Identifying individuals with chronic pain after knee replacement:a population-cohort, cluster-analysis of Oxford Knee Scores in 128,145 patients from the English National Health Service

Background: Approximately one in five patients undergoing knee replacement surgery experience chronic pain after their operation, which can negatively impact on their quality of life. In order to develop and evaluate interventions to improve the management of chronic post-surgical pain, we aimed to derive a cut-off point in the Oxford Knee Score pain subscale to identify patients with chronic pain following knee replacement, and to characterise these patients using self-reported outcomes. Methods: Data from the English Patient-Reported Outcome Measures (PROMs) programme were used. This comprised patient-reported data from 128,145 patients who underwent primary knee replacement surgery in England between 2012 and 2015. Cluster analysis was applied to derive a cut-off point on the pain subscale of the Oxford Knee Score. Results: A high-pain group was identified, described by a maximum of 14 points in the Oxford Knee Score pain subscale six months after surgery. The high-pain group, comprising 15% of the sample, was characterised by severe and frequent problems in all pain dimensions, particularly in pain severity, night pain and limping, as well as in all dimensions of health-related quality of life. Conclusions: Patients with Oxford Knee Score pain subscale scores of 14 or less at six months after knee replacement can be considered to be in chronic pain that is likely to negatively affect their quality of life. This derived cut-off can be used for patient selection in research settings to design and assess interventions that support patients in their management of chronic post-surgical pain.</p

Progression of chronic pain and associated health-related quality of life and healthcare resource use over 5 years after total knee replacement: evidence from a cohort study

Objective As part of the STAR Programme, a comprehensive study exploring long-term pain after surgery, we investigated how pain and function, health-related quality of life (HRQL), and healthcare resource use evolved over 5 years after total knee replacement (TKR) for those with and without chronic pain 1 year after their primary surgery. Methods We used data from the Clinical Outcomes in Arthroplasty Study prospective cohort study, which followed patients undergoing TKR from two English hospitals for 5 years. Chronic pain was defined using the Oxford Knee Score Pain Subscale (OKS-PS) where participants reporting a score of 14 or lower were classified as having chronic pain 1-year postsurgery. Pain and function were measured with the OKS, HRQL using the EuroQoL-5 Dimension, resource use from yearly questionnaires, and costs estimated from a healthcare system perspective. We analysed the changes in OKS-PS, HRQL and resource use over a 5-year follow-up period. Multiple imputation accounted for missing data. Results Chronic pain was reported in 70/552 operated knees (12.7%) 1 year after surgery. The chronic pain group had worse pain, function and HRQL presurgery and postsurgery than the non-chronic pain group. Those without chronic pain markedly improved right after surgery, then plateaued. Those with chronic pain improved slowly but steadily. Participants with chronic pain reported greater healthcare resource use and costs than those without, especially 1 year after surgery, and mostly from hospital readmissions. 64.7% of those in chronic pain recovered during the following 4 years, while 30.9% fluctuated in and out of chronic pain. Conclusion Although TKR is often highly beneficial, some patients experienced chronic pain postsurgery. Although many fluctuated in their pain levels and most recovered over time, identifying people most likely to have chronic pain and supporting their recovery would benefit patients and healthcare systems

Osteoarthritis: 119. The Effectiveness of Exercise Therapy with and without Manual Therapy for Hip Osteoarthritis: A Multicentre Randomised Controlled Trial

Background: Current evidence indicates that exercise therapy (ET) has a short and medium-term benefit for hip osteoarthritis (OA), but evidence is inconclusive regarding the effect of manual therapy (MT). The primary aim of this randomised controlled trial was to determine the effectiveness of ET with and without MT on clinical outcomes for individuals with hip OA. A secondary aim was to ascertain the effect of an 8-week waiting period on outcomes. Methods: 131 men and women with hip OA recruited in four hospitals were initially randomised to one of three groups: ET (n = 45), a combination of ET and MT (n = 43) and wait-list control (n = 43). The two intervention groups underwent individualised ET or ET/MT for 8 weeks. Patients in the control group waited 8 weeks and were randomised to receive either ET or ET/MT after 9 week follow-up, and pooled with original treatment group data: ET (n = 66) and ET/ MT (n = 65). All participants were followed up at 9 and 18 weeks and the control group was reassessed at 27 weeks (18 weeks post-treatment) by the same blinded assessor. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Other outcomes included sit-to-stand, 50-foot walk test, pain severity, hip range of motion (ROM), anxiety, depression, quality of life (QOL), analgesic usage, physical activity, patient-perceived change and patient satisfaction. Intention-to-treat analysis was performed to determine within-group change and between-group differences for the three groups at baseline and 9 weeks, and the two treatment groups at baseline, 9 and 18 weeks. Results: Eight patients (6.1%) were lost to follow-up at 9 weeks and 19 (14.5%) were lost to follow-up by 18 weeks. Both ET (n = 66) and ET/MT groups (n = 65) showed significant within-group improvements in WOMAC, pain severity, sit-to-stand and HROM measures at 9 weeks, which were still evident at 18 weeks. There was no significant within-group change in anxiety, depression, QOL, analgesic usage, 50-foot walk test or physical activity. There was no significant difference between the two intervention groups for any of the outcomes. Regarding the results of the original ET, ET/MT and control group allocation, there was a significant improvement in one or both ET and ET/MT groups compared with the control group in the same outcomes, as well as patient perceived improvement at 9 weeks. There was no significant difference between the three groups in analgesic usage, WOMAC stiffness subscale, sit-to-stand and 50 foot walk tests, QOL and physical activity. There was an overall deterioration in anxiety and depression scores. Conclusions: The addition of MT to an 8 week programme of ET for hip OA resulted in similar improvements in pain, function and ROM at 9 and 18 weeks. The significant improvement which occurred in the same outcomes in the two treatment groups compared with a wait-list control of 8 weeks has implications for waiting list management Disclosure statement: The authors have declared no conflicts of interes

