Impact of depressive symptoms on direct medical cost among medicare recipients with knee osteoarthritis.

OBJECTIVE: Depressive symptoms are prevalent among knee osteoarthritis (KOA) patients and may lead to additional medical costs. We compared medical costs in Medicare Current Beneficiary Survey (MCBS) respondents with KOA with and without self-reported depressive symptoms. METHODS: We identified a KOA cohort using ICD-9/10 diagnostic codes in both Part A and Part B claims among community-dwelling MCBS respondents from 2003 to 2019. We determined the presence of depressive symptoms using self-reported data on sadness or anhedonia. We considered three groups: 1) without depressive symptoms, 2) with depressive symptoms, no billable services, and 3) with depressive symptoms and billable services. We used a generalized linear model with log-transformed outcomes to compare annual total direct medical costs among the three groups, adjusting for age, gender, race, history of fall, Total Joint Replacement, comorbidities, and calendar year. RESULTS: The analysis included 4118 MCBS respondents with KOA. Of them, 27% had self-reported depressive symptoms, and 6% reported depressive symptoms and received depression-related billable services. The adjusted mean direct medical costs were $8598/year for those without depressive symptoms, $9239/year for those who reported depressive symptoms and received no billable services, and $14,229/year for those who reported depressive symptoms and received billable services. CONCLUSION: While over one quarter of Medicare beneficiaries with KOA self-reported depressive symptoms, only 6% received billable medical services. The presence of depressive symptoms led to higher direct medical costs, even among those who did not receive depression-related billable services.

Teaching transposon classification as a means to crowd source the curation of repeat annotation - a tardigrade perspective.

BACKGROUND: The advancement of sequencing technologies results in the rapid release of hundreds of new genome assemblies a year providing unprecedented resources for the study of genome evolution. Within this context, the significance of in-depth analyses of repetitive elements, transposable elements (TEs) in particular, is increasingly recognized in understanding genome evolution. Despite the plethora of available bioinformatic tools for identifying and annotating TEs, the phylogenetic distance of the target species from a curated and classified database of repetitive element sequences constrains any automated annotation effort. Moreover, manual curation of raw repeat libraries is deemed essential due to the frequent incompleteness of automatically generated consensus sequences. RESULTS: Here, we present an example of a crowd-sourcing effort aimed at curating and annotating TE libraries of two non-model species built around a collaborative, peer-reviewed teaching process. Manual curation and classification are time-consuming processes that offer limited short-term academic rewards and are typically confined to a few research groups where methods are taught through hands-on experience. Crowd-sourcing efforts could therefore offer a significant opportunity to bridge the gap between learning the methods of curation effectively and empowering the scientific community with high-quality, reusable repeat libraries. CONCLUSIONS: The collaborative manual curation of TEs from two tardigrade species, for which there were no TE libraries available, resulted in the successful characterization of hundreds of new and diverse TEs in a reasonable time frame. Our crowd-sourcing setting can be used as a teaching reference guide for similar projects: A hidden treasure awaits discovery within non-model organisms.

Cost-Effectiveness of Community-Based Diet and Exercise for Patients with Knee Osteoarthritis and Obesity or Overweight.

OBJECTIVE: Obesity exacerbates pain and functional limitation in persons with knee osteoarthritis (OA). In the Weight Loss and Exercise for Communities with Arthritis in North Carolina (WE-CAN) study, a community-based diet and exercise (D + E) intervention led to an additional 6 kg weight loss and 20% greater pain relief in persons with knee OA and body mass index (BMI) >27 kg/m2 relative to a group-based health education (HE) intervention. We sought to determine the incremental cost-effectiveness of the usual care (UC), UC + HE, and UC + (D + E) programs, comparing each strategy with the "next-best" strategy ranked by increasing lifetime cost. METHODS: We used the Osteoarthritis Policy Model to project long-term clinical and economic benefits of the WE-CAN interventions. We considered three strategies: UC, UC + HE, and UC + (D + E). We derived cohort characteristics, weight, and pain reduction from the WE-CAN trial. Our outcomes included quality-adjusted life years (QALYs), cost, and incremental cost-effectiveness ratios (ICERs). RESULTS: In a cohort with mean age 65 years, BMI 37 kg/m2, and Western Ontario and McMaster Universities Osteoarthritis Index pain score 38 (scale 0-100, 100 = worst), UC leads to 9.36 QALYs/person, compared with 9.44 QALYs for UC + HE and 9.49 QALYS for UC + (D + E). The corresponding lifetime costs are $147,102, $148,139, and $151,478. From the societal perspective, UC + HE leads to an ICER of $12,700/QALY; adding D + E to UC leads to an ICER of $61,700/QALY. CONCLUSION: The community-based D + E program for persons with knee OA and BMI >27kg/m2 could be cost-effective for willingness-to-pay thresholds greater than $62,000/QALY. These findings suggest that incorporation of community-based D + E programs into OA care may be beneficial for public health.

