The effects of specific medical conditions on the functional limitations of elders in the Framingham Study

Prevalence and Correlates of Functional Disability in Multiethnic Elderly Singaporeans

OBJECTIVES

To make comparative estimates of prevalence of late-life functional disability, examine sociodemographic and health correlates, investigate sex and ethnic differences, and estimate population attributable risk of modifiable risk factors.

DESIGN

Population-based survey.

SETTING

Multiethnic population of Singapore (3 million residents).

PARTICIPANTS

Noninstitutionalized Chinese, Malay, and Indian people aged 60 and older (N=1,079)

MEASUREMENTS

Functional disability was defined as needing help in at least one basic activity of daily living (ADL) task in the 10 items of the Barthel Index. Five basic ADLs (eating, bathing, dressing, transferring, toileting) were used to compare prevalence with those reported from other national surveys and with reported past prevalence within the country.

RESULTS

The prevalence of disability in at least one of five ADL items (6.6% in those aged > or = 65) appeared lower than elsewhere, including China, but higher than reported past prevalence within the country. Functional disability on at least one of the 10 ADL items was independently associated with female sex, Indian ethnicity, older age, poor self-rated health, specific chronic diseases, cognitive impairment, sensory impairment, and living with others. The population attributable risks for leading modifiable factors were arthritis (12%) and cognitive impairment (14%).

CONCLUSION

Lower prevalence of functional disability accompanies rapid aging and health transition in Singapore than in other countries but higher prevalence than reported past prevalence within the country. Associations with sociodemographic and health-related factors were consistent with Western studies, including unexplained sex and ethnic differences.

Disparities in Disability Life Expectancy in US Birth Cohorts: The Influence of Sex and Race

Racial and sex disparities in chronic diseases and mortality are sources of health inequality and have been observed from infancy to adulthood. Disparities in health and mortality contribute to corresponding disparities in healthy life. I address two previously unanswered questions in the aging literature. First, does the racial and sex gap in healthy life narrow, persist, or expand over age and time, particularly considering severity of ill health, among the oldest old? Second, do some race-sex groups of birth cohorts live not just longer lives, but longer healthier lives, while others spend additional years in illness? To estimate the quantities, I employ a refined definition of physical disability and apply a new extension of Sullivan's method to true birth cohorts. The results suggest among the oldest old, few racial or sex disparities exist over age and time in mild disability. Yet, racial and sex disparities persist over age and time in severe disability.

Determinants of self efficacy for physical tasks in people with knee osteoarthritis

OBJECTIVE

Self efficacy, the confidence an individual has to perform a task, is an important determinant of physical performance in individuals with knee osteoarthritis (OA). The purpose of this study was to determine what personal, pathophysiologic, and impairment factors relate to self efficacy for physical tasks in community-dwelling adults with knee OA.

METHODS

Fifty-four persons with radiographically confirmed knee OA (mean +/- SD age 68.3 +/- 8.7 years, range 50-87 years) participated. The Functional Self-Efficacy subscale of the Arthritis Self-Efficacy Scale was the dependent measure. Independent measures included age, education, scores from the Center for Epidemiologic Studies Depression and State-Trait Anxiety Inventory questionnaires, medial joint space and varus/valgus tibiofemoral angle from radiographs, body mass index, and isokinetic quadriceps and hamstrings strength. Knee pain and stiffness, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index, were independent measures.

RESULTS

Fifty-one percent of the variance of Functional Self Efficacy was explained by knee stiffness, hamstrings strength, age, and depression scores. Pain, education, anxiety, radiographic joint space, and body weight did not significantly contribute to the variance in Functional Self-Efficacy scores. Substituting quadriceps strength for hamstrings strength resulted in a regression model that included only stiffness, age, and depression, which explained nearly as much variance as the original model.

CONCLUSION

Self efficacy for physical tasks is related to the sensation of stiffness, hamstrings strength, age, and level of depressive symptoms in persons with knee OA. Clinicians and researchers could consider these variables when assessing the level of self efficacy for physical tasks in persons with knee OA.

Osteoarthritis: an overview of the disease and its treatment strategies

Osteoarthritis (OA) is currently defined by the American College of Rheumatology as a "heterogeneous group of conditions that leads to joint symptoms and signs which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins." Its prevalence after the age of 65 years is about 60% in men and 70% in women. The etiology of OA is multifactorial, with inflammatory, metabolic, and mechanical causes. A number of environmental risk factors, such as obesity, occupation, and trauma, may initiate various pathological pathways. OA indicates the degeneration of articular cartilage together with changes in subchondral bone and mild intraarticular inflammation. The principal treatment objectives are to control pain adequately, improve function, and reduce disability. Acetaminophen is frequently used for symptomatic OA with mild to moderate pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are more effective in the case of moderate-severe pain, but they have an increased risk of serious upper gastrointestinal adverse events. The newer cyclooxygenase COX-2 specific inhibitors (Coxibs) are as efficacious as traditional NSAIDs and have a better gastrointestinal safety profile. Other compounds (eg, chondroitin sulfate, diacerein, glucosamine sulfate) have a symptomatic effect that is slower and less than that of NSAIDs. The structure-modifying effects of drugs are currently being evaluated, and both glucosamine sulfate and diacerein have been shown in some trials to have a beneficial structural effect. Nonpharmacological interventions are frequently and widely used in the management of OA patients, but there is little evidence that they are effective: the best studied and most successful nonpharmacological interventions are patient education, self-management, and exercise. There is some evidence for the pain-relieving efficacy of thermotherapy and transcutaneous electrical nerve stimulation (TENS) but not of electrotherapy, acupuncture, homeopathy, or manual therapy. The value of interventions aimed at improving function and maximizing independence (occupational therapy, walking aids, workplace adaptation) is also unclear. The disease course and patient's requirements often change over time, thus requiring a periodic review and readjustment of therapy rather than the rigid continuation of a single treatment.

Does Knee Osteoarthritis Alter the Neuromuscular Responses to a Perturbation During Single Lower Limb Stance?

PURPOSE

Evidence substantiating an association between knee osteoarthritis (OA) and altered joint protection responses is relevant to the management of knee OA. The purpose of this study was to detect neuromuscular response times of the vastus lateralis and biceps femoris muscles following a perturbation during single lower limb stance. We hypothesized that muscle response times are: (1) delayed in older adults with knee OA when compared to young and older adults (without diagnosed knee OA) and (2) dependent on the magnitude of load released.

SUBJECTS

Ten young adults, 10 older adults, and 7 older adults with symptomatic knee OA participated.

METHODS

While in single lower limb stance, the subjects flexed the knee into a range of 33 to 37 degrees while a posterior load of either 6 or 9 kg was applied at the proximal tibia. The load was released after the subjects held the required position for 1 full second. Muscle response times were measured by electromyography. Separate 3 (group) by 2 (load) mixed factorial analysis of variance procedures were performed for electromyography data from the vastus lateralis and biceps femoris.

RESULTS

There was no difference in vastus lateralis response times between older adults with knee OA and older adults or between older adults with knee OA and young adults. Older adults did have longer vastus lateralis response times than young adults. There was no difference in biceps femoris response times between older adults with knee OA and older adults; however, both groups had longer biceps femoris response times than young adults. Furthermore, there were no differences in either vastus lateralis or biceps femoris response times between 6 kg and 9 kg loads.

CONCLUSION

Although knee OA did not alter muscle responses in our study, the type of functional weightbearing perturbation described could be safely used in the physical therapy clinic to help improve balance and stability while decreasing discomfort in older adults with symptomatic knee OA.

The relationship between cartilage loss on magnetic resonance imaging and radiographic progression in men and women with knee osteoarthritis

OBJECTIVE

To determine the relationship between radiographic progression of joint space narrowing and cartilage loss on magnetic resonance imaging (MRI) in patients with symptomatic knee osteoarthritis (OA), and to investigate the location of MRI-based cartilage loss in the knee and its relation to radiographic progression.

