General practitioners' views on the challenges of managing knee pain attributed to degenerative meniscal tears in primary care: a qualitative study.

INTRODUCTION: Knee pain is estimated to affect at least 25% of people older than 50 years. In Ireland, knee pain accounts for the greatest number of new consultations seen in publicly funded orthopaedic clinics and meniscal pathology is the most common knee diagnosis after osteoarthritis. Exercise therapy is recommended as first line treatment for degenerative meniscal tears (DMT), while clinical practice recommendations advise against surgery. Nonetheless, arthroscopy rates remain high internationally for menisectomy in middle aged and older adults. While Irish knee arthroscopy figures are not available, referral in substantial numbers to orthopaedic clinics suggests surgery may be considered a treatment option for patients with DMTs by some primary care practitioners. This warrants further investigation with the GPs themselves; therefore, the aim of this qualitative study is to explore GPs' views on managing DMT and factors influencing their clinical decision making. METHODS: Ethical approval was granted by the Irish College of General Practitioners. Semi-structured interviews were conducted online with 17 GPs. Question topics included assessment and management approach, role of imaging and factors influencing referral to orthopaedics, and future supports that would enhance management of this type of knee pain. Transcribed interviews are being analysed using an inductive approach to thematic analysis guided by the research aim and Braun and Clarke's six-step approach. RESULTS: Data analysis underway. Results available for WONCA in June 2022Discussion: These results will contribute to the development of a knowledge translation and exercise intervention for the management of DMT in primary care.

Nervous System Sensitization as a Predictor of Outcome in the Treatment of Peripheral Musculoskeletal Conditions: A Systematic Review.

BACKGROUND: Research suggests that peripheral and central nervous system sensitization can contribute to the overall pain experience in peripheral musculoskeletal (MSK) conditions. It is unclear, however, whether sensitization of the nervous system results in poorer outcomes following the treatment. This systematic review investigated whether nervous system sensitization in peripheral MSK conditions predicts poorer clinical outcomes in response to a surgical or conservative intervention. METHODS: Four electronic databases were searched to identify the relevant studies. Eligible studies had a prospective design, with a follow-up assessing the outcome in terms of pain or disability. Studies that used baseline indices of nervous system sensitization were included, such as quantitative sensory testing (QST) or questionnaires that measured centrally mediated symptoms. RESULTS: Thirteen studies met the inclusion criteria, of which six were at a high risk of bias. The peripheral MSK conditions investigated were knee and hip osteoarthritis, shoulder pain, and elbow tendinopathy. QST parameters indicative of sensitization (lower electrical pain thresholds, cold hyperalgesia, enhanced temporal summation, lower punctate sharpness thresholds) were associated with negative outcome (more pain or disability) in 5 small exploratory studies. Larger studies that accounted for multiple confounders in design and analysis did not support a predictive relationship between QST parameters and outcome. Two studies used self-report measures to capture comorbid centrally mediated symptoms, and found higher questionnaire scores were independently predictive of more persistent pain following a total joint arthroplasty. CONCLUSION: This systematic review found insufficient evidence to support an independent predictive relationship between QST measures of nervous system sensitization and treatment outcome. Self-report measures demonstrated better predictive ability. Further high-quality prognostic research is warranted.

"You're stuck in the middle here": a qualitative study of GPs' experiences of managing knee pain attributed to a degenerative meniscal tear.

