Short-Term Recovery Trajectories of Acute Flares in Knee Pain: A UK-Netherlands Multicenter Prospective Cohort Analysis.
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ABSTRACT: Objective
To identify distinct recovery trajectories of acute flares of knee pain and associated participant characteristics.Methods
Data were from the FLARE randomized controlled trial, a multicenter trial in 27 primary care centers in the UK and Netherlands of 3 regimes of oral nonsteroidal antiinflammatory therapy for acute flares of knee pain. Individuals with a history of inflammatory/crystal arthritis, fibromyalgia, and chronic pain syndrome were excluded. Latent class growth analysis was applied to measures of pain intensity repeated over 5 days to identify distinct recovery trajectories. The concurrent courses of interference with activity, stiffness, and swelling for each trajectory group were modelled using generalized estimating equations. Participant age, sex, obesity, and osteoarthritis diagnosis were described for each trajectory group.Results
A total of 449 participants were included (median age 55 years, 41% female, 35% obese, and 42% diagnosed with osteoarthritis). A 6-group cubic model was deemed optimal, with trajectories distinguished by rate of pain reduction and absolute level at final measurement. At the extremes were rapid and near-complete resolution (n = 41, 9%) and persistent, high pain (n = 25, 6%), but most participants showed a reduction and plateau in pain severity within 3-5 days. Within each pain trajectory group, interference with activity, stiffness, and swelling followed the same course as pain. Baseline characteristics did not differ substantially between trajectory groups.Conclusion
Even under a well-adhered to regime of oral nonsteroidal antiinflammatory medication, recovery following acute flares of knee pain is heterogeneous. Our observations that favorable trajectories are apparent within 3-5 days can help to inform treatment decision-making in the patient-health care professional consultation.
SUBMITTER: Thomas MJ
PROVIDER: S-EPMC7145729 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionDifferent multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes.MethodsData from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea.ResultsIn 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3).ConclusionIn conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.
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Project description:Understanding the plasma proteome dynamics in sepsis patients is crucial for improving prognostic and therapeutic strategies, as sepsis remains a leading cause of mortality in intensive care units. In this study, 363 patients with newly diagnosed sepsis were enrolled and plasma was collected on the first and fourth day after diagnosis. Proteome analysis was performed using liquid chromatography–tandem mass spectrometry. The plasma proteome was analyzed via classical statistical analysis and machine learning to identify associations with 30-day survival. Out of 363 sepsis patients, 224 survived and 139 did not survive the 30-day period. Significant differences in the abundance of 87 proteins on day 1 and 95 proteins on day 4 were found between survivors and non-survivors. Additionally, between days 1 and 4, 63 proteins were differentially regulated between both groups. We found that protein regulations within the first days of sepsis were generally associated with a worse outcome. Statistical analysis revealed the underlying proteins to be foremost related to blood coagulation, immune response and complement activation. Complementarily, the machine learning classifier achieved an area under the receiver operating characteristic curve of 0.75 for predicting 30-day survival. The feature importance analysis highlighted additional proteins and substantiated the findings of univariate statistics. This study describes the temporal alterations of the plasma proteome and the underlying protein networks that are associated with survival. These findings enhance the understanding of sepsis pathophysiology and the identified proteins might serve as starting points for further investigations and guide the development of targeted therapeutic strategies.
