Course of Functional Status and Pain in Osteoarthritis of the Hip or Knee: a Systematic Review of the Literature
Appendix 1 & 2
Gabriella M. van Dijk1, PT, MSc., Joost Dekker2, PhD., Cindy Veenhof 1, PT, MSc., Cornelia H.M. van den Ende1, PT, PhD, for the CARPA
Study Group. In: Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55. No. 5. October 15 2006
Appendix 1: Authors of the excluded studies, year of publication and reasons for exclusion.
Authors, year of publication
Auquier, 1974
Bagge, 1992
Bagis, 2002
Baird, 2000
Bellamy, 1986
Braeken, 1997
Bruyere, 2002
Bruyere, 2003
Cerejo, 2002
Chevalier, 2002
Conrozier, 1998
Cushnagan, 1988
Danielson, 1964
Danielson, 1970
Doherty, 2001
Dougados, 1996
Eberle, 1999
Felson, 1988
Felson, 1993
Felson, 1995
Felson, 2004
Goorman, 2000
Hasegawa, 1994
Harrison, 1953
Hochberg, 1989
Reasons for exclusion
D
P-O
T
IR
R
T
T
T
O
F
O
F
IR
T-O
F
T
F
R
R
O
O
T
P
P-T-O
P
Authors, year of publication
Hochberg, 1995
Hochberg, 1996
Huskisson, 1979
Kee, 2003
Lachance, 2002
Lethbridge-Cejku, 1994
Lievense, 2002
Maillefert, 2003
McAlindon, 1993
McAlindon, 1999
Miyazaki, 2002
Murphy, 1998
Peat, 2004
Schouten, 1992
Seifert, 1969
Sharma, 1996
Sharma, 2004
Shioda, 1983
Spector, 1994
Steultjens, 2001
Summers, 1988
Thomas, 2003
Thorstenssen, 2003
Uno, 1993
Wolfe, 2002
Reasons for exclusion
P-0
R
T
T
P
P-O
R
O
T
P-O
O
R
F
O
F
T
F
O
O
T
T
T
O
O
O
D: other reasons for exclusion (described in the results); F: no full-text article; IR: incomplete references; O: outcome measures (article did not
report on functional outcome measures or pain); P: study population (study population did not consist of patients with hip or knee OA); R:
review; T: type of study (follow-up was less than 6 months or study was clinical trial);
Appendix 2: Characteristics of included studies: authors, methodological quality, design, outcome measures, prognostic factors and results. A
distinction is made between studies on hip osteoarthritis and knee osteoarthritis.
Authors
MQ
Design
Outcome
measures
HIP
Dieppe (1)
73%
Hip (N=29)
knee (N=198)
hospital
cohort
prospective
follow-up 3
and 8 years
radiological
and clinical
criteria
Functional
status
Reported
change in
overall
condition
Hip (N=106)
hospital
cohort
prospective
follow-up 28
months
radiological
and clinical
criteria
Functional
status
Steinbrocker
index,
reported
exercise
tolerance
Ledingham
(2)
46%
Prognostic factors
Follow-up 3 years
43% reported worsening of overall condition, 39% improvement. No
changes in percentage reporting pain.
Follow-up 8 years
54% reported worsening of overall condition, 21% improvement.
Percentage with no pain and with severe pain unchanged, percentage
with mild pain decreased (48% to 34%), percentage with moderate
pain increased (31% to 48%).
Pain
Reported
pain
Pain
Reported
change, pain
scores
Results
Age, BMI, symptom
duration, gender,
pain, patient
assessment of
change, exercise
tolerance,
radiographs, severity
of OA at entry
90% no change in function (Steinbrocker index), function improved
in 4 patients and deteriorated in 13. 31% reduction in exercise
tolerance, 62% no change. 88% worsening of pain, 66% increased
pain scores.
Pain scores increased in women and in hips with radiographic
changes. Improved pain scores were seen more commonly in men
and in hips with chondrocalcinosis, mild osteoarthritis at entry and
showing no radiographic progression. Other patient characteristics
did not associate with changes in pain or with patient’s assessment of
pain.
