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線維筋痛症を含む広い概念の慢性広範痛症は人工膝関節置換術後に痛みが改善しない危険性が高い

Widespread pain広範な疼痛)とは線維筋痛症を含むより広い概念、線維筋痛症はWidespread painの中でも症状が強い一群。通常線維筋痛症の有病率は2%、線維筋痛症を含むWidespread painの有病率は10%。


バックグラウンド:
保存的治療が効かない場合、
TKAは変形性膝関節症患者にとって最良の選択肢かもしれませんが、TKA 後の臨床的に重要な改善 は比較的大きな割合ではありません。また、女性は男性よりもTKA恩恵を受ける可能性が低いことを示唆していますが、理由は不明です。Widespread pain広範な疼痛)は女性に不釣り合いに影響し、関節形成術後のより悪い転帰と関連しているが、TKA転帰に対する広範な疼痛の影響が患者の性別によって異なるかどうかは不明である。質問/目的:1TKA 2年後の広範な 痛みと変形性関節症関連の痛みと障害の臨床的に重要な改善の関係は、男性と女性で異なりますか?(2TKA 2年後の鎮痛剤の使用は、手術前に広範囲の痛みを伴うものと広範囲に痛みを伴わないものとで異なりますか?方法:変形性関節症イニシアチブ(https://nda.nih.gov/oai/)の研究参加者は、20053月から201510月まで毎年追跡されました。TKA 前のプロトコール計画受診時に痛み/障害評価を受け7年間の経過観察を受け術後に2回目の計画受診をした参加者を解析に含んだ。4796人の研究参加者の中で、391人はTKAが確認された(TKA前にプロトコール計画受診時に痛み/障害評価を受けた315人を含む)。全体として、参加者の95%(298人)が必要なフォローアップ評価を受けました。5%(17人)には追跡データがありませんでした。広範囲の痛みは修正されたAmerican College of Rheumatology基準に基づいて定義されました。症状は、WOMAC 疼痛(範囲0から20、より高いスコア、より多くの痛み)および障害(範囲0から68、より高いスコア、より多くの障害)スコア、および痛みに対する膝損傷および変形性関節症の結果スコア(範囲0から100;より高いスコア、より少ない痛み)を使用して評価されました。痛みや障害の改善は、確立された臨床的に重要な違いからの改善に基づいて分類された(WOMACの痛み1.5以上の減少 ; WOMAC身体障害≥6.0の減少、KneeInjury and Osteoarthritis Outcome Score for pain ≥ 9 の増加)。ベースラインでは、女性の方が男性より広範囲 の痛みをより多く示す(45[184人中84] 32[114人中36])。ロジスティック回帰分析を使用して、臨床的に重要な改善のない確率と相対リスク(RR)を推定し、広範な痛みのある参加者とそうでない参加者を比較しました。分析は男性と女性に対して別々に行われ、その後、うつ病とベースラインのアウトカムスコアに対して調整されました。結果:女性の中で、手術前の広範囲 の痛みは、 TKA 2年後のWOMAC疼痛点数(13.5% versus 4.6%; RR 2.93 [95% CI 1.18 to 7.30]; p =0.02)およびthe Knee Injury and Osteoarthritis Outcome Score for pain (16.5% versus 4.9%; RR 3.39 [95% CI 1.34 to 8.59];p = 0.02)に基づいた臨床的に重要でない改善の危険性増加と関連。信頼区間の下限と上限を考えると、私たちのデータは、男性において広範囲にわたる 痛み,WOMAC疼痛スコア(RR 0.77 [95% CI 0.22 to 2.70]; p = 0.68)およびthe Knee Injury and Osteoarthritis Outcome Score for pain(RR 1.37 [95% CI 0.47 to 4.00]; p = 0.57)における臨床的に重要な改善の欠如、および男性(RR 0.72 [95%CI 0.20 to 2.55]; p = 0.61)と女性(RR 1.98 [95%CI 0.92 to 4.26]; p = 0.08)におけるWOMAC 障害点数の臨床的に重要な改善の欠如との間のさまざまな関連と互換性があります。TKA前に広範囲の痛みを呈した参加者は、TKA 2年後の少なくとも1か月間、変形性膝関節症の症状に薬物を使用する傾向が広範囲の痛みのない人よりも高かった (51% [61 of 120] versus 32% [57 of 178]; meandifference, 18.8 [95% CI 7.3 to 30.1]; p < 0.01)結論:TKA前の広範囲の痛みは、女性の術後2年で膝痛の臨床的に重要な改善がない危険性の増加と関連していた。サンプルに広範な痛みを伴う男性は少数であるため、男性の結果は決定的ではありませんでした。今後の研究では、広範な 疼痛を有する男性をより多く含め、TKA手術の前または同時の広範な 疼痛の治療が手術結果を改善できるかどうかを調査する必要があります。証拠のレベル:レベルIII、治療研究。

Clin Orthop Relat Res. 2019 Oct 16. doi: 10.1097/CORR.0000000000001001.[Epub ahead of print]

Widespread Pain IsAssociated with Increased Risk of No Clinical Improvement After TKA in Women.

