Background
Methods
Data sources and search strategy
Inclusion and exclusion criteria
Data extraction
Methodological quality assessment
Item | Criterion | Study type |
---|---|---|
Study population
| ||
1 | Selection before disease was present or at uniform point | CH/CC/CS |
2 | Cases and controls were drawn from the same population | CC |
3 | Participation rate ≥80% for cases/cohort | CH/CC/CS |
4 | Participation rate ≥80% for controls | CC |
5 | Sufficient description of baseline characteristics | CH/CC/CS |
Assessment of risk factor
| ||
6 | Psychosocial assessment was blinded | CH/CC/CS |
7 | Psychosocial factors were measured identical for cases and controls | CC |
8 | Psychosocial factors were assessed prior to the outcome | CH/CC/CS |
Assessment of outcome
| ||
9 | Knee OA/pain was assessed identical in studied population | CH/CC/CS |
10 | Presence of knee OA/pain was assessed reproducibly | CH/CC/CS |
11 | Presence of knee OA/pain was assessed according to standard definitions | CH/CC/CS |
Study design
| ||
12 | Prospective design was used | CH/CC/CS |
13 | Follow up time ≥2 years | CH |
14 | Withdrawals ≤20% | CH |
Analysis and data presentation
| ||
15 | Appropriate analysis techniques were used | CH/CC/CS |
16 | Adjusted for at least age and sex | CH/CC/CS |
Yes | No | Where/ comments | |
---|---|---|---|
1. Eligibility criteria were specified | |||
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received) | |||
3. Allocation was concealed | |||
4. The groups were similar at baseline regarding the most important prognostic indicators | |||
5. There was blinding of all subjects | |||
6. There was blinding of all therapists who administered the therapy | |||
7. There was blinding of all assessors who measured at least one key outcome | |||
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups | |||
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by “intention to treat” | |||
10. The results of between-group statistical comparisons are reported for at least one key outcome | |||
11. The study provides both point measures and measures of variability for at least one key outcome | |||
TOTAL (checked excluding eligibility criteria specified): |
Data synthesis
Level of evidence | Criteria for inclusion in best evidence synthesis |
---|---|
Strong evidence | generally consistent findings in: |
o multiple high quality cohort studies | |
Moderate evidence | generally consistent findings in: |
o 1 high quality cohort study & > 2 high quality case-control studies | |
o > 3 high quality case-control studies | |
Limited evidence | generally consistent findings in: |
o single cohort study | |
o 1 or 2 case-control studies or | |
o multiple cross-sectional studies | |
Conflicting evidence | inconsistent findings in <75% of the trials |
No evidence | No studies could be found |
Results
Identification and selection of the literature
Characteristics of included studies
Author (country, year) | Study population | No. of participants | Age (years) | Definition of OA | Previous knee injury | Pain assessment | Psychosocial factor assessment | Quality score |
---|---|---|---|---|---|---|---|---|
(% women) | mean ± SD (range) | |||||||
Cross-sectional Studies
| ||||||||
O’Reilly (England, 1998) | Community participants registered at two general practices and aged 40–70 years | 3323 (NA) | NA (range: 40–75) | NA | NA | Questions regarding knee pain on most days for at least a month (in the past year) | General mental health: Short Form 36 (SF36) subscale | 45 |
Creamer (USA, 1999) | Recruited from the Baltimore Longitudinal Study of Aging; community-based individuals >40 years | 374 (32) | Men: | NA | NA | Knee pain: National Health and Nutrition Examination Survey | Anxiety: Arthritis Impact Measurement Scales (AIMS) | 55 |
63.8 ±0.80 | ||||||||
Women: 62.8 ±1.08 | ||||||||
Depression: AIMS | ||||||||
Harcombe (New Zealand, 2010) | Randomly selected nurses, postal workers and office workers using computers | 443 (NA) | NA (range: 20–59) | NA | NA | Self-reported knee pain lasting for more than a day in the month before the survey | General Mental health: Mental Health Inventory-5 (MHI-5) | 73 |
