Falls risk is associated with pain and dysfunction but not radiographic osteoarthritis in older adults: Tasmanian Older Adult Cohort study

A Comparative Study of Risk Factors for Falls in Total Hip and Knee Arthroplasty Patients and Community-Dwelling Older Adults

OBJECTIVES

Falls in older adults are a public health concern, yet little is known about falls in adults with hip or knee total joint arthroplasty (TJA) who may be at a higher risk than the general population. The study objectives were to compare the number of fallers and fear of falling in TJA patients to age and sex matched community controls, and determine whether the type of risk factors for falls reported in TJA differed from the community group.

METHODS

A cross sectional comparative study was conducted with patients waiting or recovering from TJA and age and sex matched comparison group of older adults residing in the community. Reported falls and risk factors for falling were compared to age and sex matched controls from the community. Fear of falling was measured using the Activities-specific Balance Confidence (ABC) Scale. Logistic regression was used to determine risk factors associated with falls in TJA and community participants.

RESULTS

Of the 198 TJA participants, 29% (n = 57) reported falls within the past 12 months compared to 24% (n = 24) of 100 participants in the control group (p = 0.36). Of those who fell, 25 (44%) were recurrent fallers in the TJA cohort compared with 6 (25%) in the community cohort. Eleven participants reported falls after TJA surgery. Fear of falling was greater in the TJA group (ABC score, mean ± SD: 67.1 ± 24.4) than in the community group (88.1 ± 14.9) (p < 0.001).

CONCLUSION

Although the number of participants who reported falls was comparable in both groups, the TJA group had more recurrent falls, different risk factors for falls, and more fear of falling. Fall prevention programs should be embedded in pre-operative programs for patients undergoing surgery for TJA.

High Prevalence of Symptomatic Knee Osteoarthritis Among Patients Who Have Fragility Hip Fractures

BACKGROUND

Knee osteoarthritis (OA) is a common degenerative musculoskeletal condition that impairs mobility and balance, increasing fall risk. When combined with osteoporosis, it further increases the risk of fragility fractures. Despite its prevalence, the frequency of knee OA in patients who have fragility hip fractures (FHFs) is not well established. This study aimed to determine the prevalence of knee OA among FHF patients.

METHODS

We conducted a cross-sectional analysis of patients who underwent surgical treatment for FHF. The knee OA diagnoses followed the American College of Rheumatology criteria, and severity was assessed via the Kellgren-Lawrence classification system. Bone mineral density (BMD) was evaluated at the lumbar spine and contralateral hip, and fall risk was assessed using a self-report questionnaire.

RESULTS

Among the 162 patients who had FHF (mean age 79 ± 8.1 years; 80.2% women), 66% had symptomatic knee osteoarthritis (SKOA). Of these, 21.0% were classified as end-stage knee osteoarthritis. Notably, 47.1% of these end-stage knee osteoarthritides were recommended for knee OA surgery before their hip fracture. The presence of SKOA was significantly associated with a history of multiple falls (P = 0.013) and a high fall risk (P = 0.020). Among the 120 patients who had BMD data, 68% had low BMD (T-score ≤ -2.5) at the contralateral hip or lumbar spine. Almost half (45%) of the FHF patients had concurrent SKOA and low BMD, whereas approximately 20% had SKOA, low BMD, and a high fall risk.

CONCLUSIONS

There is a high prevalence of SKOA among FHF patients. Comprehensive evaluation and management of knee OA and osteoporosis are essential to reduce the risk of subsequent fractures in this vulnerable population.

Radiographic knee osteoarthritis severity has no impact on fall risk: the locomotive syndrome and health outcomes in the aizu cohort study (LOHAS): a cross-sectional study

BACKGROUND

To investigate factors that have an impact on the risk of falls and determine whether radiographic knee osteoarthritis (KOA) is a factor involved in falls independent of knee pain, psychological factors, and physical function.

METHODS

A cross-sectional analysis was conducted on 1083 subjects for the 2009 Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study (LOHAS). A logistic regression analysis was performed to examine the relationship between radiographic KOA and fall history.

