OBJECTIVE:There is an urgent need to identify clinical markers that can help physicians determine when additional treatment is necessary to manage the symptoms of knee osteoarthritis (OA). Patterns of physical activity that occur within a day, eg, low activity in the morning and/or evening, may be a novel means to identify treatment need, given that symptoms may reduce daily activity at specific times of the day. The purpose of this study is to explore the relationship between within-day patterns of physical activity and all-cause mortality in adults with or at high risk for knee OA. METHODS:We performed a secondary analysis of the Osteoarthritis Initiative (NCT00080171). Our exposure was within-day patterns of physical activity using a multidimensional (14-hour) multilevel (4-day) functional principal component analysis to analyze accelerometer data from analytic baseline. The outcome was all-cause mortality assessed up to eight years. Kaplan-Meier survival curves and Cox proportional hazards regressions were used to calculate adjusted hazard ratios (aHR). RESULTS:There were 1,927 adults with or at high risk for knee OA included in this analysis. We identified four primary within-day activity patterns accounting for around 82% of sample variability. Participants who demonstrated low levels of activity in the morning and evening had 2.09 times the risk of death compared with those demonstrating the average activity pattern of the sample (aHR 2.09, 95% confidence interval 1.15-3.80). CONCLUSION:Unique within-day patterns of physical activity were associated with risk of death. Those with inactivity in the morning and evening were at increased risk for death.

Self-monitoring of blood glucose (SMBG) is a low value health care practice that does not benefit most patients with non-insulin treated type 2 diabetes (T2DM). This paper evaluates Re-Think the Strip (RTS), a multi-component study aimed at de-implementing SMBG among non-insulin treated T2DM patients in primary care. This study used a pre-post design to evaluate the effectiveness and implementation of Re-Think the Strip in 20 primary care clinics with a comparison group of 34 clinics within one health system. De-implementation strategies were implemented over 12 months and practices were followed for 18 months. There was an overall decrease in the odds of receiving a prescription for diabetes testing supplies (i.e., test strips and/or lancets) between the baseline and 12-month intervention follow-up for intervention and comparison clinics (OR 0.96, 95

OBJECTIVE:The purpose of this study was to describe activity patterns in adults with knee osteoarthritis (OA) and to examine the relation of patterns with incident slow gait speed over 4 years. DESIGN:Using data from the Osteoarthritis Initiative, we included adults with or at high risk of knee OA who walked > 1.0 m/s during a 20-meter walk at baseline, i.e., did not have slow gait speed. To determine activity patterns, we reduced the dimensions of accelerometer data (ActiGraph GTM1) using a multidimensional Multilevel Functional Principal Components Analysis to calculate between-subject principal component (PC) scores. We estimated the association of the top and bottom tertiles' PC scores with incident slow gait speed over 4 years (risk ratios with 95% confidence intervals) referenced to the middle tertile, adjusting for potential confounders. RESULTS:We identified four activity patterns (PCs): 1) high activity, 2) high evening activity, 3) high morning and evening activity, and 4) very high morning activity. Those whose daily activity patterns best matched with the pattern PC2 or PC4, were found to have 0.60 [0.37, 0.96] and 0.39 [0.22, 0.71] times the risk of developing slow gait speed, respectively; while those whose daily activity patterns least matched PC3, were found to have 1.77 [1.19, 2.62] times the risk. CONCLUSIONS:Daily activity patterns may be related to the development of slow gait speed in adults with or at risk for knee OA. TRIAL REGISTRATION:NCT00080171.

