Blikman, Tim

Bulstra, Sjoerd K.

Dijkstra, Baukje

Rienstra, Wietske

Slager, Geranda

Stevens, Martin

van den Akker-Scheek, I.

van Raay, Jos J.

Purpose: The etiology of pain in osteoarthritis (OA) is complex andmultifactorial. A growing number of studies suggest that modificationof pain-transmission in the peripheral and central nervous system,leading to sensitization, plays a role in OA pain. Sensitization seems tobe associated with neuropathic pain-like symptoms and assessment ofthese symptoms can help to identify patients who could benefit fromadditional treatment options. Several questionnaires are available todistinguish neuropathic from nociceptive pain symptoms. The modifiedpainDETECT questionnaire (mPDQ) is a self-reported questionnairedeveloped to discriminate between nociceptive- and possible/likelyneuropathic pain in knee OA patients. Recently the mPDQ was translatedinto Dutch and adjusted to also fit hip OA patients. The aim of thisstudy was to assess the validity of the mPDQ-NL in patients with hip orknee OA.Methods: Primary hip and knee OA patients were recruited from threeDutch hospitals. Based on previous research, confirmatory factor analysisfor two principal components was performed to assess structuralvalidity. Construct validity (both convergent and divergent) wasassessed using hypothesis testing. Predefined hypotheses were formulatedconcerning the correlation between the mPDQ-NL and theSelf-reported Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS),subscales of the Knee injury and Osteoarthritis Outcome score/Hip disability and Osteoarthritis Outcome Score (KOOS/HOOS), VisualAnalogue Scale for pain (VAS pain), and subscales of the RAND-36health survey (RAND-36). According to the COSMIN criteria, constructvalidity of a questionnaire is sufficient if 75% of predefined hypothesesare met. Additionally, convergent validity was assessed with blunt PainPressure Thresholds (PPTs) in a subsample of participants. A reducedPPT is a somatosensory abnormality that is considered an indication ofsensitization in OA. Therefore it was expected that reduction of PPTswas associated with higher mPDQ scores.Results: 168 participants were included. PPT measurements wereperformed in a sample of 46 participants. Factor analysis confirmed twoprincipal components. The items that loaded on the first componentcould be described as “evoked neuropathic sensations”, the items thatloaded on the second component as “spontaneous neuropathic sensations”.However there were two items that substantially loaded on bothcomponents. The item regarding pain pattern did not load on anycomponent. Considering construct analysis, 80% of the predefinedhypotheses concerning the correlation between mPDQ and self-reportedquestionnaires were met. Considering the correlation with PPTmeasurements, 50% of the predefined hypotheses were met.Conclusions: The mPDQ-NL seems to adequately reflect neuropathicpain-like symptoms experienced by hip and knee OA patients. Concerningstructural validity, two determinative components seem to bepresent, in line with previous research. However, one particular itemregarding pain pattern might not reflect the construct of neuropathicpain-like symptoms in hip or knee OA. Therefore, when using the mPDQin hip or knee OA patients, it might be considered to skip this particularitem. Construct validity can be considered sufficient, with over 75% ofthe predefined hypotheses regarding correlation between the mPDQNLand other questionnaires were met. However, only 50% of the hypotheses concerning PPT measurements were met, probably due toheterogeneity and limited sample size of this subgroup. To ourknowledge, this study is the first to assess the structural validity of themPDQ knee and hip by using factor analysis and to assess constructvalidity