Pain trajectory groups in persons with, or at high risk of, knee osteoarthritis: findings from the Knee Clinical Assessment Study and the Osteoarthritis Initiative.

OBJECTIVE: The authors aimed to characterize distinct trajectories of knee pain in adults who had, or were at high risk of, knee osteoarthritis using data from two population-based cohorts. METHOD: Latent class growth analysis was applied to measures of knee pain severity on activity obtained at 18-month intervals for up to 6 years between 2002 and 2009 from symptomatic participants aged over 50 years in the Knee Clinical Assessment Study (CAS-K) in the United Kingdom. The optimum latent class growth model from CAS-K was then tested for reproducibility in a matched sample of participants from the Osteoarthritis Initiative (OAI) in the United States. RESULTS: A 5-class linear model produced interpretable trajectories in CAS-K with reasonable goodness of fit and which were labelled "Mild, non-progressive" (N = 201, 35%), "Progressive" (N = 162, 28%), "Moderate" (N = 124, 22%) "Improving" (N = 68, 12%), and "Severe, non-improving" (N = 15, 3%). We were able to reproduce "Mild, non-progressive", "Moderate", and "Severe, non-improving" classes in the matched sample of participants from the OAI, however, absence of a "Progressive" class and instability of the "Improving" classes in the OAI was observed. CONCLUSIONS: Our findings strengthen the grounds for moving beyond a simple stereotype of osteoarthritis as "slowly progressive". Mild, non-progressive or improving symptom trajectories, although difficult to reproduce, can nevertheless represent a genuinely favourable prognosis for a sizeable minority.

The epidemiology of self-reported intermenstrual and postcoital bleeding in the perimenopausal years.

OBJECTIVE: To obtain estimates of the rates of occurrence and spontaneous resolution of intermenstrual and postcoital bleeding, and investigate any association with underlying malignancy. DESIGN: Two-year prospective cohort study with medical record review during the survey period, and for the subsequent 2 years. SETTING: Seven general practices with 67 100 registered patients. POPULATION: All women aged 40-54 years on the practices age-sex registers. METHODS: Baseline postal questionnaire, with follow-up questionnaires sent to naturally menstruating respondents at 6, 12, 18 and 24 months. Medical record review using computerised searches from baseline to 48 months. MAIN OUTCOME MEASURES: Prevalence and incidence of intermenstrual and postcoital bleeding, and rate of spontaneous resolution. RESULTS: A total of 7121 baseline questionnaires were sent out, with an initial response rate of 66%. A total of 2104 naturally menstruating women were recruited for the prospective cohort study. The 2-year cumulative incidence of intermenstrual bleeding was 24% (95% CI 21-27%), and that of postcoital bleeding was 7.7% (95% CI 6.2-9.5%). The rates of spontaneous resolution without recurrence for 2 years were 37% (95% CI 29-45) and 51% (95% CI 40-62), respectively. Of the 785 women identified with intermenstrual and/or postcoital bleeding, only one developed uterine cancer. CONCLUSION: There is a high prevalence, incidence, and spontaneous rate of resolution of intermenstrual and postcoital bleeding in naturally menstruating women during the perimenopausal years. The association of these symptoms with malignancy is weak. This is of importance to women in deciding when to consult and to those devising public health campaigns concerning symptoms of possible oncological significance.

The spontaneous resolution of heavy menstrual bleeding in the perimenopausal years.

OBJECTIVE: To obtain estimates of the rate of spontaneous resolution of heavy menstrual bleeding and to explore any association with specific menstrual symptoms. DESIGN: Two-year prospective cohort study. SETTING: Seven general practices, with 67 100 registered patients. POPULATION: All women aged 40-54 years on the practices age-sex registers. METHODS: Baseline postal questionnaire, with follow-up questionnaires sent to naturally menstruating respondents at 6, 12, 18 and 24 months. MAIN OUTCOME MEASURES: Rate of spontaneous resolution of heavy menstrual bleeding in naturally menstruating women. RESULTS: A total of 7121 baseline questionnaires were sent out, with an initial response rate of 63%. We recruited 2051 naturally menstruating women for the prospective cohort study. The spontaneous rate of resolution of heavy menstrual bleeding varied from 8.1% (95% CI 5.3-12%) in women aged 45-49 years, who had resolution without recurrence for 24 months, to 35% (95% CI 30-41%) in women aged 50-54 years, who had resolution without recurrence for 6 months. Rates were lower in those who reported interference with life from heavy menstrual bleeding. There was a strong association between the spontaneous resolution of heavy menstrual bleeding and skipped periods in women aged over 45 years. The association with 'cycle too variable to say' was significant, but weaker. CONCLUSION: There is a high prevalence, incidence and significant spontaneous rate of resolution of heavy menstrual bleeding in naturally menstruating women during the perimenopausal years. The rates have potential use for individual women, clinical decisions, devising and implementing interventions and planning the care of populations.