RESULTS

Fall history was significantly associated with the severity of knee pain. Compared to subjects with no knee pain, the odds ratio (OR) was 1.53 times higher in the subjects with mild knee pain (95% confidence interval [CI]: 1.04-2.25), 1.69 times higher in those with moderate knee pain (95%CI: 1.03-2.79), and 2.98 times higher in those with severe knee pain (95%CI: 1.67-5.30). In subjects with depression, the OR was 1.91 (95%CI: 1.25-2.92), and in those with decreased mobility, the OR was 1.70 (95%CI: 1.08-2.69). Age, gender, knee crepitus, BMI, OLST, and sleeping pill use were not significantly associated with fall risk. In a multivariate analysis, radiographic KOA severity was not significantly associated with fall risk (OR 0.81, 95%CI 0.44-1.50 in mild OA; OR 1.10, 95%CI 0.57-2.14 in severe OA).

CONCLUSION

Knee pain, decreased mobility, and depression, but not the radiographic KOA severity, were significantly associated with a fall risk. Regardless of the individual's radiographic KOA severity, the risk of falls may be reduced by treating his/her knee pain, mobility problems, and/or psychological factors.

Examination of the Increased Risk for Falls Among Individuals With Knee Osteoarthritis: A Canadian Longitudinal Study on Aging Population-Based Study

OBJECTIVE

To characterize the profile of individuals with and without knee osteoarthritis (OA) who fell, and to identify factors contributing to an individual with knee OA experiencing 1 or multiple injurious falls.

METHODS

Data are from the baseline and 3-year follow-up questionnaires of the Canadian Longitudinal Study on Aging, a population-based study of people ages 45-85 years at baseline. Analyses were limited to individuals either reporting knee OA or no arthritis at baseline (n = 21,710). Differences between falling patterns among those with and without knee OA were tested using chi-square tests and multivariable-adjusted logistic regression models. An ordinal logistic regression model examined predictors of experiencing 1 or more injurious falls among individuals with knee OA.

RESULTS

Among individuals reporting knee OA, 10% reported 1 or more injurious falls; 6% reported 1 fall, and 4% reported 2+ falls. Having knee OA significantly contributed to the risk of falling (odds ratio [OR] 1.33 [95% confidence interval (95% CI) 1.14-1.56]), and individuals with knee OA were more likely to report having a fall indoors while standing or walking. Among individuals with knee OA, reporting a previous fall (OR 1.75 [95% CI 1.22-2.52]), previous fracture (OR 1.42 [95% CI 1.12-1.80]), and having urinary incontinence (OR 1.38 [95% CI 1.01-1.88]) were significant predictors of falling.

CONCLUSION

Our findings support the idea that knee OA is an independent risk factor for falls. The circumstances in which falls occur differ from those for individuals without knee OA. The risk factors and environments that are associated with falling may provide opportunities for clinical intervention and fall prevention strategies.

The Relationship between Chronic Musculoskeletal Pain and Sarcopenia Risk in Community-Dwelling Older Adults: A Cross-Sectional Study

BACKGROUND

This study aimed to better understand the relationship between chronic musculoskeletal pain and the risk of sarcopenia in older adults.

METHODS

The risk of sarcopenia was assessed in 210 older adults using the SARC-F (strength, assistance with walking, rising from a chair, ascending stairs, and falls) questionnaire. Geriatric pain measures were used to assess pain. We also recorded the pain sites (ankles/feet, wrists/hands, upper back, lower back, neck, shoulder, hips, and knees).

RESULTS

Participant mean age was 72.4±7 years, and 109 (51.9%) of the participants were female. The prevalence rates of sarcopenia and chronic musculoskeletal pain were 60% and 92.9%, respectively. Older adults at risk of sarcopenia had a higher mean age, body mass index (BMI), number of comorbidities and falls, presence of chronic pain, pain intensity, and pain sites. Sarcopenia risk was correlated with chronic pain intensity (current and last 7 days) (r=0.506, p<0.001 and r=0.584, p< 0.001, respectively), multisite pain (r=0.442, p< 0.001), and Geriatric Pain Measure score (r=0.730; p< 0.001). Age (odds ratio [OR]=1.1; 95% confidence interval [CI], 1.0-1.2), BMI (OR=1.1; 95% CI, 1.0-1.2), and geriatric pain (OR=1.1; 95% Cl, 1.0-1.1) were associated with sarcopenia risk.