METHODS

Two hundred twenty-four men and women (mean age 66 years) were studied. Radiographs and MRI of the more symptomatic knee were obtained at baseline and at 15- and 30-month followup. Radiographs of the knee (with weight-bearing) were read for joint space narrowing (scale 0-3), with progression defined as any worsening in score. We used a semiquantitative method to score cartilage morphology in all 5 regions of the tibiofemoral joint, and defined cartilage loss as an increase in score (scale 0-4) at any region. We examined the relationship between progression of joint space narrowing on radiographic images and cartilage loss on MRI, using a generalized estimating equation proportional odds logistic regression, adjusted for baseline cartilage score, age, body mass index, and sex. The medial and lateral compartments were analyzed separately.

RESULTS

In the medial compartment, 104 knees (46%) had cartilage loss detected by MRI. The adjusted odds ratio was 3.7 (95% confidence interval 2.2-6.3) for radiographic progression being predictive of cartilage loss on MRI. However, there was still a substantial proportion of knees (80 of 189 [42%]) with cartilage loss visible on MRI when no radiographic progression was apparent. Cartilage loss occurred frequently in the central regions of the femur and tibia as well as the posterior femur region, but radiographic progression was less likely to be observed when posterior femur regions showed cartilage loss. Radiographic progression appeared specific (91%) but not sensitive (23%) for cartilage loss. Overall findings were similar for the lateral compartment.

CONCLUSION

While our results provide longitudinal evidence that radiographic progression of joint space narrowing is predictive of cartilage loss assessed on MRI, radiography is not a sensitive measure, and if used alone, will miss a substantial proportion of knees with cartilage loss.

Clinical comorbidity was specific to disease pathology, psychologic distress, and somatic symptom amplification

OBJECTIVE

To test the hypothesis that disease pathology, psychologic distress, and somatic symptom amplification separately influence health care use by investigating the patterns of comorbidity in patients with diabetes, anxiety, and upper respiratory tract infection (URTI), respectively.

METHODS

Adult diabetes (n=4,365), anxiety (13,421), and URTI (9,854) cases, and 15,000 randomly selected controls were identified from a 1-year national survey of general practice consultations. Comorbidity was based on a standard clinical morbidity classification used by general practitioners in actual consultations.

RESULTS

In case-control analyses of 122 morbidities, the number of significant comorbid associations (P<.01) for diabetes was 30, anxiety was 72, and URTI was 49. These associations showed significant heterogeneity in the odds ratios estimated using Cochran's Q and I2 statistic, both between case groups and within each case group. Diabetes associations were stronger with peripheral vascular disease (odds ratio 2.7), candidiasis (2.5), cataract (2.4), obesity (2.2), and hypertension (1.7); anxiety with depressive disorder (4.1), affective psychosis (4.0), adjustment reaction (3.2), functional gastrointestinal disorders (2.5) and general symptoms (2.5); and URTI with nonspecific blood findings (5.5), bronchitis (5.2), and injury (3.5).

CONCLUSION

Our study shows patterns of clinical comorbidity specific to the case conditions that supports the hypothesis that different mechanisms (disease pathology, psychologic distress, and somatic symptom amplification) operate to influence consultation behavior and comorbidity.

Nonoperative treatment of unicompartmental arthritis of the knee

Treatment of the knee with unicompartmental osteoarthritis remains a challenging clinical problem. Despite pharmacologic advances and surgical innovations, the ideal strategy for the patient who has single-compartment degenerative disease can be complicated. The understanding and management of this problem are further confounded by the fact that so much of the data are unreliable. Given these constraints, this article outlines the current alternatives available in nonoperatively managing the symptomatic unicompartmental arthritic knee.

Improvements in balance after total hip replacement

We have investigated whether control of balance is improved during stance and gait and sit-to-stand tasks after unilateral total hip replacement undertaken for osteoarthritis of the hip.

We examined 25 patients with a mean age of 67 years (sd 6.2) before and at four and 12 months after surgery and compared the findings with those of 50 healthy age-matched control subjects. For all tasks, balance was quantified using angular measurements of movement of the trunk.

Before surgery, control of balance during gait and sit-to-stand tasks was abnormal in patients with severe osteoarthritis of the hip, while balance during stance was similar to that of the healthy control group. After total hip replacement, there was a progressive improvement at four and 12 months for most gait and sit-to-stand tasks and in the time needed to complete them. By 12 months, the values approached those of the control group. However, trunk pitch (forwards-backwards) and roll (side-to-side) velocities were less stable (greater than the control) when walking over barriers as was roll for the sit-to-stand task, indicative of a residual deficit of balance.

Our data suggest that patients with symptomatic osteoarthritis of the hip have marked deficits of balance in gait tasks, which may explain the increased risk of falling which has been reported in some epidemiological studies. However, total hip replacement may help these patients to regain almost normal control of balance for some gait tasks, as we found in this study. Despite the improvement in most components of balance, however, the deficit in the control of trunk velocity during gait suggests that a cautious follow-up is required after total hip replacement regarding the risk of a fall, especially in the elderly.

Vertebral deformity, back symptoms, and functional limitations among older women: the Framingham Study

Vertebral deformity is the most common manifestation of osteoporosis. The purpose of this study was to determine the relation between incident vertebral deformity and back symptoms; and limitations in nine specific functional activities. Subjects were participants in the Framingham Study, a longitudinal, population-based sample involving residents of Framingham, MA, USA. Subjects consisted of 444 surviving female members of the original cohort who had baseline (1968-1975) and follow-up (1992-1993) spine radiographs evaluated for deformity using a semiquantitative scale. Ages ranged from 72 to 96 years. At the follow-up examination, subjects were asked if they experienced pain, aching, or stiffness in their back on most days and if they had difficulty performing nine specific functional skills. We found that incident vertebral deformity was associated with limitations in several functional activities, most notably, pushing or pulling a large object (OR 2.51, 95% confidence interval 1.40, 4.52). For most activities, there was no increase in the risk of functional limitations among women with vertebral deformity who did not report back symptoms at the end of the follow-up compared with those without vertebral deformity or back symptoms. For several functional activities, individuals with both vertebral deformity and back symptoms had greater limitations than would be expected from the additive contribution of both conditions. Back symptoms were associated with limitations in most functional activities, even in the absence of vertebral deformity. Efforts to prevent and treat back pain, independent of vertebral deformity status, might help to reduce functional limitations in older women.

The Effect of Diabetes on Disability in Middle-Aged and Older Adults

BACKGROUND

Physical disability is increasingly recognized as an adverse health consequence of type 2 diabetes in older adults. We studied the effect of diabetes on disability in middle-aged and older adults to: 1) characterize the association of diabetes with physical disability in middle-aged adults, and 2) determine the extent to which the effect of diabetes is explained by related covariates in either or both age groups.

METHODS

We used data from two parallel national panel studies of middle-aged and older adults to study the effect of self-reported diabetes at baseline on disability 2 years later, adjusting for baseline covariates.

RESULTS

Diabetes was strongly associated with subsequent physical disability (measured by a composite variable combining activities of daily living, mobility, and strength tasks) in middle-aged and older adults. Controlling for socioeconomic characteristics and common diabetes-related and unrelated comorbidities and conditions reduced the diabetes effect substantially, but it remained a significant predictor of disability in both groups.

CONCLUSIONS

Our analyses demonstrated that disability is an important diabetes-related health outcome in middle-aged and older adults that should be prevented or mitigated through appropriate diabetes management.

Health-related quality of life in older adults with symptomatic hip and knee osteoarthritis: a comparison with matched healthy controls

BACKGROUND AND AIMS

Health-related quality of life (HRQOL) assessment is receiving increasing attention as an outcome measure in osteoarthritis (OA). The aims of this study were to compare HRQOL among older adults aged 55 to 78 years with hip and/or knee OA with those without OA, and to assess the influence of selected variables (sex, body mass index, radiographic OA severity, educational level, comorbidities) on HRQOL.

METHODS

The generic Medical Outcome Study Short Form-36 item health status questionnaire (SF-36) was administered to a cohort of 264 OA patients (105 with hip OA alone, 108 with knee OA alone, and 51 with both hip and knee OA) and 112 healthy controls.