Incidence, progression and sequence of development of radiographic knee osteoarthritis in a symptomatic population.

OBJECTIVES: Symptomatic knee osteoarthritis (OA) is a common disabling condition. Attention has tended to focus on the tibiofemoral joint (TFJ). However, there is evidence that the patellofemoral joint (PFJ) is involved in many cases, but its place in the sequence of development and progression of knee OA is unclear. This study estimates the cumulative incidence, progression and inter-relationship of radiographic changes of OA in the TFJ and the PFJ in symptomatic adults. METHODS: A population-based observational cohort of 414 adults aged ≥ 50 years with knee pain who had knee x-rays (weight-bearing posteroanterior semiflexed, skyline and lateral views) in 2002-3 and again in 2005-6 (mean interval 36.7 months) was studied. The outcome measure was the development of incident or progressive radiographic OA. RESULTS: The 3-year cumulative incidences of patellofemoral joint osteoarthritis (PFJOA) and tibiofemoral joint osteoarthritis (TFJOA) were 28.8% and 21.7%, respectively. Corresponding estimates of 3-year cumulative progression were 18.9% and 25.3%. PFJOA at baseline was common and increased the risk of incident TFJOA (adjusted OR 2.2, 95% CI 1.1 to 4.1) but less clearly progression of TFJOA (adjusted OR 1.7, 95% CI 0.3 to 9.0). TFJOA at baseline increased the risk of PFJOA incidence and progression (adjusted OR 3.1, 95% CI 1.2 to 8.4 and OR 4.5, 95% CI 1.8 to 11.2, respectively). CONCLUSIONS: These results suggest a common sequence in the development of radiographic knee OA in symptomatic adults beginning in the PFJ, with subsequent addition and progression of TFJOA. It is proposed that isolated symptomatic PFJOA may be one marker for the future development of TFJOA and a target for the early management of knee OA.

OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009.

OBJECTIVE: To update evidence for available therapies in the treatment of hip and knee osteoarthritis (OA) and to examine whether research evidence has changed from 31 January 2006 to 31 January 2009. METHODS: A systematic literature search was undertaken using MEDLINE, EMBASE, CINAHL, AMED, Science Citation Index and the Cochrane Library. The quality of studies was assessed. Effect sizes (ESs) and numbers needed to treat were calculated for efficacy. Relative risks, hazard ratios (HRs) or odds ratios were estimated for side effects. Publication bias and heterogeneity were examined. Sensitivity analysis was undertaken to compare the evidence pooled in different years and different qualities. Cumulative meta-analysis was used to examine the stability of evidence. RESULTS: Sixty-four systematic reviews, 266 randomised controlled trials (RCTs) and 21 new economic evaluations (EEs) were published between 2006 and 2009. Of 51 treatment modalities, new data on efficacy have been published for more than half (26/39, 67%) of those for which research evidence was available in 2006. Among non-pharmacological therapies, ES for pain relief was unchanged for self-management, education, exercise and acupuncture. However, with new evidence the ES for pain relief for weight reduction reached statistical significance, increasing from 0.13 [95% confidence interval (CI) -0.12, 0.36] in 2006 to 0.20 (95% CI 0.00, 0.39) in 2009. By contrast, the ES for electromagnetic therapy which was large in 2006 (ES=0.77, 95% CI 0.36, 1.17) was no longer significant (ES=0.16, 95% CI -0.08, 0.39). Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed. The ES for pain relief with acetaminophen diminished numerically, but not significantly, from 0.21 (0.02, 0.41) to 0.14 (0.05, 0.22) and was no longer significant when analysis was restricted to high quality trials (ES=0.10, 95% CI -0.0, 0.23). New evidence for increased risks of hospitalisation due to perforation, peptic ulceration and bleeding with acetaminophen >3g/day have been published (HR=1.20, 95% CI 1.03, 1.40). ES for pain relief from IA hyaluronic acid, glucosamine sulphate, chondroitin sulphate and avocado soybean unsponifiables also diminished and there was greater heterogeneity of outcomes and more evidence of publication bias. Among surgical treatments further negative RCTs of lavage/debridement were published and the pooled results demonstrated that benefits from this modality of therapy were no greater than those obtained from placebo. CONCLUSION: Publication of a large amount of new research evidence has resulted in changes in the calculated risk-benefit ratio for some treatments for OA. Regular updating of research evidence can help to guide best clinical practice.