Assessment of Residual Pain and Dissatisfaction in Total Knee Arthroplasty: Methods Matter.

Background: Residual pain after total knee arthroplasty (TKA) refers to knee pain after 3 to 6 months postoperatively. The estimates of the proportion of patients who experience residual pain after TKA vary widely. We hypothesized that the variation may stem from the range of methods used to assess residual pain. We analyzed data from 2 prospective studies to assess the proportion of subjects with residual pain as defined by several commonly used metrics and to examine the association of residual pain defined by each metric with participant dissatisfaction. Methods: We combined participant data from 2 prospective studies of TKA outcomes from subjects recruited between 2011 and 2014. Residual pain was defined using a range of metrics based on the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain score (0 to 100, in which 100 indicates worst), including the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS). We also examined combinations of MCID and PASS cutoffs. Subjects self-reported dissatisfaction following TKA, and we defined dissatisfied as somewhat or very dissatisfied at 12 months. We calculated the proportion of participants with residual pain, as defined by each metric, who reported dissatisfaction. We examined the association of each metric with dissatisfaction by calculating the sensitivity, specificity, positive predictive value, and Youden index. Results: We analyzed data from 417 subjects with a mean age (and standard deviation) of 66.3 ± 8.3 years. Twenty-six participants (6.2%) were dissatisfied. The proportion of participants defined as having residual pain according to the various metrics ranged from 5.5% to >50%. The composite metric Improvement in WOMAC pain score ≥20 points or final WOMAC pain score ≤25 had the highest positive predictive value for identifying dissatisfied subjects (0.54 [95% confidence interval, 0.35 to 0.71]). No metric had a Youden index of ≥50%. Conclusions: Different metrics provided a wide range of estimates of residual pain following TKA. No estimate was both sensitive and specific for dissatisfaction in patients who underwent TKA, underscoring that measures of residual pain should be defined explicitly in reports of TKA outcomes. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association Between Baseline Meniscal Symptoms and Outcomes of Operative and Nonoperative Treatment of Meniscal Tear in Patients With Osteoarthritis.

OBJECTIVE: Patients with meniscal tears reporting meniscal symptoms such as catching or locking have traditionally undergone arthroscopy. The present study was undertaken to investigate whether patients with meniscal tears who report meniscal symptoms have greater improvement with arthroscopic partial meniscectomy (APM) than physical therapy (PT). METHODS: We used data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, which randomized participants with knee osteoarthritis (OA) and meniscal tear to APM or PT. The frequency of each meniscal symptom (clicking, catching, popping, intermittent locking, giving way, swelling) was measured at baseline and 6 months. We used linear regression models to determine whether the difference in improvement in Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score at 6 months between patients treated with APM versus PT was modified by the presence of each meniscal symptom. We also determined the percentage of participants with resolution of meniscal symptoms by treatment group. RESULTS: We included 287 participants. The presence (versus absence) of any of the meniscal symptoms did not modify the improvement in KOOS pain score between APM versus PT by >0.5 SD (all P interaction >0.05). APM led to greater resolution of intermittent locking and clicking than PT (locking 70% versus 46%, clicking 41% versus 25%). No difference in resolution of the other meniscal symptoms was observed. CONCLUSION: Meniscal symptoms were not associated with improved pain relief. Although symptoms of clicking and intermittent locking had a greater reduction in the APM group, the presence of meniscal symptoms in isolation should not inform clinical decisions surrounding APM versus PT in patients with meniscal tear and knee OA.

Association Between Preoperative Radiographic Severity of Osteoarthritis and Patient-Reported Outcomes of Total Knee Replacement.

