George Peat | Keele University (original) (raw)

Papers by George Peat

Research paper thumbnail of Population-wide incidence estimates for soft tissue knee injuries presenting to healthcare in southern Sweden: data from the Skåne Healthcare Register

Arthritis Research & Therapy, 2014

Introduction: Soft tissue knee injury is a well-established and potent risk factor for developmen... more Introduction: Soft tissue knee injury is a well-established and potent risk factor for development of knee osteoarthritis. However, there is a paucity of epidemiological data from the general population. Our aim was to estimate the annual person-level incidence for a wide spectrum of clinically diagnosed soft tissue knee injuries, and their distribution by age, sex, and season. Methods: In Sweden, in-and outpatient health care is registered using each individuals' unique personal identifier including International Classification of Diseases (ICD) 10 diagnostic code(s) as determined by physicians' clinical examination. For the calendar years 2004-2012, we studied the population in southern Sweden, Skåne region (approx. 1.3 million). We identified residents who had at least one visit to a physician with clinically diagnosed knee ligament, meniscal, or other soft-tissue injury (S80.0, S83 and all subdiagnoses). We then calculated the mean annual incidence over the 9-year period. As a secondary objective, we investigated potential seasonal variation. Results: The annual incidence for males and females was 766 (95% CI: 742, 789) and 676 (649, 702) per 100,000 persons/year respectively. For males and females, the peak rate occurred in 15 to 19 year-olds (1698 per 100,000 men and 1464 per 100,000 women, respectively). In women, rates were lowest in the 25 to 34 year-old age range before rising again between the ages of 35 and 49 years. We found substantial seasonal variation, greatest in men, with peaks in March-May and August-October. Conclusions: The incidence of clinically diagnosed soft-tissue knee injury peaks in adolescence and emerging adulthood. However, a range of knee injuries continue to occur across the adult lifespan including at ages when osteoarthritis is typically diagnosed and managed. The potential cumulative effect on osteoarthritis progression of these injuries may warrant further investigation.

Research paper thumbnail of Clinical outcomes from a physiotherapist-led intra-articular hyaluronic acid injection clinic

Musculoskeletal Care, 2008

To describe the clinical course of knee osteoarthritis following a single course of intra-articul... more To describe the clinical course of knee osteoarthritis following a single course of intra-articular hyaluronic acid (HA) injection clinic, and specifically to explore treatment withdrawal. Prospective consecutive case series with follow-up, set in an innovative physiotherapist-led clinic, based in a hospital orthopaedic surgery department. A total of 100 patients with knee osteoarthritis referred to the clinic received a single course of five injections of Hyalgan. Patients were followed up in clinic at five, 13, 26 and 52 weeks. The primary outcome measures were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) Likert 3.0 pain (0-20) and physical function (0-68) scores. In addition, at 13 and 26 weeks, patients were reviewed independently by an orthopaedic surgeon, with the option of withdrawing for alternative management those patients who had not responded. Ninety (90%) patients were successfully followed to study endpoint. Improvements were seen at five weeks and, to a lesser extent, at 13 weeks (mean reduction in WOMAC pain at 13 weeks = 1.3; 95% confidence interval [CI] 0.5, 2.0; mean reduction in WOMAC Physical Function at 13 weeks = 5.6; 95% CI 3.0, 8.1). Of 34 treatment withdrawals, most had returned to baseline levels by 13 weeks. The remaining 56 patients maintained improvements up to 52 weeks, although the pattern of outcome was highly variable between individuals. Withdrawals and non-responders had higher initial pain severity. Physiotherapist-led intra-articular HA clinics are feasible. Clinical outcomes for individual patients are highly heterogeneous up to one year after injections. Patients with initially high levels of pain may be less likely to benefit.