RESULTS

Compared with the healthy controls, OA of the lower extremities has a detrimental effect on the eight-scale profile score, as well as on physical and mental summary measures of the SF-36. The most striking impact was seen in the physical measures "physical functioning", "physical role" and "pain" (p<0.0001). No statistically significant differences in SF-36 scores were found among the three groups of OA patients. The physical and mental summary scales of the SF-36 were closely correlated (p<0.0001). One hundred and forty-five patients (54.9%) reported at least one chronic coexisting disease. There was a significant inverse association with measures of comorbidity (number of comorbidities and comorbidity index score) and both physical and mental summary scores of the SF-36 questionnaire. In patients with OA of the knee alone (but not in hip OA alone or hip and knee OA), the SF-36 pain score was inversely correlated with years of formal education (p=0.016). In addition, the impact of hip and knee SF-36 dimensions was not influenced by the degree of radiographic severity.

CONCLUSIONS

Older adults with OA of the lower extremities undergo a significant impact on multiple dimensions of HRQOL, compared with healthy controls. The use of a generic measure of HRQOL such as the SF-36, in studies of OA where comorbidity is common, should be useful in characterizing the global burden of this disease.

Impact of osteoarthritis: results of a nationwide survey of 10,000 patients consulting for OA

The clinical burden of osteoarthritis (OA) is difficult to assess because of the substantial variability between patients.

OBJECTIVE

Evaluate the human consequences of OA in patients.

METHODS

In 2000, a nationwide survey was conducted among a sample of more than 5000 physicians (90.3% general practitioners and 9.7% rheumatologists), representative of French physicians. Each recruited the first two patients consulting for hip, knee, or hand OA after the survey began. The functional limitation rates were compared with those for age- and sex-matched controls obtained from the 1999 population-based national survey on disability (HID survey).

RESULTS

Clinical and demographic information was obtained for 10,412 OA patients (mean-age 66.2 years, sex ratio F:M 1.96). The OA diagnosis was based on both clinical and radiographic findings for 84.5%. More than 80% of all patients reported limitations in their activities of daily living, either for basic tasks, leisure activities, or work. OA patients were substantially more limited than controls: the standardised limitation rate ratios (SLRR) were 6.0 (95% confidence interval: 5.9:6.1) for mobility outside the home, 2.1 (2.0:2.1) for house cleaning, 1.6 (1.5:1.8) for dressing oneself, and 1.6 (1.5:1.8) for sports. Of the 17.6% of OA patients and 17.5% of the controls still working, 64.4% and 14.3%, respectively, were limited in their job duties, for a SLRR of 4.5 (4.3:4.7).

CONCLUSION

This study shows that OA-related disability has a significant impact on the retired as well as on those still involved in the labour market.

Effect of pulsed short-wave diathermy on pain and function of subjects with osteoarthritis of the knee: a placebo-controlled double-blind clinical trial

OBJECTIVE

To examine the effects of pulsed short-wave diathermy (PSWD), delivered at an intensity sufficient to induce a thermal sensation and at an athermal intensity, in comparison with a placebo short-wave diathermy treatment, on reported pain, stiffness and functional ability and on mobility performance of patients with osteoarthritis of the knee.

DESIGN

A placebo-controlled double-blind trial with sequential allocation of patients to different treatment groups.

SETTING

Outpatient physiotherapy department.

SUBJECTS

One hundred and three consecutive patients, mean age 73.7 (+/-6.6) years with osteoarthritis of one or both knees for at least three months.

INTERVENTIONS

All participants received three 20-min-long treatments per week for three weeks. One group received PSWD with mean power of 18 W (thermal effect), one group received PSWD with mean power of 1.8 W (athermal effect), and one group received sham short-wave diathermy treatment. Patients were assessed before the initial treatment, immediately following the last treatment, and at a three-month follow-up.

MAIN MEASURES

Outcome measures included the WOMAC Osteoarthritis Index, which assessed reported pain, stiffness, and functional ability, and four measures of mobility performance: Timed Get Up and Go test (TGUG), stair-climbing, stair, descending and a 3-min walk.

RESULTS

A difference across time was observed for the pain and stiffness categories of the WOMAC Osteoarthritis Index (p = 0.033 and p = 0.008, respectively), with no differences between groups. No other significant differences across time or between groups were observed in any of the other measures.

CONCLUSION

The findings do not demonstrate pulsed short-wave diathermy, as it is utilized in clinical settings, to be effective in the treatment of osteoarthritis of the knee.

Family caregiving and congestive heart failure. Review and analysis

BACKGROUND

There is increasing evidence that discharge planning and post-discharge support for CHF patients can contribute greatly to the medical management of heart failure (CHF) in the community and that the quality of the CHF patient's close personal relationships can influence outcome in CHF. However, there has been little research on the impact of CHF on the family or the role of the family in the management of the condition. In this paper, we provide a review and analysis of studies that have explicitly investigated these issues in the informal carers of CHF patients.

RESULTS OF THE REVIEW

Sixteen papers were identified that examined the role and/or impact of informal caregiving for CHF patients. Our main findings were: demands specific to CHF caregiving were identified, e.g., monitoring complex medical and self-care regimen, disturbed sleep and frequent hospitalisation of patients. Relatively high levels of emotional distress were identified in CHF caregivers. Few studies explicitly investigated the role of informal carers in the management of CHF. Studies were limited in number, scope and quality.

CONCLUSION

Caring for a family member with CHF can affect the well-being of those responsible for care, which may have consequences for the CHF patient's health. Further studies are needed to clarify these issues and to examine the role of informal caregivers in the management of CHF in the community.

Factors associated with hip cartilage volume measured by magnetic resonance imaging: the Tasmanian Older Adult Cohort Study

OBJECTIVE

To compare associations between anthropometric and lifestyle factors and femoral head cartilage volume/thickness and radiographic features of osteoarthritis (OA) and to provide evidence of construct validity for magnetic resonance imaging (MRI) assessment of femoral cartilage volume and thickness.

METHODS

We studied a cross-sectional sample of 151 randomly selected subjects (79 men, 72 women; mean age 63 years) from the Tasmanian Older Adult Cohort Study. A sagittal T1-weighted fat-suppression MRI scan of the right hip was performed to determine femoral head cartilage volume, cartilage thickness, and size. An anteroposterior radiograph of the pelvis with weight bearing was performed and scored for radiographic evidence of OA in the right hip. Other factors measured were height, weight, leg strength, serum vitamin D levels, and bone mineral density.

RESULTS

Hip cartilage volume was significantly associated with female sex, body mass index, and femoral head size, whereas hip cartilage thickness was significantly associated only with the size of the femoral head. Only female sex was significantly associated with the total radiographic OA score and the joint space narrowing (JSN) score, but not the osteophyte score. Radiographic JSN of the hip, especially axial JSN (but not osteophytes), was significantly correlated with hip cartilage volume and thickness.

CONCLUSION

Femoral head cartilage volume and thickness have modest but significant construct validity when correlated with radiographic findings. Furthermore, the generally stronger associations with volume compared with radiographic OA suggest that MRI may be superior at identifying risk factors for hip OA.

Chondroitins 4 and 6 sulfate in osteoarthritis of the knee: a randomized, controlled trial

OBJECTIVE

To determine whether chondroitin sulfate (CS) is effective in inhibiting cartilage loss in knee osteoarthritis (OA).

METHODS

In this randomized, double-blind, placebo-controlled trial, 300 patients with knee OA were recruited from an outpatient clinic, from private practices, and through advertisements. Study patients were randomly assigned to receive either 800 mg CS or placebo once daily for 2 years. The primary outcome was joint space loss over 2 years as assessed by a posteroanterior radiograph of the knee in flexion; secondary outcomes included pain and function.

RESULTS

Of 341 patients screened, 300 entered the study and were included in the intent-to-treat analysis. The 150 patients receiving placebo had progressive joint space narrowing, with a mean +/- SD joint space loss of 0.14 +/- 0.61 mm after 2 years (P = 0.001 compared with baseline). In contrast, there was no change in mean joint space width for the 150 patients receiving CS (0.00 +/- 0.53 mm; P not significant compared with baseline). Similar results were found for minimum joint space narrowing. The differences in loss of joint space between the two groups were significant for mean joint space width (0.14 +/- 0.57 mm; P = 0.04) and for minimum joint space width (0.12 +/- 0.52 mm; P = 0.05). CS was well tolerated, with no significant differences in rates of adverse events between the two groups.