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

Pain characterization in knee osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis in the world, and it has been estimated that about one tenth of the worldâs population, aged over 60, have symptoms that can be attributed to OA. Despite the size of the global impact of OA, there is a significant unmet need for effective treatments. Knee replacement surgery is commonly used in patients with moderate to severe knee OA, in order to reduce pain. However, 10-34&percnt; of patients report an unfavourable long-term outcome with persistent pain after surgery. The neural mechanisms for the generation of pain in knee OA are not fully understood. Previous work has shown that around 20&percnt; of patients have features of neuropathic pain, and that the underlying mechanism for this may be through central sensitisation. This mechanism-based understanding of pain is important in order to aid targeted intervention, and it may be that this patient group is more likely to have an adverse outcome following surgery. This thesis uses a combination of methods to investigate the neural mechanisms underlying pain experienced by patients with knee OA, across the full spectrum of disease severity. Quantitative sensory testing (QST) was initially used in a community-based cohort to show that pain sensitisation can be detected in early disease, and also contributes to the observed discordance between radiographic structural and symptomatic disease. The clinical relevance of neuropathic pain was then investigated in patients with knee OA, who were awaiting knee replacement surgery. Prior to surgery patients with neuropathic pain had increased sensitivity to experimental pain, as well as higher symptom severity and psychological distress. Functional magnetic resonance imaging (fMRI) was then used to confirm that these features were also associated with central sensitisation in the form of increased descending facilitation as well as reduced descending inhibition prior to surgery. The presence of neuropathic pain prior to surgery was associated with statistically and clinically significantly worse outcome following surgery, compared to those with purely nociceptive pain in the absence of any significant structural differences between the two groups. Taken together, this mechanism-based understanding of the pain provides an opportunity for targeted therapy prior to surgery, which may enhance outcome following surgery.</p

Pain characterization in knee osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis in the world, and it has been estimated that about one tenth of the world’s population, aged over 60, have symptoms that can be attributed to OA. Despite the size of the global impact of OA, there is a significant unmet need for effective treatments. Knee replacement surgery is commonly used in patients with moderate to severe knee OA, in order to reduce pain. However, 10-34% of patients report an unfavourable long-term outcome with persistent pain after surgery. The neural mechanisms for the generation of pain in knee OA are not fully understood. Previous work has shown that around 20% of patients have features of neuropathic pain, and that the underlying mechanism for this may be through central sensitisation. This mechanism-based understanding of pain is important in order to aid targeted intervention, and it may be that this patient group is more likely to have an adverse outcome following surgery. This thesis uses a combination of methods to investigate the neural mechanisms underlying pain experienced by patients with knee OA, across the full spectrum of disease severity. Quantitative sensory testing (QST) was initially used in a community-based cohort to show that pain sensitisation can be detected in early disease, and also contributes to the observed discordance between radiographic structural and symptomatic disease. The clinical relevance of neuropathic pain was then investigated in patients with knee OA, who were awaiting knee replacement surgery. Prior to surgery patients with neuropathic pain had increased sensitivity to experimental pain, as well as higher symptom severity and psychological distress. Functional magnetic resonance imaging (fMRI) was then used to confirm that these features were also associated with central sensitisation in the form of increased descending facilitation as well as reduced descending inhibition prior to surgery. The presence of neuropathic pain prior to surgery was associated with statistically and clinically significantly worse outcome following surgery, compared to those with purely nociceptive pain in the absence of any significant structural differences between the two groups. Taken together, this mechanism-based understanding of the pain provides an opportunity for targeted therapy prior to surgery, which may enhance outcome following surgery.</p

A case of macroprolactinoma encasing an internal carotid artery aneurysm, presenting as pituitary apoplexy.

