Does aerobic exercise effect pain sensitisation in individuals with musculoskeletal pain? A systematic review.

BACKGROUND: Pain sensitisation plays a major role in musculoskeletal pain. However, effective treatments are limited, and although there is growing evidence that exercise may improve pain sensitisation, the amount and type of exercise remains unclear. This systematic review examines the evidence for an effect of aerobic exercise on pain sensitisation in musculoskeletal conditions. METHODS: Systematic searches of six electronic databases were conducted. Studies were included if they examined the relationship between aerobic physical activity and pain sensitisation in individuals with chronic musculoskeletal pain, but excluding specific patient subgroups such as fibromyalgia. Risk of bias was assessed using Cochrane methods and a qualitative analysis was conducted. RESULTS: Eleven studies (seven repeated measures studies and four clinical trials) of 590 participants were included. Eight studies had low to moderate risk of bias. All 11 studies found that aerobic exercise increased pressure pain thresholds or decreased pain ratings in those with musculoskeletal pain [median (minimum, maximum) improvement in pain sensitisation: 10.6% (2.2%, 24.1%)]. In these studies, the aerobic exercise involved walking or cycling, performed at a submaximal intensity but with incremental increases, for a 4-60 min duration. Improvement in pain sensitisation occurred after one session in the observational studies and after 2-12 weeks in the clinical trials. CONCLUSIONS: These findings provide evidence that aerobic exercise reduces pain sensitisation in individuals with musculoskeletal pain. Further work is needed to determine whether this translates to improved patient outcomes, including reduced disability and greater quality of life.

Association between clusters of back and joint pain with opioid use in middle-aged community-based women: a prospective cohort study.

BACKGROUND: To determine the relationship between clusters of back pain and joint pain and prescription opioid dispensing. METHODS: Of 11,221 middle-aged participants from the Australian Longitudinal Study of Women's Health, clusters of back pain and joint pain from 2001 to 2013 were identified using group-based trajectory modelling. Prescription opioid dispensing from 2003 to 2015 was identified by linking the cohort to Pharmaceutical Benefit Scheme dispensing data. Multinomial logistic regression was used to examine the association between back pain and joint pain clusters and dispensing of prescription opioids. The proportion of opioids dispensed in the population attributable to back and join pain was calculated. RESULTS: Over 12 years, 68.5 and 72.0% women reported frequent or persistent back pain and joint pain, respectively. There were three clusters ('none or infrequent', 'frequent' and 'persistent') for both back pain and joint pain. Those in the persistent back pain cluster had a 6.33 (95%CI 4.38-9.16) times increased risk of having > 50 opioid prescriptions and those in persistent joint pain cluster had a 6.19 (95%CI 4.18-9.16) times increased risk of having > 50 opioid prescriptions. Frequent and persistent back and joint pain clusters together explained 41.7% (95%CI 34.9-47.8%) of prescription opioid dispensing. Women in the frequent and persistent back pain and joint pain clusters were less educated and reported more depression and physical inactivity. CONCLUSION: Back pain and joint pain are major contributors to opioid prescription dispensing in community-based middle-aged women. Additional approaches to reduce opioid use, targeted at those with frequent and persistent back pain and joint pain, will be important in order to reduce the use of opioids and their consequent harm in this population.

Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: Data from the Australian Longitudinal Study on Women's Health.

OBJECTIVE: There are concerns that lumbar spine imaging represents low value care. Our aim was to examine the use of lumbar spine imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] over 20 years, and costs and person-level characteristics of imaging in a large cohort of Australian women. METHODS: The Australian Longitudinal Study on Women's Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973-1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database. RESULTS: 38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. In women with self-reported back pain, depression and poorer physical health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30-39 years were AU$51,735,649 over 2011-2015. CONCLUSIONS: Lumbar spine imaging was common in population-based Australian women, with rates increasing over 20 years. Depression and poor physical health were associated with lumbar spine imaging. Raising awareness of this in clinicians is likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.