BACKGROUND: Exercise is the recommended first-line therapy for a degenerative meniscal tear (DMT). Despite this, knee pain attributed to DMTs are a common presentation to specialist orthopaedic clinics. In the primary care setting, the general practitioner (GP) plays a central role in managing patients with knee pain, but to date their perspective has not been explored in relation to DMTs. This study explored GPs' experiences of managing people with knee pain attributed to a DMT. METHODS: A qualitative research design was adopted and practices in the South and Mid-West of Ireland were contacted via recruitment emails circulated through professional and research networks. Interested GPs contacted the researchers via email, and purposive and snowball sampling was used for recruitment. Semi-structured interviews were conducted online or over the telephone. Interviews were digitally recorded and transcribed. Data was analysed using an inductive approach to thematic analysis. Ethical approval was granted by the Irish College of General Practitioners (ICGP_REC_21_0031). RESULTS: Seventeen semi-structured one-on-one interviews were conducted. Three main themes were identified with related subthemes: (1) GPs' experiences of relational aspects of care, (2) GP beliefs about what constitutes best care for patients with a DMT, and (3) how GP practice is enacted within the current healthcare setting. GPs described the challenge of maintaining a strong clinical alliance, while managing perceived patient expectations of a 'quick fix' and advanced imaging. They reported slowing down clinical decisions and feeling 'stuck' with limited options when conservative treatment had failed. GPs believed that exercise should be the core treatment for DMTs and emphasised engaging patients in an active approach to recovery. Some GPs believed arthroscopy had a role in circumstances where patients didn't improve with physiotherapy. Limited access to public physiotherapy and orthopaedic services hampered GPs' management plans and negatively impacted patient outcomes. CONCLUSIONS: GP beliefs around what constitutes best care for a DMT generally aligned with the evidence base. Nonetheless, there was sometimes tension between these beliefs and the patient's own treatment expectations. The ability to enact their beliefs was hampered by limited access to conservative management options, sometimes leading to early escalation of care.

Relationship Between Pain and Sedentary Behavior in Rheumatoid Arthritis Patients: A Cross-Sectional Study.

OBJECTIVE: Despite the known benefits of physical activity, high numbers of individuals with rheumatoid arthritis (RA) remain physically inactive and sedentary. Little is known about the determinants of sedentary behavior (SB) in RA. This cross-sectional study was undertaken to examine a range of pain characteristics and RA-related symptoms and their relationship with objectively measured SB. METHODS: In total, 76 adults with RA wore an activPAL4 accelerometer (PAL Technologies) over a 7-day period. Pain characteristics (pain intensity, painful joint count, nonarticular pain), fatigue, sleep, depression, anxiety, and disease activity were assessed. Analyses were first conducted to evaluate correlations with sedentary time. The independent contribution of pain characteristics to variation in SB was analyzed with multivariable linear regression (adjusted for demographic data and disease activity). RESULTS: Participants with valid accelerometer data (n = 72) spent a mean ± SD of 533.7 ± 100.1 minutes/day in SB. Positive associations with daily SB were found for pain intensity (r = 0.31, P < 0.01) and number of painful joints (r = 0.24, P < 0.05) but not nonarticular pain. In multivariable analyses, pain characteristics were not independently associated with SB. Analyses indicated that disease activity had an indirect association with SB mediated by pain intensity. Other correlates of daily SB included anxiety and depression but not fatigue or sleep. CONCLUSION: Results suggest that while pain and other RA-related factors do play a role in SB, they do not appear to have a significant influence after accounting for other variables. Future research should investigate SB and the role of factors unrelated to the symptoms of RA.

"You'd be better off to do the keyhole and make a good job of it" a qualitative study of the beliefs and treatment expectations of patients attending secondary care with degenerative meniscal tears.

BACKGROUND: Current clinical practice guidelines for degenerative meniscal tears recommend conservative management yet patients are frequently referred to the consultant orthopaedic surgeon despite a lack of evidence for the use of arthroscopy. OBJECTIVES: To explore the beliefs about their condition and treatment expectations of patients referred to a secondary care orthopaedic clinic with a degenerative meniscal tear. DESIGN AND METHODS: Design and MethodsThis qualitative study involved ten patients who participated in semi-structured telephone interviews. Data were subjected to thematic analysis and findings were reported in accordance with the Consolidated Criteria for Reporting Qualitative Studies. RESULTS: Analysis identified five themes. Participants described beliefs, strongly influenced by magnetic resonance imaging (MRI) results, that damaged structures were causing their knee problems ("The meniscus is busted"), and expected their knee problems to inevitably worsen over time ("It's only going to get worse"). Participants were hopeful the orthopaedic consultation would clarify their problem and lead to a subsequent definitive intervention ("Hopefully they will give me answers"). Most participants viewed surgery as "the quick and straightforward solution" necessary to repair faulty cartilage. Exercise was not seen as compatible with the recovery process by most ("Would I make it worse?"). CONCLUSIONS: How participants understand their knee problem contributes to surgical expectations and perceptions that it is not amenable to conservative management. Findings suggest a need to educate both patients and primary care clinicians about the safety and efficacy of exercise as first-line therapy for degenerative meniscal tears. The negative role of MRI in promoting surgical expectations needs further consideration.