PURPOSE:Peripheral vascular disease (PVD) is a well-established risk factor for lower-extremity amputations and is associated with poor outcomes and increased mortality for patients undergoing these procedures. However, the outcomes and mortality risks for vasculopathic patients undergoing upper-extremity amputations (UEA), particularly of the hand, are less understood. This study aimed to elucidate the mortality risks associated with UEA in patients with PVD. METHODS:The TriNetX database was retrospectively queried using International Classification of Diseases-10th Clinical Modification and Current Procedural Terminology coding to identify patients with and without PVD who underwent UEA procedures. Patients were split into the following two cohorts: (1) UEA without PVD (no PVD), and (2) UEA with PVD (PVD). Cohorts were matched 1:1 using propensity scoring based on age, sex, body mass index, diabetes, and tobacco use. Relative risks, hazard ratios of mortality, and Kaplan-Meier survival analyses were performed to determine mortality rates at 6 months, 1 year, 5 years, and 10 years after initial UEA. RESULTS:This study identified 36,368 patients, with 6,750 patients in the UEA with PVD cohort, and 29,213 patients in the UEA with no PVD cohort. Each matched cohort consisted of 4,952 patients. Patients without a history of PVD undergoing UEA were considerably less likely to die at each time point. Furthermore, the risk of mortality was lower for the no PVD cohort, and mortality rates were higher for the PVD group at each time point. CONCLUSIONS:These findings showed increased mortality risk for UEA patients with PVD compared with patients without PVD. TYPE OF STUDY/LEVEL OF EVIDENCE:Prognosis II.

Objective:To conduct an exploratory randomized controlled trial of a physical activity intervention for individuals with osteoarthritis (OA) involving telephone-delivered coaching, activity self-monitoring, and connection with resources to support activity (Osteoarthritis Physical Activity Care Pathway; OA-PCP). Methods:Older adults (age ≥65 years) with symptomatic hip or knee OA and comorbid health conditions (N ​= ​240) were randomized to OA-PCP or an attention control (AC) condition. OA-PCP included coaching calls at baseline and at 3-month intervals through 12 months, as well as email-delivered content. The ACgroup received calls and emails focused on OA education. The primary outcome was minutes of moderate to vigorous physical activity (MVPA) per week, measured at baseline, 6-months and 12-months via accelerometer. Secondary outcomes included other physical activity metrics and the Western Ontario and McMaster Universities Osteoarthritis Index pain and function subscales. Linear mixed regression was used to estimate between-group differences from baseline to follow-up time points. Results:At 6-month and 12-month follow-up, the changes in weekly MVPA favored the OA-PCP by 9.5 ​min (95 ​% Confidence Interval -6.7, 25.8; p ​= ​0.252) and 12.3 ​min (95 ​% Confidence Interval -3.8, 28.4; p ​= ​0.136), respectively, but differences were not statistically or clinically significant. There were no significant between-group differences in secondary outcomes other than steps per day at 12-months. Conclusions:A more intensive intervention approach may be needed to enhance physical activity among older adults with OA and comorbid health conditions.