Association Between Inflammatory Biomarkers and Nonspecific Low Back Pain: A Systematic Review.

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

Associations between television viewing and physical activity and low back pain in community-based adults: A cohort study.

Two systematic reviews concluded that there was limited evidence to support an association between physical activity and sedentary behavior and developing low back pain (LBP). The aim of this study was to examine the associations of physical activity and television viewing time with LBP intensity and disability in community-based adults.Five thousand fifty-eight participants (44% men) of the Australian Diabetes, Obesity and Lifestyle Study had physical activity and television viewing time measured in 1999 to 2000, 2004 to 2005, and 2011 to 2012, and LBP intensity and disability assessed in 2013 to 2014 using the Chronic Pain Grade Questionnaire. Multinomial logistic regressions were used to estimate the odds ratio for LBP intensity and disability associated with physical activity and television viewing time. Analyses were adjusted for age, education, smoking, dietary guideline index score, body mass index, and mental component summary score. To test whether associations of physical activity or television viewing time with LBP intensity and disability were modified by sex, obesity, or age, interactions were tested using the likelihood ratio test.As gender modified the associations between physical activity and television viewing time and LBP disability (P = 0.05), men and women were examined separately. A total of 81.7% men and 82.1% women had LBP. Most men (63.6%) and women (60.2%) had low intensity LBP with fewer having high intensity LBP (18.1% men, 21.5% women). Most participants had no LBP disability (74.5% men, 71.8% women) with the remainder reporting low (15.8% men, 15.3% women) or high (9.7% men, 12.9% women) LBP disability. Insufficient physical activity (<2.5 hours/week) was not associated with LBP intensity or disability. High television viewing time (≥2 hours/day) was associated with greater prevalence of LBP disability in women (low disability OR 1.35, 95% CI 1.04-1.73; high disability OR 1.29, 95% CI 1.01-1.72).Although it needs to be confirmed in RCTs our findings suggest that targeting time spent watching television and possibly other prolonged sedentary behaviors may have the potential to reduce LBP disability in community-based adults, particularly in women.

A Dose-response relationship between severity of disc degeneration and intervertebral disc height in the lumbosacral spine.

INTRODUCTION: Varied definitions of disc pathology exist in the literature. Magnetic Resonance Imaging (MRI) classification systems incorporate several qualitative features including disc appearance, the distinction between the nucleus and the annulus, signal intensity and intervertebral disc height. The lack of a continuous measure has made it difficult to sensitively examine degenerative disc disease. This study sought to examine the relationship between disc degeneration and intervertebral disc height. METHODS: 72 community-based individuals not selected for low back pain had MRI from which the presence of lumbosacral disc degeneration was identified using the Pfirrmann grading system, and intervertebral disc height was measured. RESULTS: At each lumbosacral level, with higher grade of disc degeneration, intervertebral disc height was reduced (all p ≤ 0.003). Results remained unchanged when grade 5 disc degeneration, which necessitated a collapsed disc space, was excluded from analyses (all p ≤ 0.03). To quantify these associations, at each lumbosacral level, for every grade increase in disc degeneration, there was a reduction in intervertebral disc height, after adjusting for age, gender, Body mass index and smoking history (ß range from -0.98 mm to -1.60 mm, 95 % CI range from -2.37 to -0.31, all p ≤ 0.005). CONCLUSION: This study has demonstrated a negative dose-response relationship between increasing severity of disc degeneration with a reduction in intervertebral disc height. Although the assessment of disc degeneration incorporates a number of qualitative measures, these data substantiate the utility of intervertebral disc height as a quantitative and continuous outcome measure in epidemiological studies, and potentially clinical practice.

Could low grade bacterial infection contribute to low back pain? A systematic review.