The Relationship Between Clinical and Quantitative Measures of Pain Sensitization in Knee Osteoarthritis.

OBJECTIVES: Pain sensitization in knee osteoarthritis (OA) is associated with greater symptom severity and poorer clinical outcomes. Measures that identify pain sensitization and are accessible to use in clinical practice have been suggested to enable more targeted treatments. This merits further investigation. This study examines the relationship between quantitative sensory testing (QST) and clinical measures of pain sensitization in people with knee OA. METHODS: A secondary analysis of data from 134 participants with knee OA was performed. Clinical measures included: manual tender point count (MTPC), the Central Sensitization Inventory (CSI) to capture centrally mediated comorbidities, number of painful sites on a body chart, and neuropathic pain-like symptoms assessed using the modified PainDetect Questionnaire. Relationships between clinical measures and QST measures of pressure pain thresholds (PPTs), temporal summation, and conditioned pain modulation were investigated using correlation and multivariable regression analyses. RESULTS: Fair to moderate correlations, ranging from -0.331 to -0.577 (P<0.05), were identified between MTPC, the CSI, number of painful sites, and PPTs. Fair correlations, ranging from 0.28 to 0.30 (P<0.01), were identified between MTPC, the CSI, number of painful sites, and conditioned pain modulation. Correlations between the clinical and self-reported measures and temporal summation were weak and inconsistent (0.09 to 0.25). In adjusted regression models, MTPC was the only clinical measure consistently associated with QST and accounted for 11% to 12% of the variance in PPTs. DISCUSSION: MTPC demonstrated the strongest associations with QST measures and may be the most promising proxy measure to detect pain sensitization clinically.

Pain sensitisation and the risk of poor outcome following physiotherapy for patients with moderate to severe knee osteoarthritis: protocol for a prospective cohort study.

INTRODUCTION: Pain is the dominant symptom of knee osteoarthritis (OA), and recent evidence suggests factors outside of local joint pathology, such as pain sensitisation, can contribute significantly to the pain experience. It is unknown how pain sensitisation influences outcomes from commonly employed interventions such as physiotherapy. The aims of this study are, first, to provide a comprehensive description of the somatosensory characteristics of people with pain associated with knee OA. Second, we will investigate if indicators of pain sensitisation in patients with knee osteoarthritis are predictive of non-response to physiotherapy. METHODS AND ANALYSIS: This is a multicentre prospective cohort study with 140 participants. Eligible patients with moderate to severe symptomatic knee osteoarthritis will be identified at outpatient orthopaedic and rheumatology clinics. A baseline assessment will provide a comprehensive description of the somatosensory characteristics of each participant by means of clinical examination, quantitative sensory testing, and validated questionnaires measuring pain and functional capacity. Participants will then undergo physiotherapy treatment. The primary outcome will be non-response to physiotherapy on completion of the physiotherapy treatment programme as defined by the Osteoarthritis Research Society International treatment responder criteria. A principal component analysis will identify measures related to pain sensitisation to include in the predictive model. Regression analyses will explore the relationship between responder status and pain sensitisation while accounting for confounders. ETHICS AND DISSEMINATION: This study has been approved by St James' Hospital/AMNCH Research Ethics Committee and by the St Vincent's Healthcare Group Ethics and Medical Research Committee. The results will be presented at international conferences and published in a peer review journal. TRIAL REGISTRATION NUMBER: NCT02310945.