Research paper thumbnail of The relative importance of perceived doctor’s attitude on the decision to consult for symptomatic osteoarthritis: a choice-based conjoint analysis study

BMJ Open, 2015

Some patients spend years with painful osteoarthritis without consulting for it, including times ... more Some patients spend years with painful osteoarthritis without consulting for it, including times when they are experiencing persistent severe pain and disability. Beliefs about osteoarthritis and what primary care has to offer may influence the decision to consult but their relative importance has seldom been quantified. We sought to investigate the relative importance of perceived service-related and clinical need attributes in the decision to consult a primary care physician for painful osteoarthritis. Partial-profile choice-based conjoint analysis study, using a self-complete questionnaire containing 10 choice tasks, each presenting two scenarios based on a combination of three out of six selected attributes. General population. Adults aged 50 years and over with hip, knee or hand pain registered with four UK general practices. Relative importance of pain characteristics, level of disruption to everyday life, extent of comorbidity, assessment, management, perceived general practitioner (GP) attitude. 863 (74%) people responded (55% female; mean age 70 years, range: 58-93). The most important determinants of the patient's decision to consult the GP for joint pain were the extent to which pain disrupted everyday life ('most' vs 'none': relative importance 31%) and perceived GP attitude ('legitimate problem, requires treatment' vs 'part of the normal ageing process that one just has to accept': 24%). Thoroughness of assessment (14%), management options offered (13%), comorbidity (13%) and pain characteristics (5%) were less strongly associated with the decision to consult. Anticipating that the GP will regard joint pain as 'part of the normal ageing process that one just has to accept' is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care. Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception.

Research paper thumbnail of Annual consultation incidence of osteoarthritis estimated from population-based health care data in England

Rheumatology, 2015

Objectives. To estimate the consultation incidence of OA using population-based health care data ... more Objectives. To estimate the consultation incidence of OA using population-based health care data in England and compare OA incidence figures with those derived in other countries.

Research paper thumbnail of Investigation of potential phenotypes of foot osteoarthritis: Cross-sectional analysis from the Clinical Assessment Study of the Foot

Arthritis care & research, Jan 3, 2015

Objective To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on p... more Objective To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on pattern of joint involvement and comparative symptom and risk profiles. Methods Participants aged ≥50 years reporting foot pain in the previous year were drawn from a population-based cohort. Radiographs were scored for OA in the 1(st) metatarsophalangeal (MTPJ), 1(st) and 2(nd) cuneometatarsal, navicular first cuneiform and talonavicular joints according to a published atlas. Chi-square tests established clustering, and odds ratios examined symmetry and pairwise associations of radiographic OA in the feet. Distinct underlying classes of foot OA were investigated by latent class analysis (LCA) and their association with symptoms and risk factors was assessed. Results In 533 participants (mean age 64.9 years, 55.9% female) radiographic OA clustered across both feet (p<0.001), and was highly symmetrical (adjusted odds ratio 3.0, 95% CI: 2.1,4.2). LCA identified three distinct classes of ...

Research paper thumbnail of Prevalence and management of osteoarthritis in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network

CMAJ Open, 2015

Osteoarthritis is a common chronic condition that affects many older Canadians and is a considera... more Osteoarthritis is a common chronic condition that affects many older Canadians and is a considerable cause of disability. Our objective was to describe the epidemiology of osteoarthritis in patients aged 30 years and older using electronic medical records (EMRs) in a Canadian primary care population. In this retrospective cohort study, we analyzed the EMRs of 207 610 patients over 30 years of age (extracted on December 31, 2012) who had at least one clinic visit during the preceding 2 years. We calculated the age-sex standardized prevalence of diagnosed osteoarthritis and its association with comorbidities and covariates available in the Canadian Primary Care Sentinel Surveillance Network database. The estimated prevalence of diagnosed osteoarthritis was 14.2% (15.6% among women, 12.4% among men). The diagnosis of osteoarthritis was associated with several comorbidities: hypertension (prevalence ratio [PR] 1.17, 95% confidence interval [CI] 1.15-1.18), depression (PR 1.26, 95% CI 1.22-1.3), chronic obstructive pulmonary disease (COPD) (PR 1.16, 95% CI 1.11-1.21) and epilepsy (PR 1.27, 95% CI 1.13-1.43). In addition, 56.6% of patients had received a prescription for a range of nonsteroidal anti-inflammatory drugs, 45% of which were topical. Opioid medications were prescribed to 33% of patients for pain management. Osteoarthritis is a common disease in middle-aged and older Canadians. It is more common in women than in men and is associated with comorbid conditions. Most patients with osteoarthritis received pharmacotherapy for inflammation and pain management. As the Canadian population ages, osteoarthritis will become an increasing burden for individuals and the health care system.

