Background 

There is mounting evidence that objective measures of pathophysiology do not correlate well with symptom intensity. A growing line of inquiry identifies statistical combinations (so-called “phenotypes”) of various levels of distress and unhelpful thoughts that are associated with distinct levels of symptom intensity and magnitude of incapability. As a next step, it would be helpful to understand how distress and unhelpful thoughts interact with objective measures of pathologic conditions such as the radiologic severity of osteoarthritis. The ability to identify phenotypes of these factors that are associated with distinct levels of illness could contribute to improved personalized musculoskeletal care in a comprehensive, patient-centered model.

Questions/purposes 

(1) When measures of mental health are paired with radiologic osteoarthritis severity, are there distinct phenotypes among adult patients with hip and knee osteoarthritis? (2) Is there a difference in the degree of capability and pain self-efficacy among the identified mental health and radiologic phenotypes? (3) When capability (Patient-reported Outcomes Measurement Information System Physical Function [PROMIS PF]) is paired with radiographic osteoarthritis severity, are there distinct phenotypes among patients with hip and knee osteoarthritis? (4) Is there a difference in mental health among patients with the identified capability and radiologic phenotypes?

Methods 

We performed a secondary analysis of data from a study of 119 patients who presented for musculoskeletal specialty care for hip or knee osteoarthritis. Sixty-seven percent (80 of 119) of patients were women, with a mean age of 62 ± 10 years. Seventy-six percent (91 of 119) of patients had knee osteoarthritis, and 59% (70 of 119) had an advanced radiographic grade of osteoarthritis (Kellgren-Lawrence grade 3 or higher). This dataset is well-suited for our current experiment because the initial study had broad enrollment criteria, making these data applicable to a diverse population and because patients had sufficient variability in radiographic severity of osteoarthritis. All new and returning patients were screened for eligibility. We do not record the percentage of eligible patients who do not participate in cross-sectional surveys, but the rate is typically high (more than 80%). One hundred forty-eight eligible patients started the questionnaires, and 20% (29 of 148) of patients did not complete at least 60% of the questionnaires and were excluded, leaving 119 patients available for analysis. We measured psychologic distress (Patient Health Questionnaire-2 [PHQ-2] and Generalized Anxiety Disorder-2 questionnaire [GAD-2]), unhelpful thoughts about pain (Pain Catastrophizing Scale-4 [PCS-4]), self-efficacy when in pain (Pain Self-Efficacy Questionnaire-2), and capability (PROMIS PF). One of two arthroplasty fellowship–trained surgeons assigned the Kellgren-Lawrence grade of osteoarthritis based on radiographs in the original study. We used a cluster analysis to generate two sets of phenotypes: (1) measures of mental health (PHQ-2, GAD-2, PCS-4) paired with the Kellgren-Lawrence grade and (2) capability (PROMIS PF) paired with the Kellgren-Lawrence grade. We used one-way ANOVA and Kruskal-Wallis H tests to assess differences in capability and self-efficacy and mental health, respectively.

Results 

When pairing measures of psychologic distress (PHQ-2 and GAD-2) and unhelpful thoughts (catastrophic thinking) with the grade of radiographic osteoarthritis, six distinct phenotypes arose. These groups differed in terms of capability and pain self-efficacy (for example, mild pathology/low distress versus average pathology/high distress [PROMIS PF, mean ± standard deviation]: 43 ± 6.3 versus 33 ± 4.8; p = 0.003). When pairing the degree of capability (PROMIS PF) with the Kellgren-Lawrence grade, four distinct phenotypes arose. Patients in three of these did not differ in terms of disease severity but had notable variation in the degree of limitations. Patients with these radiologic and capability phenotypes differed in terms of distress and unhelpful thoughts (for example, moderate pathology/low capability versus mild pathology/high capability [PHQ-2, median and interquartile range]: 3 [1 to 5] versus 0 [0 to 0]; p < 0.001).

Conclusion 

Statistical groupings (“phenotypes”) that include both measures of pathology and mental health are associated with differences in symptom intensity and magnitude of incapability and have the potential to help musculoskeletal specialists discern mental and social health priorities. Future investigations may test whether illness phenotype-specific comprehensive biopsychosocial treatment strategies are more effective than treatment of pathology alone.

Level of Evidence 

Level III, prognostic study.

