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Why It’s Important

The number of total knee replacements performed in the United States continues to rise, and although the surgery has high success rates, up to 20% of patients experience suboptimal outcomes. The great majority of total knee replacements is performed due to osteoarthritis, which is diagnosed mainly through knee radiographs. The goal of this study was to investigate associations between preoperative radiographic findings and post-operative outcomes, to help inform preoperative planning and setting of expectations for patients.

What We Did

We used data from the AViKA trial, which consists of 308 patients undergoing primary unilateral total knee replacement. We measured preoperative radiographic osteoarthritis severity using the Osteoarthritis Research Society International (OARSI) score, which results in a more standardized and specific assessment of severity than the Kellgren-Lawrence (KL) system. We obtained pain relief and functional improvement outcomes using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores and Knee injury and Osteoarthritis Outcome Score (KOOS) from questionnaires at 6 weeks pre-surgery and 2 years post-surgery. We investigated the relationship of these outcomes to OARSI scores, KL grade, and joint-space narrowing scores.

What We Found

We did not observe a clinically important association between preoperative radiographic severity of osteoarthritis and patient-reported outcomes 2 years post total knee replacement, consistent with prior literature. Regardless of preoperative severity, subjects experienced meaningful postoperative pain relief and functional improvement. Our findings only reflect outcomes of individuals already indicated for total knee replacement, and radiographic osteoarthritis assessment should not be used alone to indicate a patient for this surgery.

Why It’s Important

Some patients with knee osteoarthritis (OA) experience slow disease progression, while others experience rapid deterioration. Identifying patients who experience rapid disease worsening could allow better recruitment strategies for clinical trials and identifying risk factors for rapid progression could shed light on targets for the prevention of structural deterioration.

What We Did

We used data from the Osteoarthritis Initiative (OAI) for our analysis, and our study cohort included subjects with radiographic and symptomatic knee OA. The outcome we assessed was joint space width (JSW, the measurement of separation between the femur and tibia) assessed at baseline and at least one follow-up time over a period of 8 years. We used a method called latent class growth analysis to identify subgroups of JSW progression. Since we might expect that subjects who progress more rapidly are more likely to undergo total knee replacement (TKR), we modeled time to knee replacement to correct for biases due to these subjects dropping out.

What We Found

Rapid disease progression is relatively rare. The majority of subjects fell into a stable trajectory group with an average loss of 0.5 mm of JSW over 8 years. Around 4% of subjects fell into a late progressing trajectory with stable JSW over the first 3-4 years and an average loss of 2 mm JSW over years 4-8. Lastly, around 8% of subjects were in an early progressing trajectory, with a loss of 2 mm JSW over the first 4 years then stabilizing. Patients who undergo total knee replacement are usually in worse condition prior to surgery, but since TKR is relatively uncommon when you consider the size of the population with knee OA, incorporating TKR information doesn’t make a big difference in estimates of disease progression. Lastly, obesity, varus alignment (bowlegged), and previous knee surgery increased the odds of subjects falling into one of the progressing trajectories.

Why It’s Important

The growth of cause-based running has created a race within the race for the Boston Marathon. Charity runners are younger, female, and generally from the Boston area, while qualifiers are largely middle-aged, male, and reside throughout the United States and internationally. Therefore, the Boston Marathon is uniquely positioned to examine race-day medical risks for different groups of runners. By understanding the unique patterns of illness and injury among these groups, we can help optimize the health and safety of runners as well as assist with planning for races like the Boston Marathon.

What We Did

In addition to compiling data about the Boston Marathon and reviewing prior research regarding the health and safety of race runners, we interviewed three experienced coaches who work directly with cause-based runners preparing for the Boston Marathon. The three collectively coach more than 1000 charity runners each year, and each is affiliated with multiple teams.

What We Found

Each coach emphasizes strength training and cross-training to prepare for the race and provides access to educational resources regarding training, nutrition, and injury prevention. Medical providers should understand that cause-based runners are often inexperienced and require focused screening, prevention, and treatment. Lastly, education may be the key to reducing injury risk at endurance events; prior research has shown that providing an educational program to high-risk runners can reduce serious medical encounters during the race.

Why It’s Important

Knee osteoarthritis (OA) can have varying pain and imaging presentations in different patients, which can make predicting the progression of the disease difficult. As research into disease modifying osteoarthritis drugs (DMOADs) is ongoing, it is important to investigate different potential targets for these therapeutics. Further understanding of patterns in groups of patients who display similar levels of pain and knee deterioration on imaging can play a key role in future DMOAD clinical trials. If the rate of disease progression differs among patients in different groups (based on their pain and joint structure), this could prove especially relevant when looking for future DMOAD targets.

What We Did

We analyzed data from over 400 patients in the Foundation for National Institutes of Health (FNIH) Osteoarthritis Biomarkers Consortium cohort, which was comparable in size to a clinical trial population. These patients were split into 4 groups based on their radiographic and symptomatic progression: patients with both types of progression (composite), patients with neither, patients with only radiographic progression (JSL), and patients with only pain progression. Patients were further categorized by the presence of knee inflammation, cartilage loss/meniscal tear, and/or bone marrow lesions (BML). The relationship between each phenotype to the odds of being either in the JSL or composite group compared with those who do not exhibit that phenotype was evaluated using logistic regression.

What We Found

Those exhibiting BML had a higher odds of being in the JSL and composite categories (increased odds of having both radiographic and pain progression). Inflammation and cartilage loss/meniscal tear were not strongly associated with any particular outcome. This method of categorizing patients by their structural and pain progression may prove useful in future clinical trials.

Why It’s Important

Knee osteoarthritis (OA) affects about 14 million adults in the United States, and there are no non-surgical treatments proven to reverse or stop structural damage to the knee joint. The only non-surgical ways of effectively treating knee OA involve reducing pain and improving knee function. These non-pharmacological, non-surgical (NPNS) treatments are low cost and low risk, which makes them the ideal first-line approaches for treating patients with knee OA. These NPNS treatments can include acupuncture, exercise, ultrasound, laser, and transcutaneous electrical nerve stimulation (TENS). Previous studies have shown that these NPNS treatments are underused by physicians, so further research to understand their effectiveness can help to inform future treatment strategies.

What We Did

We reviewed previously published literature to identify randomized controlled trials testing the effectiveness of NPNS strategies. We analyzed 25 studies and split them into two groups, one for acupuncture and one for topical energy modalities (TEM). The proportion of the treatment effect, or reduction in pain, that can be attributed to contextual effects (which can include the placebo effect, effects of simultaneously occurring therapies, other factors not related to the treatment itself) is an important metric in understanding the effects of a treatment alone. We calculated these contextual effects (PCE) by dividing the change in pain in the placebo group by the change in pain for the treatment group for each trial. The PCE was then log transformed and combined across studies using a random effects model.

What We Found

Contextual effects may explain about 61% and 69% of the treatment effect experienced by patients using acupuncture and TEM treatments, respectively. This shows that factors outside the direct effect of an active treatment may play a large role in the reduction of pain. If contextual effects play such a role in the analgesic effects of NPNS treatments, this may indicate that ethically increasing contextual effects could help to further reduce pain in the future.

Why It’s Important

Full thickness cartilage loss (FTCL) is a major determinant of future knee arthroplasty in older adults with minimal to moderate knee osteoarthritis. Therefore, identifying patients who will progress to FTCL may help in developing strategies to prevent OA progression. It is not known if there is a threshold for baseline cartilage thickness or decrease in cartilage thickness over time that could be used to predict relevant future cartilage damage. The goal of this study was to investigate if quantitative baseline cartilage thickness and its change over a year, measured using quantitative MRI, are associated with FTCL in KOA.

What We Did

This study used a retrospective cohort of participants from the Foundation for the NIH OA Biomarkers consortium, consisting of 600 participants with baseline KL (Kellgren and Lawrence) radiographic severity grade of 1, 2, or 3. We quantitatively assessed each knee’s tibial and femoral cartilage thickness, and examined the odds of developing widespread FTCL (wsFTCL) in these knee regions at 24 months according to baseline and 12 month cartilage thickness in the same region. We also investigated whether there were optimal cut-off values for baseline thickness or 12-month change in thickness that were associated with incidence of wsFTCL at 24 months.