CONCLUSION

While there was no significant symptomatic effect in this study, long-term treatment with CS may retard radiographic progression in patients with OA of the knee. However, the clinical relevance of the observed structural results has to be further evaluated, and further studies are needed to confirm the structural effects of CS.

Functional recovery after hip fracture in old-old elderly patients

Hip fracture is epidemic and prevalence increased with advanced age. Impact of comorbid and cognitive status, gender, type of fracture, operative delay and pre-fracture ambulatory levels on functional outcome was shown in previous studies. We studied functional outcome after rehabilitation for hip fracture in old-old elderly (85 years and older) and compared it to young elderly (65-74 years) community-dwelling patients. Before the fracture, old-old elderly patients were more functional dependent, has had more comorbid diseases, and more of them live alone than young elderly. The waiting time to surgery and mean length of stay in orthopedic ward were longer than in young elderly. On admission to rehabilitation treatment, old-old patients presented with more depressed mood, were more cognitive impaired, and more suffer from pain. Old-old patients presented with laboratory data of malnutrition (decreased serum levels of albumin, cholesterol, hemoglobin, hematocrit, lymphocyte count) and inflammation (increased of transferrin and C-reactive protein). Improvement in Functional Independence Measurement (FIM) scale was found in both groups but significantly better in young elderly than in old-old elderly. The change in FIM during the rehabilitation period (DeltaFIM) were in FIM total and in those parts of FIM concerning locomotion. The mean duration of rehabilitation stay was significantly longer in old-old elderly patients. On discharge old-old elderly patients more suffer from pain and difference between the groups according to the laboratory and to the cognitive data increased. Age per se is indicator of frailty and determinate functional recovery after hip fracture.

Newly Reported Chronic Conditions and Onset of Functional Dependency

OBJECTIVES

To examine the relationship between newly reported chronic conditions and subsequent functional dependency in older adults.

DESIGN

Three-year cohort study.

SETTING

United States.

PARTICIPANTS

A national sample of Americans age 65 and older (N=4,968) who participated in the Medicare Current Beneficiary Survey.

MEASUREMENTS

Self-reports of new physician diagnoses between baseline and 12 months and functional dependency onset at 12-, 24-, and 36-month follow-up. Functional dependency is defined as needing help with or being unable to perform one or more activities of daily living or residence in a long-term care facility.

RESULTS

After 12 months of follow-up, 29.8% of participants reported one or more newly diagnosed conditions, increasing to 48.7% at 24 months and 61.3% at 36 months. Number of newly reported conditions was associated with greater probability of functional dependency; this association was strongest at 12 months. The odds of becoming functionally dependent were nearly twice as great in participants who reported one new chronic condition (odds ratio (OR)=1.9, 95% confidence interval (CI)=1.3-2.8), more than four times as great in those who reported two new chronic conditions (OR=4.3, 95%=CI 2.7-6.9), and 13 times as great in those who reported three or more new chronic conditions (OR=13.0, 95%=CI 6.5-26.3) as in those who reported no new chronic conditions. Newly reported dementia, stroke, psychological disorders, low body mass index, and obesity were significantly and consistently related to functional dependency throughout all 3 years of observation (OR=2.1-14.1).

CONCLUSION

Findings from this study demonstrate the strong relationship between newly diagnosed chronic conditions and functional dependency and highlight the potential benefit of prevention in older adults.

Relationship between objective measures of peripheral arterial disease severity to self-reported quality of life in older adults with intermittent claudication

OBJECTIVES

The aim of this study was to determine the relation between functional measures of peripheral arterial disease (PAD) severity with both disease-specific and generic self-reported health-related quality-of-life (HR-QOL) measures, as well as the relation between the two types of HR-QOL measures.

METHODS

This was a cross-sectional observation of participants from the community and primary care or vascular surgery clinics in an academic Veterans Administration medical center. Eighty patients with symptomatic Fontaine stage II PAD provided physiologic measures and self-response questionnaires. Objective measures included the ankle-brachial index (ABI), time to maximum claudication pain on a graded exercise test, and a 6-minute floor-walking distance. Self-reports included the Walking Impairment Questionnaire (WIQ), a disease-specific HR-QOL measure and the Medical Outcomes Study (MOS) Short-Form 36 (SF-36), a generic HR-QOL measure.

RESULTS

Patients (mean age 70 +/- 8 [+/- SD] and 85% men) exhibited moderate-to-severe PAD by objective measures of ABI (0.65 +/- 0.19) and time in minutes to maximal claudication on a graded exercise test (7:54 +/- 4:58). Significant correlations were found between these measures and the WIQ distance, MOS-Physical Function, and MOS-Role Limitations due to physical dysfunction. The SF-36 and the WIQ subscales were significantly correlated.

CONCLUSION

In older PAD patients with intermittent claudication, objective measures of disease severity are correlated with a self-reported, disease-specific and generic HR-QOL.

Evaluation of the comparative efficacy of etoricoxib and ibuprofen for treatment of patients with osteoarthritis: A randomized, double-blind, placebo-controlled trial

OBJECTIVE

To directly compare the efficacy and safety of etoricoxib, 30 mg once daily, ibuprofen, 800 mg 3 times daily, and placebo for treatment of osteoarthritis (OA) of the hip and knee.

PATIENTS AND METHODS

A randomized, double-blind, placebo-controlled trial of patients with OA of the knee or hip was performed between February 2003 and November 2003 in 61 medical centers in the United States. Qualified patients aged 40 to 89 years were randomized to receive placebo, etoricoxib, 30 mg once daily, or ibuprofen, 800 mg 3 times daily, for 12 weeks. Primary efficacy end points Included the Western Ontario and McMaster Universities Osteoarthritis Index pain and physical function subscales and Patient Global Assessment of Disease Status. Response to treatment was assessed by the time-weighted average change from baseline over 12 weeks.

RESULTS

In 528 patients, baseline values for the 3 primary end points ranged from 67.78 to 72.60 mm (0-100 mm visual analog scale). Near-maximal efficacy was achieved by week 2 with both active treatments and sustained over the course of the trial. During the 12-week period, least squares mean changes in the primary end points (Western Ontario and McMaster Universities Osteoarthritis Index and Patient Global Assessment of Disease Status subscales) ranged from -16.53 to -13.55 mm, -27.89 to -23.68 mm, and -26.53 to -22.97 mm in the placebo, etoricoxib, and Ibuprofen groups, respectively. Both etoricoxib and ibuprofen were more effective (P<.001) than placebo for all primary end points. Etoricoxib and ibuprofen treatment responses for the primary end points were determined to be comparable with use of prespecified comparability criteria. Results for all other efficacy end points were consistent with responses observed for the primary end points. Etoricoxib and ibuprofen generally were well tolerated.

CONCLUSION

For patients with OA, treatment with etoricoxib, 30 mg/d, is well tolerated and provides sustained clinical effectiveness that is superior to placebo and comparable to ibuprofen, 2400 mg/d.

An optimal duration of daily wear for an insole with subtalar strapping in patients with varus deformity osteoarthritis of the knee

OBJECTIVE

To assess the optimal duration of daily wear for a laterally wedged insole with subtalar strapping in subjects with medial compartment osteoarthritis of the knee (knee OA).

DESIGN

The setting was an outpatient clinic. Eighty-one patients with knee OA were prospectively randomized according to birth date and to either 2 weeks of treatment with a lateral wedge with subtalar strapping for less than 5 h (the short group), 5-10 h (the medium group) or greater than 10 h (the long group) each day, or to treatment with a subtalar strapping band without lateral wedge (the placebo group). Standing radiographs were used to analyze the femorotibial angle for each subject, both with and without their respective orthotic device. The remission scores of Lequesne index were compared among the four groups at the conclusion.

RESULTS

The short (n=21), medium (n=20) and long (n=18) groups demonstrated a significant greater valgus correction of the femorotibial angle than the placebo group (n=22) (P<0.0001). The remission score was significantly improved in the medium group compared to the placebo (P=0.001) and long (P=0.001) groups.

CONCLUSIONS

An optimal duration of insole with subtalar strapping wear for patients with varus deformity knee OA may be between 5 and 10 h each day.