Long-term outcome following total knee arthroplasty: a controlled longitudinal study.

OBJECTIVES: To assess long-term outcome and predictors of prognosis following total knee arthroplasty (TKA) for osteoarthritis. METHODS: We followed-up 325 patients from 3 English health districts approximately 6 years after TKA, along with 363 controls selected from the general population. Baseline data, collected by interview and examination, included age, sex, comorbidity, body mass index (BMI), functional status and preoperative radiographic severity of osteoarthritis. Functional status at follow-up was assessed by postal questionnaire. Predictors of change in physical function were analysed by linear regression. RESULTS: Between baseline and follow-up, patients reported an improvement of 6 points in median Short Form 36 Health Survey (SF-36) physical function score, whereas in controls there was a deterioration of 14 points (p<0.001). Median SF-36 vitality score declined by 10 points in patients and 5 points in controls (p = 0.005), while their median SF-36 mental health scores improved by 12 and 13 points, respectively (p = 0.2). The improvement in physical function was smaller in patients who were obese than in patients who were non-obese, but compared favourably with a substantial decline in the physical function of obese controls. Better baseline physical function and older age predicted worse changes in physical function in patients and controls. Improvement in physical function tended to be greater in patients with more severe radiological disease of the knee, and was less in those who reported pain at other joint sites at baseline. CONCLUSIONS: Improvements in physical function following TKA for osteoarthritis are sustained beyond 5 years. The benefits are apparent in patients who are obese as well as non-obese, and there seems no justification for withholding TKA from obese patients solely on the grounds of their body mass index.

Does isolated patellofemoral osteoarthritis matter?

OBJECTIVES: To describe the structure-pain and structure-function associations in isolated patellofemoral osteoarthritis (PF OA). DESIGN: Population-based study of 819 adults aged > or =50 years with knee pain. The severity of knee pain, stiffness and disability were measured using the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Three radiographic views of the knee were obtained. RESULTS: Isolated PF OA was mild in 142 participants and moderate/severe in 44. Mean WOMAC scores for pain, stiffness and function were associated with radiographic severity of PF OA (F(2,389)=4.7, P=0.01; F(2,392)=4.5, P=0.012 and F(2,392)=6.1, P=0.002, respectively, adjusted for age, gender, and body mass index (BMI)). Post-hoc tests demonstrated statistically significant differences for mean pain, stiffness and function score between those with mild PF OA and those with normal X-rays. In task-specific items there was evidence of a stepped response, the proportion of participants with moderate/severe/extreme pain or difficulty in performing everyday tasks increasing with the severity of PF OA. The strongest association was observed for pain going up and down stairs (age-gender-BMI adjusted odds ratio (OR) 3.0; 95% confidence interval (CI) 1.4,6.6. Functional tasks most strongly related to radiographic severity were: descending stairs (OR 3.2; (CI 1.5,6.5)), getting in/out of the bath (3.2; 1.5,6.6), getting in/out of a car (3.0; 1.4,6.1). CONCLUSIONS: Mild isolated PF OA is significantly associated with symptoms of pain, stiffness and functional limitation. Further research on its recognition in clinical practice and the development of targeted treatments to prevent or slow progression are warranted.

Hand problems in community-dwelling older adults: onset and effect on global physical function over a 3-year period.