What We Found

KL grade provides an incomplete picture of knee osteoarthritis severity, as adults with FTCL have a greater likelihood of progressing to knee replacement than adults with the same KL grade without FTCL. This investigation showed that tibial and femoral baseline cartilage thickness are associated with wsFTCL over 24 months, on a continuous scale. This may help to stratify patients with low cartilage thickness in weight-bearing knee regions into a progressor group that should receive a more intensive treatment despite radiographic disease status. Cut-off values for baseline thickness and 12 month change in thickness could not accurately predict wsFTCL incidence, limiting their utility as a classification tool for risk of wsFTCL development.

Why It’s Important

Knee arthroscopy is one of the most commonly performed outpatient orthopaedic procedures, and opioid prescriptions are standard of care afterwards. Recent evidence suggests that patients do not take all the pills prescribed to them, as well as that NSAIDS can offer adequate pain relief post arthroscopy.

Previous work has shown that patient resilience can affect post-surgical outcomes. The goal of this study was to evaluate the Brief Resilience Score (BRS) as a predictor for patient satisfaction with nonopioid pain management and patient-reported outcome measures (PROMs) after arthroscopic partial meniscectomy or chondroplasty.

What We Did

We followed 132 patients receiving arthroscopic partial meniscectomy or chondroplasty from the same surgeon. Each patient underwent an outpatient procedure and was prescribed ibuprofen or acetaminophen. We determined their BRS before surgery and documented patient recorded outcome measures (PROMs) with 3- and 6-month post-op questionnaires.

What We Found

Our findings suggest that preoperative resilience score, as measured by the BRS, does not correlate with patient-reported functional outcome or satisfaction with a nonopioid pain regimen after knee arthroscopy. Although many knee arthroscopy patients report high satisfaction with nonopioid postoperative pain regimens, some still report dissatisfaction. It is important to identify a reliable predictor for satisfaction with nonopioid regimens, as a step toward decreasing the orthopaedic community’s significant contribution to opioid overprescribing.

Why It’s Important

Although physical activity (PA) has health and pain benefits for individuals with knee OA, levels of PA in the US knee OA population remain low. Long-term sustainability of programs is a common concern surrounding funding for PA programs in the OA population. We aimed to evaluate how even a program with short-lived direct efficacy could be beneficial and cost-effective over a lifetime horizon.

What We Did

We used the OAPol Model to analyze the cost-effectiveness of adding a 3-year PA-promoting program (health coaching, wearable activity monitor, & financial incentives) to usual care, compared to usual care alone. We examined long-term impacts on disease incidence and quality of life in a population of adults with knee OA who were inactive at the start of the program.

What We Found

The PA program we modeled was cost-effective and reduced long-term incidence of cardiovascular disease and diabetes, even if only 10% of the inactive OA population participated. These results offer justification for policymakers and payers considering a PA program incorporated into standard knee OA care.

Why It’s Important

Previous work has shown that diet and exercise is an effective and cost-effective intervention for knee osteoarthritis. The affordability of diet and exercise is less clear but just as important, as the intervention is unlikely to be utilized if it is unaffordable for insurers. The aim of this study was to better understand the impact of a knee osteoarthritis diet and exercise program on insurer budgets.

What We Did

Using our Osteoarthritis Policy Model (OAPol), we estimated changes in medical expenditures with and without a diet and exercise program for two types of insurance: a commercial plan covering 200,000 people between the age of 25 and 64 and a Medicare Advantage plan covering 200,000 people over the age of 64. We modeled the efficacy of the diet and exercise intervention (measured by pain and weight fluctuations), in addition to intervention costs and adherence. Sensitivity analyses were also done, in which time horizon, intervention efficacy, and intervention cost were varied.

What We Found

There is no established threshold defining what is affordable and what is not. Our results, however, show that a diet and exercise program for knee osteoarthritis is comparable in cost to other health-promotion interventions. Over three years, the modeled diet and exercise intervention increased spending by $752,200 and $6 million in the commercial and Medicare plans, respectively. During those three years, opioid use was reduced by 6% and total knee replacements by 5% in the commercial plan. In the Medicare plan, opioid use was reduced by 5% and knee replacements by 4%.

Why It’s Important

The treatment of spinal metastases poses a challenging decision regarding surgical vs. non-surgical management. Surgery poses additional risks, but may improve function, pain, and cognition. Little is known, however, about how patients weigh these considerations. A better understanding of patient preferences about treatment for metastatic spinal disease can inform discussions with patients and their families, as well as improve shared-decision making.

What We Did

We interviewed 23 patients with spinal metastases. We asked patients about how they make the decision to pursue surgical or non-surgical treatment and what they expected the outcome of each treatment to be. We analyzed the interviews to identify themes related to this decision-making process.

What We Found

The gravity of being diagnosed with spinal metastatic disease and the implications of the treatment choice shaped patients’ views of who should make the decision and how much risk they were willing to accept. Feeling a sense of urgency and anxiety regarding their diagnosis, patients tended to defer to physicians’ treatment recommendations, frequently without a thorough understanding of the different treatment options. Our findings can help clinicians better understand patients’ decision-making process when considering treatments for spinal metastases and may inform their approach to discussing treatment options and addressing patients’ sense of urgency to make a treatment decision.

Why It’s Important

The burden of trauma disproportionately affects people in low- and middle-income countries. In Malawi, a low-income country, the resources to manage musculoskeletal trauma remain inadequate. The majority of healthcare services are provided by public hospitals, which includes both district and more specialized central hospitals. Femoral shaft fracture is a common injury treated either non-operatively and operatively in Malawian hospitals. We were motivated to better understand the current capacity of public hospitals in Malawi to manage musculoskeletal trauma.

What We Did

We developed a survey tool to measure the capacity to manage femoral shaft fractures at the public hospitals in Malawi. The survey assessed the infrastructure, manpower, and essential material resources (such as pain management, inpatient ward nurses, and x-ray diagnosis) that were available to manage these fractures in both operative and non-operative settings. The survey also captured the most common reasons for the unavailability of resources, and we were able to identify the most commonly missing essential items. Survey data was collected from all 25 Malawian district hospitals and 4 central hospitals.

What We Found

None of the district or central hospitals had every essential resource to manage femoral fractures. District hospitals had an average of 71% of essential resources, and central hospitals had 76% of essential resources. Operative treatment of femoral shaft fractures was available at three out of four of the central hospitals. Our findings provide areas within the musculoskeletal trauma system in Malawi to target for future improvement.

Why It’s Important

Spinal metastatic disease, a type of cancer with a poor prognosis and high mortality, is becoming increasingly common. Treatment for spinal metastatic disease can be complex, and the best course of treatment for each individual patient can be ambiguous. While several prognostic scores have been developed to guide treatment decisions, they can be difficult to assess and do not accurately predict the prognosis of all patients with spinal metastatic disease. Thus, there is a need for a prognostic score that is both easy to calculate and accurately predicts the prognosis of patients with spinal metastatic disease.

The New England Spinal Metastatic Score (NESMS) is a recently developed prognostic score that is easy to compute, and therefore could fill this need. However, the ability of this score to predict a range of patient’s prognosis has yet to be determined.

What We Did

To address this question, we developed the prospective observational study of spinal metastasis treatment (POST). During POST, we followed 200 patients with spinal metastatic disease for one year. At the beginning of the study, we determined patients’ NESMS score and recorded information about patients’ disease and planned course of treatment. One, three, six, and twelve months after the beginning of the study we recorded information about the progression of patient’s disease and treatment.

What We Found

We are currently analyzing the data collected during the POST project in order to determine the utility of NESMS as a prognostic score for patients with spinal metastatic disease.

Why It’s Important

There are more than 20,000 new diagnoses of metastatic epidural compression made each year, which can increase risk of physiologic decline, neurological deterioration, and mortality within the year of diagnosis. Treatment of patients with spinal metastases is complex, and both operative and non-surgical management have shown benefit in various situations. This study aims to describe specific characteristics that may be associated with non-operative failure leading to surgery.

What We Did

Conducted a retrospective review of patients treated for spinal metastases from 2005 – 2017. Using multivariable Poisson regression, we identified factors associated with non-operative failure, which was defined as any individual who underwent a surgical intervention within 1 year of starting a non-operative treatment regimen.

What We Found

Based on the retrospective evaluation of patients who failed non-operative treatment measures, we found that 9% of patients with spinal metastases initially treated non-operatively received surgical intervention within 1 year. Additionally, we identified several factors that are independently associated with a greater risk of non-operative treatment failure, including vertebral body collapse, pathologic fracture, and neurologic signs or symptoms at presentation.