CONCLUSIONS

The risk of sarcopenia is linked to chronic pain, which frequently occurs in geriatric populations. Our study results also showed that higher pain intensity was associated with a higher risk of sarcopenia. Older adults at risk for sarcopenia often experience chronic musculoskeletal pain, which must be better recognized. Moreover, its significance must be noted in the treatment process.

Factors associated with subjective knee joint stiffness in people with knee osteoarthritis: A systematic review

INTRODUCTION

Subjective knee stiffness is a common symptom in patients with knee osteoarthritis treated conservatively. However, the influencing factors or effects of knee joint stiffness are unknown. The aim of this study was to explore the factors associated with subjective knee stiffness in patients with knee osteoarthritis.

METHODS

The MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PEDro databases were searched in November 2021. Prospective or retrospective cohort studies were included. The methodological quality of the selected articles was assessed using the Scottish Intercollegiate Guidelines Network checklist.

RESULTS

Twenty out of 1943 screened articles were included in this systematic review. Eighteen and two studies were rated as having acceptable and low quality, respectively. All the included studies measured subjective knee stiffness using the Western Ontario and McMaster Universities Osteoarthritis Index. The main findings were that worse preoperative subjective knee stiffness was associated with worse pain, subjective knee stiffness, and patient satisfaction at 1 year after total knee arthroplasty. In addition, worse subjective knee stiffness was associated with future degenerative changes in the knee joint, such as joint space narrowing and osteophyte growth progression.

CONCLUSION

Subjective knee stiffness may be associated with the prognosis after total knee arthroplasty and degenerative changes in the knee joint. Early detection and treatment of knee stiffness could lead to a good prognosis after total knee arthroplasty and prevent the progression of degenerative changes in the knee joint.

The Association Between Severity of Radiographic Knee OA and Recurrent Falls in Middle and Older Aged Adults: The Osteoarthritis Initiative

BACKGROUND

Knee osteoarthritis (KOA) is the most prevalent type of OA and a leading cause of disability in the United States. Falls are a major public health concern in older adults. Our aim was to examine how the severity of radiographic KOA affects recurrent falls in a cohort of middle-aged and older individuals enrolled in the Osteoarthritis Initiative.

METHODS

About 3 972 participants, mean age of 63 years, 58% female were included. Participants were divided into 5 mutually exclusive groups based on their worst Kellgren-Lawrence grade of radiographic KOA from annual x-rays from baseline to 36 months. Generalized estimating equations for repeated logistic regression were used to model the association between KOA severity and the likelihood of recurrent falls (≥2 falls/year) over 5 years of follow-up (>36 to 96 months).

RESULTS

Older adults (≥age 65) with KOA were at higher odds of recurrent falls in comparison to individuals without KOA in multivariate models (possible OA odds ratio [OR] = 2.22, 95% CI = 1.09-4.52; mild OA OR = 2.48, 95% CI = 1.34-4.62; unilateral moderate-severe OA OR = 2.84, 95% CI = 1.47-5.50; bilateral moderate-severe OA OR = 2.52, 95% CI = 1.13-5.62). Middle-aged adults (aged 45-64) with KOA did not have increased odds of recurrent falls in comparison to those without KOA except for possible KOA (OR = 1.86, 95% CI = 1.01-2.78; KOA severity × Age interaction = 0.025).

CONCLUSION

Older adults with radiographic evidence of KOA have an increased likelihood of experiencing recurrent falls in comparison to those without KOA independent of established risk factors. Our results suggest that fall prevention efforts should include older adults with all stages of KOA.

Influencing factors of weak grip strength and fall: a study based on the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND

Fall is a major cause of mortality and cause a significant burden on the healthcare system and economic system. Weak grip strength signifies impaired function. Older people with weak grip strength are at a higher risk of death. China has the largest ageing population in the world today. This study aims to analyze the factors contributing to weak grip strength and fall among Chinese.

METHODS

This study analyzed data from the 2011 baseline and 2015 follow-up survey of the China Health and Retirement Longitudinal Study (CHARLS). To identify the risk factors of fall and weak grip strength, we used a stepwise multivariable logistic regression model and a least absolute shrinkage and selection operator (LASSO) regression model.