Deterioration in function more common in patients with worsening
symptoms, increased pain scores and radiographic progression.
Auquier (3)
Lane (4)
KNEE
Dieppe (1)
36%
36%
73%
Hip (N=273)
hospital
cohort
retrospective
follow-up 10
years
radiological
criteria
Functional
Gender,
status
primary or
Combination secondary OA
measure
(pain, use of
walking aids,
walking
distance,
activity)
The percentage with minimal functional problems unchanged (24.1 21.2), percentage with moderate problems decreases (60.5 – 49.1),
percentage with moderate-severe problems (12.5 – 20.9) and
percentage with severe functional problems (2.9 – 8.8) increases. All
changes p<0.001.
Hip (N=745)
community
cohort
prospective
follow-up 8.3
years
radiological
and clinical
criteria
Functional
status
Disability
score
22.8% of women with baseline radiographic findings of hip OA had
worsening of disability
Hip (N=29)
knee (N=198)
hospital
cohort
prospective
follow-up 3 /
8 years
Functional
status
Reported
change in
overall
condition
Pain
In primary coxarthrosis more women (41.9%) than men (24.2%)
deteriorated (0.05<p<0.02). In secondary coxarthrosis more men
(16.9%) than women (5%) improved. No statistical analyses were
performed.
The percentage of patients that thought they had deteriorated was
higher in primary (41.9%) coxarthrosis than in secondary
coxarthrosis (25.5%) 0.02<p<0.05)
Women with hip pain more likely to have worsened disability than
those without pain (29.3% vs. 17.6%; OR 1.82; p=0.0053)
Follow-up 3 years
The percentage with no pain was unchanged; percentage with mild
pain decreased (30% to 25%) and percentage with severe pain
decreased (29% to 23%); percentage with moderate pain increased
(37% to 49%). 57% showed worsening of overall condition, 21%
showed improved overall condition.
Follow-up 8 years
Sharma (5)
64%
radiological
and clinical
criteria
Pain
Reported
pain
Knee (N=285)
community
cohort
prospective
follow-up 3
years
radiological
and clinical
criteria
Functional
status
WOMAC
and chairstand-rate
(good and
poor
outcome)
The percentage with no pain and with severe pain was unchanged.
Percentage with mild pain decreased (30% to 18%), percentage with
moderate pain increased (36% to 47%). 66% showed worsening
overall condition.
Age, sex, marital
status, comorbidity,
radiographic
severity, prevalence
of unilateral vs.
bilateral knee OA,
BMI, knee pain
intensity,
mechanical factors,
neuromuscular
factors, activity
level, psychological
factors
113 (48%) good outcome / 123 (52%) poor outcome in WOMAC
physical function, 80 (34%) good outcome / 156 (66%) poor outcome
in chair-stand-rate
Factors that significantly increased the likelihood of a poor WOMAC
outcome were baseline laxity (OR 1.48), BMI (OR 1.21), knee pain
intensity (OR 1.21) and baseline to 18-month increase in knee pain
(OR 1.32). Factors that significantly protected against a poor
WOMAC outcome were better baseline mental health (OR 0.62),
self-efficacy (OR 0.79), social support (OR 0.86) and greater amount
of aerobic exercise (OR 0.75).
Factors that increased the likelihood for a poor outcome by chair
stand rate were greater baseline age and proprioceptive inaccuracy.
Factors that reduced the likelihood for poor chair stand rate were
quadriceps strength, hamstrings strength, self-efficacy and aerobic
exercise.
Other prognostic factors were not linked to outcome.