Why It’s Important

Vitamin D and marine ꙍ-3 fatty acids (n-3 FA) are two supplements widely consumed due to advertised benefits of disease prevention and systemic inflammation reduction. The potential health benefits associated with these supplements has drawn considerable attention from both the medical field and popular press. There has been substantial observational evidence in favor of the supplements; however, measurable effects on systemic inflammation in the general adult population has yet to be well established as many past trials have been inconsistent. Because both supplements have little to no negative side effects, if found to be efficacious, they would provide a valuable treatment option for systemic inflammation.

What We Did

The VITamin D and OmegA-3 Trial (VITAL) is a recently completed clinical study (enrolling men over 50 and women over 55 for a total of 25,871 subjects) that looked for a potential link between Vitamin D and ꙍ-3 fatty acids to cancer and cardiovascular disease prevention. Participants were randomized into four treatment arms: Vitamin D and n-3 FA, Vitamin D only, n-3 FA only, or placebo only. As part of the study, consenting participants filled out questionnaires (relating to demographics), provided blood samples, and followed eating/fasting protocols at baseline and 1-year follow-up.

Interleukin-6 (IL-6), tumor necrosis factor receptor 2 (TNFR2), and high sensitivity C-reactive protein (hsCRP) are common biomarkers used to assess levels of systemic inflammation. We identified 1561 participants within the VITAL trial who had sufficient blood samples drawn at baseline and 1-year follow-up in order to perform assays of these biomarkers. Furthermore, we ensured this population was balanced by the various demographic variables collected and that there was equal representation from each treatment arm. Using the assays, we compared each biomarker’s concentration from the baseline blood sample to the 1-year follow-up sample, hypothesizing that one or both supplements would significantly reduce IL-6, TNFR2, and/or hsCRP.

What We Found

We found no evidence that either vitamin D or n-3 FA – two widely used over-the-counter nutritional supplements – reduced any of the three systemic inflammation biomarkers tested over 1 year. These results contradict our original hypothesis and prove challenging to explain from a biological perspective. Furthermore, they conflict with past studies that found inverse relationships between vitamin D and n-3 FA levels and biomarkers of systemic inflammation. Ultimately, our findings address important questions about the impact that these supplements have on inflammatory pathways and suggest that it is unlikely to experience anti-inflammatory benefits from taking them. It is important to note that although often small and involving varied doses and durations, other studies have shown n-3 FA supplements have a greater positive effect on patients with chronic inflammation, are overweight, or who take them for longer. Recently, scientists have become interested in determining if the biomarkers measured here do not show the full picture, and that perhaps n-3 FA’s impact a different pathway.

Why It’s Important

Musculoskeletal trauma poses a disproportionately large burden of disease to low- and middle-income countries, in part because they cannot afford the imaging and medical equipment necessary to perform surgical fixation of fractures. While the Surgical Implant Generation Network (SIGN) has greatly increased access to treatment in these countries with the creation of intramedullary nails, which do not require intraoperative fluoroscopy equipment, these countries still lack radiographic imaging equipment and a uniform assessment for determining whether a musculoskeletal fracture has fully healed. In fact, no such assessment exists in the global medical community, even in well-resourced countries with access to post-operative radiographic imaging equipment. In this paper, we assess the reliability of the Squat and Smile (S&S) test as a measure of fracture healing and as a predictor of future healing. The S&S involves photographing the patient at a distance while he or she squats as deeply as possible, with as little support as possible.

What We Did

Using the SIGN database, which contains S&S test results from patients treated in facilities that receive aid from SIGN, we selected 150 patients who underwent intramedullary nail treatment for a femur or tibia fracture between January 2010 and January 2015. We visually analyzed each patient’s S&S photographs from the one-year follow-up and assigned grades to patients on a 0 to 2 scale, based on the extent of flexion when squatting. We also analyzed these patients’ radiographic data to calculate Radiographic Union Scale for Tibia fractures (RUST) scores, which is one of the primary methods used by clinicians today to assess fracture healing after intramedullary nailing and which we used as a gold standard comparator.

What We Found

In this retrospective review of patients who have undergone fracture fixation with SIGN intramedullary implants, we found that the S&S test demonstrates reliable scoring with the RUST method but has low sensitivity and specificity (11% and 85%, respectively, at one-year follow-up). Overall, these findings suggest that the S&S test does not describe radiographic healing and that it should not be used in isolation when making decisions about clinical management. Indeed, further data, including clinical findings such as infection, pain, and ability to bear weight and/or radiographic findings, should be used to make clinical decisions regarding the status of fracture healing.

Why It’s Important

Total joint replacements are common in the U.S., with more than 100,000 being performed each year. Diabetic patients who receive total joint replacement are at increased risk for a poor surgical outcome if they have hyperglycemia (high blood sugar) prior to surgery. However, we don’t know how often patients are screened for hyperglycemia before total joint replacement. The goal of this study was to determine how often hemoglobin A1c (which indicates excess sugar in the blood) was measured within three months prior to total joint replacement among Medicare enrollees.

What We Did

We used Medicare claims data filed between January 2010 and December 2014 to determine the proportion of total joint replacement patients who had their hemoglobin A1c level tested within 90 days before their surgery. Serum blood glucose level testing was also tracked. A total of 465,566 patients were included in the analysis.

What We Found

Among diabetic patients getting total joint replacement, hemoglobin A1c was tested within 90 days of surgery in 26% of those not receiving diabetes medication, 39% of those receiving noninsulin medication, and 43% of those receiving insulin medication. Hemoglobin A1c was tested in just 5% of non-diabetic patients. Serum blood glucose level testing was done for 45% – 50% of diabetic patients (depending on their medication status) and just 37% of non-diabetic patients.

Despite the importance of screening for hyperglycemia prior to total joint replacement, especially among diabetic patients, the appropriate tests were not done in nearly half of all diabetic patients included in the analysis.

Why It’s Important

Symptomatic knee osteoarthritis (OA) affects approximately 14 million adults in the United States. Moreover, 60-90% of people with symptomatic OA have meniscal tears. While physical therapy (PT) is accepted as a first-line treatment for patients with knee OA and meniscal tear, there are many musculoskeletal treatment regimens and scarce literature on the efficacy of PT interventions for patients with meniscal tear in the setting of OA. Thus, understanding which elements of a PT or home exercise program provide the best results for this patient population, and the role of contextual factors, remains and important research gap.

What We Did

An interdisciplinary team of physical therapists, physicians, and researchers sought to develop and refine a standardized PT intervention and a standardized home exercise program for people with meniscal tear and knee OA to be implemented in the Treatment of Meniscal Tear in Osteoarthritis (TeMPO) study with and without physical therapist supervision respectively.

Phase 1: A core group of physical therapists, physicians, and research methodologists assembled an expert panel of physical therapists from four academic US centers to guide the creation of both TeMPO programs.

Phase 2: Literature on physical therapy and strengthening programs for patients with both degenerative meniscal tear and concomitant knee OA was reviewed.

Phase 3: An e-mail survey was administered to experienced physical therapists to better understand PT treatments currently used in our target population.

Phase 4: The initial expert panel was expanded to add more orthopaedic surgeons, rheumatologists, researchers and physical therapists from the four study sites to form the trial research team.

Phase 5: The research team and physical therapists created a standardized instructional video and hard copy program booklet to guide patients who would be completing the TeMPO exercises without physical therapist supervision.

Phase 6: The research team held focus groups with potential patients to solicit feedback for final edits to the TeMPO exercise program and its instructional materials.

What We Found

The investigators were able to agree on a multi-faceted, in-clinic PT intervention and standardized home exercise program, which will serve as templates for in-clinic and home-based care for patients with symptomatic degenerative meniscal tear and knee OA. These interventions will be tested as part of the TeMPO trial.

Why It’s Important

Symptomatic knee osteoarthritis (OA) affects over 14 million people in the United States, and 60-90% of those with knee OA have a meniscal tear as well. Recent studies have suggested that patients with meniscal tear who are treated with arthroscopic partial meniscectomy (APM) plus physical therapy (PT) or PT alone report similar outcomes a year after treatment, indicating that PT is a reasonable initial treatment for meniscal tear in the setting of OA. No studies, however, have examined the effectiveness of PT when compared to placebo or to a home exercise program. We have designed the TeMPO Trial to better understand what aspects of PT that are effective for treating meniscal tear in individuals with OA.