Matsudaira (Japan, 2011) | Nurses, office workers, sales/marketing personnel and transportation operatives | 2290 (32) | NA (range: 19–64) | NA | NA | Self-reported knee pain in the past month and past year | General Mental health: SF36 subscale | 82 |
Creamer (USA, 1999) | Outpatients with prior physician diagnosis of knee OA and current knee pain | 68 (69.1) | 65.8 ± 10.4 | American College of Rheumatology clinical criteria | Excluded if previous total knee replacement | Knee Pain and Severity: WOMAC, VAS, MPQ | Depression: Centre for Epidemiological Studies Depression Scale (CES-D) | 55 |
Anxiety: State-Trait Anxiety Inventory (STAI) | ||||||||
Davis (USA, 1992) | Study sample from NHANES I survey, aged 45–74 years, who had knee OA and knee pain | 4056 (52) | (45–74) | OA based on radiographic criteria using the Atlas of Standard Radiographs of Arthritis. | NA | Knee pain on most days lasting one month in the past year or pain on active or passive motion during the examination | General Mental Health: NHANES General Wellbeing Index | 45 |
Salaffi (Italy, 1991) | 61 participants from outpatient clinic of a Rheumatic Disease Unit with symptomatic knee OA | 61 (100) | 63.5 ± 7.3 | American College of Rheumatology clinical criteria | NA | Knee Pain: MPQ and Visual Analogue Scale | Depression: Zung Depression Inventory | 45 |
Anxiety: Zung Anxiety Inventory | ||||||||
van Baar | Participants presenting to their GPs with hip and knee OA | Hip OA: 73 (71.2) | Hip OA: | American College of Rheumatology clinical criteria | Excluded if pathology explained the complaints | Severity of knee pain: Visual Analogue Scale | Anxiety and Depression: IRGL questionnaire | 64 |
(The Netherlands, 1998) | Knee OA: 112 (88.4) | 67.7 ± 8.7 | ||||||
Knee OA: 69.3 ± 8.1 | ||||||||
Pells (USA, 2008) | Subjects with knee OA recruited through Rheumatology, Orthopaedic Surgery, and Pain Management clinics | 174 (82) | 57.7 ± 9.8 | American College of Rheumatology clinical criteria | NA | Knee pain: AIMS | Depression and Anxiety: Psychological Disability subscale of AIMS | 64 |
Wright (USA, 2008) | Participants from the KNEE study, aged 35–64 years; pain on ≥4 days a week | 275 | NA (range 35–64) | American College of Rheumatology clinical criteria | Excluded if have inflammatory arthritis, previous knee surgery, Kellgren and Lawrence grade III-IV | Pain: WOMAC pain subscale | Depressive symptoms: CES-D | 82 |
Pain composite: pain assessments taken after physical function tests in pre-baseline assessment | ||||||||
General mental health (Vitality): subscale of the SF-36 | ||||||||
Nested case–control studies
| ||||||||
Peat (United Kingdom, 2009) | Both cases and control are recruited from the Clinical Assessment Study of the Knee | 285 (55) | Cases: | NA | Previous knee surgery n (%): 26 (9.1) | Characteristic pain intensity: Chronic Pain Grade | Anxiety and depression: Hospital Anxiety and Depression Scale | 79 |
66.3 ± 9.2 | ||||||||
Controls: 64.6 ± 8.2 | ||||||||
Pain extent: areas of pain experienced in previous month shaded on whole-body manikin | ||||||||
Night pain: single item on WOMAC | ||||||||
Longitudinal Studies
| ||||||||
Piva (USA, 2009) | Subjects diagnosed with patella-femoral pain syndrome (PFPS) recruited from rehabilitation clinics | 74 (52) | 29 ± 9 | NA | Excluded if previous patellar dislocation, knee surgery past 2 years, ligamentous injury or laxity, internal derangement | Knee pain intensity measured using 11-point numerical pain rating scale (NPRS) | Anxiety: Beck Anxiety Index | 85 |
Riddle (USA, 2011) | Community based recruitment through 4 teaching hospitals from different states (Osteoarthritis initiative study) | 3405 (59.1%) | 60.62 ±9.04 | Modified Kellgren and Lawrence Knee OA | NA | Knee Pain: WOMAC pain scale | General mental health: SF-12 Mental Component Summary (MCS) | 92 |
Disability: WOMAC disability scale | ||||||||
Depression: 20-item CES-D | ||||||||
Randomised controlled trials
| ||||||||