BACKGROUND: Recently, there has been both immense interest and controversy regarding a randomised, controlled trial which showed antibiotics to be effective in the treatment of chronic low back pain (disc herniation with Modic Type 1 change). While this research has the potential to result in a paradigm shift in the treatment of low back pain, several questions remain unanswered. This systematic review aims to address these questions by examining the role of bacteria in low back pain and the relationship between bacteria and Modic change. METHODS: We conducted electronic searches of MEDLINE and EMBASE and included studies that examined the relationship between bacteria and back pain or Modic change. Studies were rated based on their methodological quality, a best-evidence synthesis was used to summarise the results, and Bradford Hill's criteria were used to assess the evidence for causation. RESULTS: Eleven studies were identified. The median (range) age and percentage of female participants was 44.7 (41-46.4) years and 41.5% (27-59%), respectively, and in 7 of the 11 studies participants were diagnosed with disc herniation. Nine studies examined the presence of bacteria in spinal disc material and all identified bacteria, with the pooled estimate of the proportion with positive samples being 34%. Propionibacterium acnes was the most prevalent bacteria, being present in 7 of the 9 studies, with median (minimum, maximum) 45.0% (0-86.0) of samples positive. The best evidence synthesis found moderate evidence for a relationship between the presence of bacteria and both low back pain with disc herniation and Modic Type 1 change with disc herniation. There was modest evidence for a cause-effect relationship. CONCLUSIONS: We found that bacteria were common in the spinal disc material of people undergoing spinal surgery. There was moderate evidence for a relationship between the presence of bacteria and both low back pain with disc herniation and Modic Type 1 change associated with disc herniation and modest evidence for causation. However, further work is needed to determine whether these organisms are a result of contamination or represent low grade infection of the spine which contributes to chronic low back pain.

Non-pharmacological interventions for preventing job loss in workers with inflammatory arthritis.

BACKGROUND: Work participation of patients with inflammatory arthritis (IA) is important not only economically but also for physical and psychological health. There is no Cochrane Review to date on studies of non-pharmacological interventions specifically aimed at preventing job loss in people with IA. OBJECTIVES: To assess the effects of non-pharmacological interventions that aim to prevent job loss, work absenteeism or improve work functioning for employees with IA (rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), other spondylarthritis (SpA) or IA associated with connective tissue diseases, such as Systemic Lupus Erythematosus (SLE)). SEARCH METHODS: We searched the following databases from inception up to 30 April 2014; The Cochrane Library (including Cochrane Central Register of Controlled Trials, i.e. CENTRAL and DARE), MEDLINE (PubMed), EMBASE (Embase.com), CINAHL (EbSCOhost), ClinicalTrials.gov and PsycINFO (ProQuest). We did not impose language restrictions in the search. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that evaluated interventions aimed at preventing job loss in adults of working age (18 to 65 years) diagnosed with IA, including RA, AS, PsA, SpA or other types of IA. Primary outcomes were job loss and sickness absenteeism and the secondary outcome was work functioning. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias in the included RCTs. MAIN RESULTS: We included three RCTs with a total of 414 participants at risk of job loss. The majority of participants had IA, most with RA and to a lesser degree AS. The interventions aimed to prevent job loss and improve work functioning in several ways: firstly by evaluating work changes or adaptations and secondly by providing any person-directed interventions including vocational counselling, advice or education. Interventions directly targeted at the work environment were minimal and included workplace visits (one trial) or any actions by an occupational physician (one trial). The duration or dose of the interventions varied from two 1.5-hour sessions (one RCT) over five months, two consultation and multidisciplinary treatments during three months (one RCT), to six to eight individual or group sessions over six months (also one RCT). All participants were recruited through rheumatology clinics, both in or outside hospitals. Included trials investigated job loss (n = two RCTs; 382 participants), work absenteeism and work functioning (n = one RCT; 32 participants). Overall, we evaluated the two smaller trials as having a high risk of bias and the large trial as having a low risk of bias. Trials showed marked differences in how they performed on risk of bias items, particularly on performance bias.We assessed the quality of the evidence using the GRADE approach and judged there to be very low quality evidence across the three reported outcomes. Of the two RCTs investigating job loss, the larger one (n = 242 participants) reported a large statistically significant reduction in job loss (relative risk (RR) = 0.35, 95% confidence interval (CI) 0.18 to 0.68) and the other RCT (n = 140) reported similar effects in both groups, although the CI was very wide (RR = 1.05, 95% CI 0.53 to 2.06). The latter one probably suffered from performance bias and we judged it to have a high risk of bias. The one small trial investigating sickness absenteeism found uncertain results at six months' follow-up (MD = -2.42 days, 95% CI -5.03 to 0.19). Finally, in the same small trial investigating work functioning using the Rheumatoid Arthritis-Work Instability Scale (RA-WIS), there was a moderate improvement of intermediate term work functioning (six months; scale range 0 to 23; mean improvement -4.67 points, 95% CI -8.43 to -0.91). We identified no adverse effects in the publications of the three trials. AUTHORS' CONCLUSIONS: This Cochrane review of three RCTs found very low quality evidence overall for job loss prevention interventions having an effect on job loss, work absenteeism and work functioning in workers with inflammatory arthritis. While this review highlights that further high quality RCTs are required, the results suggest that these strategies have potential to be effective.