Background: Knee osteoarthritis (OA) is a leading cause of pain and disability globally. Pain from knee OA leads to functional limitation. Physical activity (PA), e.g., taking more steps/day, reduces the risk of functional limitation. However, little is known about patterns of activity throughout the day and to what extent such patterns may be associated with the functional limitation. This is a major gap given activity patterns can be modified and may be an important to consider for treatment to further address functional limitation associated with knee OA. Objectives: The purpose of this study was to investigate patterns of PA in individuals with knee OA and to examine the association of patterns with incident slow gait speed over 2 years. Methods: We utilized data from the Osteoarthritis Initiative (OAI) in this analysis. Accelerometer data was collected at the 4-year follow-up visit. We calculated the total activity counts per hour reported from the accelerometer (ActiGraph GT1M). We utilized four days per participant and included the hours of 8 am to 9 pm. A multidimensional (12 hours) multilevel (4 days) Functional Principal Components Analysis, a dimensionality reduction technique, was applied to investigate major sample activity patterns. An individual’s activity patterns were summarized into numerical scores called individual level principal components (PC) scores. These individual scores indicate the extent to which a particular individual’s activity is explained by the sample’s corresponding activity pattern. Gait speed was measured at baseline (year 4) and again at 2-year follow-up (year 6). A speed of <1 m/s during a 20-meter walk was classified as a slow gait speed. Demographic information, radiographic OA presence, knee pain, and depressive symptoms were also collected. We examined the association of PC scores, categorized into quartiles, with incident slow gait speed over a 2-year follow-up period. We calculated risk ratios (RR) and 95% confidence intervals (CI) for the association of the top quartile each PC with the bottom quartile (referent) with incident slow gait speed adjusted for potential confounders. Results: Of the 1457 participants included in the analytic sample (Age 60.1 years (8.8), 53.3% Women, BMI 28.2 kg/m2 (4.5), 53.8% with radiographic knee OA), we found four patterns of activity. Figure 1 displays loadings of the first four-person level PCs that explain about 82% of participant level variation. PC1 represents an overall increase over the sample’s mean activity such that positive PC1 values represent being more active throughout the day compared to the sample mean. PC2 shows decreased activity from morning to afternoon and increased activity in the evening. PC3 shows decreased activity levels in the middle of the day with increased activity in the morning and evening. PC4 shows low levels of activity in the early morning with fluctuating activity levels throughout the remainder of the day. Participants in the highest quartile of PC4, meaning those whose daily patterns of activity best match PC4, were found to have 2.76 times the risk of developing slow gait speed compared to those in the lowest quartile of PC4 (Table 1). Participants in the highest quartile of PC3 had 72% less risk of developing slow gait speed compared to those in the lowest quartile of PC3 which met statistical significance. Conclusion: Four preliminary patterns of activity were identified among adults with or at high risk of knee OA. Adults whose activity level fluctuates constantly throughout the day could be at increased risk for developing slow gait speed, while those who are active in the mornings and evenings could be at decreased risk. Future studies should examine how these patterns of activity could be related to other OA-related outcomes.Table 1. Incident slow gait speed development rate according to the corresponding Principal Component*Adjusted for age, sex, race, pain intensity, presence of radiographic OA and Center for Epidemiologic Studies Depression Scale REFERENCES: NIL. Acknowledgements: NIL. Disclosure of Interests: None declared.Figure 1Graphs of Patterns of PA counts per hour for each Principal Component (PC)*Large positive loadings show that a particular hour has a strong positive relationship to the corresponding PC

Purpose (the aim of the study): Pain from knee osteoarthritis (OA) limits the ability to perform activities, such as getting up from a chair and walking. Consequently, excessive time in sedentary behavior (SB), defined as low energy expenditure while sitting or reclining while awake, is common for adults with knee OA. In the past, SB was described using a single summary measure of total average time over multiple days. However, SB can vary within and between days. Little is known about patterns of SB among adults with knee OA and adults in general.

Purpose (the aim of the study): In adults with knee osteoarthritis (OA), excessive sedentary behavior (SB) exacerbates pain and limits function, amplifying the risk of poor health outcomes, including all-cause mortality, cardiovascular disease, and metabolic disorders. Previous studies have measured SB as low energy expenditure alone (low EE); however, the current standardized definition of SB from the Sedentary Behavior Research Network (SBRN) requires both low EE and seated or lying body position.

Abstract Background Shoulder pain is a leading cause of disability. Occupations requiring high upper extremity demands may put workers at greater risk of shoulder injury and resulting pain. We examined associations of occupation with shoulder pain and upper extremity disability in the Johnston County Osteoarthritis Project. Methods Work industry and occupational tasks for the longest job held were collected from participants. At follow-up ranging from 4–10 years later, participants were asked about shoulder symptoms (pain, aching, or stiffness occurring most days of 1 month in the last year) and given a 9-item, modified Disabilities Arm Shoulder and Hand (DASH) questionnaire to categorize disability from 0–4 (none-worst). Logistic regression and cumulative logit regression models were used to estimate associations with prevalent shoulder symptoms and with worse disability category, respectively. Models were adjusted for cohort, age, sex, race, education and time to follow-up. Sex- and race-stratified associations were evaluated. Results Among 1560 included participants, mean age was 62 years (standard deviation ± 9 years); 32% were men, and 31% were Black. Compared to the managerial/professional industry, higher odds of both shoulder symptoms and worse upper extremity disability were seen for most industrial groups with physically demanding jobs, particularly the service industry. Work that often or always required lifting/moving > 10 lbs. was associated with higher odds of shoulder symptoms. Work that sometimes or always required heavy work while standing was associated with higher odds of shoulder symptoms, and this association was stronger among men and White workers. Conclusion Physically demanding occupations were associated with increased occurrence of shoulder pain and disability. Mitigating specific physical work demands may reduce shoulder-related disability.