BACKGROUND: The goal of this study was to investigate the association between preoperative radiographic severity of knee osteoarthritis (OA) and patient-reported outcomes following total knee replacement. METHODS: We used data from a prospective cohort study of individuals who underwent total knee replacement at a high-volume medical center. Patient-reported outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score and the Knee injury and Osteoarthritis Outcome Score (KOOS) activities of daily living (ADL) subscore, assessed preoperatively and 2 years postoperatively. We measured preoperative radiographic OA severity using the Osteoarthritis Research Society International (OARSI) Atlas score, dichotomized at the median. We assessed the association between radiographic OA severity and postoperative patient-reported outcomes in bivariate analyses and in multivariable linear regression, with adjustment for age, sex, body mass index, and comorbidity score. RESULTS: The analytic cohort included 240 patients with a mean age at surgery of 66.6 years (standard deviation, 8 years); 61% were female. The median total OARSI radiographic severity score was 10 (range, 3 to 17). The cohort improved substantially at 2 years following total knee replacement, with WOMAC pain and KOOS ADL score improvements on the order of 30 points. We did not observe significant or clinically important differences in pain relief or functional improvement between patients with milder and more severe radiographic OA. Sensitivity analyses using other radiographic assessment measures yielded similar findings. CONCLUSIONS: Total knee replacement offers substantial symptomatic relief and functional improvement regardless of preoperative radiographic OA severity. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Longitudinal Trajectories of Pain and Function Improvement Following Total Knee Replacement.

OBJECTIVE: Up to 30% of patients experience persistent pain and functional limitations following total knee replacement (TKR). Rapid symptom relief in the early postoperative period may be linked to longer-term outcome improvements. We sought to identify early improvement trajectories and to identify risk factors for suboptimal outcomes. METHODS: We used data from the Adding Value in Knee Arthroplasty (AViKA) Cohort study, a prospective longitudinal study of patients with knee osteoarthritis who underwent TKR. We assessed pain and function using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). We used group-based trajectory modeling to identify distinct patterns of pain and function improvement over 6 months. We assessed the association between these early improvement trajectories and 24-month outcomes, including pain, function, and satisfaction. RESULTS: We analyzed data from 107 subjects. Mean baseline WOMAC pain and function scores were 42 (SD 17) and 44 (SD 15), respectively (0-100; 100 = worst). We identified two pain-improvement trajectories (suboptimal vs optimal improvement) and two function-improvement trajectories (suboptimal vs optimal improvement). Greater pain catastrophizing, worse mental health status, and use of a supportive device prior to TKR were associated with being in a suboptimal trajectory. Recipients of TKR in the suboptimal trajectories had higher pain, high functional disability, and lower satisfaction at 24 months post-TKR. CONCLUSION: Patients with slower improvement over the first 6 months post-TKR had worse outcomes at 24 months, suggesting that this early postoperative period may represent a window during which interventions aimed at speeding recovery may improve long-term TKR outcomes.

Validating Fitbit for Evaluation of Physical Activity in Patients with Knee Osteoarthritis: Do Thresholds Matter?

OBJECTIVE: We sought to evaluate the performance of Fitbit in estimating ActiGraph-derived moderate-to-vigorous physical activity (MVPA) and sedentary time in the knee osteoarthritis (OA) population. METHODS: We used data from two weeks of Fitbit and ActiGraph wear among knee OA subjects. In primary analyses, we used literature-based ActiGraph thresholds of 200 and 1924 counts/min (triaxial vector magnitude) for sedentary and MVPA time as the gold standard to which we compared three sets of Fitbit thresholds informed by literature and data (Youden index). We also considered personalized, stride length-based Fitbit thresholds. In sensitivity analyses, we used uniaxial, vertical axis-based as well as personalized, BMI-based ActiGraph thresholds. We calculated agreement, sensitivity, and specificity of Fitbit in classifying sedentary and MVPA time. RESULTS: In the primary analysis (vector magnitude thresholds), maximum agreement for sedentary and MVPA time was 67.0% from the Youden index-based and 91.1% from the stride length-based Fitbit thresholds. For sedentary time, the 20 strides/min threshold had the highest sensitivity (97.6%), and Youden-derived 1 stride/min had the highest specificity (51.6%). For MVPA, Youden-derived 14 strides/min yielded 72.8% sensitivity, and using stride length yielded 98.6% specificity. MVPA time ranged from 49-323 min/d, depending on threshold used, with literature-based and personalized thresholds leading to more conservative estimates of MVPA than Youden-derived thresholds. CONCLUSION: Using Fitbit for MVPA and sedentary time assessment may lead to inaccurate estimates of both. Fitbit MVPA estimates were generally more conservative than ActiGraph estimates. Incorporating individuals' characteristics did not meaningfully improve Fitbit performance. Caution should be exercised when measuring activity using Fitbit.

