aged ≥ 40 years registered with two general practices who had consulted their general practitioner for knee pain/OA in the last 2 years were recruited. Participants completed a baseline questionnaire and scheduled (control-period) questionnaires at follow-up weeks 1, 5, and 9. Participants were invited to self-declare via the website on any occasion they experienced a knee pain flare-up lasting ≥ 24 h. Upon notification, an event-driven (case-period) questionnaire comparable to the scheduled questionnaires was completed and daily measurements on the course and consequences were taken until resolution. A sub-study of 10 participants logged daily pain measurements. The analysis estimated key parameters including recruitment (selective non-participation, eligibility, consent), retention, and flare-up capture processes. Questionnaire completeness and website usability were evaluated.ResultsOf 442 patients invited, 14 completed baseline questionnaires. Eligibility rate was 26.9% (95% CI 19.3, 36.2), consent rate 53.6% (35.8, 70.5), and overall recruitment rate 3.2% (1.9, 5.2). Compared to those mailed, baseline responders were more likely to be male and ≥ 65 years, as were those reporting ≥ 1 flare-up. Eleven scheduled questionnaires were completed (mean response 35%). Although seven participants (50%) self-declared 11 flare-ups, only one event-driven questionnaire was completed and three participants contributed daily flare measurement for four flares. Missing data was ≤ 3.7% across completed baseline, scheduled, and event-driven questionnaires. Aspects of website usability require minor refinement.ConclusionsRecruitment was not feasible with the current strategy. An evaluation of processes has suggested several substantial changes in design that may enhance recruitment, retention, and data quality in a future full-scale study.
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