title: Significant pain variability in persons with, or at high risk of, knee osteoarthritis: preliminary investigation based on secondary analysis of cohort data.
abstract: While knee osteoarthritis (OA) is characterised as a slowly progressive disease, acute flares, episodes of severe pain, and substantial fluctuations in pain intensity appear to be part of the natural history for some patients. We sought to estimate what proportion of symptomatic community-dwelling adults might be affected, and to identify patient and problem characteristics associated with higher risk of such variability in pain.
  
  
  
  We analysed data collected at baseline, 18, 36, 54, and 72 month follow-up of a prospective cohort of symptomatic adults aged over 50 years with current/recent knee pain. At each time point we estimated the proportion of participants reporting 'significant pain variability' (defined as worst pain intensity in the past 6 months ≥5/10 and ≥2 points higher than average pain intensity during the same 6-month period). The associations between significant pain variability and demographic, socioeconomic, lifestyle, clinical, radiographic, and healthcare utilisation factors measured at baseline were estimated by adjusted odds ratios and 95% confidence intervals (aOR; 95%CI) from multivariable discrete-time survival analysis.
  
  
  
  Seven hundred and nineteen participants were included in the final analysis. At each time point, 23-32% of participants were classed as reporting significant pain variability. Associated factors included: younger age (aOR (per year): 0.96; 95% CI 0.94, 0.97), higher BMI (per kg/m2:1.03; 1.01, 1.06), higher WOMAC Pain score (per unit: 1.06; 1.03, 1.10), longer time since onset (e.g. 1-5 years vs < 1 year: 1.79; 1.16, 2.75) and morning stiffness (≤30 min vs none: 1.43; 1.10, 1.85). The models accounting for multiple periods of significant symptom variability found similar associations.
  
  
  
  Our findings are consistent with studies showing that, for some patients OA symptoms are significantly variable over time. Future prospective studies on the nature and frequency of flare ups are needed to help determine triggers and their underlying pathophysiology in order to suggest new avenues for effective episode management of OA to complement long-term behaviour change.
authors.affiliation: NIHR In-Practice Fellow, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK. e.clarke@keele.ac.uk.
authors.forename: Emma
authors.identifier: 0000-0003-0278-6898
authors.initials: E
authors.lastname: Parry
authors.affiliation: Research Fellow in Biostatistics, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, ST5 5BG, Staffordshire, UK.
authors.forename: Reuben
authors.initials: R
authors.lastname: Ogollah
authors.affiliation: Professor of Clinical Epidemiology, Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, ST5 5BG, Staffordshire, UK.
authors.forename: George
authors.initials: G
authors.lastname: Peat
mesh_terms: D000368:Aged; D018771:Arthralgia / Q000453:epidemiology* / Q000209:etiology; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000150:complications / Q000453:epidemiology*; D012307:Risk Factors; D006113:United Kingdom / Q000453:epidemiology
keywords: Association; Flare; Frequency; Knee; Osteoarthritis; Symptom; Variability