OBJECTIVE: To determine the impact of the onset of hand problems on global physical functioning in community-dwelling older adults. METHODS: Three-year follow-up postal survey of a population sample of older adults (50 yrs and over) previously recruited to the North Staffordshire Osteoarthritis Project. Questionnaires at baseline and 3-yr collected data on joint pain in the past 12 months in the hands and lower limbs, and physical functioning [SF-36 subscale (PF-10)]. Onset of hand problems at 3 yrs was determined in two subgroups: (i) those free from hand problems and lower limb pain at baseline (n = 762) and (ii) those free from hand problems but with lower limb pain at baseline (n = 754). Changes in PF-10 scores from baseline to 3 yrs were examined in these two subgroups. RESULTS: Onset of hand problems was similar in the two subgroups (20.6 and 24.3% in those without and with baseline lower limb pain, respectively). Females had a higher onset than males but age had little influence. Significantly greater mean change in PF-10 scores was seen in those who reported hand problem onset compared with persons who remained free of hand problems; 8.47 vs 4.62 and 4.78 vs 1.08 in those without and with baseline lower limb pain, respectively. CONCLUSIONS: The development of hand problems has a detrimental effect on global physical functioning even in the absence of concurrent lower limb problems. The assessment and effective treatment of hand problems could prove to be important components of maintaining function in the older adult with joint pain and OA.

Predicting the course of functional limitation among older adults with knee pain: do local signs, symptoms and radiographs add anything to general indicators?

OBJECTIVE: To determine the additional prognostic value of clinical history, physical examination and x-ray findings to a previously derived simple generic model (age, body mass index, anxiety and pain severity) in a cohort of older adults with knee pain. METHODS: Prospective cohort study in community-dwelling adults in North Staffordshire. 621 participants (aged >or=50 years) reporting knee pain who attended a research clinic at recruitment and were followed up by postal questionnaire at 18 months. Poor functional outcome was measured by the Physical Functioning Scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 18-month follow-up defined in 60% of participants. RESULTS: Three clinical history variables (bilateral knee pain, duration of morning stiffness and inactivity gelling) were independently associated with poor outcome. The addition of the "clinical history" model to the "generic" model led to a statistical improvement in model fit (likelihood ratio (LR) = 24.84, p = 0.001). Two physical examination variables (knee tender point count and single-leg balance) were independently associated with poor outcome but did not lead to a significant improvement when added to the "clinical history and generic" model (LR = 6.34, p = 0.50). Functional outcome was significantly associated with severity of knee radiographic osteoarthritis (OA), but did not lead to any improvement in fit when added to the "generic, clinical history and physical examination" model (LR = 1.86, p = 0.39). CONCLUSIONS: Clinical history, physical examination and severity of radiographic knee OA are of limited value over generic factors when trying to predict which older adults with knee pain will experience progressive or persistent functional difficulties.

Predictors of onset and progression of knee pain in adults living in the community. A prospective study.

OBJECTIVE: To investigate determinants of the onset and progression of knee pain in a population-based sample of people aged > or = 50 yrs. METHODS: Prospective cohort study of 2982 people registered with three general practices in North Staffordshire, UK. Using questionnaire surveys at baseline and 3 yrs, demographic, knee-related and general health factors were assessed for their relationship with onset of new knee pain, and progression from non-severe to severe knee pain. RESULTS: Response rates were 77% (baseline) and 75% (follow-up). Baseline factors significantly associated with onset of knee pain were knee injury [odds ratio (OR) 1.6, 95% CI 1.2, 2.2], depression (OR 1.4, 95% CI 1.1, 1.8), widespread pain (OR 1.5, 95% CI 1.1, 1.9 compared with no pain) and younger age. Onset of severe knee pain was associated most strongly with obesity (OR 2.9, 95% CI 1.7, 5.1) and physical limitations (OR 2.5, 95% CI 1.5, 4.1), and with widespread pain, older age, female gender and comorbidity. The strongest independent predictors of progression from non-severe to severe knee pain were chronicity (OR 3.1, 95% CI 2.1, 4.6), previous use of health care (OR 2.2, 95% CI 1.5, 3.3) and obesity (OR 2.1, 95% CI 1.2, 3.6). CONCLUSION: In addition to a focus on obesity, there is potential for primary prevention of knee pain by tackling knee injuries and treating depression. Other factors are likely to determine whether the knee pain then progresses. An area for future research is the ineffectiveness of current health care in halting or reversing progression of knee pain at a population level.

How do pain and function vary with compartmental distribution and severity of radiographic knee osteoarthritis?