Tratamiento farmacológico de la artrosis. Expectativas y realidades

In order to assess agent with modulating properties of the course of the arthrosic condition, the so-called SYSADOA (Symptomatic Slow Acting Drugs for Osteoarthritis) and "structure modifiers" have been defined. Glucosamine sulfate, chrondroitin sulfate and diacerein have been considered among these agents. Based on the published data and according to the evidence available, the SYSADOA have symptomatic effects and can modify the structure. However, although there is scientific evidence for the use of these drugs in arthrosis treatment, the limited intensity of their action over the placebo makes it necessary to evaluate the clinical relevance of their application before recommending their generalized use.

Inner city African-American elderly patients' perceptions and preferences for the care of chronic knee and hip pain: findings from focus groups

BACKGROUND

African Americans undergo joint replacement less often than do white persons. The authors studied African-American perceptions and preferences for the care of knee and hip pain.

METHODS

10 focus groups were conducted in an inner city community. Participants, older persons with chronic knee or hip pain, were asked to discuss their perceptions and preferences for the care of knee and hip pain. Transcripts were coded for thematic structure using NUD*ST software.

RESULTS

Cultural preferences and perceptions for care emerged as a major theme. Important subcategories of this theme included respect for the patient's faith and religiosity and perceptions of physician ethnicity, race, and sex.

CONCLUSIONS

This sample of older inner city African Americans expressed unique cultural perceptions and preferences for the care of their knee and hip pain. Respect for patients' faith was important, whereas physicians' race, ethnicity, and religious background were not.

Association of cognitive status with functional limitation and disability in older adults

BACKGROUND AND AIMS

Although cognitive status is known to be associated with physical function in older people, the role it plays in the disability process is not well established. This study aimed at determining whether cognitive ability predicts functional limitations, as well as disability, and whether it is associated with the rate of change in physical functions.

METHODS

A community-based longitudinal study was conducted, involving 977 older persons aged 65 and older living in an urban community. Physical functions were assessed by tests scoring functional limitations (upper and lower body) and disability (activities of daily living). Cognitive function was evaluated using the Mini-Mental State Examination. Linear regression analyses with generalized estimating equations modeled the two physical function scores separately, as functions of cognitive status and time, in a one-year follow-up, controlling for sociodemographic and health-related characteristics.

RESULTS

Cognitive status independently predicted functional limitations as well as disability in older people. In addition, the strength of the association of cognitive status with physical functions increased over time, as revealed by the significant interaction between cognitive ability and time. Cognitive status influenced the rate of change in disability scores, more among women and in those aged 75 or older. The relationship was unaffected by baseline physical functional status, but was significant only among those with no cognitive impairment at baseline.

CONCLUSIONS

Cognitive status appears to be a useful indicator of the disablement process in older people. It may play an important role in the development of disability, implying that strategies for early intervention to prevent the progression of disability may need to take cognitive functions into account. The increasing strength of the relationship between cognitive and physical functions over time further attests to its value in monitoring functional change.

Osteoarthritis of the knees increases the propensity to trip on an obstacle

Tripping on an object is the most frequent cause of falls. We examined the effects of painful osteoarthritis of the knee on obstacle avoidance success rates in older adults. Obstacle avoidance success rates, pain, body mass index, visual acuity, contrast sensitivity, depth perception, and single-leg stance duration were evaluated in 17 patients with painful osteoarthritis of the knees (age range, 59.6 +/- 8.1 years) and 14 age-matched healthy control subjects (age range, 61.1 +/- 10.0 years). The patients with osteoarthritis of the knees had a 37% lower obstacle avoidance success rate, a 54% lower single-leg stance duration, and a 24% greater body mass index than the control subjects. Age, visual acuity, contrast sensitivity, and depth perception were not different between the two groups. Obstacle avoidance success rates and single-leg stance durations decreased linearly as pain increased in the patients with osteoarthritis of the knees. Obstacle avoidance success rates also decreased linearly as single-leg stance duration decreased in the patients with osteoarthritis of the knees. Osteoarthritis of the knees reduced obstacle avoidance success rates, supporting epidemiologic studies that have found osteoarthritis to be a risk factor for falls. This study showed that pain associated with osteoarthritis of the knees increased the propensity to trip on an obstacle (the greater the pain the greater the propensity to trip and fall) and underscores the importance of treating pain associated with osteoarthritis.

Epidemiologic studies for osteoarthritis: new versus conventional study design approaches

This article discusses epidemiologic study designs for osteoarthritis and why traditional designs are outmoded. It reviews the design of new studies, the Osteoarthritis Initiative and Multicenter Ostroarthritis Study.

Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty

Background

Physical performance measures play an important role in the measurement of outcome in patients undergoing hip and knee arthroplasty. However, many of the commonly used measures lack information on their psychometric properties in this population. The purposes of this study were to examine the reliability and sensitivity to change of the six minute walk test (6MWT), timed up and go test (TUG), stair measure (ST), and a fast self-paced walk test (SPWT) in patients with hip or knee osteoarthritis (OA) who subsequently underwent total joint arthroplasty.

Methods

A sample of convenience of 150 eligible patients, part of an ongoing, larger observational study, was selected. This included 69 subjects who had a diagnosis of hip OA and 81 diagnosed with knee OA with an overall mean age of 63.7 ± 10.7 years. Test-retest reliability, using Shrout and Fleiss Type 2,1 intraclass correlations (ICCs), was assessed preoperatively in a sub-sample of 21 patients at 3 time points during the waiting period prior to surgery. Error associated with the measures' scores and the minimal detectable change at the 90% confidence level was determined. A construct validation process was applied to evaluate the measures' abilities to detect deterioration and improvement at two different time points post-operatively. The standardized response mean (SRM) was used to quantify change for all measures for the two change intervals. Bootstrapping was used to estimate the 95% confidence intervals (CI) for the SRMs.

Results

The ICCs (95% CI) were as follows: 6MWT 0.94 (0.88,0.98), TUG 0.75 (0.51, 0.89), ST 0.90 (0.79, 0.96), and the SPWT 0.91 (0.81, 0.97). Standardized response means varied from .79 to 1.98, being greatest for the ST and 6MWT over the studied time intervals.

Conclusions

The test-retest estimates of the 6MWT, ST, and the SPWT met the requisite standards for making decisions at the individual patient level. All measures were responsive to detecting deterioration and improvement in the early postoperative period.

Reports of joint instability in knee osteoarthritis: its prevalence and relationship to physical function

OBJECTIVE

To report the prevalence and relationship of self-reported knee instability to physical function in a sample of subjects with knee osteoarthritis (OA), and to discuss the implications of these observations for rehabilitation.

METHODS

Subjects were 105 individuals (80 females) with knee OA who rated their knee instability severity on a 6-point numeric scale in response to the query "To what degree does giving way, buckling, or shifting of the knee affect your level of daily activity?" A principal component analysis was used to combine The Western Ontario and McMaster Universities pain, stiffness, and physical function subscale scores, and the Timed Get Up and Go Test score into a principal component score for physical function (PCPF). Other variables that could affect the PCPF such as age, sex, years with knee OA, radiographic severity of knee OA, knee pain, knee motion, and quadriceps strength were also recorded. The prevalence of self-reported knee instability was determined by calculating the proportion of subjects who reported each severity level of knee instability. Hierarchical regression analysis was performed to determine if the level of self-reported knee instability could predict the PCPF, even after accounting for the effects of the other variables.

RESULTS

Sixty-three percent of the subjects reported knee instability during activities of daily living, and 44% reported that instability affects their ability to function. The severity of self-reported knee instability was associated with the PCPF (eta2=0.40, P <0.001), and after controlling for all other independent variables, significantly increased the prediction of the PCPF (r2=0.56, r2 change=0.05; P <0.001).

CONCLUSION

The results indicate that a substantial proportion of individuals with knee OA report episodes of knee instability during activities of daily living, and instability affects physical function beyond that which can be explained by contributions from other impairments such as knee pain, range of motion, and quadriceps strength. Knee instability is a problem that should be specifically addressed in rehabilitation programs and may require interventions beyond those that address pain, joint motion, and muscular strength, to maximize the effectiveness of rehabilitation for individuals with knee OA.