Prevalence and Anatomical Distribution of Bone Stress Injuries in the Elite Para Athlete.

Bone stress injury is a common overuse injury in athletes. Risk factors for bone stress injury in athletes include the female athlete triad (triad); this has not been evaluated in para athletes. The aim of this study was to identify risk factors, prevalence, and anatomical distribution of bone stress injury in para athletes. A cross-sectional online survey on health characteristics and previous fractures including bone stress injury was completed by para athletes training for the 2016 or 2018 Paralympic Games. Two hundred sixty para athletes completed the survey (659 invited, response rate = 40%). Half reported previous fracture, and bone stress injury was reported in 9.2% of all athletes. Twenty-four athletes (11 men and 13 women) sustained one or more bone stress injury, including 13 athletes with two bone stress injuries. No risk factors of the triad, disability type, or duration of disability were associated with bone stress injury. Injuries were most common in the metatarsals (n = 8) and hand/wrist (n = 7). In an elite para athlete population, locations for bone stress injury included both the upper and lower limbs. Clinically, para athletes presenting with pain localized to bone require further workup to evaluate for bone stress injury particularly for pain in both upper and lower limbs. Further research is required to identify risk factors for bone stress injury in para athletes.

Race Differences in Physical Activity Uptake Within a Workplace Wellness Program: A Comparison of Black and White Employees.

PURPOSE: To examine differences in physical activity (PA) uptake between black and white employees during a financial incentive-based workplace intervention. DESIGN: Prospective cohort study from July 2014 to June 2015 (NCT02850094). SETTING: Tertiary academic medical center. PARTICIPANTS: Forty-three black and 182 white nonclinical employees. INTERVENTION: Participants self-selected or were assigned to teams. Participants completed a 24-week intervention receiving rewards for meeting weekly PA goals (increasing moderate-to-vigorous PA [MVPA] by 10% from previous week or meeting Guidelines threshold of 150 minutes of MVPA). MEASURES: Outcomes included weekly MVPA in minutes, average daily step counts, number of weeks meeting personal goals and the Guidelines, and Fitbit adherence in days and weeks. ANALYSIS: We performed an analysis of covariance for each outcome, with race as the primary independent variable of interest, adjusting for demographic and health-related covariates. RESULTS: During the intervention, blacks walked 9128 steps per day while whites walked 7826 steps per day, a difference of approximately 1300 steps (P < .05). Blacks also demonstrated a greater uptake in both steps and MVPA from baseline than did whites, resulting in similar MVPA throughout the intervention. CONCLUSIONS: Findings suggest that workplace PA interventions using financial incentives may result in similar engagement in MVPA among white and black employees, while black employees walk more steps during the intervention. Limitations include a primarily white female sample which may not generalize.

Validation of the Fitbit Charge 2 compared to the ActiGraph GT3X+ in older adults with knee osteoarthritis in free-living conditions.

OBJECTIVE: To evaluate physical activity (PA) and sedentary time in subjects with knee osteoarthritis (OA) measured by the Fitbit Charge 2 (Fitbit) and a wrist-worn ActiGraph GT3X+ (AGW) compared to the hip-worn ActiGraph (AGH). DESIGN: We recruited a cohort of subjects with knee OA from rheumatology clinics. Subjects wore the AGH for four weeks, AGW for two weeks, and Fitbit for two weeks over a four-week study period. We collected accelerometer counts (ActiGraphs) and steps (ActiGraphs, Fitbit) and calculated time spent in sedentary, light, and moderate-to-vigorous activity. We used triaxial PA intensity count cut-points from the literature for ActiGraph and a stride length-based cadence algorithm to categorize Fitbit PA. We compared Fitbit wear times calculated from a step-based algorithm and a novel algorithm that incorporates steps and heart rate (HR). RESULTS: We enrolled 15 subjects (67% female, mean age 68 years). Relative to AGH, Fitbit, on average, overestimated steps by 39% and sedentary time by 37% and underestimated MVPA by 5 minutes. Relative to AGH, AGW overestimated steps 116%, underestimated sedentary time by 66%, and captured 281 additional MVPA minutes. The step-based wear time Fitbit algorithm captured 14% less wear time than the HR-based algorithm. CONCLUSIONS: Fitbit overestimates steps and underestimates MVPA in knee OA subjects. Cut-offs validated for AGW should be developed to support the use of AGW for PA assessment. The HR-based Fitbit algorithm captured more wear time than the step-based algorithm. These data provide critical insight for researchers planning to use commercially-available accelerometers in pragmatic studies.