RESULTS

In the LASSO regression model, all the risk factors were not shrunken. In the stepwise logistic regression model, adjusted for gender, age, grip strength, depression, and chronic disease, we found that female (aOR = 1.376, 95% CI = 1.243-1.523; P < 0.001), history of ischemic stroke (aOR = 1.786, 95% CI = 1.263-2.524; P = 0.001), depression (aOR = 1.559, 95% CI = 1.396-1.742; P < 0.001), weak grip strength (aOR = 1.285, 95% CI = 1.105-1.494; P = 0.001), older age (aOR = 1.227, 95% CI = 1.163-1.294; P < 0.001), rheumatoid arthritis (aOR = 1.410, 95% CI = 1.270-1.560; P < 0.001), history of kidney disease (aOR = 1.383, 95% CI = 1.136-1.682; P = 0.001) were factors associated with fall significantly. After further adjusting, we found the risk factors of weak grip strength included symptomatic knee osteoarthritis (aOR = 1.755, 95% CI 1.158-2.661; P = 0.008), living in rural area (aOR = 2.056, 95% CI 1.290-3.277; P = 0.002), depression (aOR = 1.523, 95% CI 1.116-2.078; P = 0.008), older age (aOR = 2.116, 95% CI 1.801-2.486; P < 0.001).

CONCLUSION

From the study, we found that older age and depression were risk factors of weak grip strength and fall. Weak grip strength was a risk factor of fall. Female, ischemic stroke, kidney disease, rheumatoid arthritis were risk factors of fall; living in rural area and symptomatic knee osteoarthritis were risk factors of weak grip strength.

Severe low back or lower limb pain is associated with recurrent falls amongst older Australians

Background

Few studies have explored the impact of low back or lower limb pain severity on recurrent (≥2) falls in older adults.

Objectives

Investigate the association between the severity of low back or lower limb pain, and ≥2 falls or falls‐related injuries.

Methods

Community‐dwelling Australian males and females in the ASPREE Longitudinal Study of Older Persons (ALSOP), aged ≥70 years. Self‐reported, cross‐sectional questionnaire data regarding number of falls and falls‐related injuries in the last 12 months; and sites and severity of pain experienced on most days. Adjusted relative risks (RR) were estimated from multivariable Poisson regression models, for males and females separately.

Results

Of 14,892 ALSOP participants, 13% (n = 1983) reported ≥2 falls (‘recurrent fallers’) in the last 12 months. Males and females who reported severe low back, or severe lower limb pain on most days were more likely to report ≥2 falls in the last 12 months compared to those with mild pain (lower back: males RR = 1.70 and females RR = 1.5, p = 0.001; lower limb: males RR = 2.0, p < 0.001 and females RR = 1.4, p = 0.003). Female recurrent fallers who reported severe low back (RR = 1.3, p = 0.029) or lower limb (RR = 1.2, p = 0.024) pain on most days were more likely to report a falls‐related injury in the last 12 months compared to females with mild pain.

Conclusion

Severe low back or lower limb pain was associated with an increased likelihood of recurrent falls (males/females) or falls‐related injuries (females only). Assessment of severe low back and lower limb pain should be considered as a priority when undertaking falls‐risk evaluation.

Significance

Severe low back pain, or severe lower limb pain is associated with an increased likelihood of recurrent falls in older males and females, and an increased likelihood of falls‐related injuries in older female recurrent fallers. Assessment and management of severe low back and lower limb pain should be prioritized when undertaking falls‐risk assessment. Future longitudinal research is required to further interrogate this relationship and its underlying mechanisms.

A Comprehensive Review of Pain Interference on Postural Control: From Experimental to Chronic Pain

Motor control, movement impairment, and postural control recovery targeted in rehabilitation could be affected by pain. The main objective of this comprehensive review is to provide a synthesis of the effect of experimental and chronic pain on postural control throughout the available literature. After presenting the neurophysiological pathways of pain, we demonstrated that pain, preferentially localized in the lower back or in the leg induced postural control alteration. Although proprioceptive and cortical excitability seem modified with pain, spinal modulation assessment might provide a new understanding of the pain phenomenon related to postural control. The literature highlights that the motor control of trunk muscles in patient presenting with lower back pain could be dichotomized in two populations, where the first over-activates the trunk muscles, and the second under-activates the trunk muscles; both generate an increase in tissue loading. Taking all these findings into account will help clinician to provide adapted treatment for managing both pain and postural control.