Association of obesity and systemic factors with bone marrow lesions at the knee: a systematic review.

OBJECTIVE: The objective of this study was to systematically review the literature to determine whether obesity and systemic factors, including age, gender, heritability, dietary factors, smoking, serum and urine biomarkers of cartilage or bone metabolism, bone-related factors, and medication, are associated with knee bone marrow lesions (BMLs) identified on magnetic resonance imaging in asymptomatic pre-osteoarthritis and osteoarthritis populations. METHODS: Electronic searches of MEDLINE and EMBASE were performed from January 1, 1996 to September 30, 2012 using the following keywords: bone marrow lesion(s), bone marrow (o)edema, osteoarthritis, and knee. Studies examining obesity and non-biomechanical factors in relation to the presence, incidence, or change in BMLs were included. Two independent reviewers extracted data and assessed methodological quality of selected studies. Due to the heterogeneity of the studies, we performed a best evidence synthesis. RESULTS: Among 30 studies, 17 were considered high quality. The study populations were heterogeneous in terms of symptoms and radiographic knee osteoarthritis. There was strong evidence for an association between serum lipids and BMLs and no association between age and BMLs. There was moderate evidence for a relationship between obesity and BMLs. There was limited evidence for gender, smoking, C-telopeptide of type I collagen, anti-bone-resorptive treatments, licofelone, and chondroitin sulfate. There was a paucity of evidence for heritability and conflicting evidence for dietary fatty acids. CONCLUSION: There is strong evidence for serum lipids and moderate evidence for obesity as risk factors for knee BMLs. Given the role of BMLs in the pathogenesis of knee osteoarthritis, identification of modifiable risk factors of BMLs and therapeutic interventions targeting BMLs has the potential to reduce the burden of knee osteoarthritis.

Are biomechanical factors, meniscal pathology, and physical activity risk factors for bone marrow lesions at the knee? A systematic review.

OBJECTIVE: To systematically review the literature to determine whether biomechanical factors, meniscal pathology, and physical activity are risk factors for bone marrow lesions (BMLs) at the knee identified from magnetic resonance imaging in pre-osteoarthritis and osteoarthritis populations. METHODS: Electronic searches of MEDLINE and EMBASE were performed from January 1, 1996 to October 31, 2012 using the keywords of bone marrow lesion(s), bone marrow (o)edema, osteoarthritis, and knee. Studies examining biomechanical factors, meniscal pathology, or physical activity in relation to the presence, incidence, or change in BMLs at the knee were included. Two independent reviewers extracted the data and assessed the methodological quality of selected studies. Due to the heterogeneity of the studies, we performed a best evidence synthesis. RESULTS: Fifteen studies were included in this review, of which 9 were considered high quality. The study populations were heterogeneous in terms of the symptoms and radiographic knee osteoarthritis. There was strong evidence for relationships of mechanical knee alignment and meniscal pathology with BMLs in osteoarthritis populations. There was a paucity of evidence for a relationship between physical activity and BMLs. CONCLUSION: Despite the heterogeneity of included studies, these data suggest that mechanical knee alignment and meniscal pathology are risk factors for BMLs in knee osteoarthritis. It suggests that BMLs in individuals with osteoarthritis are more susceptible to mechanical knee alignment. Given the role of BMLs in the pathogenesis of knee osteoarthritis, identifying strategies to modify these risk factors will be important in slowing the progression and reducing the burden of knee osteoarthritis.