Low energy availability, menstrual dysfunction, and impaired bone health: A survey of elite para athletes.

INTRODUCTION: The Female Athlete Triad (Triad) is a syndrome describing three interrelated conditions: low energy availability (LEA), menstrual dysfunction, and low bone mineral density (BMD). Relative Energy Deficiency in Sport (RED-S) expands the Triad to include multiple physiologic consequences of LEA in both sexes. The purpose of this study is to determine the prevalence of factors associated with the Triad/RED-S in an elite para athlete population. METHODS: Athletes were U.S. elite para athletes training to qualify for the 2016 or the 2018 Paralympic Games. Participants completed an online questionnaire characterizing nutrition, menstrual status (in females), bone health, and awareness of the Triad/RED-S. RESULTS: The athletes were 260 elite para athletes (150 male, 110 female). While few reported prior eating disorder (3.1%), 32.4% had elevated Eating Disorder Examination Questionnaire (EDE-Q) pathologic behavior subscale scores. Most athletes (95 male, 65 female) were attempting to change their body composition or weight to improve performance. Forty-four percent of premenopausal females had oligomenorrhea/amenorrhea. Bone stress injury was reported in 9.2% of athletes; of these, 54.5% (n = 12) had low BMD. Less than 10% of athletes reported awareness of the Triad/RED-S. CONCLUSIONS: Factors associated with the Triad/RED-S are present in an elite para athlete population, regardless of sex or sport type. Awareness of the Triad/RED-S in para athletes is low. The consequences of LEA in para athlete populations are poorly understood. However, the high prevalence of factors observed suggests value in advancing screening tools and education efforts to optimize health in this population.

Influence of Baseline Magnetic Resonance Imaging Features on Outcome of Arthroscopic Meniscectomy and Physical Therapy Treatment of Meniscal Tears in Osteoarthritis.

BACKGROUND: Arthroscopic partial meniscectomy (APM) is used to treat meniscal tears, although its efficacy is controversial. PURPOSE: This study used magnetic resonance imaging (MRI) to determine characteristics that lead to greater benefit from APM and physical therapy (PT) than from PT alone among patients with meniscal tear and knee osteoarthritis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Using data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial, the authors first assessed whether the effect of treatment on pain scores at 6 months differed according to baseline MRI features (bone marrow lesions, cartilage and meniscal damage). Second, the authors summed MRI features associated with differential pain relief between APM and PT to create a "damage score," which included bone marrow lesion number and cartilage damage size with possible values of 0 (least damage), 1 (moderate), and 2 (greatest). The authors used linear models to determine whether the association between damage score and pain relief at 6 months differed for APM versus PT. RESULTS: The study included 220 participants: 13%, had the least damage; 52%, moderate; and 34%, greatest. Although treatment type did not significantly modify the association of damage score and change in pain ( P interaction = .13), those with the least damage and moderate damage had greater improvement with APM than with PT in Knee injury and Osteoarthritis Outcome Score pain subscale-by 15 and 7 points, respectively. Those with the greatest damage had a similar improvement with APM and PT. CONCLUSION: Among patients with osteoarthritis and meniscal tear, those with less intra-articular damage on MRI may have greater improvement in pain with APM and PT than with PT alone. However, these results should be interpreted cautiously owing to the limited sample size.

Relationship Between Patient-Reported Swelling and Magnetic Resonance Imaging-Defined Effusion-Synovitis in Patients With Meniscus Tears and Knee Osteoarthritis.