Research paper thumbnail of One-year trajectories of depression and anxiety symptoms in older patients presenting in general practice with musculoskeletal pain: a latent class growth analysis

Journal of Psychosomatic Research, 2015

Objective: Distinguishing transient from persistent anxiety and depression symptoms in older peop... more Objective: Distinguishing transient from persistent anxiety and depression symptoms in older people presenting to general practice with musculoskeletal pain is potentially important for effective management. This study sought to identify distinct post-consultation depression and anxiety symptom trajectories in adults aged over 50 years consulting general practice for non-inflammatory musculoskeletal pain. Methods: Self-completion questionnaires, containing measures of anxiety and depressive symptoms, age, gender, pain status, coping and social status were mailed within 1 week of the consultation and at 3, 6 and 12 months. Latent class growth analysis was used to identify anxiety and depression symptoms trajectories, which were ascertained with cut-off score ≥8 on Hospital Anxiety and Depression Scale subscales. Associations between baseline characteristics and cluster membership were examined using multivariate multinomial logistic regression analysis (the 3-step approach). Results: Latent class growth analyses determined a 3-cluster anxiety model (n = 499) and a 3-cluster depression model (n = 501). Clusters identified were: no anxiety problem (44.1%), persistent anxiety problem (33.9%) and transient anxiety symptoms (22.2%); no depression problem (74.1%), persistent depression problem (22.0%) and gradual depression symptom recovery (4.0%). Widespread pain, interference with valued activities, coping by increased behavioral activities, catastrophizing, perceived lack of instrumental support, age ≥70 years, being female, and performing manual/routine work were associated with anxiety and/or depression clusters. Conclusions: Older people with non-inflammatory musculoskeletal pain are at high risk of persistent anxiety and/ or depression problems. Biopsychosocial factors, such as pain status, coping strategies, instrumental support, performing manual/routine work, being female and age ≥70 years, may help identify patients with persistent anxiety and/or depression.

Research paper thumbnail of Research into practice: improving musculoskeletal care in general practice

The British journal of general practice : the journal of the Royal College of General Practitioners, 2014

Research paper thumbnail of Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis

Br J Sports Med, 2014

Objective To determine whether there is sufficient evidence to conclude that exercise interventio... more Objective To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis.

Research paper thumbnail of Improving the transparency of prognosis research: the role of reporting, data sharing, registration, and protocols

The Guidelines and Guidance section contains advice on conducting and reporting medical research.

Research paper thumbnail of Quality of care for OA: the effect of a point-of-care consultation recording template

Rheumatology, 2014

Objective. The aims of this study were to determine the feasibility of introducing a computerized... more Objective. The aims of this study were to determine the feasibility of introducing a computerized template for identifying quality of care during an OA consultation, describe quality of OA care in practices in which the template was introduced and assess the effect of the template on routinely recorded clinician behaviour in those practices.

Research paper thumbnail of Patterns of pain and mobility limitation in older people: cross-sectional findings from a population survey of 18,497 adults aged 50 years and over

Quality of Life Research, 2008

Mobility limitation is the most common disability in the general population, and pain is a freque... more Mobility limitation is the most common disability in the general population, and pain is a frequent symptom at older ages. We have investigated the association of different patterns of pain and mobility limitation in a large sample of older adults. A cross-sectional postal survey of all adults aged 50 years and over registered with eight general practices in North Staffordshire, UK, resulted in 18,497 respondents (adjusted response=70.8%). Information on demographics, recent pain and the self-reported level of mobility limitation was collected. Associations between pain and mobility limitation were assessed using a partial proportional odds model, taking into account age, gender and socio-economic status. Limitation in walking 100 yards was reported by 29% of respondents. Limitation increased sharply with age, and was higher in the female and lower socio-economic groups. Persons reporting pain were significantly more likely to report limitation. The relationship between mobility limitation and pain was stronger in the youngest age group, but proportionally more people in the oldest age groups have mobility limitation associated with pain. Lower limb and multiple pains present a potential target for the prevention of mobility limitation up to the oldest age groups.

Research paper thumbnail of The clinical assessment study of the foot (CASF): study protocol for a prospective observational study of foot pain and foot osteoarthritis in the general population

Journal of Foot and Ankle Research, 2011

Background: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 year... more Background: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care. Methods: All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records. Discussion: This three-year prospective epidemiological study will combine survey data, comprehensive clinical, xray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.

Research paper thumbnail of Diagnostic discordance: we cannot agree when to call knee pain 'osteoarthritis

Family Practice, 2004

and Croft P, for the KNE-SCI Study Group. Diagnostic discordance: we cannot agree when to call kn... more and Croft P, for the KNE-SCI Study Group. Diagnostic discordance: we cannot agree when to call knee pain 'osteoarthritis'. Family Practice 2005; 22: 96-102.