Chappell | Male and female outpatients ≥ 40 years of age. Recruitment by clinical sites | Antidepressant (intervention)= 128(69.5%) | Antidepressant= 63.2 ± 8.8 | American College of Rheumatology clinical criteria | Excluded patients with invasive therapies to the index knee during the past 3 months or previous joint replacement anytime | Knee Pain: Brief Pain Inventory (BPI); WOMAC pain and stiffness subscales | Depression: Beck Depression Inventory-II (BDI-II); | 8* |
(USA, 2011) | ||||||||
Placebo= | ||||||||
Placebo Control= 128(83.6%) | 61.9 ± 9.2 | |||||||
in Canada, Greece, Russia, Sweden, and the USA by | Perceived improvement: Clinical Global Impressions of Severity (CGI-S) | Hospital Anxiety and Depression Scale anxiety subscale | ||||||
general practitioner and rheumatologists | ||||||||
(HADS-A) | ||||||||
Chappell | Outpatients of ≥40 years male and female with pain for 14 days of each month for 3 months before study entry, with a mean score on the 24-h average pain score (0–10) using the average of daily ratings from visit 1 to visit 2 | Antidepressant | Antidepressant= 62.1 ± 9.6 | American College of Rheumatology clinical criteria | Excluded patients with previous invasive knee surgery, arthroscopy and joint replacement | Knee Pain: Weekly 24-h worst pain; WOMAC pain subscale | Depression: Beck Depression Inventory-II | 9* |
(USA, 2009) | (intervention)= 111 (63.1%) | |||||||
Placebo= | ||||||||
Placebo Control | 62.5 ± 9.3 | |||||||
120 (67.5%) | Hospital | |||||||
Severity: BPI-S, Brief Pain Inventory-Severity; CGI-S, Clinical Global Impressions of Severity | Anxiety and Depression Scale (HADS) | |||||||
Abou-Raya | Aged 65 years and above attending the outpatient clinic | Antidepressant | Antidepressant= 68.9 ± 6.2 | American College of Rheumatology clinical criteria Radiographic criteria K/L grade I–III | NA | Knee Pain: Visual analogue pain scale | Depression: Geriatric depression scale | 10* |
(Egypt, 2012) | (intervention)= 144 (84%) | |||||||
Placebo= 68.5 ± 5.8 | ||||||||
Placebo Control 144 (84%) | WOMAC pain score |
Diagnosis of OA in study participants
Assessment of pain
Assessment of psychosocial factors
Methodological quality assessment
Relationship between depression and knee pain
Author (year) | Study design | Assessment of depression | Assessment of pain pain/OA | Results | Conclusion | Quality score |
---|---|---|---|---|---|---|
Creamer (1999- Baltimore study) | Cross-sectional | Arthritis Impact Measurement Scales (AIMS) Questionnaire (Depression subscale) | Pain on most days for at least one month (National Health and Nutrition Examination Survey (NHANES-1)) | Pain reporting was not related to depression (statistics not provided). | Depression was not associated with knee pain. | 55 |
Depression scores were higher in subjects reporting ‘ever’ pain in the presence of normal radiographs than in those without reported knee pain (1.70 ± 0.27 versus 1.16 ± 0.09), but this was not statistically significant (P= 0.06). | ||||||
Creamer (1999) | Cross-sectional | Centre for Epidemiological Studies Depression Scale (CES-D) | Pain Severity | Unadjusted Correlations: MPQ: r= 0.31 (p < 0.05). | There was no association between depression and pain severity after adjustment. | 55 |
(WOMAC, Visual Analogue Scale, | VAS: r= 0.19 (NS) | |||||
McGill Pain Questionnaire (MPQ)) | WOMAC: r= 0.15 (NS) | |||||
In the stepwise regression models after adjustment, depression did not remain in the model. | ||||||
Salaffi (1991) | Cross-sectional | Zung Depression Inventory | Pain | Stepwise multiple regression: | Depression was found to be associated with the pain experience. | 45 |
(McGill Pain Questionnaire (MPQ), Visual Analogue Scale (VAS)) | ||||||
MPQ: R= 0.41; t= 2.99; p < 0.01 | ||||||
VAS R= 0.39; t= 2.77; p < 0.01 | ||||||
van Baar (1998) | Cross-sectional | IRGL Questionnaire | Severity of pain: Visual Analogue Scale | Bivariate Correlation: | Depression was not associated with knee pain. | 64 |
Knee pain: r= 0.28 p ≤ 0.01 | ||||||
Regression Analysis: NS (not remain in the model) | ||||||
Wright (2008) | Cross-sectional | CES-D | WOMAC pain scale | WOMAC: mean= 17.76 ± 14.47 | There was an association between knee pain and depressive symptoms. | 82 |
Psychological Disability subscale of AIMS | ||||||