Basic Science of Articular Cartilage and Osteoarthritis

Articular cartilage is a specialized tissue uniquely suited for load distribution with a low-friction articulating surface. Its compressive and tensile properties are determined by its matrix and fluid composition, and are maintained by chondrocytes in the homeostatic joint. Osteoarthritis (OA) is increasingly understood as a family of disorders in which the biomechanical properties of cartilage are altered and ultimately fail as the tissue is degraded by local proteases. Mechanically mediated and cytokine-mediated pathways of cartilage degeneration have been identified in the pathogenesis of OA. Further insight into the basic science of cartilage and OA is necessary to develop diagnostic and treatment strategies for this pervasive disease.

Does hand osteoarthritis predict future hip or knee osteoarthritis?

OBJECTIVE

To evaluate the risk of future hip or knee osteoarthritis (OA) in subjects with hand OA at baseline and to evaluate whether the concurrent presence of hand OA, other risk factors for OA, or an OA biomarker (type II collagen C-telopeptide degradation product [CTX-II]) further increases the risk.

METHODS

Radiographs of the hands (baseline) and the hips and knees (baseline and 6.6 years later) were obtained in a randomly selected subset of participants in the Rotterdam Study who were ages 55 years and older. Radiographs were scored for the presence of OA using the Kellgren/Lawrence (K/L) system. A total of 1,235 subjects without OA of the hip/knee (K/L score 0-1) at baseline were included in the study. CTX-II levels were measured at baseline. The independent risk of future hip/knee OA in subjects with hand OA at baseline was assessed by logistic regression, as stratified for age, sex, body mass index, family history of OA, and heavy workload.

RESULTS

Overall 12.1% of the participants (19.7% of those with hand OA versus 10.0% of those without) developed hip or knee OA (odds ratio [OR] 2.1 [95% confidence interval (95% CI) 1.3-3.1]). Subjects with hand OA had an increased risk of future hip OA (OR 3.0 [95% CI 1.6-5.4]), which was further increased in those with a family history of OA. Subjects with hand OA had an OR of 1.6 [95% CI 1.0-2.8) for the future development of knee OA, which was further increased in those who were overweight. Concurrent hand OA and high levels of CTX-II further increased the risk of having hip or knee OA at followup (OR 4.2 [95% CI 2.3-7.8]).

CONCLUSION

The presence of hand OA at baseline showed an increased risk of future hip/knee OA (higher for hip OA than for knee OA). The concurrent presence of hand OA and other OA risk factors or high CTX-II levels further increased the risk of future hip/knee OA.

Subject retention and adherence in a randomized placebo-controlled trial of a disease-modifying osteoarthritis drug

OBJECTIVE

To describe the methods by which remarkable levels of subject retention and adherence were achieved in a 30-month multicenter randomized placebo-controlled trial (RCT) of a disease-modifying osteoarthritis drug (DMOAD).

METHODS

Subjects were obese 45-64-year-old women with unilateral knee osteoarthritis. Before randomization, each volunteer completed a 4-week "faintness-of-heart" (FOH) test, during which she was required to demonstrate reliable appointment keeping and > or =80% adherence to the dosing regimen. Subjects who passed the FOH test were randomized to treatment with doxycycline or placebo for 30 months. The double-blind phase entailed 15 bimonthly followup visits; intervisit adherence data were downloaded from the dosing monitor and used to estimate therapeutic coverage and to identify correctable patterns of nonadherence. Subjects received token incentives and a small cash payment at each followup visit. Measures to prevent or treat side effects of doxycycline were dispensed free of charge. Study coordinators monitored safety and reinforced participation through between-visit telephone calls.

RESULTS

Of 463 eligible volunteers, 32 (7%) failed the FOH test and were excluded from the double-blind phase. Among the 431 subjects randomized to treatment groups, 307 (71%) completed the 30-month RCT and 124 discontinued the study drug prematurely. Nearly half of the dropouts returned for their 16- and 30-month radiographs, resulting in loss to followup of 14.8% of randomized subjects. The 2 treatment groups did not differ significantly with respect to rates of discontinuation or retention. Therapeutic coverage over 30 months was very high in both groups.

CONCLUSION

The rate of discontinuation in this 30-month RCT (29%) was lower than that of any DMOAD trial of > or =2 years duration published to date. The proportion of subjects for whom 30-month radiographs were available (85%) and adherence to the dosing regimen (mean >80%) also were remarkably high.

Thrust during ambulation and the progression of knee osteoarthritis

OBJECTIVE

To determine whether the presence of varus thrust at baseline increases the risk of progression of medial tibiofemoral osteoarthritis (OA), whether knees with thrust have a greater adduction moment, whether thrust has any additional impact on top of static varus, and whether thrust is associated with poor physical function outcome.

METHODS

Two hundred thirty-seven patients with knee OA (definite osteophytes and symptoms) underwent baseline gait observation to assess varus thrust and full-limb radiography to assess alignment. Sixty-four of these 237 patients also underwent quantitative gait analysis to determine the maximum knee adduction moment. Two hundred thirty patients (97%) returned for followup at 18 months. At baseline and 18 months, the 230 participants had semiflexed, fluoroscopically confirmed knee radiographs (with progression defined as worsening of medial joint space grade); self-reported and performance-based measures of function were also assessed. Logistic regression with generalized estimating equations was used to estimate odds ratios (ORs) for medial OA progression, after excluding knees that were not at risk for progression.

RESULTS

Varus thrust was present in 67 of 401 knees. Thrust increased 4-fold (age-, sex-, body mass index-, and pain-adjusted OR 3.96, 95% confidence interval [95% CI] 2.11-7.43) the odds of medial progression, with some reduction after further adjustment for varus alignment severity. In varus-aligned knees, thrust increased the odds of OA progression 3-fold (adjusted OR 3.17, 95% CI 1.60-6.31). In the gait substudy, the adduction moment was greater in knees with a thrust compared with knees without a thrust. Having a thrust in both knees versus neither knee was associated with a 2-fold increase in the OR for poor physical function outcome (P not significant).

CONCLUSION

Varus thrust is a potent risk factor, identifiable by simple gait observation, for disease progression in the medial compartment, the most common site of OA involvement at the knee. Varus thrust may also predict poor physical function outcome. Varus thrust increased the odds of progression among varus-aligned knees considered separately, suggesting that knees with a thrust are a subset of varus-aligned knees at particularly high risk for progression of OA.

Soy protein may alleviate osteoarthritis symptoms

Alternative and complementary therapeutic approaches, such as the use of a wide array of herbal, nutritional, and physical manipulations, are becoming popular for relieving symptoms of osteoarthritis (OA). The present study evaluated the efficacy of soy protein (SP) supplementation in relieving the pain and discomfort associated with OA. One hundred and thirty-five free-living individuals (64 men and 71 women) with diagnosed OA or with self-reported chronic knee joint pain not attributed to injury or rheumatoid arthritis were recruited for this double-blind, placebo-controlled, parallel design study. Study participants were assigned randomly to consume 40 g of either supplemental SP or milk-based protein (MP) daily for 3 months. Pain, knee range of motion, and overall physical activity were evaluated prior to the start of treatment and monthly thereafter. Serum levels of glycoprotein 39 (YKL-40), a marker of cartilage degradation, and insulin-like growth factor-I (IGF-I), a growth factor associated with cartilage synthesis, were assessed at baseline and at the end of the study. Overall, SP improved OA-associated symptoms such as range of motion and several factors associated with pain and quality of life in comparison to MP. However, these beneficial effects were mainly due to the effect of SP in men rather than women. Biochemical markers of cartilage metabolism further support the efficacy of SP in men as indicated by a significant increase in serum level of IGF-I and a significant decrease in serum level of YKL-40 compared to MP. This study is the first to provide evidence of possible beneficial effects of SP in the management of OA. Examining and verifying the long-term effects of SP on improving symptoms of OA, particularly in men, is warranted.

Bathing Disability in Community-Living Older Persons: Common, Consequential, and Complex

OBJECTIVES

To identify the specific bathing subtasks that are affected in community-living-older persons with bathing disability and to determine the self-reported reasons for bathing disability.

DESIGN

Cross-sectional study.