Three-dimensional foot trajectory in female patients with end-stage hip osteoarthritis during walking

Osteoarthritis (OA) is a risk factor for falls. To decrease the fall risk, it is important to evaluate the detailed features of the gait of patients with OA. This study aimed to investigate the spatio-temporal parameters of gait in patients with end-stage hip OA, especially foot trajectory. We measured normal speed gait in patients with hip OA and in healthy controls (HCs) using inertial measurement units attached to shanks. The stride lengths in the affected and unaffected sides in the patients with hip OA were shorter than those in the HCs, but the position of maximum foot clearance was not significantly different between the two groups. The patients with hip OA compensated the position of maximum foot clearance to avoid fall risk. The horizontal plane foot trajectory in patients with hip OA suggests that the lateral bending of the trunk during walking, which is frequently seen in them, was a result of the lateral distance at swing down being located significantly more medially on the unaffected side than on the affected side. Herein, a new gait parameter of lateral distance at swing was discovered by a detailed evaluation of three-dimensional foot trajectory of female patients with end-stage hip OA.

Knee symptom but not radiographic knee osteoarthritis increases the risk of falls and fractures: results from the Osteoarthritis Initiative

OBJECTIVE

To describe the effect of knee symptoms and radiographic osteoarthritis (ROA) on the risk of falls, recurrent falls, and fractures.

DESIGN

Participants from the Osteoarthritis Initiative were classified as having 'no', 'unilateral' or 'bilateral' knee symptoms (≥19 on a 0-96 Western Ontario and McMaster Universities Osteoarthritis Index) and ROA (Kellgren-Lawrence grade ≥2) for each visit. Self-reported falls and fractures in the past 12 months were extracted at baseline and follow-up visits until month 96. Recurrent falls were defined as having ≥2 falls in the past 12 months. Hazard ratios (HR) with 95% confidence intervals (CI) were estimated using mixed-effects complementary log-log regression.

RESULTS

Of 4465 participants, 3145 (70%), 1681 (38%), and 806 (18%) experienced at least one fall, recurrent fall, and fracture, respectively, over 96 months. Compared to participants without symptomatic knee, unilateral and bilateral knee symptoms were associated with a 17% increased risk of falls and a 36-46% increased risk of recurrent falls, and bilateral knee symptoms increased the risk of fractures (HR 1.45, 95%CI 1.17 to 1.81). Compared to participants with no ROA in either knee, bilateral ROA was associated with a reduced risk of falls (HR 0.87, 95%CI 0.77 to 0.99) and fractures (HR 0.78, 95%CI 0.64 to 0.96). No statistically significant interactions between knee symptoms and ROA were observed.

CONCLUSIONS

This large population-based study showed that knee symptoms but not ROA increased the risk of falls, recurrent falls, and fractures, and that adults with bilateral ROA may have a lower risk of falls and fractures.

Increased recurrent falls experience in older adults with coexisting of sarcopenia and knee osteoarthritis: a cross-sectional study

Background

Sarcopenia and knee osteoarthritis (OA) are two major risk factors for falls in older adults. The coexistence of these two conditions may exacerbate the risk of falls. This cross-sectional study aimed to test the hypothesis that older adults with coexisting sarcopenia and knee OA displayed an increased risk of falls experience.

Methods

Participants recruited from an orthopedic clinic were divided into four groups according to the presence of sarcopenia and radiographic knee OA: isolated sarcopenia, isolated knee OA, sarcopenia + knee OA, and control (i.e., non-sarcopenia with non-OA) groups. We used questionnaires to assess falls experience in the prior 12 months. We performed logistic regression analyses to evaluate the relationship between the four groups and falls experience.

Results

Of 291 participants (age: 60–90 years, 78.7% women) included in this study, 25 (8.6%) had sarcopenia + knee OA. Participants with sarcopenia + knee OA had 4.17 times (95% confidence interval: 0.84, 20.6) higher odds of recurrent falls (≥2 falls) than controls after adjustment for age, sex, and body mass index. The increased recurrent falls experience was not clearly confirmed in participants with isolated sarcopenia and isolated knee OA.

Conclusions

People with coexisting of sarcopenia and knee OA displayed increased recurrent falls experience. This study suggests a new concept, “sarcopenic knee OA”, as a subgroup associated with higher risk of falls, which should be validated in future large cohort studies.