Depressive Sx: mean= 1.80 ± 2.79 | ||||||
Neuroticism: mean= 2.26 ± 0.59 | ||||||
Negative affect: mean= 1.67 ± 0.51 | ||||||
Correlation between pain and depressive Sx: r= 0.21; p < 0.01
| ||||||
Correlation between pain and negative affect: r= 0.15; p < 0.05
| ||||||
Pells (2008) | Cross-sectional | Psychological Disability subscale of AIMS | AIMS | Correlation between psychosocial disability and AIMS pain scale: r= 0.24; p < 0.01. | Pain did not demonstrate an association with psychological disability. | 64 |
Multiple regression: NS | ||||||
Peat (2009) | Nested case-controlled | Hospital Anxiety and Depression Scale | Characteristic pain intensity: Chronic Pain Grade | Mean difference (95% CI) of depression between cases and controls at 18 months: 2.2 (1.2 to 3.1) | Substantial deterioration of knee pain is accompanied by an increase in depressive symptoms. | 79 |
Pain extent: areas of pain experienced in previous month shaded on whole-body manikin | ||||||
Cases were subjects who had mild knee pain at study entry and become severe at 18 months follow up. | ||||||
Night pain: single item on WOMAC | Controls were subjects who still had mild knee pain at 18 months follow up and were selected from similar cohort as cases). | |||||
Riddle (2011) | Longitudinal Cohort Study | 20-item CES-D | Knee Pain: WOMAC pain scale | dichotomised CES-D score (≥16) | Baseline depression is the most consistent psychological predictor of yearly worsening of pain. Association exists after adjusting for confounding variables. | 92 |
Disability: WOMAC disability scale | Univariate analysis: WOMAC Pain: Estimate (95% CI)= 0.36 (0.16 to 0.56); p < 0.001 | |||||
Multivariate analysis: WOMAC Pain: Estimate (95% CI)= 0.59 (0.18 to 1.01); p= 0.005 | ||||||
Chappell | Randomised Controlled Trial(RCT) investigating the effect of antidepressant (Duloxetine) on knee OA | Beck Depression Inventory-II (BDI-II) Hospital Anxiety and Depression Scale anxiety subscale (HADS-A) | Knee Pain: Brief Pain Inventory (BPI); WOMAC pain and stiffness subscales Perceived improvement: Clinical Global Impressions of Severity (CGI-S) | Mean change in pain score from baseline (at 13 weeks) | Treatment with duloxetine 60 to 120 mg was associated with significant pain reduction in patients with pain due to knee OA. | 8* |
(USA, 2011) | ||||||
BPI average pain (% response) | ||||||
≥30%= 65.3 (antidepressant group= I) & 44.1 (placebo= C); p ≤ 0.001 | ||||||
WOMAC: -13.74 (I) -17.51 (C); p ≤0.05 | ||||||
CGI-S: -0.40 (I) & -0.70(C); p ≤ 0.01 | ||||||
Chappell | RCT investigating the effect of antidepressant (Duloxetine) on knee OA | Beck Depression Inventory-II | Knee Pain: Weekly 24-h worst pain; WOMAC pain subscale | Mean change (SD) in pain score from baseline (at 13 weeks) | Duloxetine demonstrated statistically significant pain reduction compared with placebo. | 9* |
(USA, 2009) | ||||||
Hospital Anxiety and Depression Scale (HADS) | ||||||
BPI-S(Average pain): –2.82 ±0.21(C) –1.85 ± 0.21(C); p < .001 | ||||||
Severity: BPI-S, Brief Pain Inventory-Severity; CGI-S, Clinical Global Impressions of Severity | ||||||
WOMAC: –4.64 ± 0.35 (I) | ||||||
−3.24 ± 0.35(C); p= 0.003 | ||||||
CGI-S: -0.65 ±0.08(I) & –0.29 ± 0.08(C); p= 0.001 | ||||||
Abou-Raya | RCT investigating the effect of antidepressant (Duloxetine) on knee OA | Geriatric depression scale | Knee Pain Visual analogue pain scale; WOMAC pain score | WOMAC pain score | Duloxetine has a dual beneficial effect of improving depression and pain symptoms in older adults with knee OA. | 10* |
(Egypt, 2012) | (0–20): Mean (SD) | |||||
At baseline: Intervention - 9.1(4.6) | ||||||
Placebo - 8.9(5.1); p= 0.44 | ||||||
At 16 weeks : Intervention - 6.0 (4.1) Placebo - 8.4 (5.4); p= 0.05 |
Relationship between anxiety and knee pain
Author (year) | Study design | Assessment of anxiety | Assessment of pain | Results | Conclusion | Quality score |
---|---|---|---|---|---|---|
Creamer (1999 – Baltimore study) | Cross-sectional | Arthritis Impact Measurement Scales (AIMS) Questionnaire: (Anxiety subscale) | Pain on most days for at least one month (NHANES-1) | Women reporting having knee pain had higher anxiety than those reporting never having knee pain (3.06 ± 0.26 vs 2.35 ± 0.17, p= 0.025). | Anxiety was associated with pain in women, but not men. | 55 |