using elaborate hypothesis testing as proposed by the COSMINguidelines.Purpose: The etiology of pain in osteoarthritis (OA) is complex andmultifactorial. A growing number of studies suggest that modificationof pain-transmission in the peripheral and central nervous system,leading to sensitization, plays a role in OA pain. Sensitization seems tobe associated with neuropathic pain-like symptoms and assessment ofthese symptoms can help to identify patients who could benefit fromadditional treatment options. Several questionnaires are available todistinguish neuropathic from nociceptive pain symptoms. The modifiedpainDETECT questionnaire (mPDQ) is a self-reported questionnairedeveloped to discriminate between nociceptive- and possible/likelyneuropathic pain in knee OA patients. Recently the mPDQ was translatedinto Dutch and adjusted to also fit hip OA patients. The aim of thisstudy was to assess the validity of the mPDQ-NL in patients with hip orknee OA.Methods: Primary hip and knee OA patients were recruited from threeDutch hospitals. Based on previous research, confirmatory factor analysisfor two principal components was performed to assess structuralvalidity. Construct validity (both convergent and divergent) wasassessed using hypothesis testing. Predefined hypotheses were formulatedconcerning the correlation between the mPDQ-NL and theSelf-reported Leeds Assessment of Neuropathic Symptoms and Signs (SLANSS),subscales of the Knee injury and Osteoarthritis Outcome score/Hip disability and Osteoarthritis Outcome Score (KOOS/HOOS), VisualAnalogue Scale for pain (VAS pain), and subscales of the RAND-36health survey (RAND-36). According to the COSMIN criteria, constructvalidity of a questionnaire is sufficient if 75% of predefined hypothesesare met. Additionally, convergent validity was assessed with blunt PainPressure Thresholds (PPTs) in a subsample of participants. A reducedPPT is a somatosensory abnormality that is considered an indication ofsensitization in OA. Therefore it was expected that reduction of PPTswas associated with higher mPDQ scores.Results: 168 participants were included. PPT measurements wereperformed in a sample of 46 participants. Factor analysis confirmed twoprincipal components. The items that loaded on the first componentcould be described as “evoked neuropathic sensations”, the items thatloaded on the second component as “spontaneous neuropathic sensations”.However there were two items that substantially loaded on bothcomponents. The item regarding pain pattern did not load on anycomponent. Considering construct analysis, 80% of the predefinedhypotheses concerning the correlation between mPDQ and self-reportedquestionnaires were met. Considering the correlation with PPTmeasurements, 50% of the predefined hypotheses were met.Conclusions: The mPDQ-NL seems to adequately reflect neuropathicpain-like symptoms experienced by hip and knee OA patients. Concerningstructural validity, two determinative components seem to bepresent, in line with previous research. However, one particular itemregarding pain pattern might not reflect the construct of neuropathicpain-like symptoms in hip or knee OA. Therefore, when using the mPDQin hip or knee OA patients, it might be considered to skip this particularitem. Construct validity can be considered sufficient, with over 75% ofthe predefined hypotheses regarding correlation between the mPDQNLand other questionnaires were met. However, only 50% of the hypotheses concerning PPT measurements were met, probably due toheterogeneity and limited sample size of this subgroup. To ourknowledge, this study is the first to assess the structural validity of themPDQ knee and hip by using factor analysis and to assess constructvalidity using elaborate hypothesis testing as proposed by the COSMINguidelines