Research paper thumbnail of Chronic knee pain

BMJ, 2007

A 57 year old self employed painter and decorator presents with a six month history of pain and s... more A 57 year old self employed painter and decorator presents with a six month history of pain and stiffness in his left knee. The onset was insidious, and the pain has worsened over the past few weeks.

Research paper thumbnail of Discussing prognosis with older people with musculoskeletal pain: a cross-sectional study in general practice

BMC Family Practice, 2009

Background: Prognosis has been described as an important but neglected branch of clinical science... more Background: Prognosis has been described as an important but neglected branch of clinical science. While patients' views have been sought in the context of life-threatening illness, similar research is lacking for patients presenting with common, non-life-threatening musculoskeletal complaints. The aim of this study was to gauge whether and why older patients with musculoskeletal pain think prognostic information is important, and how often they felt prognosis was discussed in the general practice consultation.

Research paper thumbnail of The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot

Annals of the Rheumatic Diseases, 2013

Objectives To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) ... more Objectives To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in communitydwelling older adults. Methods 9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response. Results 5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Threequarters of those with symptomatic radiographic OA reported disabling foot symptoms. Conclusions While cautious interpretation due to nonresponse is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

Research paper thumbnail of Erosive osteoarthritis: a more severe form of radiographic hand osteoarthritis rather than a distinct entity?

Annals of the Rheumatic Diseases, 2013

Research paper thumbnail of Quality assessment of observational studies in psychiatry: An examplefrom perinatal psychiatric research

International Journal of Methods in Psychiatric Research, 2011

In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. ... more In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. Many studies are observational in nature, while others employ large databases not designed primarily for research purposes. Quality assessment of the resulting research is complicated by a lack of standardized tools specifically for this purpose. The aim of this paper is to describe the Systematic Assessment of Quality in Observational Research (SAQOR), a quality assessment tool our team devised for a series of systematic reviews and meta-analyses of evidence-based literature regarding risks and benefits of antidepressant medication during pregnancy. L.T.W. (2010) First-trimester use of paroxetine and congenital heart defects: A population-based case-control study. Oraichi D. (2007) First trimester exposure to paroxetine and risk of cardiac malformations Quality assessment in perinatal psychiatric research Ross et al. Chabrol H., Teissedre F., Armitage J., Danel M., Walburg V. (2004) Acceptability of psychotherapy and antidepressants for postnatal depression among newly delivered mothers. ., et al. (2006) Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment [corrected] [published erratum appears in JAMA 296(2): 170].

Research paper thumbnail of International comparisons of the consultation prevalence of musculoskeletal conditions using population-based healthcare data from England and Sweden

Annals of the Rheumatic Diseases, 2014

Objectives To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented... more Objectives To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented in different healthcare systems, and to determine the feasibility of comparing prevalence figures between nations. Methods The settings were an English regional database (Consultations in Primary Care Archive (CiPCA)) and the Swedish Skåne County Health Care Register. Case definitions, data extraction and analysis procedures were harmonised. The number of people consulting per 10 000 registered population in primary care, and in primary or secondary care, in the year 2010 (annual consultation prevalence) were determined for doctordiagnosed osteoarthritis (OA), rheumatoid arthritis (RA), low back pain, and spondyloarthritis including psoriatic arthritis and ankylosing spondylitis (AS). Seven-year period consultation prevalences were also determined.

Research paper thumbnail of Population-wide incidence estimates for soft tissue knee injuries presenting to healthcare in southern Sweden: data from the Skåne Healthcare Register