SETTING

General community of greater New Haven, Connecticut.

PARTICIPANTS

A total of 626 community-living persons, aged 73 and older, who completed a comprehensive assessment, including a detailed evaluation of bathing disability.

MEASUREMENTS

Trained research nurses assessed bathing disability (defined as requiring personal assistance or having difficulty washing and drying the whole body), the specific bathing subtasks that were affected, and the main reasons (up to three) for bathing disability.

RESULTS

Disability in bathing was present in 195 (31%) participants; of these, 97 required personal assistance (i.e., dependence), and 98 had difficulty bathing. Participants with bathing disability reported a mean+/-standard deviation of 4.0+/-2.4 affected subtasks. The prevalence rate of disability for the eight prespecified bathing subtasks ranged from 25% for taking off clothes to 75% for leaving the bathing position. The majority of participants (59%) provided more than one reason for bathing disability. The most common reasons cited by participants for their bathing disability were balance problems (28%), arthritic complaints (26%), and fall or fear of falling (23%).

CONCLUSION

For community-living older persons, disability in bathing is common, involves multiple subtasks, and is attributable to an array of physical and psychological problems. Preventive and restorative interventions for bathing disability will need to account for the inherent complexity of this essential activity of daily living.

Psychosocial and geriatric correlates of functional status after total hip replacement

OBJECTIVE

To determine whether psychosocial factors, chronic diseases, and common geriatric problems are associated with poor physical function 3 years after primary total hip replacement (THR).

METHODS

We studied a sample of Medicare recipients in Ohio, Pennsylvania, and Colorado (n = 922) who underwent primary THR in 1995 (mean +/- SD age 73.1 +/- 5.6 years, 32% men). Participants completed a questionnaire regarding lifestyle factors, medical history, and quality of life approximately 3 years after the surgery. Physical function was measured using the function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index. We assessed the relationship between functional outcome 3 years postsurgery and 4 predictor domains: pain or complications in the operated hip, other musculoskeletal comorbidity, medical factors (obesity, chronic medical comorbidity, rheumatoid arthritis, and such common geriatric problems as falls, poor balance, or incontinence), and psychosocial factors (mental health, regular alcohol consumption, smoking, provider role, living alone, and education).

RESULTS

Ten percent of subjects had poor functional status. In a logistic regression model controlling for sex and age, the following factors were associated with an increased risk for poor functional status (in order of importance): pain in the back or lower extremity, severe pain in the operated hip, poor mental health, more than 1 common geriatric problem, obesity, and less than college education.

CONCLUSION

Pain in the operated hip was strongly associated with poor functional status 3 years after THR. However, other factors associated with poor functional status were not related to the hip. Our results suggest that a comprehensive assessment of functional status in elderly THR patients should include assessment of common geriatric problems, mental health status, and weight.

A six-month followup of a randomized trial comparing the efficacy of a lateral-wedge insole with subtalar strapping and an in-shoe lateral-wedge insole in patients with varus deformity osteoarthritis of the knee

OBJECTIVE

To assess the effect of a lateral-wedge insole with elastic strapping of the subtalar joint on the femorotibial angle in patients with varus deformity of the knee.

METHODS

The efficacy of a wedged insole with subtalar straps and that of a traditional wedged insole shoe insert were compared. Sixty-six female outpatients with knee osteoarthritis (OA) were randomized (according to birth date) to be treated with either the strapped or the traditional inserted insole. Standing radiographs with unilateral insole use were used to analyze the femorotibial angles for each patient. In both groups, the baseline and 6-month visual analog scale (VAS) scores for subjective knee pain and the Lequesne index scores for knee OA were compared.

RESULTS

The 61 patients who completed the 6-month study were evaluated. At baseline, there was no significant difference in the femorotibial angle (P = 0.66) and the VAS score (P = 0.75) between the 2 groups. At the 6-month assessment, the 29 subjects wearing the subtalar-strapped insole demonstrated a significantly decreased femorotibial angle (P < 0.0001) and significantly improved VAS scores (P = 0.001) and Lequesne index scores (P = 0.033) compared with their baseline assessments. These significant differences were not observed in the 32 subjects assigned to the traditional shoe-inserted wedged insole.

CONCLUSION

These results suggest that an insole with a subtalar strap maintained the valgus correction of the femorotibial angle in patients with varus knee OA for 6 months, indicating longer-term clinical improvement with the strapped insert compared with the traditional insert.

Bromelain as a Treatment for Osteoarthritis: a Review of Clinical Studies

Bromelain, an extract from the pineapple plant, has been demonstrated to show anti-inflammatory and analgesic properties and may provide a safer alternative or adjunctive treatment for osteoarthritis. All previous trials, which have been uncontrolled or comparative studies, indicate its potential use for the treatment of osteoarthritis. This paper reviews the mechanism of its putative therapeutic actions, those clinical trials that have assessed its use in osteoarthritis to date, as well as considering the safety implications of this supplement for osteoarthritis and reviewing the evidence to date regarding the dosage for treating this condition. The data available at present indicate the need for trials to establish the efficacy and optimum dosage for bromelain and the need for adequate prospective adverse event monitoring in such chronic conditions as osteoarthritis.

Decomposition of differences in health expectancy by cause

Health expectancy is a widely used measure for monitoring trends in the health of a population and assessing differences in health among population groups. However, no decomposition method is available to examine the contribution made by causes of death and disability to differences in health expectancy among population groups or periods. We present a method for decomposing differences in health expectancy, based on the Sullivan method. This method is an extension of the decomposition method for life expectancy developed by Arriaga. We illustrate the method and its added value by decomposing male-female differences in health expectancy for the Netherlands.

A Longitudinal Study of Parkinsonism and Disability in a Community Population of Older People

BACKGROUND

Parkinsonian signs in patients without Parkinson's disease are often undetected but occur frequently in older people, and are often considered benign. We measured the association between parkinsonism and subsequent disability.

METHODS

We conducted a prospective, longitudinal, community-based population study in East Boston, Massachusetts, using a stratified random sample of 455 community residents, aged 65 years and older. Four categories of parkinsonian signs were measured at baseline: bradykinesia, gait disturbance, rigidity, and tremor. Parkinsonism was defined as the presence of two or more categories of parkinsonian signs, and cases of Parkinson's disease were excluded from analyses. Disability was assessed annually over a mean of 4.7 years using the Katz, Rosow-Breslau, and Nagi disability measures.

RESULTS

Parkinsonism at baseline strongly predicted subsequent disability as assessed with the three disability measures (on the Katz measure, beta = -1.30, p < .001). On average, a person with parkinsonism had a disability level at follow-up equal to that of a comparable person approximately 16.7 years for men and 8 years for women. The rate of developing disability for persons with parkinsonism increased each year; on the Katz measure, participants with parkinsonism declined on average 16.4% faster than those without. Gait impairment and bradykinesia strongly predicted subsequent disability; tremor and rigidity did not. The effect of parkinsonism was attenuated but still persistent in persons with coexistent moderate-to-severe cognitive impairment or stroke.

CONCLUSIONS

Parkinsonism strongly predicts progressive disability in the older community population and has a marked aging effect on disability level.

Does paracetamol (acetaminophen) reduce the pain of osteoarthritis? A meta-analysis of randomised controlled trials

OBJECTIVE

To assess the best available evidence for efficacy of paracetamol (acetaminophen) in the treatment of osteoarthritis (OA).

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs).

DATA SOURCES

Medline, Embase, Scientific Citation Index, CINAHL, Cochrane Library, and conference abstracts in the past 2 years from the British Society for Rheumatology, the European League Against Rheumatism, the American College of Rheumatology, and the Osteoarthritis Research Society International.

SUBJECTS

10 RCTs including 1712 patients with either symptomatic OA of the knee (6 trials) or hip/knee (3 trials) or multiple joints (1 trial).

MAIN OUTCOME MEASURES

(a). effect size (ES) for pain, stiffness, and functional scores from baseline to end point; (b). rate ratio (RR) and number needed to treat for clinical response rate and patient preference for treatment.