ObjectiveWalk With Ease (WWE) is an effective low-cost walking program. We estimated the budget impact of implementing WWE in persons with knee osteoarthritis (OA) as a measure of affordability that can inform payers’ funding decisions.MethodsWe estimated changes in two-year healthcare costs with and without WWE. We used the Osteoarthritis Policy (OAPol) Model to estimate per-person medical expenditures. We estimated total and per-member-per-month (PMPM) costs of funding WWE for a hypothetical insurance plan with 75,000 members under two conditions: 1) all individuals aged 45+ with knee OA eligible for WWE, and 2) inactive and insufficiently active individuals aged 45+ with knee OA eligible. In sensitivity analyses, we varied WWE cost and efficacy and considered productivity costs.ResultsWith eligibility unrestricted by activity level, implementing WWE results in an additional $1,002,408 to the insurance plan over two years ($0.56 PMPM). With eligibility restricted to inactive and insufficiently active individuals, funding WWE results in an additional $571,931 over two years ($0.32 PMPM). In sensitivity analyses, when per-person costs of $10 to $1,000 were added with 10-50% decreases in failure rate (enhanced sustainability of WWE benefits), two-year budget impact varied from $242,684 to $6,985,674 with unrestricted eligibility and from -$43,194 (cost-saving) to $4,484,122 with restricted eligibility.ConclusionAlong with the cost-effectiveness of WWE at widely accepted willingness-to-pay thresholds, these results can inform payers in deciding to fund WWE. In the absence of accepted thresholds to define affordability, these results can assist in comparing the affordability of WWE with other behavioral interventions.

Objective:The Walk With Ease (WWE) program was developed by the Arthritis Foundation to help people with arthritis learn to exercise safely and improve arthritis symptoms. We sought to establish the value of the WWE program. Methods:We used the Osteoarthritis Policy (OAPol) Model, a widely published and validated computer simulation of knee osteoarthritis (OA), to assess the cost-effectiveness of WWE in knee OA. We derived model inputs using data from a workplace wellness initiative in Montana that offered WWE to state employees. Our primary outcomes were quality-adjusted life years (QALYs) and costs over a 2-year period, which we used to calculate the incremental cost-effectiveness ratio (ICER). The base case analysis was restricted to subjects who were inactive or insufficiently active (<180 ​min/week of PA) at baseline. We performed scenario and probabilistic sensitivity analyses to determine the impact of uncertainty in model parameters on our results. Results:In the base case analysis, adding WWE to usual care resulted in an ICER of $47,900/QALY. When the program was offered without preselection by baseline activity level, the ICER for WWE ​+ ​usual care was estimated at $83,400/QALY. Results of the probabilistic sensitivity analysis indicated that WWE offered to inactive or insufficiently active individuals has a 52% chance of having an ICER <$50,000/QALY. Conclusion:The WWE program offers good value for inactive/insufficiently active individuals. Payers may consider including such a program to increase physical activity in individuals with knee OA.

Objective: To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA). Design: We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by & GE;80% of participants were retained, and participants could suggest addi-tional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if & GE;80% rated it & GE;6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if & GE;80% of participants rated it & GE;9 and as "optional" if & GE;80% rated it & GE;7. Results: A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics. Conclusion: The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context. Published by Elsevier Ltd on behalf of Osteoarthritis Research Society International.