What We Did

We developed the protocol for a randomized clinical trial (RCT) that includes four treatment programs:

  1. A protocolized home exercise program
  2. A protocolized home exercise program with adherence optimization (text or email reminder messages)
  3. A protocolized home exercise program with adherence optimization plus therapist-directed placebo PT
  4. A protocolized home exercise program with adherence optimization plus therapist-directed PT (exercise and manual therapy)

Subjects aged 45 to 85 years old who are seeking treatment for knee pain and meet the inclusion criteria will be randomly assigned to one of these treatment programs. We will compare participants’ self-reported pain at the beginning and end of the three-month treatment.

What We Found

The trial is currently ongoing at four sites: Brigham and Women’s Hospital (Boston, Massachusetts), University at Buffalo Jacobs School of Medicine and Biomedical Sciences (Buffalo, New York), The Cleveland Clinic (Cleveland, Ohio), and the University of Pittsburgh Medical Center (Pittsburgh, PA). We plan to recruit 856 subjects and aim complete recruitment in 2022. Results from this trial will advance our understanding of the aspects of PT that are most efficacious for treating symptomatic meniscal tear in those with knee OA.

Why It’s Important

Meniscal tears, damage to cartilage in the knee, are painful and typically treated with either surgery to remove the meniscus or physical therapy. As surgery is costly and carries risks such as infection, it is important to understand whether it is more effective than physical therapy at relieving pain.

What We Did

In this study, we followed patients with meniscal tears for five years. These patients were randomly assigned to receive either physical therapy or surgical treatment of their meniscal tears. Five years after their treatment, we asked patients to fill out a survey describing their pain level and we determined whether patients had undergone knee replacement surgery.

What We Found

We found that treatment with surgery or physical therapy resulted in similar pain relief over the five year period. We observed that the group that received meniscal surgery also underwent more total knee replacements over five years; however, we could not determine if this difference was due to random chance.

Why It’s Important

An estimated 3 million to 5 million patients are living with spinal metastatic disease. Decisions for operative or nonoperative management remain challenging for patients with spinal metastases, especially when life expectancy and quality of life are not easily predicted. We conducted the Spinal Metastasis Treatment in Determining Ambulatory Status (STRIDES) study to evaluate the effects of operative and nonoperative management on maintenance of ambulatory function and survival in patients treated for spinal metastases.

What We Did

The study included patients treated for spinal metastases between 2005 and 2017 who were 40 to 80 years old, were independent ambulators at presentation, and had fewer than 5 medical comorbidities. We used propensity matching to yield a sample in which operatively and nonoperatively treated patients were similar with respect to key baseline demographic and clinical characteristics (Age, sex, BMI , number of comorbidities, serum albumin, and vertebral body collapse). We were looking at the influence of operative care and nonoperative care on ambulatory function 6 months after presentation as the primary outcome. Survival at 6 months and survival at 1 year were secondary outcomes.

What We Found

We identified 929 individuals eligible for inclusion, with 402 (201 operative patients and 201 nonoperative patients) retained after propensity score matching. Patients treated operatively had a lower likelihood than those treated nonoperatively of being nonambulatory 6 months after presentation as well as a reduced risk of 6-month mortality. Our results indicate that in a group of patients with similar demographic and clinical characteristics, those treated operatively were less likely to lose ambulatory function 6 months after presentation than those managed nonoperatively. For patients with spinal metastases, our data can be incorporated into discussions about the treatments that align best with patients’ preferences regarding surgical risk, mortality, and ambulatory status.

Why It’s Important

Meniscal tears are a common injury among patients with knee osteoarthritis (OA) and account for approximately half of the nearly one million arthroscopic knee surgeries performed annually in the United States. Arthroscopic partial meniscectomy (APM), though, has not yet been shown to provide a clear benefit in the management of meniscal tears as compared to physical therapy (PT) or sham surgery. This study aims to answer the question of whether the degree of joint damage in a patient’s knee is associated with better or worse outcomes for APM over PT.

What We Did

Data collected from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial were used to test the hypothesis that patients with less severe joint damage would experience greater pain reduction with APM plus PT as opposed to PT alone. MeTeOR participants all had radiographic evidence of OA and an MRI-confirmed meniscal tear and had been randomly assigned to either an APM-plus-PT or a PT-alone treatment group. For this analysis, 220 MeTeOR participants were assigned a “damage score” based on MRI features such as the number of bone marrow lesions and the extent of cartilage damage. The damage score could be 0 (least damage), 1 (moderate damage), or 2 (greatest damage). Using linear models, the association between damage score and pain relief at 6 months was tested for the APM-plus-PT and PT-alone groups.

What We Found

Participants with damage scores of 0 and 1 showed greater improvement (more pain relief) with APM-plus-PT as opposed to just PT-alone. Those with a damage score of 0 experienced a 15-point average reduction in pain as quantified by the Knee injury and Osteoarthritis Outcome Score (KOOS). Those with a damage score of 1 experienced a 7-point average reduction in pain. For those with a damage score of 2 (greatest damage), pain relief at 6 months was similar for both the APM-plus-PT and PT-alone treatments. These results suggest that patients with OA, meniscal tear, and less joint damage on MRI may achieve greater pain reduction with an APM-plus-PT approach rather than just PT.

Why It’s Important

Engaging in regular physical activity (PA) has been shown to have numerous positive health impacts, including a decreased risk of cardiovascular disease, diabetes, high blood pressure and cancer, among others. Yet less than half of Americans meet PA recommendations (150 minutes per week of moderate-intensity PA or 75 minutes per week of vigorous-intensity PA). PA has also been shown to differ based on race, with black individuals engaging in less moderate-to-vigorous physical activity (MVPA) than white individuals. The racial disparity in PA is thought to contribute to racial disparities in health conditions like diabetes and high blood pressure, which are more prevalent among black individuals. One method shown to be effective at increasing PA is workplace wellness programs, but it is not known whether the outcomes of such programs differ by race. Armed with a better understanding of how workplace wellness programs may differentially affect black and white participants, we can tailor such programs to meet employees’ needs.

What We Did

The B-Well initiative, a prospective cohort study, aimed to increase PA among Brigham and Women’s Hospital employees who were insufficiently active. The study lasted 26 weeks, 24 of which incorporated financial incentives for increasing PA or meeting PA recommendations. Data on employees’ weekly minutes of MVPA, average daily step counts, frequency of meeting personal goals or PA recommendations, and Fitbit adherence were collected. An analysis of covariance was conducted for each measured outcome. Race was used as the primary independent variable.

What We Found

Analysis showed that both black and white participants increased their PA as part of the B-Well program. Black participants benefited from the program just as much as, if not more than, white participants. Black participants walked significantly more daily steps than white participants (an average of 9128 steps per day as compared to 7826 steps per day) and exhibited a greater increase in MVPA from baseline over the course of the program. No significant differences in average weekly MVPA, Fitbit adherence, or frequency of meeting personal goals or PA recommendations were found. These findings suggest that workplace wellness programs are a viable option for increasing employees’ PA, thereby decreasing the cost and burden of various health conditions.

Why It’s Important

Musculoskeletal injuries affect a large proportion of people worldwide. Prescribing opioids for pain relief following orthopaedic trauma surgeries has been common practice for quite some time. Over the past 20 years, opioid prescriptions and related deaths in the US have greatly increased causing the CDC to declare a nationwide opioid epidemic. Prescribing opioids for post-orthopaedic surgery is considered problematic as it appears to be a major contributing factor to the epidemic. As a result, US physicians and policymakers are working to reduce the rates and amounts of opioid prescriptions used to treat pain. We know that orthopaedic injuries and surgeries happen all around the world, yet variation in drug use to treat post-operative pain for similar injuries among countries around the world is not well documented or understood. This study investigated how and when physicians in two other countries, one low-income and one high-income, prescribe opioids, compared to those in the United States. A better understanding of the variation that exists across countries and cultures around the world may help inform domestic prescription as well as future policy.

What We Did

We surveyed a total of 139 residents from 9 different academic residence programs across Haiti, the Netherlands, and the US, using vignettes of 10 different orthopaedic trauma cases. Each vignette detailed the procedure done as well as the sex and age of the patient. We surveyed residents because at each of the 9 participating centers, residents were the primary prescribers of post-operative pain managing drugs. The survey asked residents to record the type of drug, dose, number of tablets, and total number of days that they would prescribe the drug to treat post-operative pain for each of the 10 cases. Due to varying availability of drugs in different countries, we standardized opioid prescriptions by converting all values to morphine milligram equivalents (MMEs). As a result, we collected data about MMEs prescribed per case, per day, and the total number of days of the prescription.