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Table 2. Association of compartmental structural abnormalities and pain inknee osteoarthritis.Pain on movement Pain on movementOR (95% CI) OR (95% CI)*Combined PFOA and TFOA 11.67 (4.73, 28.84) 12.97 (5.33, 31.55)TFOA only 6.09 (2.49, 14.91) 6.74 (2.82, 16.12)PFOA only 6.89 (2.41, 19.72) 6.36 (2.45, 16.51)No OA in TF/ PF 1.00 1.00PF ¼ patellofemoral; TF ¼ tibiofemoral.No OA in PF/ TF was set as reference.* Model adjusted for age, sex and body mass index.Abstracts / Osteoarthritis and Cartilage 24 (2016) S63eS534S440(95% CI 1.03e1.71), percent fat OR 1.45 (95% CI 1.19e1.77), fat mass OR1.23 (95% CI 1.05e1.44). For women the ORs were - BMI OR 1.39 (95% CI1.22e1.59), waist OR 1.36 (95% CI 1.22e1.52), waist-to-hip ratio OR 1.49(95% CI 1.21e1.84), percent fat (10%) OR 1.39 (95% CI 1.22e1.57), fat massOR 1.27 (95% CI 1.15e1.40). Similarly all obesity measures and fat massmeasures were associated with LBP disability. The risk of LBP intensityand disability increased in a linear manner in sex-speciﬁc quartiles of allobesity measures and fat mass measures such that the individuals in thehighest quartile had the highest risk of developing LBP.Conclusions: This study is the ﬁrst large-scale prospective population-based cohort study that addresses the association between fat masswith symptomatic LBP. The association was more noticeable amongthose who had the severest form of disease and there was a tendency ofincreasing the odds of association in the highest quartiles of fat massmeasures. Our study can therefore be viewed as one of the ﬁrst steps tounravel the link that, apart from loading; chronic inﬂammatory andatherosclerotic processes play an important role in the pathogenesis ofthe disease. Understanding this mechanism is important as this willshed light into therapeutic strategies for the prevention of the devas-tating burden of LBP.744ASSOCIATION BETWEEN RADIOGRAPHIC SEVERITY AND PAIN INKNEE OSTEOARTHRITISY.Y. Leung y,z, B. Wong x, B. Haaland k, V.B. Kraus ¶. yDept. ofRheumatology & Immunology, Singapore Gen. Hosp., Singapore,Singapore; zDuke-NUS Graduate Med. Sch., Singapore, Singapore; xDept.of Diagnostic Radiology, Singapore Gen. Hosp., Singapore, Singapore;kH. Milton Stewart Sch. of Industrial and Systems Engineering, GeorgiaInst. of Technology, Georgia, GA, USA; ¶Duke Molecular Physiology Inst.and Div. of Rheumatology, Dept. of Med., Duke Univ. Sch. of Med.,Durham, NC, USAPurpose: Concordance between radiographic severity and pain in kneeosteoarthritis (KOA) is thought to be low. We aimed to evaluate theassociation between radiographic severity and pain in KOA.Methods: We used the baseline data from a randomized controlled trialof colchicine for symptomatic KOA, where radiographic and paininformation of both knees were collected separately. Radiographicseverity of OA in both knees was assessed for Kellgren and Lawrence(KL) grade (0e4) of the tibiofemoral (TF) and patellofemoral (PF) joints.A determination of OA in a particular compartment (TF or PF) was basedon KL grade was  2 in the respective compartment. Each knee wasclassiﬁed as no OA, patellofemoral only (PFOA), tibiofemoral only(TFOA) or combined PFOA and TFOA. Severity of knee pain on move-ment was assessed by self-report with a 0e10 numeric rating scale. Wesummarized and evaluated, respectively, the association of radiographicand pain information of individual knees with odd ratios and conﬁdentintervals using generalized linear model with generalized estimatingequations that control for within-subject correlation. Analyses werealso adjusted for age, sex and body mass index (BMI).Results: Information for 109 subjects and 218 knees were included. KLgrades in TF were strongly associated with severity of knee pain in adose-response manner (Table 1). Similar results were seen for the rela-tion of compartmental involvement and severity of knee pain (Table 2).Conclusions: Using a knee based analysis, we found strong associationbetween radiographic OA and knee pain on movement. PFOA coexistingwith TFOA was associated with more knee pain on movement thanPFOA or TFOA alone.Table 1. Association of tibiofemoral Kellgren and Lawrence (KL) grades and painin knee osteoarthritisPain on movement Pain on movementOR (95% CI) OR (95% CI)*KL ¼ 4 10.02 (1.87, 53.73) 13.06 (2.49, 68.59)KL ¼ 3 7.76 (1.88, 31.99) 8.51 (2.12, 34.16)KL ¼ 2 4.41 (1.11, 17.48) 4.81 (1.24, 18.60)KL ¼ 1 1.51 (0.36, 6.29) 1.47 (0.37, 5.83)KL ¼ 0 1.00 1.00KL 0 was set as reference.