Sex hormones and structural changes in osteoarthritis: a systematic review.

AIM: To systematically review the evidence for a relationship between sex hormones and structural changes in osteoarthritis (OA). METHODS: Electronic searches of MEDLINE were performed in November-December 2010 and in February 2011 for studies of sex hormones and OA that met a predefined set of criteria. Both controlled trials and observational studies were eligible for inclusion. Two independent reviewers extracted the data and assessed the methodological quality of the included studies. Due to the heterogeneity of the studies, we were unable to perform a best evidence synthesis. However we have provided summaries for each section. RESULTS: Twenty-seven studies were included in this review, of which 11 were considered high quality. The evidence suggests an association between endogenous oestrogen and cartilage turnover and radiographic OA, and between testosterone and cartilage volume. There is also evidence for an association between exogenous oestrogen and cartilage and bone turnover, although its effects on radiographic and MRI structure as well as joint replacement are unclear. The evidence also supports an association between oestrogen receptor α and ß gene polymorphisms and OA. CONCLUSION: Although the heterogeneity of the studies means that there is insufficient evidence to form strong conclusions, the available evidence supports an effect of endogenous and exogenous oestrogen as well as oestrogen receptor polymorphisms on joint health.

Variation in rates of hip and knee joint replacement in Australia based on socio-economic status, geographical locality, birthplace and indigenous status.

BACKGROUND: Our understanding of the incidence of joint replacement across different subgroups of the Australian population is limited. This study investigated whether rates of hip and knee joint replacement vary according to socio-economic status, geographical locality, birthplace and indigenous status. METHODS: Data from the National Hospital Morbidity Database were obtained. All separations for primary hip or knee joint replacement with the principal diagnosis of arthritis were identified. Age-standardized procedure rates were compared based on socio-economic status, geographical locality, birthplace and indigenous status. RESULTS: Compared with age- and gender-matched individuals, rates of joint replacement overall were significantly lower in people living in the most disadvantaged (P < 0.05) and remote areas (P < 0.001), people born outside Australia (P < 0.05) and indigenous people (P < 0.001). However, there were some exceptions. Knee replacement rates were higher in the most disadvantaged areas than in the least disadvantaged areas (P < 0.01), and both hip and knee replacement rates were higher in regional areas than in major cities (P < 0.05). Males and females born in New Zealand and females born in the United Kingdom, Ireland and parts of Europe had a greater rate of hip replacement, and females from North Africa and the Middle East had a greater rate of knee replacement, than Australia-born people (P < 0.001). CONCLUSIONS: There is significant variation in the rates of primary total hip and knee replacement in Australia. Further investigation is needed to determine whether this simply reflects patterns of disease and disease risk factors, or is because of inequalities in health care, unmet need, and/or surgical or patient-related factors.

What is the effect of physical activity on the knee joint? A systematic review.