What We Found

Regardless of the surgery site or age of the patient, residents from the United States prescribed significantly more total MMEs per case than those in Haiti and the Netherlands, with residents in the Netherlands prescribing the second most. Residents in the US and Netherlands used oxycodone as their drug of choice, while those in Haiti chose tramadol. Within the US, patients <40 years old were prescribed greater amounts of MMEs than those >70.  Across all three countries, surgeries involving the femur and tibial plateau received the most MMEs, while ankle and wrist surgeries received the least. Beyond just total MMEs prescribed, we found that US resident physicians prescribe opioids more frequently, with a higher daily dosage, and for a greater number of days after surgery than Dutch and Haitian residents. These results suggest that US residents have a heavy reliance on opioids compared to other countries and indicate that further research is required to learn about how these other countries use non-pharmacologic ways to treat post-operative pain. Generally, our findings signal a need for reassessment of our current prescription habits as we seek to find new ways of treating pain that maximize effectiveness yet reduce provider contributions to the devastating opioid crisis.

Why It’s Important

Despite evidence that physical activity (PA) improves health, over half of the 14 million people in the US with knee osteoarthritis (OA) are not physically active. Among persons with knee OA, PA has been shown to reduce pain, improve mental health, and decrease the incidence of cardiovascular disease (CVD) and diabetes mellitus (DM). Quantifying individual and population losses in quality of life (QoL) that result from physical inactivity is therefore important for promoting PA among persons with knee OA, as well as demonstrating the need for funding public health exercise interventions that target populations that may benefit from increased PA.

What We Did

Using the OAPol model, we estimated the health-related QoL losses due to inactivity and insufficient levels of PA in the US population with knee OA, ages 45 and older. We estimated losses both at the individual level and across the entire population of interest, stratified by sex and race/ethnicity. To quantify these losses, we used “quality-adjusted life years” (QALYs), a metric that accounts for risk aversion and preferences for quantity and quality of life and allows for standardized comparisons across different health states and interventions.

What We Found

We found that the US knee OA population loses over 4.3 million QALYs due to inactivity. Further, if only 20% of the inactive knee OA population became active, over 870,000 QALYs could be saved and the incidence of disease could be significantly reduced: over 95,000 cases of cancer, 222,000 cases of cardiovascular disease, and 214,000 cases of diabetes could be averted. On an individual level, we found that an inactive person with knee OA can lose between 0.58-0.81 QALYs relative to an active counterpart, depending on race and gender, with Black-Hispanic and Black Non-Hispanic women experiencing the highest per-person QALYs lost. Going forward, these findings can help to target future PA interventions in the OA populations that will produce the greatest QoL gains.

Why It’s Important

The burden of injury and trauma related deaths are disproportionately high in low-income and middle-income countries, such as Malawi. Death and nonfatal musculoskeletal injuries result in health care costs and disability that perpetuate a vicious cycle of poverty and decreased productivity. The incidence of musculoskeletal injury is increasing without an adequate hospital infrastructure to manage such trauma. This is resulting in delayed clinic presentation which worsens the burden of trauma-related disability in low-resource settings.

What We Did

Using data from the Malawi Fracture Care Registry, we performed a retrospective cohort study including adult and pediatric patients with isolated musculoskeletal injuries. We examined 11 covariates from the registry that were thought to be associated with patient outcome. These included: age, sex, education level, occupation, season of injury, day of injury, injury mechanism, injury type or extremity of injury, referral status, hospital of presentation, and estimated travel time.

What We Found

In Malawi, delayed presentation to a clinic is common amongst patients with fractures independent of age, sex, education level, or occupation. However, sustaining injury over the weekend and living farther away from the hospital were both associated with an increased risk of delayed presentation. Also, tibial or fibular injury in the pediatric cohort was associated with a 36% increased risk of delayed presentation. This study warrants further investigation into the factors resulting in delayed clinic presentation as delayed treatment can worsen trauma-related disability. Future research is also needed to elucidate the perceptions of injury and when patients seek formal treatment in settings like Malawi.

Why It’s Important

Physical activity is associated with improved quality of life and lower all-cause mortality, and accelerometers—such as the FitBit and ActiGraph— are devices that allow us to measure physical activity. Accelerometers have been widely used in osteoarthritis (OA) research, but there was not a study that compared Fitbit estimates to ActiGraph physical activity measures. We aimed to understand the accuracy of Fitbits compared to ActiGraphs in hopes of implementing realistic physical activity interventions for people with knee OA.

What We Did

We enrolled 15 subjects who each used the hip-worn ActiGraph for four weeks, wrist-worn ActiGraph for two weeks, and Fitbit Charge 2 for two weeks during a four-week study period. We collected data on the numbers of steps and accelerometers counts recorded by each device and calculated the time spent in sedentary, light, and moderate-to-vigorous activity. We compared the activity levels among the different accelerometers and analyzed the amount of time that each device was worn.

What We Found

We found that Fitbit overestimates the number of steps taken and underestimates minutes of moderate-to-vigorous physical activity compared to the hip-worn ActiGraph in people with knee OA. The wrist-worn ActiGraph overestimated steps and minutes of moderate-to-vigorous physical activity while underestimating sedentary time. These results give insight for researchers who are planning to use commercial accelerometers in studies.

Why It’s Important

While pain catastrophizing and widespread pain have been shown to serve as predictors of pain chronicity and severity, we do not fully understand the extent to which each is a stable or a dynamic variable. If we are able to determine whether these chronic pain characteristics reflect an inherent trait or are instead the effect of an ongoing pain stimulus, we may be able to better inform clinical practice regarding pain management, expectations of surgical procedures, and potential targets for intervention.

What We Did

In order to address these questions, we examined a prospective cohort of osteoarthritis patients undergoing unilateral elective TKR. We assessed patient-reported pain (WOMAC scale), pain catastrophizing (PCS), and widespread pain (WP) 6 weeks prior to surgery and again at 12 months post TKR. To look at the change in patient-reported pain, we found the difference in the patient’s WOMAC pain score between preoperative and post-operative time points. For both pain catastrophizing and widespread pain measures, individuals identified their pain via body pain diagrams. These were then converted to scores for pain catastrophizing and widespread pain. PCS and WP scores were subsequently categorized into one of several groups (high versus low). Changes in pain catastrophizing and widespread pain were detected by looking at the movement of individuals between groups when comparing pre-op and post-op categories.

What We Found

Both pain catastrophizing and widespread pain are dynamic, state components rather than stable, inherent characteristics. Pain catastrophizing scores were more likely to improve following total knee replacement surgery and were associated with improvements in WOMAC pain score. Widespread pain scores, however, were not significantly associated with a change in WOMAC pain, and we observed both increased and decreased widespread pain scores post-operatively as compared to pre-operatively.

Why It’s Important

If people are aware at a young enough age that they may be at risk for knee osteoarthritis (OA), they can take action to decrease their risk. For example, they might start maintaining a healthy body weight or taking steps to prevent knee injury. But younger adults, in general, do not think about diseases such as OA that, based on their prior knowledge, affect mainly older adults. People who think their risk is low may see no need to take action, but those who think their risk is high may feel defeated; therefore, correctly understanding risk of OA is important if we want to help people prevent this disease.

What We Did

We built an interactive calculator that uses basic personal information to calculate an individual’s risk of OA. We tested whether using this tool improved how accurately people estimated their own risk of OA. We also tested whether using the calculator made them more willing to change behavior to prevent OA.

Subjects were divided into two groups (Calculator Group and Control Group). The Calculator Group subjects used the risk calculator to view their own personal risk of OA. Control Group subjects only saw general (not personalized) OA risk information.

What We Found

Before anyone used the tool, both groups overestimated their risk of OA. We found that the calculator helped individuals reassess their risk of developing OA more accurately. Those who used the calculator also moved closer to being ready to start exercising. Control subjects’ perceived risks remained unchanged. The risk calculator is an effective educational tool to improve perception of OA risk.

Why It’s Important

As many as 9 of 10 people with symptomatic knee osteoarthritis (OA) also have damage to their menisci, which help with load bearing and stability in the knee. Meniscal damage can include several types of tears and other injuries, which can be viewed using MRI (magnetic resonance imaging). However, we do not know which types of meniscal damage have the greatest effect on pain and other symptoms reported by patients. We wanted to know whether certain types of injury were associated with pain or with mechanical symptoms (clicking, catching, and popping).