Pain reporting was not related to anxiety in men (data not shown). | Women reporting knee pain, in the absence of radiographic osteoarthritis, had higher anxiety scores than those without pain. | |||||
Analysis stratified by radiographic severity. It showed that differences in anxiety were confined to subjects reporting knee pain in the absence of radiographic change (i.e., KL grade 0) (statistics not available). | ||||||
Creamer (1999) | Cross-sectional | State-Trait Anxiety Inventory (STAI) | Pain Severity | MPQ: r= 0.30 (p < 0.05). | Anxiety was not found to be associated with pain in patients with knee OA. | 55 |
(WOMAC, Visual Analogue Scale, | VAS: r= 0.19 (NS) | |||||
WOMAC: r= 0.23 (NS) | ||||||
McGill Pain Questionnaire (MPQ)) | In the stepwise regression models after adjustment, anxiety did not remain. | |||||
Salaffi (1991) | Cross-sectional | Zung Anxiety Inventory | Pain | Stepwise multiple regression: | Anxiety was found to be related to pain. | 45 |
(McGill Pain Questionnaire (MPQ), Visual Analogue Scale (VAS)) | MPQ: R= 0.19; t= 2.245 p < 0.05 | |||||
VAS: R= 0.21; t= 2.88; p < 0.01 | ||||||
Van Baar (1998) | Cross-sectional | IRGL Questionnaire | Severity of pain: Visual Analogue Scale | Bivariate Correlation: | Anxiety was not associated with knee pain although there was bivariate correlation between anxiety and pain. | 64 |
Knee pain: r= 0.30 p ≤ 0.01 | ||||||
Regression Analysis: NS | ||||||
Peat (2009) | Nested case control | Hospital Anxiety and Depression Scale | Characteristic pain intensity: Chronic Pain Grade | Mean difference (95% CI) of anxiety between cases and controls at 18 months: 1.0 | There was no significant association between knee pain and perceived anxiety. | 79 |
Pain extent: areas of pain experienced in previous month shaded on whole-body manikin | (−0.2 to 2.3) | |||||
Night pain: single item on WOMAC | ||||||
Piva (2009) | Longitudinal | Beck Anxiety Index | 11 point Numerical Pain Rating Scale (NPRS) | Correlation with anxiety | There was no significant association between anxiety and pain. | 85 |
NPRS: r= 0.34; P ≤ 0.01 | ||||||
Forward Multiple Regression- Not significant |
Relationship between poor mental health and knee pain
Author (year) | Study design | Assessment of general mental health | Assessment of pain | Results | Conclusion | Quality score |
---|---|---|---|---|---|---|
O’Reilly (1998) | Cross-sectional | SF-36 Questionnaire – Mental Health Component | Knee pain on most days for at least a month (in the past year) | Mental health score (<61): OR: 2.1 95% CI: 1.7-2.6 | Lower mental health scores were associated with increased odds of knee pain. | 45 |
Knee pain: Median (IQR): 72(56–84) | ||||||
No knee pain: Median (IQR): 76(64–88). P < 0.001 | ||||||
Matsudaira (2011) | Cross-sectional | SF36 subscale | Self reported knee pain in past month or in the past year | Knee pain and mental health: Not significant (Data not provided) | There was no association found between knee pain and general mental health. | 82 |
Harcombe (2010) | Cross-sectional | Mental Health Inventory-5 (MHI-5) | Self-reported knee pain lasting for more than a day in the month | Knee pain and mental health: OR (95% CI)= 0.96 (0.90 to 1.02); p value=0.194 | There was no association between self-reported knee pain and mental health. | 73 |
Standardised Nordic Questionnaires for MSDs and Brief Symptom Inventory diagram showing the area of the body | ||||||
Davis (1992) | Cross-sectional | Psychological Wellbeing: NHANES General Wellbeing Index | Pain on most days lasting one month in the past year or knee pain on active or passive motion during the examination | Psychological wellbeing (score ≤70 & reference group >94) | Psychological wellbeing was associated with knee pain among participants with and without radiographic OA. | 45 |
OA and No OA: OR (95% CI)= 1.4 (1.0 to 2.0) | ||||||
OA ± Pain: OR (95% CI)= 3.7 (1.8 to 7.6) | ||||||
Pain ± OA: OR (95% CI)= 3.2 (2.1 to 5.0) |