PURPOSE: Although several studies have examined the relationship between physical activity and knee osteoarthritis, the effect of physical activity on knee joint health is unclear. The aim of this systematic review was to examine the relationships between physical activity and individual joint structures at the knee. METHODS: Computer-aided searches were conducted up until November 2008, and the reference lists of key articles were examined. The methodological quality of selected studies was assessed based on established criteria, and a best-evidence synthesis was used to summarize the results. RESULTS: We found that the relationships between physical activity and individual joint structures at the knee differ. There was strong evidence for a positive association between physical activity and tibiofemoral osteophytes. However, we also found strong evidence for the absence of a relationship between physical activity and joint space narrowing, a surrogate method of assessing cartilage. Moreover, there was limited evidence from magnetic resonance imaging studies for a positive relationship between physical activity and cartilage volume and strong evidence for an inverse relationship between physical activity and cartilage defects. CONCLUSIONS: This systematic review found that knee structures are affected differently by physical activity. Although physical activity is associated with an increase in radiographic osteophytes, there was no related increase in joint space narrowing, rather emerging evidence of an associated increase in cartilage volume and decrease in cartilage defects on magnetic resonance imaging. Given that optimizing cartilage health is important in preventing osteoarthritis, these findings indicate that physical activity is beneficial, rather than detrimental, to joint health.

Urinary incontinence is associated with lower psychological general well-being in community-dwelling women.

OBJECTIVE: There are few studies documenting the impact of urinary incontinence (UI) on well-being in women. The aim of this study was to evaluate the relationships between different types of UI and general well-being in women in the community. METHODS: A cross-sectional survey of 542 community-dwelling women, aged 24 to 80 years, was conducted in July 2006. A detailed self-administered questionnaire was mailed to the study participants. UI was assessed using the Questionnaire for Urinary Incontinence Diagnosis, and well-being was assessed using the Psychological General Well-being Index (PGWBI). The relationships between types of UI and PGWBI scores were assessed using multiple regression analyses while adjusting for potential confounders. RESULTS: A total of 506 (94%) women provided data for analysis. Women with incontinence had a lower total PGWBI score (76.9 +/- 16.5) than did women with no UI (81.6 +/- 15.3; P = 0.001). The total PGWBI mean score was significantly lower in women with stress-only UI (77.8 +/- 16.2; P = 0.05) and mixed UI (74.2 +/- 17.8; P < 0.001) compared with women with no UI. There was no significant difference in the mean total scores between women with urge UI and women without UI. Stress-only UI was negatively associated with the PGWBI subdomains of self-control, general health, and vitality, whereas those with mixed UI had lower scores for all the PGWBI subdomains. The associations for UI remained significant after adjustment for age, systemic hormone therapy use, menopause status, smoking status, and regular exercise. CONCLUSIONS: Not only is UI associated with a significant reduction in well-being in community-dwelling women, but also, the relationship between different types of UI and well-being seems to differ.

Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review.

Although deep surgical site infection (SSI) is a major complication of primary total hip arthroplasty (THA), there are conflicting data regarding the incidence of deep SSI, and no comprehensive evaluation of the associated risk factors has been undertaken. We performed a systematic review of the literature; undertaking computer-aided searches of electronic databases, assessment of methodological quality, and a best-evidence synthesis. The incidence of SSI ranged from 0.2% before discharge to 1.1% for the period up to and including 5 years post surgery. Greater severity of a pre-existing illness and a longer duration of surgery were found to be independent risk factors for deep SSI. There is a need for high-quality, prospective studies to further identify modifiable risk factors for deep SSI after THA.

Women have increased rates of cartilage loss and progression of cartilage defects at the knee than men: a gender study of adults without clinical knee osteoarthritis.