Trial registration.

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02654-4.

Recent Advances in the Neural Control of Movements: Lessons for Functional Recovery

We review the current views on the control and coordination of movements following the traditions set by Nikolai Bernstein. In particular, we focus on the theory of neural control of effectors - from motor units to individual muscles, to joints, limbs, and to the whole body - with spatial referent coordinates organized into a hierarchy with multiple few-to-many mappings. Further, we discuss synergies ensuring stability of natural human movements within the uncontrolled manifold hypothesis. Synergies are organized within the neural control hierarchy based on the principle of motor abundance. Movement disorders are discussed as consequences of an inability to use the whole range of changes in referent coordinates (as in spasticity) and an inability to ensure controlled stability of salient variables as reflected in indices of multi-element synergies and their adjustments in preparation to actions (as in brain disorders, including Parkinson's disease, multiple-system atrophy, and stroke). At the end of the review, we discuss possible implications of this theoretical approach to peripheral disorders and their rehabilitations using, as an example, osteoarthritis. In particular, "joint stiffening" is viewed as a maladaptive strategy, which can compromise stability of salient variables during walking.

The effects of pain and a secondary task on postural sway during standing

BACKGROUND

Pain impairs available cognitive resources and somatosensory information, but its effects on postural control during standing are inconclusive. The aim of this study was to investigate whether postural sway is affected by the presence of pain and a secondary task during standing.

METHODS

Sixteen healthy subjects stood as quiet as possible at a tandem stance for 30s on a force platform at different conditions regarding the presence of pain and a secondary task. Subjects received painful stimulations on the right upper arm or lower leg according to a relative pain threshold [pain 7 out 10 on a Visual Analog Scale (VAS) - 0 representing "no pain" and 10 "worst pain imaginable"] using a computer pressurized cuff. The secondary task consisted of pointing to a target using a head-mounted laser-pointer as visual feedback. Center of Pressure (COP) sway area, velocity, mean frequency and sample entropy were calculated from force platform measures.

FINDINGS

Compared to no painful condition, pain intensity (leg: VAS = 7; arm VAS = 7.4) increased following cuff pressure conditions (P < .01). Pain at the leg decreased COP area (P < .05), increased COP velocity (P < .05), mean frequency (P < .05) and sample entropy (P < .05) compared with baseline condition regardless the completion of the secondary task. During condition with pain at the leg, completion of the secondary task reduced COP velocity (P < .001) compared with condition without secondary task.

INTERPRETATION

Pain in the arm did not affect postural sway. Rather, postural adaptations seem dependent on the location of pain as pain in the lower leg affected postural sway. The completion of a secondary task affected postural sway measurements and reduced the effect of leg pain on postural sway. Future treatment interventions could benefit from dual-task paradigm during balance training aiming to improve postural control in patients suffering from chronic pain.

Effects of hydrotherapy and land-based exercise on mobility and quality of life in patients with knee osteoarthritis: a randomized control trial

[Purpose] To determine the effects of hydrotherapy and land-based exercises on functional mobility and quality of life among patients with knee osteoarthritis. [Participants and Methods] We conducted a randomized controlled trial with knee osteoarthritis patients randomly allocated into land-based (n=17) and hydrotherapy groups (n=17). The Time-Up and Go (TUG), Five Times Sit-to-Stand (5STS), Stair Climbing Test (SCT), and Quality of Life by questionnaires including the Modified Western Ontario and McMaster Universities Osteoarthritis Index questionnaire Thai version (Thai WOMAC) were assessed at baseline and 6 weeks. The World Health Organization Quality of Life BREF Thai version (WHOQOL-BREF-THAI) questionnaire were assessed at baseline and six weeks and 6 months. [Results] There was no significant difference in outcomes between the groups after 6-weeks and 6-months of follow-up. After 6 weeks, Thai WOMAC score improved in both groups. Only 5STS was improved in the land-based group, while the hydrotherapy group showed significant TUG, 5STS, and SCT improvement. Furthermore, only hydrotherapy showed significant improvement in WHOQOL-BREF-THAI scores in the mental, social, quality of health, and total domains after six months. [Conclusion] Both exercises equally improved functional mobility and quality of life. Hydrotherapy and land-based exercise could improve functional mobility and quality of life in patients with knee osteoarthritis.