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Project description:Importance:Studies to date have not comprehensively examined pain experience after total knee arthroplasty (TKA). Discrete patterns of pain in this period might be associated with pain outcomes at 6 to 12 months after TKA. Objectives:To examine patterns of individual post-TKA pain trajectories and to assess their independent associations with longer-term pain outcome after TKA. Design, Setting, and Participants:This prospective cohort study combined data from a national US TKA cohort with ancillary pain severity data at 2 weeks and 8 weeks after the index TKA using a numeric rating scale. All participants received primary, unilateral TKA within the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR) national network of community sites in 22 states or at the lead site (University of Massachusetts Medical School). Participants had a date of surgery between May 1, 2013, and December 1, 2014. The data analysis was performed between January 13, 2015, and July 5, 2016. Exposures:Pain trajectories in the postoperative period (8 weeks). Main Outcomes and Measures:Index knee pain at 6 months after TKA using the Knee Injury and Osteoarthritis Outcome Score (KOOS) pain scale. Group-based trajectory methods examined the presence of pain trajectories in the postoperative period (8 weeks) and assessed whether trajectories were independently associated with longer-term pain (6 months). Results:The cohort included 659 patients who underwent primary TKA with complete data at 4 points (preoperative, 2 weeks, 8 weeks, and 26 weeks). Their mean (SD) age was 67.1 (8.0) years, 64.5% (425 of 659) were female, the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 30.77 (5.66), 94.5% (613 of 649) were white, and the mean (SD) preoperative 36-Item Short Form Health Survey physical component summary and mental component summary scores were 34.1 (8.2) and 53.8 (11.4), respectively. Two pain trajectory subgroups were identified at 8 weeks after TKA: patients who experienced fast pain relief in the first 8 weeks after TKA (fast pain responders, composing 72.4% [477 of 659] of the sample) and patients who did not (slow pain responders, composing 27.6% [182 of 659] of the sample). After adjusting for patient factors, the pain trajectory at 8 weeks after TKA was independently associated with the mean KOOS pain score at 6 months, with a between-trajectory difference of -11.3 (95% CI, -13.9 to -8.7). Conclusions and Relevance:The trajectory among slow pain responders at 8 weeks after surgery was independently associated with improved but greater persistent index knee pain at 6 months after TKA compared with that among fast pain responders. Early identification of patients with a trajectory of slow pain response at 8 weeks after TKA may offer an opportunity for interventions in the perioperative period to potentially improve the long-term pain outcomes after TKA.
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Project description:IntroductionEarly postoperative pain following total knee arthroplasty significantly impacts outcomes and patient satisfaction. However, the characteristics and sources of early pain after total knee arthroplasty remain unclear. Therefore, the purpose of this study was to determine the anatomic distribution and course of postoperative pain in the acute and subacute period following total knee arthroplasty.MethodsA prospective observational study of primary, elective unilateral total knee arthroplasty cases was conducted at our academic tertiary care medical center from January 2021 to September 2021. Preoperative variables were extracted from institutional electronic medical records. Postoperatively, patients utilized a knee pain map to identify the two locations with the most significant pain and rated it using the visual analog scale (VAS). The data were collected on day 0, at 2 weeks, 2 months, and 6 months after operation.ResultsThis study included 112 patients, with 6% of patients having no pain at postoperative day 0, 22% at 2 weeks, 46% at 2 months, and 86% at 6 months after operation. In those who reported pain, the VAS score (mean ± standard deviation) was 5.8 ± 2.4 on postoperative day 0 and decreased at each follow-up time point (5.4 ± 2.3 at 2 weeks, 3.9 ± 2.2 at 2 months, and 3.8 ± 2.7 at 6 months). The majority of patients were able to identify distinct loci of pain. The most common early pain loci were patellae, thigh, and medial joint line, and this distribution dissipated by 6 months.ConclusionAt 2 postoperative weeks, pain was primarily at the medial joint, and at 6 months postoperatively, pain was more likely to be at the lateral joint. No relationship was found between pain at six months and pain scores or location at postoperative day 0 or 2 weeks. Understanding the distribution and progression of knee pain following total knee arthroplasty may benefit patient education and targeted interventions.Level of evidenceLevel II, prospective observational study.