We present the first case of successful non-surgical treatment of an internal carotid aneurysm, embedded within a macroprolactinoma. A 53 year old male, with a previous history of Non-Hodgkin's Lymphoma (NHL), presented with severe right sided frontal headache, decreased visual acuity, and ophthalmolplegia due to a third nerve palsy. A CT scan showed a 4.6 by 4.8 cm mass in the pituitary fossa with bony erosion. Initially, it was thought to be a cerebral recurrence of the Non-Hodgkin's disease. Direct questioning revealed a long history of erectile dysfunction with loss of libido. Prolactin at presentation was 537, 200 mU/l and a diagnosis of macroprolactinoma, with apoplexy was made. A subsequent MRI brain confirmed a large macroadenoma with an intra cavernous aneurysm encased by the tumour. A therapeutic dilemma ensued due to the need for urgent decompression of the visual pathways, preferably by surgery. However, in the presence of an intrasellar aneurysm, surgery would have been extremely hazardous. The patient was therefore commenced on cabergoline and rapidly titrated up to 4 mg per week. The aneurysm was treated by endovascular occlusion of the right carotid artery under radiological control. The combination of these therapies, without conventional surgical intervention, resulted in resolution of the third nerve palsy and recovery of visual acuity in the left eye. The diagnosis and management of this condition was challenging and the final outcome, with non-surgical treatment and carotid artery occlusion was satisfactory

Central sensitisation in knee osteoarthritis: relating pre-surgical brainstem neuroimaging and paindetect based patient stratification to arthroplasty outcome

Objectives: the neural mechanisms of pain in knee OA are not fully understood: some patients have neuropathic‐like pain, associated with central sensitisation. We aimed to identify central sensitisation using neuroimaging and PainDETECT, and relate it to post‐arthroplasty outcome.Methods: patients awaiting arthroplasty underwent quantitative sensory testing, psychological assessment and functional neuroimaging (fMRI). fMRI was conducted during punctate (n=24) and cold pain stimulation (n=20) to the affected knee. Post‐operative outcome was measured using: Oxford Knee Score; moderate to severe long‐term pain after arthroplasty and a range of pain‐related questionnaires.Results: patients with neuropathic‐like pain pre‐surgery, identified using PainDETECT, reported significantly higher pain to punctate and cold stimuli, near the affected joint. In these patients and when compared to those without neuropathic‐like pain, neural activity was significantly lower in the rostral anterior cingulate cortex and higher in the rostral ventromedial medulla (RVM) during punctate stimulation, with significant functional connectivity between these two areas. Pre‐operative neuropathic‐like pain and higher neural activity in the RVM was associated with moderate to severe long‐term pain after arthroplasty.Conclusion: the psychophysical and neuroimaging data suggest that a subset of OA patients have centrally mediated pain sensitisation. This is likely due to supraspinally mediated reductions in inhibition, and increases in facilitation of nociceptive signaling, and was associated with a worse outcome following arthroplasty. The neurobiological confirmation of central sensitisation in patients with features of neuropathic pain, identified using PainDETECT, provides further support for the investigation of such bed‐side measures for patient stratification to better predict post‐surgical outcome

Neuropathic-like pain in fibrous dysplasia/McCune-Albright syndrome

Context: Pain is a major symptom in adults with fibrous dysplasia/McCune-Albright syndrome (FD/MAS) and response to current treatments, including bisphosphonates and standard analgesics (nonsteroidal anti-inflammatory drugs and opiates) is unpredictable. No studies have explored whether the type of pain is variable in this patient group. Objective: To determine the frequency of neuropathic-like pain in patients with FD/MAS. Design: Retrospective, dual registry study. Setting: Community. Patients: FD/MAS online registries: the US-based Familial Dysautonomia Foundation (FDF) and the UK-based Rare and Undiagnosed Diseases (RUDY) study. Intervention: Subjects completed questionnaires to evaluate the presence of features of neuropathic-like pain (painDETECT) and the impact on sleep quality (Pittsburgh Sleep Quality Index) and mental health (Hospital Anxiety and Depression Scale). Descriptive statistics were used to characterize the prevalence and associated burden of neuropathic-like pain. Main Outcome Measures: Incidence of neuropathic, nociceptive, and unclear pain. Results: Of 249 participants, one third experienced neuropathic-like pain. This group had statistically significantly (P  Conclusions Neuropathic-like pain is common in patients with FD/MAS and associated with worse quality of life. Evaluation of pain in patients with FD/MAS should include assessment of neuropathic-like pain to guide personalized approaches to treatment and inform future research