Arthritis Research & Therapy, 2014

Introduction: Soft tissue knee injury is a well-established and potent risk factor for developmen... more Introduction: Soft tissue knee injury is a well-established and potent risk factor for development of knee osteoarthritis. However, there is a paucity of epidemiological data from the general population. Our aim was to estimate the annual person-level incidence for a wide spectrum of clinically diagnosed soft tissue knee injuries, and their distribution by age, sex, and season. Methods: In Sweden, in-and outpatient health care is registered using each individuals' unique personal identifier including International Classification of Diseases (ICD) 10 diagnostic code(s) as determined by physicians' clinical examination. For the calendar years 2004-2012, we studied the population in southern Sweden, Skåne region (approx. 1.3 million). We identified residents who had at least one visit to a physician with clinically diagnosed knee ligament, meniscal, or other soft-tissue injury (S80.0, S83 and all subdiagnoses). We then calculated the mean annual incidence over the 9-year period. As a secondary objective, we investigated potential seasonal variation. Results: The annual incidence for males and females was 766 (95% CI: 742, 789) and 676 (649, 702) per 100,000 persons/year respectively. For males and females, the peak rate occurred in 15 to 19 year-olds (1698 per 100,000 men and 1464 per 100,000 women, respectively). In women, rates were lowest in the 25 to 34 year-old age range before rising again between the ages of 35 and 49 years. We found substantial seasonal variation, greatest in men, with peaks in March-May and August-October. Conclusions: The incidence of clinically diagnosed soft-tissue knee injury peaks in adolescence and emerging adulthood. However, a range of knee injuries continue to occur across the adult lifespan including at ages when osteoarthritis is typically diagnosed and managed. The potential cumulative effect on osteoarthritis progression of these injuries may warrant further investigation.

Research paper thumbnail of Clinical outcomes from a physiotherapist-led intra-articular hyaluronic acid injection clinic

Musculoskeletal Care, 2008

To describe the clinical course of knee osteoarthritis following a single course of intra-articul... more To describe the clinical course of knee osteoarthritis following a single course of intra-articular hyaluronic acid (HA) injection clinic, and specifically to explore treatment withdrawal. Prospective consecutive case series with follow-up, set in an innovative physiotherapist-led clinic, based in a hospital orthopaedic surgery department. A total of 100 patients with knee osteoarthritis referred to the clinic received a single course of five injections of Hyalgan. Patients were followed up in clinic at five, 13, 26 and 52 weeks. The primary outcome measures were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) Likert 3.0 pain (0-20) and physical function (0-68) scores. In addition, at 13 and 26 weeks, patients were reviewed independently by an orthopaedic surgeon, with the option of withdrawing for alternative management those patients who had not responded. Ninety (90%) patients were successfully followed to study endpoint. Improvements were seen at five weeks and, to a lesser extent, at 13 weeks (mean reduction in WOMAC pain at 13 weeks = 1.3; 95% confidence interval [CI] 0.5, 2.0; mean reduction in WOMAC Physical Function at 13 weeks = 5.6; 95% CI 3.0, 8.1). Of 34 treatment withdrawals, most had returned to baseline levels by 13 weeks. The remaining 56 patients maintained improvements up to 52 weeks, although the pattern of outcome was highly variable between individuals. Withdrawals and non-responders had higher initial pain severity. Physiotherapist-led intra-articular HA clinics are feasible. Clinical outcomes for individual patients are highly heterogeneous up to one year after injections. Patients with initially high levels of pain may be less likely to benefit.

Research paper thumbnail of The relative importance of perceived doctor’s attitude on the decision to consult for symptomatic osteoarthritis: a choice-based conjoint analysis study

BMJ Open, 2015

Some patients spend years with painful osteoarthritis without consulting for it, including times ... more Some patients spend years with painful osteoarthritis without consulting for it, including times when they are experiencing persistent severe pain and disability. Beliefs about osteoarthritis and what primary care has to offer may influence the decision to consult but their relative importance has seldom been quantified. We sought to investigate the relative importance of perceived service-related and clinical need attributes in the decision to consult a primary care physician for painful osteoarthritis. Partial-profile choice-based conjoint analysis study, using a self-complete questionnaire containing 10 choice tasks, each presenting two scenarios based on a combination of three out of six selected attributes. General population. Adults aged 50 years and over with hip, knee or hand pain registered with four UK general practices. Relative importance of pain characteristics, level of disruption to everyday life, extent of comorbidity, assessment, management, perceived general practitioner (GP) attitude. 863 (74%) people responded (55% female; mean age 70 years, range: 58-93). The most important determinants of the patient&#39;s decision to consult the GP for joint pain were the extent to which pain disrupted everyday life (&#39;most&#39; vs &#39;none&#39;: relative importance 31%) and perceived GP attitude (&#39;legitimate problem, requires treatment&#39; vs &#39;part of the normal ageing process that one just has to accept&#39;: 24%). Thoroughness of assessment (14%), management options offered (13%), comorbidity (13%) and pain characteristics (5%) were less strongly associated with the decision to consult. Anticipating that the GP will regard joint pain as &#39;part of the normal ageing process that one just has to accept&#39; is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care. Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception.