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Project description:ObjectivePain persistence following knee replacement (KR) occurs in ∼20-30% of patients. Although several studies have identified preoperative risk factors for persistent post-KR pain, few have focused on post-KR contributing factors. We sought to determine whether altered nociceptive signaling and other peripheral nociceptive drivers present post-operatively contribute to post-KR pain.DesignWe included participants from the Multicenter Osteoarthritis Study who were evaluated ∼12 months after KR. We evaluated the relation of measures of pain sensitivity [pressure pain threshold (PPT), temporal summation (TS), and conditioned pain modulation (CPM)] and the number of painful body sites to post-KR WOMAC knee pain, and of the number of painful sites to altered nociceptive signaling using linear or logistic regression models, as appropriate.Results171 participants (mean age 69 years, 62% female) were included. TS was associated with worse WOMAC pain post-KR (β = 0.77 95% CI:0.19-1.35) and reduced odds of achieving patient acceptable symptom state (aOR = 0.54 95%CI:0.34-0.88). Inefficient CPM was also associated with worse WOMAC pain post-KR (β = 1.43 95% CI:0.15-2.71). In contrast, PPT was not associated with these outcomes. The number of painful body sites present post-KR was associated with TS (β = 0.05, 95% CI:0.01, 0.05).ConclusionsPost-KR presence of central sensitization and inefficient descending pain modulation was associated with post-KR pain. We also noted that presence of other painful body sites contributes to altered nociceptive signaling, and this may thus also contribute to the experience of knee pain post-KR. Our findings provide novel insights into central pain mechanisms and other peripheral pain sources contributing to post-KR persistent knee pain.
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Project description:ObjectiveIt is not clear why some individuals develop pain with knee osteoarthritis (OA). We undertook this study to identify pain susceptibility phenotypes (PSPs) and their relationship to incident persistent knee pain (PKP) 2 years later.MethodsWe identified individuals free of PKP from the Multicenter Osteoarthritis Study, a longitudinal cohort of older adults with or at risk of knee OA. Latent class analysis was used to determine PSPs that may contribute to development of PKP apart from structural pathology. These included widespread pain, poor sleep, and psychological factors as well as pressure pain threshold and temporal summation (TS) as determined by quantitative sensory testing (QST). We used logistic regression to evaluate the association of sociodemographic factors with PSPs and the relationship of PSPs to the development of PKP over 2 years.ResultsA total of 852 participants were included (mean age 67 years, body mass index 29.5 kg/m2 , 55% women). Four PSPs were identified, primarily characterized by varying proportions (low/absent, moderate, or high) of the presence of pressure pain sensitivity and of facilitated TS, reflecting different measures of sensitization. Subjects in the PSP with a high proportion of pressure pain sensitivity and a moderate proportion of facilitated TS were twice as likely to develop incident PKP over 2 years (odds ratio 1.98 [95% confidence interval 1.07-3.68]) compared with subjects in the PSP having a low proportion of sensitization by both measures.ConclusionFour PSPs were identified, 3 of which were predominated by QST evidence of sensitization and 1 of which was associated with developing PKP 2 years later. Prevention or amelioration of sensitization may be a novel approach to preventing onset of PKP in OA.
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Project description: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.
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Project description:Background and purposePatients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but worse results are reported after revision surgery than after primary surgery. The trajectory of post-operative recovery during the first months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compare them with those observed after primary hip arthroplasty.MethodsThis study is a prospective cohort study of patients undergoing primary (n = 80 with 92% for an indication of osteoarthritis) and revision (n = 43) hip arthroplasties. WOMAC pain and function scores and walking speed were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of change (0-3 months and 3-12 months) between types of surgery.ResultsThe improvements in pain and function following revision arthroplasty occurred within the first 3-months with no evidence of further change beyond this initial period. While the pattern of recovery was similar to the one observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty. Patients listed for revision surgery reported lower pre-operative pain levels but similar post-operative levels compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty.ConclusionThe post-operative improvements in pain and function are larger following primary hip arthroplasty than following revision hip arthroplasty. Irrespectively of surgery type, most of the improvements occur in the first three post-operative months. More research is required to identify whether the recovery following revision surgery could be improved with specific post-operative interventions.
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