OBJECTIVE: Synovitis is a prevalent feature in patients with knee osteoarthritis (OA) and meniscal tear and is associated with pain and cartilage damage. Patient-reported swelling is also prevalent in this population. The aim of this study was to investigate the cross-sectional association between patient-reported swelling and effusion-synovitis detected by magnetic resonance imaging (MRI) in patients with OA and meniscal tear. METHODS: We used baseline data from a multicenter, randomized controlled trial, Meniscal Tear in Osteoarthritis Research (METEOR). MRI-identified effusion-synovitis, a proxy for effusion and synovitis on noncontrast MRIs, was graded as none/small versus medium/large. Using MRI-identified effusion-synovitis as the gold standard, we assessed the sensitivity, specificity, and positive predictive value of patient self-reported swelling in the previous week (none, intermittent, constant) to detect effusion and synovitis. RESULTS: We analyzed data from 276 patients. Twenty-five percent of patients reported no swelling, 40% had intermittent swelling, and 36% had constant swelling. Fifty-two percent had MRI-identified medium/large-grade effusion-synovitis. As compared with MRI-identified effusion-synovitis, any patient-reported swelling (versus none) had a sensitivity of 84% (95% confidence interval [95% CI] 77-89), a specificity of 34% (95% CI 26-43), and a positive predictive value of 57% (95% CI 54-61). A history of constant swelling (versus none or intermittent) showed a sensitivity of 46% (95% CI 37-54), a specificity of 75% (95% CI 67-82), and a positive predictive value of 66% (95% CI 58-74). CONCLUSION: We found that the sensitivity and specificity of patient-reported swelling were modest when compared with effusion-synovitis detected by MRI. These data urge caution against using patient-reported swelling as a proxy of inflammation manifesting as effusion-synovitis.

Association of Changes in Effusion-Synovitis With Progression of Cartilage Damage Over Eighteen Months in Patients With Osteoarthritis and Meniscal Tear.

OBJECTIVE: Synovitis is a feature of knee osteoarthritis (OA) and meniscal tear and has been associated with articular cartilage damage. This study was undertaken to examine the associations of baseline effusion-synovitis and changes in effusion-synovitis with changes in cartilage damage in a cohort with OA and meniscal tear. METHODS: We analyzed data from the Meniscal Tear in Osteoarthritis Research (MeTeOR) trial of surgery versus physical therapy for treatment of meniscal tear. We performed semiquantitative grading of effusion-synovitis and cartilage damage on magnetic resonance imaging, and dichotomized effusion-synovitis as none/small (minimal) and medium/large (extensive). We assessed the association of baseline effusion-synovitis and changes in effusion-synovitis with changes in cartilage damage size and depth over 18 months, using Poisson regression models. Analyses were adjusted for patient demographic characteristics, treatment, and baseline cartilage damage. RESULTS: We analyzed 221 participants. Over 18 months, effusion-synovitis was persistently minimal in 45.3% and persistently extensive in 21.3% of the patients. The remaining 33.5% of the patients had minimal synovitis on one occasion and extensive synovitis on the other. In adjusted analyses, patients with extensive effusion-synovitis at baseline had a relative risk (RR) of progression of cartilage damage depth of 1.7 (95% confidence interval [95% CI] 1.0-2.7). Compared to those with persistently minimal effusion-synovitis, those with persistently extensive effusion-synovitis had a significantly increased risk of progression of cartilage damage depth (RR 2.0 [95% CI 1.1-3.4]). CONCLUSION: Our findings indicate that the presence of extensive effusion-synovitis is associated with subsequent progression of cartilage damage over 18 months. The persistence of extensive effusion-synovitis over time is associated with the greatest risk of concurrent cartilage damage progression.

Financial Incentives and Health Coaching to Improve Physical Activity Following Total Knee Replacement: A Randomized Controlled Trial.