Research paper thumbnail of Annual consultation incidence of osteoarthritis estimated from population-based health care data in England

Rheumatology, 2015

Objectives. To estimate the consultation incidence of OA using population-based health care data ... more Objectives. To estimate the consultation incidence of OA using population-based health care data in England and compare OA incidence figures with those derived in other countries.

Research paper thumbnail of Investigation of potential phenotypes of foot osteoarthritis: Cross-sectional analysis from the Clinical Assessment Study of the Foot

Arthritis care & research, Jan 3, 2015

Objective To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on p... more Objective To investigate the existence of distinct foot osteoarthritis (OA) phenotypes based on pattern of joint involvement and comparative symptom and risk profiles. Methods Participants aged ≥50 years reporting foot pain in the previous year were drawn from a population-based cohort. Radiographs were scored for OA in the 1(st) metatarsophalangeal (MTPJ), 1(st) and 2(nd) cuneometatarsal, navicular first cuneiform and talonavicular joints according to a published atlas. Chi-square tests established clustering, and odds ratios examined symmetry and pairwise associations of radiographic OA in the feet. Distinct underlying classes of foot OA were investigated by latent class analysis (LCA) and their association with symptoms and risk factors was assessed. Results In 533 participants (mean age 64.9 years, 55.9% female) radiographic OA clustered across both feet (p<0.001), and was highly symmetrical (adjusted odds ratio 3.0, 95% CI: 2.1,4.2). LCA identified three distinct classes of ...

Research paper thumbnail of Prevalence and management of osteoarthritis in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network

CMAJ Open, 2015

Osteoarthritis is a common chronic condition that affects many older Canadians and is a considera... more Osteoarthritis is a common chronic condition that affects many older Canadians and is a considerable cause of disability. Our objective was to describe the epidemiology of osteoarthritis in patients aged 30 years and older using electronic medical records (EMRs) in a Canadian primary care population. In this retrospective cohort study, we analyzed the EMRs of 207 610 patients over 30 years of age (extracted on December 31, 2012) who had at least one clinic visit during the preceding 2 years. We calculated the age-sex standardized prevalence of diagnosed osteoarthritis and its association with comorbidities and covariates available in the Canadian Primary Care Sentinel Surveillance Network database. The estimated prevalence of diagnosed osteoarthritis was 14.2% (15.6% among women, 12.4% among men). The diagnosis of osteoarthritis was associated with several comorbidities: hypertension (prevalence ratio [PR] 1.17, 95% confidence interval [CI] 1.15-1.18), depression (PR 1.26, 95% CI 1.22-1.3), chronic obstructive pulmonary disease (COPD) (PR 1.16, 95% CI 1.11-1.21) and epilepsy (PR 1.27, 95% CI 1.13-1.43). In addition, 56.6% of patients had received a prescription for a range of nonsteroidal anti-inflammatory drugs, 45% of which were topical. Opioid medications were prescribed to 33% of patients for pain management. Osteoarthritis is a common disease in middle-aged and older Canadians. It is more common in women than in men and is associated with comorbid conditions. Most patients with osteoarthritis received pharmacotherapy for inflammation and pain management. As the Canadian population ages, osteoarthritis will become an increasing burden for individuals and the health care system.

Research paper thumbnail of One-year trajectories of depression and anxiety symptoms in older patients presenting in general practice with musculoskeletal pain: a latent class growth analysis