What We Did

Using data from the MeTeOR trial, we examined the associations between the type of meniscal damage and symptoms. Each participant had an MRI performed at the beginning of the study. We evaluated these images and placed each participant into a group based on the worst type of meniscal damage he or she had: tears to the meniscal root, maceration, long or short tears in which part of the tear is horizontal, and simple tears such as vertical tears.

What We Found

We found that root tears were associated with the highest level of pain, after taking into account other factors that influence pain. We did not find an association between the type of damage and mechanical symptoms (clicking, catching, and popping), which are often used to diagnose meniscal damage. The findings of this study suggest that root tears may contribute to greater levels of pain, and that future studies should further investigate this type of tear.

Why It’s Important

While most people who have a total knee replacement (TKR) experience large reductions in pain, some will have less pain relief following TKR. Studies have found that individuals that report ‘widespread pain’ and/or ‘pain catastrophizing’ are less likely to receive the full benefits of TKR. ‘Widespread pain’ is when someone reports having pain at many body sites far away from their knee with osteoarthritis. ‘Pain catastrophizing’ refers to a way of responding to the experience of pain, in which someone dwells on pain, worries it will get worse, and feels helpless to make it go away.

What We Did

We measured widespread pain before surgery using the body pain diagram. For each participant, we calculated a widespread pain score based on the number of body regions with pain other than the knee that was going to be replaced. We assessed whether there was any association between this widespread pain score and pain levels 12 months after surgery.

We also measured pain catastrophizing, using a survey that asks questions about how much you think about pain and whether you feel helplessness when in pain. We assessed whether having a high pain catastrophizing score would predict having worse pain at 12 months after TKR.

What We Found

We found that participants who had more widespread pain before surgery were more likely to have more knee pain at 12 months after TKR. Pain catastrophizing was also associated with higher pain 12 months after surgery. Measuring pain catastrophizing and widespread pain (using a body diagram) may help us identify people who are at risk for worse outcomes following TKR.

Why It’s Important

When meniscal tear occurs without a traumatic injury (degenerative tears), diagnosis is complicated. Degenerative meniscal tears are very common in middle-aged and older adults, but they often cause no symptoms. In addition, many people with meniscal tears also have osteoarthritis (OA). So when these patients present with knee pain, it can be hard to tell when the symptoms are caused by OA or by a torn meniscus. Doctors use physical examinations to diagnose meniscal tears that are actually causing pain (symptomatic meniscal tears or SMTs). There is a need to understand how well the physical exam works to diagnose SMT in middle-aged and older patients.

What We Did

Orthopedic surgeons assessed patients with possible SMT. If the surgeons were at least 70% confident that the patient’s symptoms were caused by meniscal tear, we considered this a diagnosis of SMT. Then, we assessed which factors were associated with having a diagnosis of SMT.

What We Found

Patients were more likely to be diagnosed with SMT if they had any of the following 6 factors: localized pain, ability to fully bend the knee, pain lasting less than 1 year, lack of varus alignment, lack of pes planus, and lack of joint space narrowing on x-rays. Doctors often use mechanical symptoms (such as locking, clicking, and popping when the knee moves) to diagnose SMT. But this study did not find that these mechanical symptoms predict experts’ diagnosis of SMT.

Why It’s Important

We know that patients with HIV are more likely to experience fractures than those without HIV. But we do not know all the factors that put patients with HIV at higher risk. There is a concern that some medications used to treat HIV (such as tenofovir disoproxil fumarate or TDF) can make bones weaker and more likely to fracture. We aimed to increase our knowledge of the safety and risks of this drug by studying whether they increase risk of fracture.

What We Did

We reviewed the medical records of 2,663 patients with HIV. Of those, 1,981 had been treated with TDF, and 682 had never used this treatment. We analyzed whether patients with certain characteristics (including the use of TDF) were more likely to have had fractures, taking into account other factors that affect the risk of fracture.

What We Found

We did not find evidence that patients who had taken TDF were more likely to experience fractures. But some factors were connected with a higher risk of fractures: being infected with hepatitis C, as well as certain markers of having advanced HIV disease. Patients with these risk factors could benefit from monitoring their bone density to help prevent fractures.

Why It’s Important

Arthroscopic partial meniscectomy (APM) is a common treatment for those with a torn meniscus (meniscal tear or MT), but it is not clear whether this surgery is better than physical therapy (PT) alone. In the MeTeOR (Meniscal Tear in Osteoarthritis) Trial, participants were randomly assigned either to have only PT (PT group) or to have APM (APM group). About one of three participants in the PT group decided to have surgery before the trial was over. After that, both groups had similar pain relief. We wanted to understand why people were switching to the surgical treatment and how much pain relief they experienced.

What We Did

We identified factors that predicted which individuals in the PT group decided to have surgery before the trial was finished.

What We Found

Patients were more likely to switch to surgery if they had a) higher pain and b) symptoms for less than 1 year before the trial. But these patients who crossed over to surgery had similar pain relief to those who had been assigned to APM in the first place. This suggests that having PT before APM may not decrease the benefits of the surgery.

Why It’s Important

Osteoarthritis (OA) is a painful and disabling condition that gets more severe over time, but it is difficult to measure this progression. One way of measuring progression is to assess features of the disease that can be seen on an MRI (“MRI biomarkers”). These include cartilage damage, osteophytes (bone growths), and damage to the meniscus and ligaments. But measuring these MRI biomarkers is only useful if they are connected with pain and other outcomes that matter to patients. We wanted to know whether changes in these biomarkers were associated with increasing pain.

What We Did

We compared patients who developed OA (pain or damage on x-rays, another way of measuring the severity of OA) at 4 years (cases) to those who did not (controls). We assessed whether worsening in each of the MRI measures of severity predicted which patients would experience OA progression and worsening pain over 2 years.

What We Found

Most of the biomarkers did predict having pain and/or damage on x-rays at 4 years. These included cartilage damage, osteophytes, meniscal extrusion, and bone marrow lesions. For all of these features, change over 2 years was also associated with worsening OA. This was the first study to examine whether worsening in MRI biomarkers can predict changes in OA that are meaningful to doctors and patients: damage to the joints as shown on x-rays, and substantial increases in pain.

Why It’s Important

In the past, people who chose to have total knee replacement (TKR) usually had severe pain, so that they felt pain even while doing less demanding activities such as walking. In recent years, more patients with low pain are choosing to have TKR. Little is known about what drives patients with low pain to make this decision, but it is plausible that they have trouble with activities like squatting, kneeling, and twisting that place higher demands on their knees. If having trouble with these activities keeps people from doing things they value (housework, recreation, etc.) they may choose TKR to regain these functions.

What We Did

Based on how much pain they had before surgery, we placed participants in 3 groups: Low, Medium, and High Pain. We asked patients how much limitation they had in less demanding activities (like walking) and more demanding activities (twisting, squatting, kneeling, jumping, and running).

What We Found

About one in five patients was in the Low Pain group before TKR. These patients were likely to report limping and other problems with daily function, as well as trouble with twisting, squatting, and kneeling. In future studies of whether TKR is appropriate for people with low pain, it will be important to consider the limitations that patients experience when trying to perform these activities.

Why It’s Important

Although total knee replacement (TKR) is common practice as a treatment for advanced osteoarthritis, not all patients experience the same degree of pain relief and knee function after this procedure. Physical therapy (PT) is prescribed immediately after the surgery in order to build muscle strength and improve mobility in the knee. We know that motivational interviewing or MI—a behavioral intervention that uses active listening to increase someone’s internal motivation—can change behavior in other areas, like addiction. We wanted to know if using MI alongside PT could help patients recover after TKR. We also wanted to discover which people might be more likely than others to benefit from MI.

What We Did

For six months following TKR, patients either (1) regularly spoke with a health coach in addition to their PT regimen, or (2) only underwent a PT regimen. We asked patients to rate their pain and knee function before surgery and six months after surgery. In addition, we asked patients to answer questions related to “pain catastrophizing,” a way of thinking in response to the experience of pain (e.g., “I worry my pain will never go away”). Our team at BWH analyzed the responses we got from patients.

What We Found

We saw improvement in both groups in terms of pain and functional ability, as well as high patient satisfaction with surgery six months after surgery. The patients who received MI improved more than the group only receiving PT; however, the difference was small. We believe it is likely that the medical support network of physicians, physical therapists, and nurses is enough motivation for patients to continue therapy in order to optimize improvement. Patients who reported having more pain catastrophizing thoughts were less likely to benefit from MI alongside PT.