Low Back Pain as a Risk Factor for Recurrent Falls in People With Knee Osteoarthritis

OBJECTIVE

Knee osteoarthritis (OA) has been suggested to increase the risk of falls. Low back pain (LBP) is a potential risk factor for falls in people with knee OA, but this issue has not been addressed adequately in previous studies. The objective of this study was to investigate the relationship between LBP and falls in people with knee OA in a 12-month period.

METHODS

Participants with knee OA (Kellgren/Lawrence [K/L] grade ≥1) completed questionnaires for LBP and falls that occurred in the preceding 12 months. Binary and ordinal logistic regression analyses were performed to assess the relationship between LBP or moderate-to-severe LBP (numeric rating scale ≥4 points) and any fall (≥1 fall) or recurrent falls (≥2 falls) after adjustment for age, sex, K/L grade, knee pain severity, and quadriceps strength. Sensitivity analyses were performed excluding people with sciatica, nonchronic LBP, K/L grade 1, and those receiving pain medications.

RESULTS

We included 189 participants (ages 61-90 years, 78.3% women) in this study. Of these participants, 41 (21.6%) reported falls in the preceding 12 months. People with any LBP (n = 101) and those with moderate-to-severe LBP (n = 45) had 2.7- and 3.7-times higher odds of recurrent falls, respectively. Sensitivity analyses revealed a strong correlation between moderate-to-severe LBP and recurrent falls.

CONCLUSION

Thorough investigation of LBP as a risk factor for recurrent falls in people with knee OA may provide a novel insight into the pathomechanics of recurrent falls in this population.

Machine Learning Predicts the Fall Risk of Total Hip Arthroplasty Patients Based on Wearable Sensor Instrumented Performance Tests

BACKGROUND

The prevalence of falls affects the wellbeing of aging adults and places an economic burden on the healthcare system. Integration of wearable sensors into existing fall risk assessment tools enables objective data collection that describes the functional ability of patients. In this study, supervised machine learning was applied to sensor-derived metrics to predict the fall risk of patients following total hip arthroplasty.

METHODS

At preoperative, 2-week, and 6-week postoperative appointments, patients (n = 72) were instrumented with sensors while they performed the timed-up-and-go walking test. Preoperative and 2-week postoperative data were used to form the feature sets and 6-week total times were used as labels. Support vector machine and linear discriminant analysis classifier models were developed and tested on various combinations of feature sets and feature reduction schemes. Using a 10-fold leave-some-subjects-out testing scheme, the accuracy, sensitivity, specificity, and area under the receiver-operator curve (AUC) were evaluated for all models.

RESULTS

A high performance model (accuracy = 0.87, sensitivity = 0.97, specificity = 0.46, AUC = 0.82) was obtained with a support vector machine classifier using sensor-derived metrics from only the preoperative appointment. An overall improved performance (accuracy = 0.90, sensitivity = 0.93, specificity = 0.59, AUC = 0.88) was achieved with a linear discriminant analysis classifier when 2-week postoperative data were added to the preoperative data.

CONCLUSION

The high accuracy of the fall risk prediction models is valuable for patients, clinicians, and the healthcare system. High-risk patients can implement preventative measures and low-risk patients can be directed to enhanced recovery care programs.

Voluntary step execution in patients with knee osteoarthritis: Symptomatic vs. non-symptomatic legs

BACKGROUND

Individuals with osteoarthritis fall at a greater rate than the general population, likely as a result of weakness, pain, movement limitations, and a decline in balance. Due to the high prevalence of osteoarthritis in the population, understanding the mechanisms leading to greater fall risk is an important issue to better understand.

RESEARCH QUESTION

What is the influence of unilateral knee osteoarthritis on the characteristics of performing a voluntary step (i.e., similar to that performed to avoid a fall after a perturbation), compared to healthy age-matched controls?

METHODS

Case-control study performed in a Health maintenance organization physical therapy clinic. The research group consisted of a referred sample of 21 patients with unilateral knee osteoarthritis. The control group consisted of 22 age-matched healthy individuals. All participants were over 65 years of age. Participants were excluded if they had a surgical procedure to back or lower limb within one year before testing, oncological or neurological disease or a deficit in tactile sense. Movements were performed with and without dual tasking.