Journal of Psychosomatic Research, 2015

Objective: Distinguishing transient from persistent anxiety and depression symptoms in older peop... more Objective: Distinguishing transient from persistent anxiety and depression symptoms in older people presenting to general practice with musculoskeletal pain is potentially important for effective management. This study sought to identify distinct post-consultation depression and anxiety symptom trajectories in adults aged over 50 years consulting general practice for non-inflammatory musculoskeletal pain. Methods: Self-completion questionnaires, containing measures of anxiety and depressive symptoms, age, gender, pain status, coping and social status were mailed within 1 week of the consultation and at 3, 6 and 12 months. Latent class growth analysis was used to identify anxiety and depression symptoms trajectories, which were ascertained with cut-off score ≥8 on Hospital Anxiety and Depression Scale subscales. Associations between baseline characteristics and cluster membership were examined using multivariate multinomial logistic regression analysis (the 3-step approach). Results: Latent class growth analyses determined a 3-cluster anxiety model (n = 499) and a 3-cluster depression model (n = 501). Clusters identified were: no anxiety problem (44.1%), persistent anxiety problem (33.9%) and transient anxiety symptoms (22.2%); no depression problem (74.1%), persistent depression problem (22.0%) and gradual depression symptom recovery (4.0%). Widespread pain, interference with valued activities, coping by increased behavioral activities, catastrophizing, perceived lack of instrumental support, age ≥70 years, being female, and performing manual/routine work were associated with anxiety and/or depression clusters. Conclusions: Older people with non-inflammatory musculoskeletal pain are at high risk of persistent anxiety and/ or depression problems. Biopsychosocial factors, such as pain status, coping strategies, instrumental support, performing manual/routine work, being female and age ≥70 years, may help identify patients with persistent anxiety and/or depression.

Research paper thumbnail of Research into practice: improving musculoskeletal care in general practice

The British journal of general practice : the journal of the Royal College of General Practitioners, 2014

Research paper thumbnail of Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis

Br J Sports Med, 2014

Objective To determine whether there is sufficient evidence to conclude that exercise interventio... more Objective To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis.

Research paper thumbnail of Improving the transparency of prognosis research: the role of reporting, data sharing, registration, and protocols

The Guidelines and Guidance section contains advice on conducting and reporting medical research.

Research paper thumbnail of Quality of care for OA: the effect of a point-of-care consultation recording template

Rheumatology, 2014

Objective. The aims of this study were to determine the feasibility of introducing a computerized... more Objective. The aims of this study were to determine the feasibility of introducing a computerized template for identifying quality of care during an OA consultation, describe quality of OA care in practices in which the template was introduced and assess the effect of the template on routinely recorded clinician behaviour in those practices.

Research paper thumbnail of Patterns of pain and mobility limitation in older people: cross-sectional findings from a population survey of 18,497 adults aged 50 years and over

Quality of Life Research, 2008

Mobility limitation is the most common disability in the general population, and pain is a freque... more Mobility limitation is the most common disability in the general population, and pain is a frequent symptom at older ages. We have investigated the association of different patterns of pain and mobility limitation in a large sample of older adults. A cross-sectional postal survey of all adults aged 50 years and over registered with eight general practices in North Staffordshire, UK, resulted in 18,497 respondents (adjusted response=70.8%). Information on demographics, recent pain and the self-reported level of mobility limitation was collected. Associations between pain and mobility limitation were assessed using a partial proportional odds model, taking into account age, gender and socio-economic status. Limitation in walking 100 yards was reported by 29% of respondents. Limitation increased sharply with age, and was higher in the female and lower socio-economic groups. Persons reporting pain were significantly more likely to report limitation. The relationship between mobility limitation and pain was stronger in the youngest age group, but proportionally more people in the oldest age groups have mobility limitation associated with pain. Lower limb and multiple pains present a potential target for the prevention of mobility limitation up to the oldest age groups.

Research paper thumbnail of The clinical assessment study of the foot (CASF): study protocol for a prospective observational study of foot pain and foot osteoarthritis in the general population

Journal of Foot and Ankle Research, 2011

Background: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 year... more Background: Symptomatic osteoarthritis (OA) affects approximately 10% of adults aged over 60 years. The foot joint complex is commonly affected by OA, yet there is relatively little research into OA of the foot, compared with other frequently affected sites such as the knee and hand. Existing epidemiological studies of foot OA have focussed predominantly on the first metatarsophalangeal joint at the expense of other joints. This three-year prospective population-based observational cohort study will describe the prevalence of symptomatic radiographic foot OA, relate its occurrence to symptoms, examination findings and life-style-factors, describe the natural history of foot OA, and examine how it presents to, and is diagnosed and managed in primary care. Methods: All adults aged 50 years and over registered with four general practices in North Staffordshire, UK, will be invited to participate in a postal Health Survey questionnaire. Respondents to the questionnaire who indicate that they have experienced foot pain in the preceding twelve months will be invited to attend a research clinic for a detailed clinical assessment. This assessment will consist of: clinical interview; physical examination; digital photography of both feet and ankles; plain x-rays of both feet, ankles and hands; ultrasound examination of the plantar fascia; anthropometric measurement; and a further self-complete questionnaire. Follow-up will be undertaken in consenting participants by postal questionnaire at 18 months (clinic attenders only) and three years (clinic attenders and survey participants), and also by review of medical records. Discussion: This three-year prospective epidemiological study will combine survey data, comprehensive clinical, xray and ultrasound assessment, and review of primary care records to identify radiographic phenotypes of foot OA in a population of community-dwelling older adults, and describe their impact on symptoms, function and clinical examination findings, and their presentation, diagnosis and management in primary care.