OBJECTIVE: Most persons who undergo total knee replacement (TKR) do not increase their physical activity following surgery. We assessed whether financial incentives and health coaching would improve physical activity in persons undergoing TKR. METHODS: We designed a factorial randomized controlled trial among persons undergoing TKR for osteoarthritis. Subjects underwent normal perioperative procedures, including postoperative physical therapy, and were assigned to 1 of 4 arms: attention control, telephonic health coaching (THC), financial incentives (FI), or THC + FI. We objectively measured step counts and minutes of physical activity using a commercial accelerometer (Fitbit Zip) and compared the changes from pre-TKR to 6 months post-TKR across the 4 study arms. RESULTS: Of the 202 randomized subjects, 150 (74%) provided both pre-TKR and 6 months post-TKR accelerometer data. Among completers, the mean ± SE daily step count at 6 months ranged from 5,619 ± 381 in the THC arm to 7,152 ± 407 in the THC + FI arm (adjusting for baseline values). Daily step count 6 months post-TKR increased by 680 (95% confidence interval [95% CI] -94, 1,454) in the control arm, 274 (95% CI -473, 1,021) in the THC arm, 826 (95% CI 89, 1,563) in the FI arm, and 1,808 (95% CI 1,010, 2,606) in the THC + FI arm. Weekly physical activity increased by mean ± SE 14 ± 10, 14 ± 10, 16 ± 10, and 39 ± 11 minutes in the control, THC, FI, and THC + FI arms, respectively. CONCLUSION: A dual THC + FI intervention led to substantial improvements in step count and physical activity following TKR.

Implementation of a workplace intervention using financial rewards to promote adherence to physical activity guidelines: a feasibility study.

BACKGROUND: We designed and implemented the Brigham and Women's Wellness Initiative (B-Well), a single-arm study to examine the feasibility of a workplace program that used individual and team-based financial incentives to increase physical activity among sedentary hospital employees. METHODS: We enrolled sedentary, non-clinician employees of a tertiary medical center who self-reported low physical activity. Eligible participants formed or joined teams of three members and wore Fitbit Flex activity monitors for two pre-intervention weeks followed by 24 weeks during which they could earn monetary rewards. Participants were rewarded for increasing their moderate-to-vigorous physical activity (MVPA) by 10% from the previous week or for meeting the Centers for Disease Control and Prevention (CDC) physical activity guidelines (150 min of MVPA per week). Our primary outcome was the proportion of participants meeting weekly MVPA goals and CDC physical activity guidelines. Secondary outcomes included Fitbit-wear adherence and factors associated with meeting CDC guidelines more consistently. RESULTS: B-Well included 292 hospital employees. Participants had a mean age of 38 years (SD 11), 83% were female, 38% were obese, and 62% were non-Hispanic White. Sixty-three percent of participants wore the Fitbit ≥4 days per week for ≥20 weeks. Two-thirds were satisfied with the B-Well program, with 79% indicating that they would participate again. Eighty-six percent met either their personal weekly goal or CDC physical activity guidelines for at least 6 out of 24 weeks, and 52% met their goals or CDC physical activity guidelines for at least 12 weeks. African Americans, non-obese subjects, and those with lower impulsivity scores reached CDC guidelines more consistently. CONCLUSIONS: Our data suggest that a financial incentives-based workplace wellness program can increase MVPA among sedentary employees. These results should be reproduced in a randomized controlled trial. TRIAL REGISTRATION: Clinicaltrials.gov, NCT02850094 . Registered July 27, 2016 [retrospectively registered].

Effect of Obesity on Pain and Functional Recovery Following Total Knee Arthroplasty.

BACKGROUND: While obesity may be a risk factor for complications following total knee arthroplasty, data remain sparse on the impact of the degree of obesity on patient-reported outcomes following this procedure. Our objective was to determine the extent to which obesity level affects the trajectory of recovery as well as patient-reported pain, function, and satisfaction with surgery following total knee arthroplasty. METHODS: We followed a cohort of patients who underwent total knee arthroplasty at 1 of 4 medical centers. Patients were ≥40 years of age with a primary diagnosis of osteoarthritis. We stratified patients into 5 groups according to the World Health Organization classification of body mass index (BMI). We assessed the association between BMI group and pain and function over the time intervals of 0 to 3, 3 to 6, and 6 to 24 months using a piecewise linear model. We also assessed the association between BMI group and patient-reported outcomes at 24 months. Multivariable models adjusted for age, sex, race, diabetes, musculoskeletal functional limitations index, pain medication use, and study site. RESULTS: Of the 633 participants included in our analysis, 19% were normal weight (BMI of <25 kg/m), 32% were overweight (BMI of 25 to 29.9 kg/m), 27% were class-I obese (BMI of 30 to 34.9 kg/m), 12% were class-II obese (BMI of 35 to 39.9 kg/m), and 9% were class-III obese (BMI of ≥40 kg/m). Study participants with a higher BMI had worse preoperative WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) pain and function scores and had greater improvement from baseline to 3 months. The mean change in pain and function from 3 to 6 and from 6 to 24 months was similar across all BMI groups. At 24 months, participants in all BMI groups had similar levels of pain, function, and satisfaction. CONCLUSIONS: Because of the differential trajectory of recovery in the first 3 months following total knee arthroplasty, the participants in the higher BMI groups were able to attain absolute pain and function scores similar to those in the nonobese and class-I obese groups. These data can help surgeons discuss expectations of pain relief and functional improvement with total knee arthroplasty candidates with higher BMI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Physical activity and unplanned illness-related work absenteeism: Data from an employee wellness program.