OBJECTIVES: In radiographic OA (ROA) of the knee, how does radiographic severity and pattern of compartmental involvement influence symptoms? METHODS: Population-based study of 819 adults aged > or =50 yrs with knee pain. The severity of knee pain and function were measured using the Western Ontario and McMaster Universities scale. Three radiographic views of the knees were obtained. RESULTS: Seven hundred and seventy-seven participants were eligible (mean age 65.5 yrs, 357 males). Higher ROA severity in each of the tibiofemoral (TF) and patellofemoral (PF) compartments was independently associated with higher mean pain scores (TF: F(2, 700) = 9.0, P < 0.0001, PF: F(2, 700) = 12.7, P < 0.0001). The same pattern was found for mean function scores (TF: F(2, 705) = 7.1, P = 0.001, PF: F(2, 705) = 15.9, P < 0.0001). If either the TF or PF compartment was affected by moderate/severe OA, the added presence of OA in the other compartment did not increase the mean pain or function scores. CONCLUSIONS: It is the severity of radiographic disease within a compartment, rather than the distribution of radiographic disease between compartments that is associated with symptoms. ROA in the PF joint is associated with symptoms, emphasizing the importance of radiographic changes in his joint.

Morbidity severity classifying routine consultations from English and Dutch general practice indicated physical health status.

OBJECTIVE: To investigate the construct validity of morbidity severity scales based on routine consultation data by studying their associations with sociodemographic factors and physical health. STUDY DESIGN AND SETTING: Study participants were 11,232 English adults aged 50 years and over and 9,664 Dutch adults aged 18 years and over, and their consulting morbidity data in a 12-month period were linked to their physical health data. Consulters with any of 115 morbidities classified on four ordinal scales of severity ("chronicity," "time course," "health care use," and "patient impact") were compared to all other consulters. RESULTS: As hypothesized, in both countries, morbidity severity was associated with older age, female gender, more deprivation (all comparisons P< or =0.05), and poor physical health (all trends P<0.001). The estimated strengths of association of poor physical health with the highest severity category expressed as odds ratios, for each of the four scales, were 5.4 for life-threatening on the "chronicity" scale, 1.8 for time course, 2.8 for high health care use, and 3.7 for high patient impact. CONCLUSIONS: Four scales of morbidity severity have been validated in English and Dutch settings, and they offer the potential to use simple routine consultation data as an indicator of physical health status in populations from general practice.

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice.

BACKGROUND: Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain. METHODS: For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat. FINDINGS: Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded. INTERPRETATION: Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies.

OBJECTIVES: There is little consensus regarding the burden of pain in the UK. The purpose of this review was to synthesise existing data on the prevalence of various chronic pain phenotypes in order to produce accurate and contemporary national estimates. DESIGN: Major electronic databases were searched for articles published after 1990, reporting population-based prevalence estimates of chronic pain (pain lasting >3 months), chronic widespread pain, fibromyalgia and chronic neuropathic pain. Pooled prevalence estimates were calculated for chronic pain and chronic widespread pain. RESULTS: Of the 1737 articles generated through our searches, 19 studies matched our inclusion criteria, presenting data from 139 933 adult residents of the UK. The prevalence of chronic pain, derived from 7 studies, ranged from 35.0% to 51.3% (pooled estimate 43.5%, 95% CIs 38.4% to 48.6%). The prevalence of moderate-severely disabling chronic pain (Von Korff grades III/IV), based on 4 studies, ranged from 10.4% to 14.3%. 12 studies stratified chronic pain prevalence by age group, demonstrating a trend towards increasing prevalence with increasing age from 14.3% in 18-25 years old, to 62% in the over 75 age group, although the prevalence of chronic pain in young people (18-39 years old) may be as high as 30%. Reported prevalence estimates were summarised for chronic widespread pain (pooled estimate 14.2%, 95% CI 12.3% to 16.1%; 5 studies), chronic neuropathic pain (8.2% to 8.9%; 2 studies) and fibromyalgia (5.4%; 1 study). Chronic pain was more common in female than male participants, across all measured phenotypes. CONCLUSIONS: Chronic pain affects between one-third and one-half of the population of the UK, corresponding to just under 28 million adults, based on data from the best available published studies. This figure is likely to increase further in line with an ageing population.