Why It’s Important

Total knee arthroplasty (TKA) is one of the best treatments to decrease pain and restore function in osteoarthritis (OA), and more than 600,000 of these surgeries are performed every year in the United States. But some subgroups of people with OA may be less likely to receive TKA. The overall rates of TKA are lower for Hispanics and African Americans than for whites, and sex may affect TKA rates as well. From a health equity standpoint, it is important to understand racial, ethnic, and sex-based differences in who receives TKA.

What We Did

Using data from the Osteoarthritis Initiative, we calculated the risk of having a TKA over time in each sex, racial, or ethnic group. We determined whether demographic factors were related to the risk of TKA.

What We Found

Nonwhites with OA had lower rates of TKA than whites, adjusting for differences in their baseline severity of OA, pain, BMI, number of comorbidities, age, sex, and education. This finding confirms the racial differences in TKA use that have been observed in the general population, and highlights the need to address these racial disparities.

Why It’s Important

In light of the epidemic of opioid abuse in the United States, it is important to understand how opioid use practices after surgery vary internationally. Opioids are offered regularly after total joint replacement in the United States. But what about in developing countries? Operation Walk Boston, an international medical mission that performs total joint replacements in the Dominican Republic, provided an opportunity for cross-cultural comparison of opioid use to control pain before and after surgery.

What We Did

We interviewed surgeons in the Dominican Republic and the United States (22 in total). We asked about how surgeons help patients manage pain after total joint replacement, and the factors that go into the decision to prescribe certain medications. Our team analyzed the themes present in the interview transcripts.

What We Found

Decisions about prescribing pain medications were made differently in the two countries. American surgeons described giving patients more control in deciding which drugs to prescribe, while Dominican surgeons felt it was the doctor’s role to make these decisions. While Dominican doctors tended to follow a strict protocol for managing pain, American doctors said that prescriptions vary a lot for different patients and different doctors. In both countries, though, doctors said they try to avoid using opioids or use them for only a short time.

Differences in culture, medical practice, and the willingness to prescribe powerful opioids lead to very different strategies for pain management in the two countries.

Why It’s Important

In light of growing attention to the appropriateness of opioid use in the United States, it is important to understand how opioid use after surgery varies internationally. Opioids are offered regularly after total joint replacement (TJR) in the United States. But patients in some other countries request less opioid medication after TJR. The team of Operation Walk Boston, an international medical mission that performs TJR in the Dominican Republic, noticed that Dominican patients receive fewer opioids than patients in the United States and may manage their pain differently.

What We Did

We interviewed patients with advanced osteoarthritis (OA) who were scheduled to have a TJR. We asked open-ended questions about how they coped with pain, and how they expected to control their pain after the surgery. Then, our team analyzed the themes present in the interview transcripts.

What We Found

Most patients said they used drugs to manage pain only when necessary, and they usually used non-steroidal anti-inflammatory drugs. Many had a limited knowledge of opioid medications. Instead, patients described non-drug strategies to manage pain including relaxing, distracting oneself, exercise, faith, and prayer. Religion was used to explain pain (the idea that it was God’s will) and to cope. Personal strength and support from family members helped many patients endure pain. Patients expected to use similar strategies to manage pain after surgery.

This was the first qualitative study of how patients with advanced OA in a developing country manage their pain. It revealed a set of resources that Dominican patients use—including faith, family support, and minimal use of medications—that are different from those used by US patients.

Why It’s Important

Published studies suggest that nerve growth factor inhibitors (NGFi) relieve pain, but they may also lead to faster disease progression in osteoarthritis (OA) patients. We wanted to understand how low the cost and toxicity (negative drug effects) of NGFi would have to be in order to make them a cost-effective treatment for knee OA.

What We Did

Using the OAPol Model, we evaluated cost and toxicity thresholds under which NGFi would be a cost-effective option for knee OA treatment.

What We Found

We found that cost and the setting in which the drugs are given both play important roles in the cost-effectiveness of NGFi treatments. Our analyses also suggest that NGFi treatments could decrease the use of total knee replacement. The cost-effectiveness of this treatment will depend heavily on how the drugs are priced and on identifying patients who are suited to receive this treatment.

Why It’s Important

After total knee replacement (TKR), it is important to provide anticoagulant medications to help prevent potentially dangerous clotting events: deep vein thrombosis (DVT) and pulmonary embolism (PE). Currently, there are not clear guidelines about the best medications to use or how long they should be prescribed. Our goal was to provide guidance for physicians making these treatment decisions.

What We Did

We assessed the cost-effectiveness of different strategies for anticoagulation after TKR. We chose a variety of strategies that are realistic options in clinical practice.

What We Found

A 35-day course of rivaroxaban or of warfarin were the treatments most likely to be cost-effective after TKR. For all the medications we studied, extending the treatment from 14 days to 35 days increased the cost-effectiveness.

Why It’s Important

There is great interest in how we can help people increase their physical activity (PA) and promote weight loss. PA has many health benefits for those with chronic conditions, but few adults do the recommended amount of PA. Financial incentives (FI) can be used to give an immediate reward for healthy behavior. FI has been successful in increasing healthy behavior in a number of studies, but the data are limited for PA in those with chronic conditions.

What We Did

Using several databases, we searched for randomized controlled trials (RCTs) that met our requirements: assigning some participants to receive financial incentives (FI) for reaching their PA or weight loss goals and some to a control group not receiving FI, measuring PA objectively, and including people with chronic conditions and/or sedentary lifestyles.

What We Found

The combined results show that FI helps to increase PA and weight loss in adults with chronic conditions or sedentary lifestyles.

Why It’s Important

Postinjection paralysis (PIP) and gluteal fibrosis (GF) are two disabling conditions that may be caused by injection practices. In Uganda, they are common in children, but the exact numbers of children with these conditions was not known.

What We Did

We reviewed musculoskeletal (MSK) clinic logs and community outreach logs from the Kumi Hospital in Kumi, Uganda, to find cases of GF and PIP. We calculated the proportion of all children seen in these clinics who had a diagnosis of GF or PIP.

What We Found

Over 30% of MSK clinic visits and 40% of all outreach visits were due to GF or PIP. This highlights the need for research, treatment, and prevention of these conditions.

Why It’s Important

Celecoxib is a specific type of non-steroidal anti-inflammatory drug (NSAID) and is used to treat osteoarthritis (OA). This type of NSAID may carry a higher risk of cardiovascular side effects but has a lower risk of gastrointestinal side effects. We wanted to understand whether using generic celecoxib is cost-effective compared with traditional NSAIDs.

What We Did

Using the OAPol model, we assessed the clinical outcomes, costs, and cost-effectiveness of generic celecoxib in people with knee OA. We compared celecoxib with several other common, NSAID-based treatments.

What We Found

In knee OA patients with no comorbid conditions, we found that generic celecoxib is not cost-effective at its current cost of $880/year. Costs and/or cardiovascular side effects would have to be lower for celecoxib to be cost-effective.

Why It’s Important

Musculoskeletal conditions are common in low-resource countries and contribute to substantial disability. We have limited data on the specific conditions that are common in different countries, especially among children. Some conditions can be treated surgically, so it is important to understand how common they are and whether people are receiving appropriate care.

What We Did

We reviewed the notes for almost 5,000 children who were treated in musculoskeletal clinics at a hospital in Kumi, Uganda or in nearby communities. We noted the diagnosis and what treatment was recommended in each case.

What We Found

The most common conditions were contractures, post-injection paralysis, and infection. Some of these are caused by injections. We estimate that 50% of these cases could be prevented through earlier treatment and through policy and education to change injection practices. Detailed information on musculoskeletal conditions can help health officials make decisions about how to use healthcare resources.

Why It’s Important

Many patients with knee osteoarthritis and meniscal tear have synovitis, which refers to inflammation in the synovial membrane (a membrane located in the knee). Synovitis is important because it is associated with pain and worsening of osteoarthritis. Patients also often notice swelling in their knees. We wanted to know whether swelling can help us identify who will have synovitis as shown on MRI.

What We Did

We looked at reports of knee swelling among 276 subjects. About half had synovitis confirmed on an MRI. We assessed how well the patients’ own reports of swelling could predict who would have synovitis on MRI.

What We Found

Patient-reported swelling had only a modest ability to predict who would have synovitis on MRI. Clinically, swelling reported by patients is not an especially useful marker of synovitis on MRI.