Dougados
(6)
64%
Knee (N=736)
hospital
cohort
prospective,
follow-up 1
year
ACR-criteria
Functional
status
Lequesne
index,
reported
change
Joint space
narrowing
Pain
VAS
Dieppe (7)
64%
Knee (N=193)
knee as index
joint (n=90)
hospital
prospective
cohort
follow-up 3
years
radiological
and clinical
criteria
Functional
Radiographic
status
changes
Reported
change in
overall
condition,
Steinbrocker
index
Pain
Reported
change in
overall joint
pain
Significant improvement in pain: VAS-score changed from 51 (SD
21) to 41 (SD 23) p<0.01 and a significant improvement in physical
function: score on Lequesne index changed from 11 (SD4) to 10 (SD
4) p<0.001
After 1 year 143 patients (41%) said their general condition had
improved, 97 (28%) said it had worsened. 112 patients thought their
condition had not changed.
Deterioration of clinical status was greater among patients with
considerable JSN (>66%) than among those with slight or moderate
narrowing (<66%): 39% vs. 24% (p=0.012)
27.5% of the patients with worsening radiological observation
considered their general condition deteriorated, vs. 20% among those
whose radiographs showed no deterioration
The decrease in pain was less in the group of patients with no
increased OA.
There was little evidence of strong association between any of the
clinical outcomes and any of the radiographic changes seen.
Ledingham
(8)
55%
Knee (N=188)
hospital
prospective
cohort
follow up 2.26
years
radiological
criteria
Functional
Age, clinical and
status
radiological
Steinbrocker symptoms
index,
reported
exercise
tolerance
Pain
Reported
change in
symptoms,
knee pain
scores
Massardo
(9)
Miller (10)
55%
55%
Knee (N=48)
Retrospective
and
prospective
cohort
Follow up 8
years
radiological
and clinical
criteria
Functional
status
Walking
ability /
difficulty,
reported
change
Knee (N=248)
community
prospective
cohort
Functional
status
Reported
functional
48% felt their symptoms had deteriorated, 23% described
improvement. Reported exercise tolerance remained unchanged in
62% and deteriorated in 35% of the patients.
Worsening of pain associated with severity of knee OA (OR 1.29),
warmth (OR 2.14) and CPPD (OR 1.89). Increased pain score
associated with severity of knee OA (OR 1.29), and CPPD (OR
1.88). Increased disability (Steinbrocker index) associated with
warmth (OR 4.25) and age (OR 1.07). Decreased exercise tolerance
associated with severity of knee OA (OR 1.52), warmth (OR 2.24)
and CPPD (OR 1.04). All (adjusted) odds ratios were significant.
No significant change in overall pain scores; significant loss of
walking ability developed in most patients. Four patients reported
that their knees were better; seven patients reported no change and
twenty (65%) patients worse.
Pain
Knee
symptoms:
pain
Significant decline in function measured by ambulatory performance
task (-2.41; p<0.05) and transfer performance task (-3.78; p<0.05).
follow up 30
months
radiological
and clinical
criteria
performance,
ambulatory
performance
task (stair
climb),
transfer
performance
task (car
time)
Pain
Pain
intensity
subscales
(Knee Pain
Scale)
Sharma (11) 46%
Knee (N=237)
community
prospective
cohort
follow-up 18
months
radiological
criteria
Functional
status
Chair-standrate
Alignment
No results on course of functional status and pain
Alignment associated with significantly greater functional
deterioration. Odds of functional decline were doubled (OR 2.33) by
having one knee with alignment of >5 dgr. vs. both knees with
alignment of 5 dgr. or less. Odds of functional decline were tripled
(OR 3.22) by having both knees with alignment of >5 dgr. vs. both
knees with alignment of 5 dgr. or less.
Davis (12)
46%
Knee (N=191)
community
prospective
cohort
follow up 9,5
years
radiological
criteria
Functional
status
Difficulty
with
functional
activities
Radiographic OA
Persons with radiographic knee OA were more likely to report
difficulty with physical functioning 10 years on than without knee
OA.
For women with moderate or severe knee OA difficulty scores were
higher than for women with minimal knee OA (p<0.05)
Dieppe (13)
46%
Knee (N=100)
hospital
prospective
cohort
follow-up 5
years
radiological
and clinical
criteria
Functional
status
Walking
ability
Knee pain at entry,
BMI, gender
Walking ability worsened in 45%, improved in 9% and remained
unchanged in 46%.