Vina ER1, Ran D, Ashbeck EL, Kwoh CK.

1

E. R. Vina, C. K. Kwoh, Division ofRheumatology, Department of Medicine, University of Arizona, Tucson, AZ, USA E.R. Vina, D. Ran, E. L. Ashbeck, C. K. Kwoh, Arthritis Center, University ofArizona, Tucson, AZ, USA D. Ran, Department of Epidemiology and Biostatistics,Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson,AZ, USA.

Abstract

BACKGROUND:

When conservative treatments donot work, TKA may be the best option for patients with knee osteoarthritis,although a relatively large proportion of individuals do not have clinically importantimprovement after TKA. Evidence also suggests that women are less likely to benefitfrom TKA than men, but the reasons are unclear. Widespreadpain disproportionately affects women and hasbeen associated with worse outcomes after joint arthroplasty, yet it is unknownif the effect of widespread pain on TKA outcomes differs by patient gender.

QUESTIONS/PURPOSES:

(1) Does the association betweenwidespread pain andno clinically important improvement in osteoarthritis-related pain and disability 2 years after TKA differ betweenmen and women? (2) Does the use of painmedications 2 years after TKA differ between those with widespreadpain and those without widespreadpain before surgery?

METHODS:

Osteoarthritis Initiative(https://nda.nih.gov/oai/) study participants were followed annually from March2005 until October 2015. Participants who underwent TKA up to the 7-yearfollow-up visit with pain/disability assessmentat the protocol-planned visit before TKA and at the second planned annual visitafter surgery were included in the analysis. Among 4796 study participants, 391had a confirmed TKA, including 315 with pain/disabilityassessment at the protocol-planned visit before TKA. Overall, 95% ofparticipants (298) had the required follow-up assessment; 5% (17) did not havefollow-up data. Widespread pain was defined based on the modified American Collegeof Rheumatology criteria. Symptoms were assessed using the WOMAC pain (range 0 to 20; higher score, more pain) and disability (range 0 to 68; higher score, moredisability) scores, and the Knee Injury andOsteoarthritis Outcome Score for pain (range 0 to100; higher score, less pain). Improvements in pain and disability were classified based on improvementfrom established clinically important differences (decrease in WOMAC pain ≥ 1.5; decrease in WOMAC disability ≥ 6.0;increase in Knee Injury and Osteoarthritis OutcomeScore for pain ≥ 9). At baseline, more womenpresented with widespread painthan men (45% [84 of 184] versus 32% [36 of 114]). Probability and the relativerisk (RR) of no clinically important improvement were estimated using alogistic regression analysis in which participants with widespreadpain and those without were compared. Theanalyses were done for men and women separately, then adjusted for depressionand baseline outcome scores.

RESULTS:

Among women, preoperative widespread pain wasassociated with an increased risk of no clinically important improvement 2years after TKA, based on WOMAC pain scores(13.5% versus 4.6%; RR 2.93 [95% CI 1.18 to 7.30]; p = 0.02) and the Knee Injury and Osteoarthritis Outcome Score for pain (16.5% versus 4.9%; RR 3.39 [95% CI 1.34 to 8.59];p = 0.02). Given the lower and upper limits of the confidence intervals, ourdata are compatible with a broad range of disparate associations between widespread pain and lackof clinically important improvement in WOMAC painscores (RR 0.77 [95% CI 0.22 to 2.70]; p = 0.68) and the Knee Injury and Osteoarthritis Outcome Score for pain (RR 1.37 [95% CI 0.47 to 4.00]; p = 0.57) amongmen, as well as clinically important improvement in WOMAC disability scoresamong men (RR 0.72 [95% CI 0.20 to 2.55]; p = 0.61) and women (RR 1.98 [95% CI0.92 to 4.26]; p = 0.08). Participants presenting with widespreadpain before TKA were more likely than thosewithout widespread painto use medication for symptoms of knee osteoarthritis most days for at least 1month 2 years after TKA (51% [61 of 120] versus 32% [57 of 178]; meandifference, 18.8 [95% CI 7.3 to 30.1]; p < 0.01).

CONCLUSIONS:

Widespread pain before TKA was associated with anincreased risk of no clinically important improvement in knee pain 2 years postoperatively among women. Because ofthe small number of men with widespread pain in the sample, the results for men wereinconclusive. In clinical practice, screening TKA candidates for widespread pain may be useful,and expectations of surgical outcomes may need to be tempered if patients havea concurrent diagnosis of widespread pain. Future studies should include more men with widespread pain andinvestigate if treatment of widespread pain before or concurrent with TKA surgery may improvesurgical outcomes.

LEVEL OF EVIDENCE:

Level III, therapeutic study.




by fibromyalgia11 | 2019-10-23 18:27 | FMの疫学
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世界標準の線維筋痛症を専門家が説明します


by fibromyalgia11
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