Why It’s Important

Most people who receive a total knee replacement (TKR) do not substantially increase their physical activity after the TKR, despite having improved pain. A combination of health coaching and financial incentives can help people increase their physical activity after TKR.

What We Did

We used the OAPol Model to evaluate the cost-effectiveness of a program of health coaching and financial incentives, compared to usual care.

What We Found

Health coaching plus financial incentives is a cost-effective choice in this population if the physical activity levels that people achieve during the intervention persist.

Why It’s Important

In individuals who have knee osteoarthritis (OA) and BMI over 40, weight loss is associated with improved pain, function, and quality of life. Bariatric surgery is an effective weight loss procedure. Bariatric surgery can be considered in this group both to help with weight loss and as a treatment for OA symptoms.

What We Did

We examined trends in the bariatric surgeries performed on adults with a diagnosis of knee OA between 2005 and 2014, using data from the National Inpatient Sample. We collected data on the hospital characteristics, demographics, and surgical outcomes.

What We Found

Although the use of bariatric surgery in this population stayed constant between 2005 and 2014, the types of surgery were becoming less invasive and rates of complications decreased.

Why It’s Important

An intensive diet and exercise (D+E) program can be an effective way to reduce weight and relieve pain for patients with knee osteoarthritis (OA), as shown in the IDEA (Intensive Diet and Exercise for Arthritis) trial.

What We Did

We wanted to know whether it is cost-effective to augment typical OA treatments with a D+E intervention like the one in the IDEA trial in overweight and obese patients. We used the OAPol Model to estimate the quality-adjusted life expectancy (the time subjects live, weighted by their quality of life during that time) and lifetime costs for patients, either with or without this D+E program.

What We Found

Adding D+E to usual care in these patients was cost-effective and should be considered as part of clinical care.

Why It’s Important

Thigh muscle strength is important for helping people maintain their physical function and activities. People with knee osteoarthritis (OA) and a torn meniscus often have weaker thigh muscles than people without OA, which can contribute to worse pain, mobility, and function. We wanted to understand how thigh muscle strength relates to important clinical outcomes: pain, ability to do daily activities, and performance on functional tests.

What We Did

We tested the hamstrings and quadriceps strength of patients using a hand-held dynamometer. We assessed whether strength was associated with pain and other clinical outcomes.

What We Found

The group with the strongest quadriceps had less pain, better function, and better mobility, compared with those who had the weakest quadriceps. The same was true when comparing subjects with the strongest and weakest hamstrings.

Why It’s Important

Living with a chronic illness, such as arthritis, can require individuals to seek out healthcare, buy medication, and do other things to protect their health. Doing all this is especially challenging for individuals who live in resource-limited settings.

What We Did

We interviewed adults with arthritis in the Dominican Republic who were scheduled to receive total knee or total hip replacements. We then conducted an analysis to identify strategies that the participants use to get medical care or to make do without it.

What We Found

Dominicans with limited resources in our study used a broad variety of strategies to manage their illnesses. Their strategies fall along a spectrum from “making do with less” to finding more resources, such as loans or help with transportation to appointments. Understanding these strategies can help providers discuss treatments with their patients in resource-limited settings.

Why It’s Important

A substantial number of people with higher BMI (body mass index) undergo total knee replacement (TKR) each year. Some studies have suggested that patients with high BMI have a higher risk of medical complications after TKR compared to those with lower BMI. But we wanted to find out whether they have the same outlook in terms of improved pain and knee function following knee replacement surgery.

What We Did

We analyzed data from 633 participants who had received a TKR and filled out questionnaires at 3, 6, and 24 months after surgery. We grouped participants into the 5 BMI categories used by World Health Organization: normal weight, overweight, class-I obese, class-II obese, and class-III obese.

What We Found

Study participants in higher BMI categories started with worse pain and function, but they had larger improvements in pain and function at 3 months after surgery. By 24 months, people in all BMI categories had similar knee function and pain scores.

Why It’s Important

Adaptive sports can provide many benefits for people with disabilities. But many people who are eligible for adaptive sports do not participate. For that reason, there is interest in helping more people take part in adaptive sports. Qualitative studies can help us understand the experiences that individuals have when they do participate in adaptive sports in order to promote participation.

What We Did

We held focus groups with 17 current and former participants in the adaptive sports programs of a Boston rehabilitation hospital. Focus groups were audio-recorded and transcribed. We analyzed the transcripts to identify themes related to a) the benefits that sports participants say they experience and b) barriers to taking part in the sports program.

What We Found

Individuals who participated regularly reported that the sports programs benefited their physical health and helped them maintain positive ideas about themselves. However, they had to overcome several challenges including: transportation difficulties, the risk of being injured, and a lack of information about what each adaptive sport looks like and what skills are required. Our findings suggest ways that adaptive sports programs can promote knowledge about adaptive sports and help people overcome problems with access.

Why It’s Important

The prevalence of knee injuries is rising, and several studies have shown that knee injuries are associated with increased risk for knee osteoarthritis (OA). It is important to understand the risk of developing OA that patients face when they have already had injuries such as ACL (anterior cruciate ligament) tears.

What We Did

We used the OAPol model to forecast the risk of knee OA over the course of the lifetime in individuals who had a complete ACL tear by age 25. We also estimated their lifetime risk of undergoing total knee replacement (TKR).

What We Found

Having an ACL tear before the age of 25 puts people at higher lifetime risk for developing knee OA and for having a TKR. Those who also have a meniscal tear (MT) are at even higher risk. This study highlights the importance of preventing knee injury in young adults.

Why It’s Important

After a total knee replacement (TKR) most people do not increase the amount of physical activity (PA) they do, even if their knee pain and function improve. There is a lot of interest in finding strategies that might help people do more PA following TKR.

What We Did

We assigned participants to one of four treatments after their knee replacement surgery: attention control, health coaching conducted over the telephone, financial incentives, or a combination of health coaching and financial incentives. We asked participants to wear a Fitbit Zip before their surgery and after the intervention (at 6 months) so that we could measure their activity. We measured how many minutes of PA each participant had and how many steps each participant took daily.

What We Found

The combined intervention—health coaching and financial incentives—led to substantial increases in daily steps and daily minutes of physical activity.

Why It’s Important

Using opioids to manage pain in knee osteoarthritis (OA) involves trade-offs; pain relief is greater, but there are higher toxicities (negative effects), and patients on opioids must be monitored more frequently. In addition, many patients with OA will eventually have a total knee replacement (TKR), and those who take opioids have worse outcomes after TKR. Although the use of opioids is increasing, there are not clear guidelines for using opioids in the treatment of OA.

What We Did

We used the OAPol model to evaluate the cost-effectiveness of tramadol and oxycodone in individuals with knee OA, but with no other chronic diseases. We used published studies to find input values for the model—information about how much pain reduction and what side effects a group of patients is likely to experience due to the drugs.

What We Found

Neither tramadol nor tramadol plus oxycodone was a cost-effective treatment for knee OA. Both treatments increased cost and decreased quality adjusted life expectancy, mainly because they lead to worse pain relief after TKR. Future research should continue to investigate the impact opioids have on the outcomes of TKR.

Why It’s Important

We studied behavior in a workplace program that used financial incentives to encourage people to do more physical activity. We wanted to know if several geographic and weather-related factors that generally influence physical activity would also have an influence on participants in this program.

What We Did

We measured associations between participants’ moderate to vigorous physical activity (MVPA) and influences from the environment: weather (temperature, rain, snow, and wind) and geography (urban or rural location, distance from home to work).

What We Found

Participants who lived farther from work and in urban locations did fewer minutes of MVPA on average. Cold weather was associated with less physical activity. Future financial incentives programs may wish to consider these factors in their design.

Why It’s Important

Many patients with osteoarthritis (OA) also have multiple other chronic conditions (comorbidities) that make physicians cautious about recommending first-line OA treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs). Adding stronger pain medications can bring greater pain relief, but these medications also carry a risk of serious side effects.

What We Did

Using the OAPol Model, we examined the long-term outcomes of using NSAIDs and opioids to treat pain in patients with knee OA and multiple other chronic conditions. We assessed pain relief, ill effects such as fractures, costs, and quality-adjusted life expectancy (the time subjects live, weighted by their quality of life during that time).

What We Found

We found that, for this group of older adults with multiple chronic conditions, certain NSAIDs (naproxen and ibuprofen) were more effective and cost-effective in managing OA pain than opioids or the other NSAIDs (including celecoxib).

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