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Borkhoff C.M.,University of Ottawa | Borkhoff C.M.,Canadian Osteoarthritis Research Program | Hawker G.A.,University of Toronto | Hawker G.A.,Womens College Hospital | Wright J.G.,University of Toronto
Clinical Orthopaedics and Related Research

Background: Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients' preferences for surgery, gender bias influencing physicians' clinical decision-making, and the patient-physician interaction. Questions/purposes: We propose a framework of how patient gender affects the patient and physician decision-making process of referral and recommendation for total joint arthroplasty and consider potential interventions to close the gender gap in total joint arthroplasty utilization. Methods: The process involved in the referral and recommendation for total joint arthroplasty involves eight discrete steps. A systematic review is used to describe the influence of patient gender and related clinical and nonclinical factors at each step. Where are we now? Patient gender plays an important role in the process of referral and recommendation for total joint arthroplasty. Female gender primarily affects Steps 3 through 8, suggesting barriers unique to women exist in the patient-physician interaction. Where do we need to go? Developing and evaluating interventions that improve the quality of the patient-physician interaction should be the focus of future research. How do we get there? Potential interventions include using decision support tools that facilitate shared decision-making between patients and their physicians and promoting cultural competency and shared decision-making skills programs as a core component of medical education. Increasing physicians' acceptance and awareness of the unconscious biases that may be influencing their clinical decision-making may require additional skills programs. © 2011 The Association of Bone and Joint Surgeons®. Source

Hochman J.R.,Womens College Hospital | Hochman J.R.,Canadian Osteoarthritis Research Program | Davis A.M.,University of Toronto | Davis A.M.,University of Western Ontario | And 7 more authors.
Osteoarthritis and Cartilage

Objective: Clinical tools are needed to identify and target a neuropathic-like phenotype, which may be associated with central sensitization (CS), in osteoarthritis (OA). The modified painDETECT questionnaire (mPD-Q) has face and content validity for identifying neuropathic-like symptoms in knee OA. To further validate the mPD-Q, this study assessed the unknown relationship between mPD-Q scores and signs of CS on quantitative sensory testing (QST) in knee OA. Design: 36 Individuals were recruited with chronic, symptomatic, knee OA without other pain/neurological conditions. Reference QST data were obtained from 18 controls/32 eligible knees, enabling identification of sensory abnormalities/CS among case knees. A standardized questionnaire assessed psychological factors (depressive symptoms and pain catastrophizing), and for individual knees, mPD-Q and pain intensity scores. A standardized/comprehensive QST protocol was conducted for each knee. QST signs of CS were defined as: mechanical hyperalgesia and/or enhanced temporal summation and/or allodynia. The relationship between the presence of CS (yes/no) and a pre-selected mPD-Q score (≤12 or >12), by knees, was assessed using generalized estimating equations. Results: Among 57 eligible case knees, 45.6% had ≥1 sign of CS. Controlling for age, knees with higher mPD-Q scores (>12.0) had higher odds of having QST signs of CS (adjusted odds ratio (OR)=5.6; 95% confidence interval (CI), 1.3-22.9). This relationship was unaffected by controlling for depression and pain intensity, but was attenuated by pain catastrophizing. Conclusions: Among painful OA knees, higher mPD-Q scores were associated with greater odds of having signs of CS. Thus, the mPD-Q may aid the identification of CS in people with chronic knee OA. © 2013 Osteoarthritis Research Society International. Source

Hochman J.R.,Womens College Hospital | Hochman J.R.,Canadian Osteoarthritis Research Program | Gagliese L.,York University | Gagliese L.,Ontario Cancer Institute | And 5 more authors.
Osteoarthritis and Cartilage

Objective: A neuropathic pain (NP) questionnaire may facilitate the identification of a neuropathic component to osteoarthritis (OA) pain. An existing questionnaire, the painDETECT, was modified for use in knee OA and administered to measure the prevalence and correlates of NP symptoms among adults with this condition. Method: Sensibility of the modified painDETECT (mPD-Q) was assessed in 20 OA subjects followed by mail administration in an established knee OA cohort. NP symptoms were defined using a previously established, painDETECT cut-point. Correlates of NP symptoms, including OA severity (Western Ontario and McMaster Universities Osteoarthritis Index, Von Korff Chronic Pain Grade pain subscale score), psychological factors (Centre for Epidemiological Studies Depression Scale, Pain Catastrophizing Scale), and concomitant medical conditions, were evaluated using logistic regression. Construct validity of the mPD-Q was evaluated through co-administration with another NP questionnaire (S-LANSS). Results: The mPD-Q had face and content validity. Of 259 eligible cohort members, 171 (66%) completed the questionnaire; 28% had NP symptoms on the mPD-Q (19% among those without neurological conditions). Independent correlates of NP symptoms were: pain intensity (adjusted odds ratio [OR]. =2.1 per 10 unit increase, P<0.0001), the presence of referred back/hip pain (adjusted OR. =2.9, P=0.024), number of painful joints (OR. =1.2, P=0.20) and one or more self-reported neurological condition (OR. =3.0, P=0.026). Conclusions: Among older adults with chronic symptomatic knee OA, over one-quarter had NP symptoms localized to their knees using the mPD-Q. The mPD-Q may facilitate the identification of a neuropathic component to pain in adults with knee OA who may benefit from further evaluation and/or treatment for NP. © 2011 Osteoarthritis Research Society International. Source

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