* Model adjusted for age, sex and body mass index.745VALIDITY OF THE DUTCH MODIFIED PAINDETECT QUESTIONNAIRE(MPDQ-NL) FOR PATIENTS WITH HIP OR KNEE OSTEOARTHRITISW. Rienstra y, T. Blikman y, B. Dijkstra z, J.J. van Raay x, G.E. Slager k,S.K. Bulstra y, M. Stevens y, I. van den Akker-Scheek y. yUniv. Med. Ctr.Groningen, Groningen, Netherlands; zMed. Ctr. Leeuwarden,Leeuwarden, Netherlands; xMartini Hosp., Groningen, Netherlands; k Sch.of Hlth. Care Studies, Hanze Univ. of Applied Sci., Groningen, NetherlandsPurpose: The etiology of pain in osteoarthritis (OA) is complex andmultifactorial. A growing number of studies suggest that modiﬁcationof pain-transmission in the peripheral and central nervous system,leading to sensitization, plays a role in OA pain. Sensitization seems tobe associated with neuropathic pain-like symptoms and assessment ofthese symptoms can help to identify patients who could beneﬁt fromadditional treatment options. Several questionnaires are available todistinguish neuropathic from nociceptive pain symptoms. The modiﬁedpainDETECT questionnaire (mPDQ) is a self-reported questionnairedeveloped to discriminate between nociceptive- and possible/likelyneuropathic pain in knee OA patients. Recently the mPDQ was trans-lated into Dutch and adjusted to also ﬁt hip OA patients. The aim of thisstudy was to assess the validity of the mPDQ-NL in patients with hip orknee OA.Methods: Primary hip and knee OA patients were recruited from threeDutch hospitals. Based on previous research, conﬁrmatory factor anal-ysis for two principal components was performed to assess structuralvalidity. Construct validity (both convergent and divergent) wasassessed using hypothesis testing. Predeﬁned hypotheses were for-mulated concerning the correlation between the mPDQ-NL and theSelf-reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), subscales of the Knee injury and Osteoarthritis Outcome score/Hip disability and Osteoarthritis Outcome Score (KOOS/HOOS), VisualAnalogue Scale for pain (VAS pain), and subscales of the RAND-36health survey (RAND-36). According to the COSMIN criteria, constructvalidity of a questionnaire is sufﬁcient if 75% of predeﬁned hypothesesare met. Additionally, convergent validity was assessed with blunt PainPressure Thresholds (PPTs) in a subsample of participants. A reducedPPT is a somatosensory abnormality that is considered an indication ofsensitization in OA. Therefore it was expected that reduction of PPTswas associated with higher mPDQ scores.Results: 168 participants were included. PPT measurements wereperformed in a sample of 46 participants. Factor analysis conﬁrmed twoprincipal components. The items that loaded on the ﬁrst componentcould be described as “evoked neuropathic sensations”, the items thatloaded on the second component as “spontaneous neuropathic sensa-tions”. However there were two items that substantially loaded on bothcomponents. The item regarding pain pattern did not load on anycomponent. Considering construct analysis, 80% of the predeﬁnedhypotheses concerning the correlation between mPDQ and self-repor-ted questionnaires were met. Considering the correlation with PPTmeasurements, 50% of the predeﬁned hypotheses were met.Conclusions: The mPDQ-NL seems to adequately reﬂect neuropathicpain-like symptoms experienced by hip and knee OA patients. Con-cerning structural validity, two determinative components seem to bepresent, in line with previous research. However, one particular itemregarding pain pattern might not reﬂect the construct of neuropathicpain-like symptoms in hip or knee OA. Therefore, when using themPDQin hip or knee OA patients, it might be considered to skip this particularitem. Construct validity can be considered sufﬁcient, with over 75% ofthe predeﬁned hypotheses regarding correlation between the mPDQ-NL and other questionnaires were met. However, only 50% of theAbstracts / Osteoarthritis and Cartilage 24 (2016) S63eS534 S441hypotheses concerning PPT measurements were met, probably due toheterogeneity and limited sample size of this subgroup. To ourknowledge, this study is the ﬁrst to assess the structural validity of themPDQ knee and hip by using factor analysis and to assess constructvalidity using elaborate hypothesis testing as proposed by the COSMINguidelines.746CO-EXISTING HIP SYMPTOMS ARE ASSOCIATEDWITH