Clustering of pain and its associations with health in people aged 50†years and older: cross-sectional results from the North Staffordshire Osteoarthritis Project.

OBJECTIVE: Most pain in patients aged ≥50 years affects multiple sites and yet the predominant mode of presentation is single-site syndromes. The aim of this study was to investigate if pain sites form clusters in this population and if any such clusters are associated with health factors other than pain. SETTING: Six general practices in North Staffordshire, UK. DESIGN: Cross-sectional, postal questionnaire, study. PARTICIPANTS: Community-dwelling adults aged ≥50 years registered at the general practices. MAIN OUTCOMES MEASURES: Number of pain sites was measured by asking participants to shade sites of pain lasting ≥1 day in the past 4 weeks on a blank body manikin. Health factors measured included anxiety and depression (Hospital and Anxiety Depression Scale), cognitive complaint (Sickness Impact Profile) and sleep. Pain site clustering was investigated using latent class analysis. Association of clusters with health factors, adjusted for age, sex, body mass index and morbidities, was analysed using multinomial regression models. RESULTS: 13 986 participants (adjusted response 70.6%) completed a questionnaire, of whom 12 408 provided complete pain data. Four clusters of participants were identified: (1) low number of pain sites (36.6%), (2) medium number of sites with no back pain (31.5%), (3) medium number of sites with back pain (17.9%) and (4) high number of sites (14.1%). Compared to Cluster 1, other clusters were associated with poor health. The strongest associations (relative risk ratios, 95% CI) were with Cluster 4: depression (per unit change in score) 1.11 (1.08 to 1.14); cognitive complaint 2.60 (2.09 to 3.24); non-restorative sleep 4.60 (3.50 to 6.05). CONCLUSIONS: These results indicate that in a general population aged ≥50 years, pain forms four clusters shaped by two dimensions-number of pain sites (low, medium, high) and, within the medium cluster, the absence or presence of back pain. The usefulness of primary care treatment approaches based on this simple classification should be investigated.

Oral contraceptive pill use and fractures in women: a prospective study.

It has been suggested that use of the oral contraceptive pill by women confers protection against osteoporosis later in life. However, cross-sectional studies of bone density among pill users have yielded discrepant results. We therefore investigated the relationship between pill use and subsequent occurrence of fracture in a cohort of 46,000 women enrolled in the Royal College of General Practitioners Oral Contraception Study during 482,083 person-years of follow-up. Fracture risk was lower among multiparous women, non-smokers, and those of lower socio-economic class. The risk of subsequent fractures among the women who had ever used the oral contraceptive pill was significantly greater than that among women who had never used it (relative risk 1.20, 95% confidence intervals 1.08-1.34) after adjustment for these variables. When the analysis was confined to forearm fractures, no significant effect of pill use on fracture risk was detected. Although the study only includes limited observation of older women to date, these data do not support the hypothesis that pill use protects women against the occurrence of osteoporotic fractures in later life.

Influence of previous pain experience on the episode incidence of low back pain: results from the South Manchester Back Pain Study.

BACKGROUND: A pathological cause cannot be identified for most new episodes of low back pain (LBP) presenting to the general practitioner. One important potential influence on susceptibility is previous pain experience. To accurately investigate the contribution of this phenomenon to the onset of new episodes of LBP a prospective population study is required. AIMS: To determine the relationship of prior pain in the back and other musculoskeletal sites to risk of subsequent new episodes of LBP. METHODS: The population studied included all 2715 adults from the South Manchester Back Pain Study who were free of LBP during the month prior to the baseline survey. At baseline a detailed musculoskeletal pain history was obtained. New episodes of LBP over the subsequent 12 months were ascertained by: (i) prospectively monitoring all primary care consultations in the study cohort (consulting episodes) and (ii) a follow-up survey after 1 year to determine new episodes during that 12-month period not leading to consultation (non-consulting episodes). RESULTS: The 12-month cumulative incidence of new consulting episodes was 3% in males and 5% in females, and for new non-consulting episodes 31% in males and 32% in females. Those with a history of previous LBP had twice the rate of new episodes, both consulting and non-consulting, compared to those with no LBP in the past. Neck pain or pain in other musculoskeletal sites at baseline also doubled the risk of a subsequent new episode of LBP. Adjusting for psychological distress and the other pain variables had little influence on the findings. CONCLUSION: In those currently free of LBP a previous history of the symptom substantially increases the risk of a further episode, with pain in other sites an equally strong independent predictor of subsequent LBP.