BACKGROUND: Illness-related absenteeism is a major threat to work productivity. Our objective was to assess the relationship between physical activity and unplanned illness-related absenteeism from work. METHODS: We implemented physical activity program for sedentary non-clinician employees of a tertiary medical center. Financial rewards were available for reaching accelerometer-measured ambulatory physical activity goals over a 24-week period. We categorized participants into three groups based on mean levels of physical activity: low (0-74 min/week), medium (75-149 min/week) and meeting CDC guidelines (≥150 min/week). We built a multivariable Poisson regression model to evaluate the relationship between physical activity and rates of unplanned illness-related absenteeism. RESULTS: The sample consisted of 292 employees who participated in the program. Their mean age was 38 years (SD 11), 83% were female, and 38% were obese. Over the 24 intervention weeks, participants engaged in a mean of 90 min/week (SD 74) of physical activity and missed a mean of 14 hours of work (SD 38) due to illness. Unplanned absenteeism due to illness was associated with physical activity. As compared to the group meeting CDC guidelines, in multivariable analyses those in the medium physical activity group had a 2.4 (95% CI 1.3-4.5) fold higher rate of illness-related absenteeism and those in the lowest physical activity group had a 3.5 (95% CI 1.7-7.2) fold higher rate of illness-related absenteeism. DISCUSSION: Less physical activity was associated with more illness-related absenteeism. Workforce-based interventions to increase physical activity may thus be a promising vehicle to reduce unplanned illness-related absenteeism.

Impact of Preoperative Opioid Use on Total Knee Arthroplasty Outcomes.

BACKGROUND: There is growing concern about the use of opioids prior to total knee arthroplasty (TKA), and research has suggested that preoperative opioid use may lead to worse pain outcomes following surgery. We evaluated the pain relief achieved by TKA in patients who had and those who had not used opioids use before the procedure. METHODS: We augmented data from a prospective cohort study of TKA outcomes with opioid-use data abstracted from medical records. We collected patient-reported outcomes and demographic data before and 6 months after TKA. We used the Pain Catastrophizing Scale and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) to quantify the pain experiences of patients treated with TKA who had had a baseline score of ≥20 on the WOMAC pain scale (a 0 to 100-point scale, with 100 being the worst score), who provided follow-up data, and who had not had another surgical procedure within the 2 years prior to TKA. We built a propensity score for preoperative opioid use based on the Pain Catastrophizing Scale score, comorbidities, and baseline pain. We used a general linear model, adjusting for the propensity score and baseline pain, to compare the change in the WOMAC pain score 6 months after TKA between persons who had and those who had not used opioids before TKA. RESULTS: The cohort included 156 patients with a mean age of 65.7 years (standard deviation [SD] = 8.2 years) and a mean body mass index (BMI) of 31.1 kg/m (SD = 6.1 kg/m); 62.2% were female. Preoperatively, 36 patients (23%) had had at least 1 opioid prescription. The mean baseline WOMAC pain score was 43.0 points (SD = 12.8) for the group that had not used opioids before TKA and 46.9 points (SD = 15.7) for those who had used opioids (p = 0.12). The mean preoperative Pain Catastrophizing Scale score was greater among opioid users (15.5 compared with 10.7 points among non-users, p = 0.006). Adjusted analyses showed that the opioid group had a mean 6-month reduction in the WOMAC pain score of 27.0 points (95% confidence interval [CI] = 22.7 to 31.3) compared with 33.6 points (95% CI = 31.4 to 35.9) in the non-opioid group (p = 0.008). CONCLUSIONS: Patients who used opioids prior to TKA obtained less pain relief from the operation. Clinicians should consider limiting pre-TKA opioid prescriptions to optimize the benefits of TKA. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.