SELF-EFFICACYAND PAIN-RELATED FEAR IN OLDER ADULTS WITH A PRIMARYCOMPLAINT OF LOW BACK PAIN: THE DELAWARE SPINE STUDIESG.E. Hicks, J. Sions, T. Velasco. Univ. of Delaware, Newark, DE, USAPurpose: Low back pain (LBP) is the most common musculoskeletalcomplaint among the geriatric population. Musculoskeletal clinicianshave often proposed a link between the hip and lumbar spine in olderadults. Ofﬁerski and McNab originally described hip-spine syndrome asthe presence of lumbar symptoms due to an abnormal biomechanicalrelationship between the hip joint and spine likely related to degen-erative pathology in one or both joints; but, little work has been done tounderstand whether the additional burden of co-existing hip symptomsmight impact pain-related psychologic factors in an individual with LBP.The purpose of this study was to determinewhether the presence of hipsymptoms, which are indicative of hip osteoarthritis (OA), are asso-ciated with self-efﬁcacy, kinesiophobia and fear-avoidance beliefsamong older adults with a primary complaint of low back pain.Methods: We have conducted an analysis of baseline data from theDelaware Spine Studies cohort study of 228 older adults with a primarycomplaint of LBP that is greater than any other musculoskeletal paincomplaint (mean age: 69.75þ/6.85 years). We examined clinical hipsymptoms that were proposed predictors of radiographic hip OAaccording to American College of Rheumatology (ACR) guidelines byAltman et al, including hip joint pain, morning stiffness in the hip thatlasts less than 60 minutes and pain with hip internal rotation (IR). Thefollowing subscales of the Low Back Activity Conﬁdence Scale wereused to assess self-efﬁcacy: self-efﬁcacy for functional activities, self-efﬁcacy for self-regulation of back health and self-efﬁcacy for regularexercise. The Tampa Scale for Kinesiophobia (TSK-11) was used tocapture kinesiophobia. And, the Physical Activity subscale of the FearAvoidance Beliefs Questionnaire (FABQ-PA) was used to capture fearavoidance beliefs about LBP. Analysis of covariance (ANCOVA) was usedto determine the association between presence of any hip symptoms (1or more hip symptoms) and our psychologic outcomes of interest, self-efﬁcacy, kinesiophobia and fear avoidance. ANCOVA models wereadjusted for age, sex and education.Results: Of the 228 participants with LBP, 166 (72.8%) had one or morehip symptoms. Co-existence of 1 or more hip symptoms was associatedwith lower levels of self-efﬁcacy for functional activities (12.22 points,95%CI: 19.43, 5.02, p ¼ .001), greater levels of fear-avoidance beliefs(þ3.48 points, 95%CI: 0.46, 6.50, p ¼ .024) and greater levels of kine-siophobia (þ4.55 points, 95%CI: 0.17, 8.93, p ¼ .042) as compared toabsence of hip symptoms. Presence of hip symptomswas not associatedwith self-efﬁcacy for self-regulation of back health or self-efﬁcacy forexercise (p&gt.05).Conclusions: Hip symptoms are prevalent among older adults with aprimary complaint of LBP; and, the additional burden of these hipsymptoms is associated with reduced self-efﬁcacy, as well as height-ened kinesiophobia and fear avoidance beliefs. There has long beenconsensus that researchers should focus on classifying patients intoclinically relevant subgroups that share similar clinical characteristics toimprove treatment outcomes. It appears that one such subgroup amongolder adults with LBP consists of those with co-existing hip symptoms.Given that poor self-efﬁcacy and elevated pain-related fears are relatedto poor outcomes in low back pain747DOES PAIN AT OTHER SITES INFLUENCE THE ASSOCIATION BETWEENKNEE PATHOLOGY AND KNEE PAIN?F. Pan y, D. Aitken y, J. Tian y, F. Cicuttini z, T. Winzenberg y, G. Jones y.yUniv. of Tasmania, Hobart, Australia; zMonash Univ. Med. Sch.,Melbourne, AustraliaPurpose: The association between structural abnormalities and kneepain remains controversial. It may be that the association is weaker inthose with generalized pain compared to localized pain. The aim of thisstudy therefore was to describe the effect of pain at other sites on theassociation between knee structural pathology and pain in knee OA.Methods: 1099 participants (average age 63 years; range 51e81 years)from the population-based Tasmanian Older Adult Cohort study werestudied. Presence of pain (yes/no) at the neck, back, hands, shoulders,hips, knees and feet was assessed by questionnaire. T1-weighted or T2-weighted fat