Research paper thumbnail of Diagnostic discordance: we cannot agree when to call knee pain 'osteoarthritis

Family Practice, 2004

and Croft P, for the KNE-SCI Study Group. Diagnostic discordance: we cannot agree when to call kn... more and Croft P, for the KNE-SCI Study Group. Diagnostic discordance: we cannot agree when to call knee pain 'osteoarthritis'. Family Practice 2005; 22: 96-102.

Research paper thumbnail of Chronic knee pain

BMJ, 2007

A 57 year old self employed painter and decorator presents with a six month history of pain and s... more A 57 year old self employed painter and decorator presents with a six month history of pain and stiffness in his left knee. The onset was insidious, and the pain has worsened over the past few weeks.

Research paper thumbnail of Discussing prognosis with older people with musculoskeletal pain: a cross-sectional study in general practice

BMC Family Practice, 2009

Background: Prognosis has been described as an important but neglected branch of clinical science... more Background: Prognosis has been described as an important but neglected branch of clinical science. While patients' views have been sought in the context of life-threatening illness, similar research is lacking for patients presenting with common, non-life-threatening musculoskeletal complaints. The aim of this study was to gauge whether and why older patients with musculoskeletal pain think prognostic information is important, and how often they felt prognosis was discussed in the general practice consultation.

Research paper thumbnail of The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot

Annals of the Rheumatic Diseases, 2013

Objectives To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) ... more Objectives To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in communitydwelling older adults. Methods 9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response. Results 5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Threequarters of those with symptomatic radiographic OA reported disabling foot symptoms. Conclusions While cautious interpretation due to nonresponse is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

Research paper thumbnail of Erosive osteoarthritis: a more severe form of radiographic hand osteoarthritis rather than a distinct entity?

Annals of the Rheumatic Diseases, 2013

Research paper thumbnail of Quality assessment of observational studies in psychiatry: An examplefrom perinatal psychiatric research

International Journal of Methods in Psychiatric Research, 2011

In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. ... more In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. Many studies are observational in nature, while others employ large databases not designed primarily for research purposes. Quality assessment of the resulting research is complicated by a lack of standardized tools specifically for this purpose. The aim of this paper is to describe the Systematic Assessment of Quality in Observational Research (SAQOR), a quality assessment tool our team devised for a series of systematic reviews and meta-analyses of evidence-based literature regarding risks and benefits of antidepressant medication during pregnancy. L.T.W. (2010) First-trimester use of paroxetine and congenital heart defects: A population-based case-control study. Oraichi D. (2007) First trimester exposure to paroxetine and risk of cardiac malformations Quality assessment in perinatal psychiatric research Ross et al. Chabrol H., Teissedre F., Armitage J., Danel M., Walburg V. (2004) Acceptability of psychotherapy and antidepressants for postnatal depression among newly delivered mothers. ., et al. (2006) Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment [corrected] [published erratum appears in JAMA 296(2): 170].

Research paper thumbnail of International comparisons of the consultation prevalence of musculoskeletal conditions using population-based healthcare data from England and Sweden

Annals of the Rheumatic Diseases, 2014

Objectives To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented... more Objectives To assess the consultation prevalence of musculoskeletal (MSK) conditions as presented in different healthcare systems, and to determine the feasibility of comparing prevalence figures between nations. Methods The settings were an English regional database (Consultations in Primary Care Archive (CiPCA)) and the Swedish Skåne County Health Care Register. Case definitions, data extraction and analysis procedures were harmonised. The number of people consulting per 10 000 registered population in primary care, and in primary or secondary care, in the year 2010 (annual consultation prevalence) were determined for doctordiagnosed osteoarthritis (OA), rheumatoid arthritis (RA), low back pain, and spondyloarthritis including psoriatic arthritis and ankylosing spondylitis (AS). Seven-year period consultation prevalences were also determined.