Purpose: Reduced physical function (PF) is a common consequence of osteoarthritis (OA), and poor PF is associated with premature death. Reduction in physical activity due to poor PF may also increase an individual’s risk of development or progression of life-threatening chronic diseases such as CVD and diabetes. We previously found that individuals with painful knee and/or hip OA were more likely to experience premature mortality, independent of key comorbidities. We therefore sought to explore whether poorer PF among those with knee and/or hip OA was associated with 10-year mortality, independent of comorbidities associated with reduced PF.

Purpose: Osteoarthritis studies typically utilize multiple individual performance-based function tests. It is difficult to select one as the primary endpoint and it requires multiple models to analyze. The motivation for this work is to develop the methodology of combining multiple performance-based tests and to develop a single metric of objective physical function, without making one test preferred over another.

Objective:To describe the point prevalence of hip symptoms, radiographic hip osteoarthritis (rHOA), severe rHOA, and symptomatic rHOA (sxHOA) at five time points in the longitudinal, population-based Johnston County Osteoarthritis Project (JoCoOA).Design:Data were from 3068 JoCoOA participants who attended up to five study visits (1991-2018). Standardized supine pelvis radiographs were read by a single, expert musculoskeletal radiologist with high reliability. The four outcomes were: 1) self-reported hip symptoms: "On most days, do you have pain, aching, or stiffness in your right/left hip?"; 2) rHOA: Kellgren-Lawrence grade (KLG) of 2-4; 3) severe rHOA: KLG of 3-4; and 4) sxHOA: both symptoms and rHOA in the same joint. Weighted point prevalence and 95% confidence intervals (CI) were generated overall and by age group (45-54, 55-64, 65-74, 75+ years), sex, race (Black/White), and body mass index (BMI; 18.5-24.9; 25-29.9; 30+ kg/m2).Results:At the most recent follow-up (2017-2018), the point prevalence (%) of hip symptoms, rHOA, severe rHOA, and sxHOA were 30% (95% CI 25%, 35%), 53% (95% CI 48%, 58%), 9% (95% CI 6%, 12%), and 15% (95% CI 11%, 19%), respectively. RHOA and severe rHOA were most prevalent in those 75+ years. Women were more likely than men to have hip symptoms and sxHOA. No consistent trends were noted by race or BMI.Conclusion:These updated point prevalence estimates demonstrate a large and increasing burden of HOA in the general population, particularly with aging. Black and White individuals were affected similarly in this cohort.

Introduction Biochemical biomarkers may provide insight into musculoskeletal pain reported at individual or multiple body sites. The purpose of this study was to determine if biomarkers or pressure-pain threshold (PPT) were associated with individual or multiple sites of pain. Methods This cross-sectional analysis included 689 community-based participants. Self-reported symptoms (ie, pain, aching, or stiffness) were ascertained about the neck, upper back/thoracic, low back, shoulders, elbows, wrist, hands, hips, knees, ankles, and feet. Measured analytes included CXCL-6, RANTES, HA, IL-6, BDNF, OPG and NPY. A standard dolorimeter measured PPT. Logistic regression was used determine the association between biomarkers and PPT with individual and summed sites of pain. Results Increased IL-6 and HA were associated with knee pain (OR=1.30, 95% CI 1.03, 1.64) and (OR=1.32, 95% CI 1.01, 1.73) respectively; HA was also associated with elbow/wrist/hand pain (OR=1.60, 95% CI 1.22, 2.09). Those with increased NPY levels were less likely to have shoulder pain (OR=0.56, 95% CI 0.33, 0.93). Biomarkers HA (OR=1.50, 95% CI 1.07, 2.10), OPG (OR=1.74, 95% CI 1.00, 3.03), CXCL-6 (OR=1.75, 95% CI 1.02, 3.01) and decreased PPT (OR=3.97, 95% CI 2.22, 7.12) were associated with multiple compared to no sites of pain. Biomarker HA (OR=1.57, 95% CI 1.06, 2.32) and decreased PPT (OR=3.53, 95% CI 1.81, 6.88) were associated with multiple compared to a single site of pain. Conclusion Biomarkers of inflammation (HA, OPG, IL-6 and CXCL-6), pain (NPY) and PPT may help to understand the etiology of single and multiple pain sites.