saturated MRI of the right knee was performed tomeasurecartilage defects, bone marrow lesions (BMLs) and effusion. Osteo-phytes and joint space narrowing (JSN) were assessed by X-ray. Datawere analysed using multi-nominal logistic regressionwith adjustmentfor potential confounders including age, sex, body mass index, physicalactivity, smoking history and pain medication.Results: Knee pain only, knee plus any other site pain, and any other sitepainwere respectively present in 3%, 44% and 41% of the participants. Inmultivariable analyses, knee pain only was strongly associated with thepresence of cartilage defects (OR 16.96, 95% CI 4.03e71.32), BMLs (OR3.27, 95% CI 1.01e10.53), effusion (OR 3.52, 95% CI 1.06e11.68) andosteophytes (OR 8.22, 95% CI 2.10e32.27). Signiﬁcant results were alsofound for knee pain plus any other site pain, but these associations wereweaker (OR ¼ 3.03e3.38, all P&lt0.05). Any other site pain was notfound to be associated with all knee structural pathologies. There was adose-response relationship between number of knee structural path-ologies, and knee pain only and knee plus any other site pain (both P fortrend&lt ¼ 0.002).Conclusions: Knee structural pathologies are more strongly associatedwith knee pain in those with localized pain suggesting that kneestructural pathologies appear to be the origin of pain in knee OA, and acombination of peripheral and central mechanisms may be involved inthe pain processing. The inﬂuence of pain at other sites needs to beconsidered while assessing the knee.748CHANGES IN KNEE PAIN AND SENSITIZATION AFTER BARIATRICSURGERYJ. Stefanik y,z, D. Felson z, J. Niu z, M. Clancy z, C. Apovian z,x,M. LaValley z, T. Neogi z. yNortheastern Univ., Boston, MA, USA; zBostonUniv. Sch. of Med., Boston, MA, USA; xBoston Med. Ctr., Boston, MA, USAPurpose: Obesity is associated with knee pain and believed to berelated to abnormal loading and/or systemic inﬂammatory effects.Mechanical stimuli, as may be due to excessive loading, and inﬂam-mation have also been shown to induce central and/or peripheralsensitization (altered pain processing of the nervous system) in animalmodels. Further, clinically, sensitization is associated with pain and itsseverity in knee osteoarthritis (OA). Whether knee pain improvementsnoted after massive weight loss may be partly related to resolution ofsensitization is not clear. We sought ﬁrst to corroborate that knee painimproves after massive weight loss, and second, to determine whethersensitization improves after massive weight loss in individuals under-going bariatric surgery.Methods: Individuals for the current study were part of the Osteo-arthritis Before and After Bariatric Surgery (OABS) Study. Individualsaged 25e60were included if they had BMI35, knee pain onmost daysof the month and were approved for bariatric surgery (laparoscopicgastric bypass surgery or laparoscopic sleeve gastrectomy); there wasno requirement regarding knee OA itself. To determine what anexpected change in pain and sensitization over one year may be in thispatient population with obesity who do no undergo massive weightloss with bariatric surgery, we also assessed those who were deemedappropriate for bariatric surgery but did not undergo the surgery andunderwent medical management. All subjects had knee pain assessedat baseline and one year follow-up in the knee that was more painful atbaseline (index knee) using the WOMAC (activity-related knee pain;0e20; 0 ¼ no pain) and VAS (overall knee pain; 0e100; 0 ¼ no pain). Apressure algometer applied at 0.5 kg/s was used to assess pressure painthreshold (PPT) at the index patella (indicator of peripheral and/orcentral sensitization) and the right wrist (indicator of central sensiti-zation) as the point at which the pressure ﬁrst changed to slight pain.Three PPT trials at each anatomical site were averaged. Lower PPTsrepresent more sensitization or pain sensitivity. To determine the meanchange in measures of pain and pain sensitization at baseline and fol-low-up, we performed separate paired t-tests in the surgery andmedical management groups.

Validity of the Dutch modified painDETECT questionnaire (MPDQ-NL) for patients with hip or knee osteoarthritis

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Validity of the Dutch modified painDETECT questionnaire (MPDQ-NL) for patients with hip or knee osteoarthritis

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