OBJECTIVE: Women have an increased risk of knee osteoarthritis (OA). However, little is known about gender differences in cartilage health before the onset of clinical knee OA. The aim of this study was to examine whether there are longitudinal gender differences in knee cartilage in a cohort of healthy, asymptomatic adults with no clinical knee disease. METHODS: Two hundred seventy-one participants (169 women) aged between 50 and 79 years with no clinical history of knee pain or pathology were examined using magnetic resonance imaging at baseline and 2.3 years later. From these images, changes in tibial and patella cartilage volume and progression of cartilage defects were determined. RESULTS: In multivariate analyses, after adjustment for potential confounders, the average annual percentage loss of total tibial cartilage volume was significantly greater in women (1.6% [95% CI, 1.1-2.2]) than in men (0.4%[95% CI, -0.4 to 1.2]) (P = 0.05 for difference). Likewise, the female gender was also associated with an increased risk for the progression of tibiofemoral cartilage defects (odds ratio, 3.0; 95% CI, 1.1-8.1; P = 0.03). At the patella,the average annual percentage loss of cartilage volume was significantly greater in women (2.3% [95% CI, 1.7-2.8]) than in men (0.8% [95% CI, 0.1-1.6]) (P = 0.02 for difference). CONCLUSIONS: The female predisposition toward knee OA may, at least in part, be due to gender differences in cartilage health, even before the onset of clinical knee disease. Understanding the mechanism for these gender differences may provide a means to reduce the risk of knee OA in women.

Low back pain and disability in community-based women: prevalence and associated factors.

OBJECTIVE: Although low back pain is characterized by both pain and disability, there is a paucity of studies that have concurrently examined risk factors for these features in community-dwelling women. We aimed to investigate the prevalence and identify factors associated with both back pain and disability. DESIGN: A questionnaire was mailed to 542 women from a community-based research database. Detailed demographic data were collected, including participants' menopause, relationship, and employment status. Point and period prevalence estimates for back pain were derived. Participants were classified based on pain intensity and disability scores calculated from the Chronic Pain Grade Questionnaire, and factors associated with high levels of pain and disability were examined. RESULTS: A total of 506 (93.4%) women completed the questionnaire. More than 90% of participants had experienced low back pain, with 75.1% and 22.5% reporting pain in the past 12 months and currently, respectively. Seven percent of women reported a high level of disability and 16% reported high-intensity pain. Women with higher levels of disability were more likely to have a higher body mass index and to have pain currently, whereas those with greater pain intensity were more likely to be younger, have a higher body mass index, not be employed outside the home, drink alcohol, and have current pain. CONCLUSIONS: Low back pain is a common problem for community-based women. A high body mass index and current pain were factors independently associated with both high pain intensity and disability. Longitudinal investigation is required to determine the predictive nature of these factors and their potential role in preventing pain and disability.

In-hospital outcomes and hospital resource utilization of hip replacement procedures.

BACKGROUND: Although the incidence of hip replacement surgery is rapidly increasing, there are few data describing the hospital resource utilization associated with these procedures. We aimed to examine the in-hospital outcomes and resource utilization of primary and revision hip replacement. METHODS: We analysed data from the 2005/2006 Victorian Admitted Episodes Database that included one or more of the International Classification of Diseases procedure codes for hip replacement. Demographic parameters and in-hospital outcomes, including length of stay, duration of intensive/coronary care and discharge destination, were examined. RESULTS: A total of, 7724 separations had a hip replacement. Primary procedures accounted for 86.8% of all separations. Of these, 79.3% were total hip replacements and the remainder were partial hip replacements. Most partial hips were managed (81.6%) and funded (60.0%) within the public system, whereas revisions were largely managed privately (59.0%). Revisions had less satisfactory outcomes than primary total hips, with 22.9% more revisions remaining in hospital for more than a week (P < 0.0001), 14.6% more requiring intensive care (P < 0.0001) and 10.9% less being discharged to a private residence (P < 0.001) (adjusting for confounders). Although primary partial and revision replacements accounted for only 16.8 and 13.2% of all hip replacements, they utilised up to 27.5 and 34.6% of hospital resources, respectively. CONCLUSION: Partial and revision hip replacements are resource intensive for the public and private health-care systems, respectively. It is imperative that strategies to reduce the incidence of these procedures are implemented, as failure to do so will have important implications for the allocation of health-care funding.

Outcomes of patients with orthopaedic trauma admitted to level 1 trauma centres.

BACKGROUND: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. METHODS: Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. RESULTS: Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. CONCLUSION: A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.