RESULTS

Paracetamol was effective in relieving pain due to OA (ES = 0.21, 95% confidence interval (CI) 0.02 to 0.41). Non-steroidal anti-inflammatory drugs (NSAIDs) were better than paracetamol for pain relief (ES = 0.20, 95% CI 0.10 to 0.30). Clinical response rate was higher with NSAIDs than with paracetamol (RR = 1.24, 95% CI 1.08 to 1.41), and the number of patients who preferred NSAIDs was more than twice the number of those preferring paracetamol (RR = 2.46, 95% CI 1.51 to 4.12). NSAIDs were associated with more frequent gastrointestinal discomfort than paracetamol (RR = 1.35, 95% CI 1.05 to 1.75).

CONCLUSION

Paracetamol is an effective agent for pain relief due to OA. Although safer, it is less effective than NSAIDs. For safety reasons paracetamol should be the first line treatment, with NSAIDs reserved for those who do not respond.

Health-related quality of life in patients with hip or knee osteoarthritis: comparison of generic and disease-specific instruments

Health-related quality of life (HRQL) assessment is receiving increased attention as an outcome measure in osteoarthritis (OA). The aims of the study were to assess the health status impact of hip and knee OA in the general older population and to compare the metric properties of the WOMAC disease-specific questionnaire (Western Ontario and McMaster Universities) with generic measures [i.e., the Short Form 36 (SF-36) in patients with OA of the lower extremities]. This cross-sectional survey included a total of 244 patients (99 male, 145 female), aged 50 years and over, with symptomatic OA of the hips (107 patients) and knees (137 patients). All patients completed the WOMAC and the SF-36 questionnaires and were assessed for radiographic damage and for the presence of specific comorbid conditions. The overall impact on health was substantial for both groups of patients with OA of the lower extremities. The most striking impact was seen in OA of the hip for SF-36 "physical function" (p=0.03) and "physical role" (p=0.04), as well as WOMAC "physical function" (p=0.001). Furthermore, impairment of HRQL was only weakly associated with increasing radiographic changes. The SF-36 overall scores showed a better gradient with comorbidities than the WOMAC. This investigation has confirmed that WOMAC is the instrument of choice for evaluating patients with lower limb OA. For a more general insight into patient's health and in particular cross-sectional studies of the elderly, where comorbidity is common, the SF-36 should also be used. This study also provides an estimate of the impact of OA of the hip and knee on HRQL.

Prescription of anti-oedema agents and short-term mortality in older patients with acute ischaemic stroke

BACKGROUND AND OBJECTIVE

In Western countries, stroke is the third most common cause of death and one of the main causes of disability in individuals aged over 65 years. Mortality at 1 month after stroke is still high, at around 25-30%. Despite the widespread use of anti-oedema agents in clinical practice, there are only a few studies that have investigated the effect of these drugs on stroke outcome. In this study we evaluated the effect of intravenously administered glycerol or mannitol individually and in combination with corticosteroids, on short-term mortality (30 days). The sample included patients aged over 65 years who were admitted to hospital for acute ischaemic stroke.

STUDY DESIGN

This was a retrospective cohort study. The odds ratio, estimated by means of multivariate logistic regression method, was used to compare short-term mortality risk across treatment groups after adjusting for possible confounders.

METHODS

This study included 442 consecutive patients aged over 65 years with severe ischaemic stroke who were admitted to either the University School of Internal Medicine (Ferrara) or the Geriatric Department (Perugia), Italy, over a 4-year period (1996-2000). All patients underwent a computed tomography (CT) scan of the brain within 72 hours of admission. Stroke type was classified according to the system used by the Oxfordshire Community Stroke Project. The data recorded included: (i) clinical features of stroke; (ii) detailed medical history, including vascular risk factors (arterial hypertension, diabetes mellitus, atrial fibrillation, coronary heart disease, congestive heart failure, alcohol abuse, smoking, previous transient ischaemic attacks or stroke); (iii) 12-lead ECG; and (iv) routine blood analysis and urine tests.

RESULTS

No reduction in short-term mortality risk was observed in patients treated with intravenous (IV) glycerol. However, an increase in short-term mortality risk was observed in the patients who were concurrently treated with IV corticosteroids. Similarly, treatment with mannitol did not reduce the risk of short-term mortality; however, concurrent treatment with IV corticosteroids did not show a significant rise in short-term mortality risk. When treatment with IV glycerol and mannitol was considered together, the treatment did not decrease short-term mortality risk, while concurrent therapy with corticosteroids was associated with an increase in short-term mortality risk.

CONCLUSION

This study does not support the use of IV osmotic agents such as glycerol or mannitol in the prevention of short-term mortality in older patients with acute ischaemic stroke. Furthermore, our data suggest a possible harmful effect of IV corticosteroids on short-term mortality risk.

Association of sensorimotor function with knee joint kinematics during locomotion in knee osteoarthritis

OBJECTIVE

To evaluate the relationship between quadriceps sensorimotor function (knee joint-position sense, quadriceps strength, and quadriceps onset of activity) and knee joint kinematics (knee flexion at initial contact and loading) during level walking and stair descent in a large cohort of 220 people with knee osteoarthritis.

DESIGN

Cross-sectional correlational study.

RESULTS

Joint-position sense correlated with knee flexion at initial contact during both tasks (r = -0.20 and -0.14, P <0.05). Strength correlated with peak loading response knee flexion during both tasks (r = 0.17 and 0.20, P < 0.05). Quadriceps onset correlated with knee flexion at initial contact during stair descent (r = 0.14, P < 0.05). Furthermore, differences in kinematic variables were observed when participants were divided into those with best and worst sensorimotor function.

CONCLUSION

Impaired sensorimotor function as measured in this study is not strongly associated with altered knee joint kinematics observed in knee osteoarthritis patients during locomotion.

MR imaging findings in early osteoarthritis of the knee

PURPOSE

To carry out a modern diagnostic survey among patients with a clinical and radiological diagnosis of early osteoarthritis of the knee.

MATERIALS AND METHODS

A magnetic resonance imaging survey was performed on 70 patients (82 knees) with a mean age of 59 years. (range, 40-71 years) who had chronic knee pain, clinical diagnosis of early osteoarthritis of the knee and conventional knee radiographs classified as 1 and 2 on the Kellgren-Lawrence scale.

RESULTS

A variety of different disorders was found; degenerative meniscal lesions with or without ruptures of the anterior cruciate ligament in 70.7% of the knees, osteonecrosis of the femoral and tibial condyles in 9.75%, osteophytes and degenerative articular cartilage lesions in 8.54%, transient osteoporosis in 2.44% and benign neoplasms and cysts in 6.1%.

CONCLUSIONS

The existence of such a heterogenous group of disorders in these "early osteoarthritic knees" may explain failures in treatment and it may justify a modern MRI imaging approach to proper diagnosis.

Falls in a community of older adults: findings and implications for practice

The purpose of this study was to describe the falls that occurred over a 5-year period in a group of older adults living in a continuing care retirement community (CCRC) and to test two models, one mediating whether or not the individual fell and the second the number of falls the individual experienced. Of the 312 participants, 177 (57%) residents experienced at least one fall. There were a total of 594 falls with the mean number of falls per person being 1.9 (SD = 3.0), and the range of falls from 1 to 19. Age, gender, and neurologic disease significantly influenced whether or not a fall occurred. Mental health, regular use of alcohol, and neurologic problems all significantly influenced the number of falls that occurred.

Knee pain and driving duration: a secondary analysis of the Taxi Drivers' Health Study

OBJECTIVES

We explored a postulated association between daily driving time and knee pain.

METHODS

We used data from the Taxi Drivers' Health Study to estimate 1-year prevalence of knee pain as assessed by the Nordic musculoskeletal questionnaire.

RESULTS

Among 1242 drivers, the prevalence of knee pain, stratified by duration of daily driving (< or = 6, > 6 through 8, > 8 through 10, and > 10 hours), was 11%, 17%, 19%, and 22%, respectively. Compared with driving 6 or fewer hours per day, the odds ratio of knee pain prevalence for driving more than 6 hours per day was 2.52 (95% confidence interval = 1.36, 4.65) after we adjusted for socioeconomic, work-related, and personal factors in the multiple logistic regression.

CONCLUSIONS

The dose-related association between driving duration and knee pain raises concerns about work-related knee joint disorders among professional drivers.