中文翻译：

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在接受特殊护理的髋关节和膝关节骨关节炎患者中，心理健康因素和病理生理学严重程度是否有不同的统计分组？

背景 

越来越多的证据表明病理生理学的客观测量与症状强度没有很好的相关性。越来越多的研究确定了不同程度的痛苦和无益的想法的统计组合（所谓的“表型”），这些组合与不同程度的症状强度和无能程度相关。下一步，了解痛苦和无益的想法如何与病理状况的客观测量（例如骨关节炎的放射学严重程度）相互作用将很有帮助。识别与不同疾病水平相关的这些因素的表型的能力可能有助于在以患者为中心的综合模型中改善个性化肌肉骨骼护理。

问题/目的 

(1) 当心理健康指标与放射学骨关节炎严重程度相结合时，成年髋关节和膝关节骨关节炎患者是否存在不同的表型？(2) 已确定的心理健康和放射学表型之间的能力和疼痛自我效能程度是否存在差异？(3) 当能力（患者报告的结果测量信息系统身体功能 [PROMIS PF]）与放射学骨关节炎严重程度配对时，髋关节和膝关节骨关节炎患者是否存在不同的表型？(4) 经鉴定的能力和放射学表型的患者心理健康状况是否存在差异？

方法 

我们对一项研究数据进行了二次分析，该研究涉及 119 名因髋关节或膝骨关节炎而接受肌肉骨骼专业护理的患者。百分之六十七（119 名患者中的 80 名）是女性，平均年龄为 62 ± 10 岁。76%（119 名患者中的 91 名）患有膝骨关节炎，59%（119 名患者中的 70 名）患有晚期骨关节炎放射学分级（Kellgren-Lawrence 3 级或更高）。该数据集非常适合我们当前的实验，因为最初的研究具有广泛的入组标准，使这些数据适用于不同的人群，并且因为患者的骨关节炎的放射学严重程度具有足够的变异性。所有新患者和返回患者均经过资格筛查。我们没有记录不参加横断面调查的符合条件的患者的百分比，但该比例通常很高（超过 80%）。148 名符合条件的患者开始了问卷调查，20% 的患者（148 名患者中的 29 名）未完成至少 60% 的调查问卷而被排除，留下 119 名患者可供分析。我们测量了心理困扰（患者健康问卷 2 [PHQ-2] 和广泛性焦虑症 2 问卷 [GAD-2]）、对疼痛无益的想法（疼痛灾难化量表 4 [PCS-4]）、自我效能感疼痛（疼痛自我效能问卷-2）和能力（PROMIS PF）。两位接受过关节成形术专科培训的外科医生中的一位根据最初研究中的放射线照片确定了骨关节炎的 Kellgren-Lawrence 分级。我们使用聚类分析生成两组表型：(1) 心理健康指标（PHQ-2、GAD-2、PCS-4）与 Kellgren-Lawrence 等级配对；(2) 能力 (PROMIS PF) 与 Kellgren-Lawrence 等级配对凯尔格伦-劳伦斯等级。我们使用单因素方差分析和 Kruskal-Wallis H 检验分别评估能力、自我效能和心理健康方面的差异。

结果 

当将心理困扰（PHQ-2 和 GAD-2）和无益的想法（灾难性思维）的测量值与放射学骨关节炎的分级配对时，出现了六种不同的表型。这些组在能力和疼痛自我效能方面存在差异（例如，轻度病理/低痛苦与平均病理/高痛苦[PROMIS PF，平均值±标准差]：43 ± 6.3 与 33 ± 4.8；p = 0.003）。当将能力程度 (PROMIS PF) 与 Kellgren-Lawrence 等级配对时，出现了四种不同的表型。其中三例患者的疾病严重程度没有差异，但限制程度有显着差异。具有这些放射学和能力表型的患者在痛苦和无益的想法方面有所不同（例如，中度病理/低能力与轻度病理/高能力[PHQ-2，中位数和四分位数范围]：3[1至5]与0[ 0 至 0]；p < 0.001）。

结论 

包括病理学和心理健康指标的统计分组（“表型”）与症状强度和无能力程度的差异相关，并有可能帮助肌肉骨骼专家辨别心理和社会健康的优先事项。未来的研究可能会测试疾病表型特异性的综合生物心理社会治疗策略是否比单独的病理治疗更有效。

证据水平 

III级，预后研究。