28% reported that their symptoms (knee pain) got worse, 35% same,
34% better
Pain
Reported
change in
knee pain
Relation between knee pain at entry (p<0.001), clinical factors such
as swelling (p<0.001), crepitus (p<0.01) and instability (p<0.001)
and change in knee pain over 5 years and between gender and change
in knee pain (p<0.05).
Association between radiological changes such as interbone distance
(p<0.01), number of compartments affected (p<0.05) and change in
knee pain over 5 years.
Knee (N=169)
hospital
prospective /
retrospective,
cohort
follow-up 11
years
radiological
criteria
Pain
Presence of
knee pain,
reported
change in
knee pain,
VAS
56% thought their pain had gotten worse.
VAS -scores remained unchanged (changed from 53mm to
48mm; ns)
Reported knee pain was present in 69% of the subjects at onset and
52% reported to have pain at follow-up
Spector (14) 46%
Ettinger (15) 46%
Knee (N=93)
community
retrospective
and
prospective
cohort
follow-up 10
years
radiological
criteria
Functional
status
Difficulty in
ambulation,
difficulty in
transfer
Odenbring
(16)
Knee (N=157)
hospital
prospective
cohort
follow-up 16
years
radiological
criteria
Functional
Age
status
Satisfactory
knee (pain
free walking
distance of
more than
500 meters,
ROM of at
least 5-90
degrees and
knee is stable
when patient
is walking)
In 20 of the 31 knees a poor result was recorded (no satisfactory
knee). 15 of the 23 patients could only manage on a low level of
activity. No information of situation at baseline: no results of course
of functional status
Knee (N=244)
hospital
retrospective
cohort
follow-up 1018 years
Functional
status
Reported
change of
clinical
course,
Patients reported change of clinical course: 17% improved, 27%
unchanged, 56% worse
Hernborg
(17)
36%
36%
Symptomatic OA,
co-morbidity
Age, age at onset of
pain, gender, lateral
stability
Symptomatic knee OA was associated with self-reported difficulty in
ambulation [men OR 3.19 (1.76-5.77), women OR 5.28 (3.09-9.00)]
and transfer [men OR 2.54 (1.40-4.59), women OR 4.37 (2.53-7.56)]
10 years later. The presence of coexistent chronic disease, especially
pulmonary disease and obesity) increased the likelihood of
subsequent disability from knee OA
Patients 60 years or younger at baseline had better function
(satisfactory knee) at follow-up
Gender and age not correlated to pain. Patients with a painless knee
at follow-up were significantly older than the painful cases.
Restriction of function increases significantly with age
radiological
criteria
classification
of function
Pain
Pain index
Berkhout
(18)
27%
Knee (N=72)
hospital
retrospective
cohort
follow-up 6.7
months
radiological
criteria
Pain
Start pain,
nocturnal
pain, pain
under stress
Global
improvement
(pain,
swelling,
quadriceps
weakness
and effusion)
In patients with LOA and a duration of complaints of more than one
year the number of patients with start pain decreases from 15 to 9,
the number of patients with nocturnal pain decreases from 13 to 4,
and the number of patients with pain under stress decreases from 22
to 13. Global improvement was seen in 54% of the patients with
LOA.
In patients with GOA, including knee OA and a duration of
complaints of more than one year the number of patients with start
pain decreases from 22 to 10, the number of patients with nocturnal
pain decreases from 17 to 6, and the number of patients with pain
under stress decreases from 19 to 12.
Global improvement was seen in 46% of the patients with GOA.
ACR: American College of Rheumatology; BMI: Body Mass Index (overweight); CPPD: Calcium PyroPhosphate Crystals; dgr.: degrees; GOA:
generalized osteoarthritis; JSN: joint space narrowing; LOA: localized osteoarthritis; mm: millimeters; MQ: methodological quality score; N or
n: number of subjects; ns: not significant; OA: osteoarthritis; OR: Odds ratio; p: level of significance; ROM: range of motion; SD: standard
deviation; VAS: Visual Analogue Scale; vs.: versus; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index.
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