Predictors of early improvement in low back pain amongst consulters to general practice: the influence of pre-morbid and episode-related factors.

Low back pain symptoms are extremely common. affecting as many as 80% of the population at some time in their lives. However, the majority of the medical costs arise from the minority of patients whose symptoms become chronic. The authors propose a model in which chronicity is determined not only by factors related to the episode of low back pain, but also factors prior to the onset of symptoms (pre-morbid factors). No previous study has collected information on predictors of low back pain chronicity prior to the onset of symptoms. Participants in the South Manchester Low Back Pain Study, recruited by means of a cross-sectional population survey were followed prospectively over 18 months to identify those who consulted their general practitioner with a new episode of low back pain. At interview, 1-2 weeks post-consultation, it was determined whether or not subjects' symptoms had improved. In males, low levels of psychological distress, a higher than average reported level of physical activity, being in employment, and being satisfied with current work status were associated with a quick improvement in symptoms. In addition factors related to the episode, namely a short duration before consultation and symptoms with a sudden onset and confined to the lower back area, also strongly predicted a good early outcome. Using information on both pre-morbid and episode related factors, groups of male patients were identified whose probability of an early resolution of symptoms ranged between 0.25 and 1. Few factors, either pre-morbid or episode-related, were strongly associated with outcome amongst females. This large population-based study has shown, despite the known heterogeneity in the origin of low back pain and the pathologies associated with symptoms, an early improvement in symptoms amongst male attenders at general practice can be predicted on the basis of a small number of variables.

Is the quality of asthma prescribing, as measured by the general practice ratio of corticosteroid to bronchodilator, associated with asthma morbidity?

The objective of this study was to determine whether the quality of asthma prescribing in general practice is associated with the severity of asthma patients' symptoms. Cross-sectional survey of asthma-like symptoms in patients prescribed antiasthma therapy was used. The setting was two general practices with contrasting ratios of corticosteroid to bronchodilator (high vs. low). The main outcome measures were: patient symptoms score and patient characteristics (age, gender, diagnosis, smoking, social class, and deprivation status). Patients on antiasthma therapy from the practice with the low corticosteroid to bronchodilator ratio had a higher mean symptom score (20.1, 95% CI 18.6, 21.7) than patients on antiasthma therapy from the practice with the high corticosteroid to bronchodilator ratio (13.2, 95% CI 11.8, 14.5). The mean difference in patient symptom score between the two practices was 7.0 (95% CI 4.9, 9.0); this changed little after adjustment for potential confounders. The quality of prescribing, as measured by the practice ratio of corticosteroid to bronchodilator, appears to be an important factor in the outcome of asthma care. The ratio of corticosteroid to bronchodilator in a general practice is one indicator of the quality of prescribing for asthma.

Use of a cross-sectional survey to estimate outcome of health care: the example of anxiety and depression.

Our study proposes that a population-based cross-sectional survey can be used to estimate the outcome of health care by linking general practice morbidity records to the survey. Using the example of anxiety and depression to test this idea, we conducted a survey of an adult population registered with one general practice in the UK. The Hospital Anxiety and Depression (HAD) questionnaire was used to identify cases and controls. After mailing to a randomly selected adult population of 4002, there was an adjusted response rate of 66% (n = 2,606), with 416 (16%) high-score cases, 506 (19%) medium-score cases, and 1684 (65%) low-score controls. All cases were compared with a sample of controls (n = 450). In the 12 months before the survey, the high-score case group had experienced significantly higher GP contacts (n = 377 [91%] versus 354 [79%]), diagnoses for anxiety or depression (119 [29%] versus 21 [5%]), and related drug treatments (111 [27%] versus 22 [5%]) compared with the control sample. Most of the diagnoses and drug treatments had been initiated at least 9 months before the survey. The linkage between the survey and the clinical records suggested that the health outcome of previously identified anxious and depressed patients was poor, with an estimated two-thirds who will not have fully recovered within an average of 9 months. This study demonstrates the potential for using cross-sectional population surveys to estimate not only the need for health care but also the outcome of health care.