MEASUREMENTS

Duration of the initiation phase (cue to step initiation), preparatory phase (step initiation to foot off) and swing phase (foot off to foot contact).

RESULTS

In the preparatory phase and swing phase, the osteoarthritis group moved more slowly than the control group, and these differences were larger for forward compared to backward movements. Dual-tasking slowed responses in the pre-movement initiation stage across groups.

SIGNIFICANCE

The differences in basic parameters, and the slower movements in the osteoarthritis group, are consistent with known features of osteoarthritis, being a disease commonly regarded as primarily "mechanical", and are likely to increase fall risk. These response deficits suggest we should take advantage of advanced rehabilitation techniques, including cognitive loading, to help prevent falls in older adults with osteoarthritis.

[Falls and pathology of the musculoskeletal system in the older age groups]

BACKGROUND

Fall in the elderly is considered as a geriatric syndrome, which increases the risk of new falls, decreases physical functioning and autonomy and is associated with other geriatric syndromes. One of the most common risk factors for falls is the pathology of the musculoskeletal system, including osteoarthritis, sarcopenia, osteopenia and osteoporosis, as well as chronic pain.

AIM

To characterize diseases of the musculoskeletal system in elderly patients with falls.

MATERIAL AND METHODS

The study included 289 patients (mean age 75,8±7,9 years, 224 women) who underwent falls during the last year. All patients had polymorbid pathology (mean number of diseases 5,13±2,3, the Charlson index 5,63±1,8 points). All patients underwent general clinical studies, a comprehensive geriatric assessment, X-ray examination of the joints, dual-energy X-ray absorptiometry.

RESULTS AND CONCLUSION

The risk of falls assessed with a self-assessment scale as 7,45±3 points had 90,3% of patients, 34,6% of patients had the high hospital risk of falls. All patients had aggravated geriatric status (on average 7 geriatric syndromes). Among the risk factors for falls, one of the most common was the condition associated with the pathology of the musculoskeletal system: chronic pain (84,7%), physical inactivity (56,1%), disorders of balance (60,2%) and gait (35,9%), the use of mobility aids (30,4%), orthopedic pathology (9,7%) and vitamin D deficiency (86,1%). Osteoarthritis prevailed (75,8%) among nosological forms. One hundred and forty-two (64,8%) patients had pain in the joints, the duration of pain was 6,2±5,6 days, the pain intensity was 47,2±20,7 mm on a visual analogue scale and 106,3±112,3 points by WOMAC. The neuropathic component was diagnosed on DN4 scale in 34 (23,9%) patients. Dynapenia was detected in 109 (37,7%) patients, and sarcopenia in 28 (25,6%) of them. The risk of osteoporotic fractures was 17,4±7,9%. The significantly higher incidence of dynapenia, insufficiency and deficiency of vitamin D and a higher risk of osteoporotic fractures was observed in 289 patients with falls compared to 213 people without falls.

Acute Effects of Whole-Body Vibration Exercise on Pain Level, Functionality, and Rating of Exertion of Elderly Obese Knee Osteoarthritis Individuals: A Randomized Study

Introduction: Among chronic diseases, knee osteoarthritis (KOA) is a joint disease that causes important progressive alterations in the articular and periarticular structures, including synovial inflammation. Exercise has been suggested as an intervention to KOA individuals, and studies suggest that whole-body vibration (WBV) exercise decreases pain levels and favours the functionality of KOA individuals. Objective: The aim of the present study is to analyze the acute effects of WBV exercise on pain levels, functionality (Timed Up and Go (TUG test), anterior trunk flexion (ATF)), and rating of exertion of elderly obese KOA individuals. Methods: Thirty-seven individuals with KOA were allocated to a WBV exercise group (WBVEG), n = 19 (15 females/4 males), and a control group (CG), n = 18 (15 females/3 males). WBVEG performed one session of WBV exercise (11 min, using 5 Hz, 2.5, 5.0, and 7.5 mm, 0.12, 0.25, and 0.37 g). Three bouts were performed (working time of 3 min and rest time of 1 min) using a side-alternating vibrating platform (VP). The same position was used in CG; however, the VP was turned off and there was equipment coupled to the VP that emitted a sound like the vibrations. The pain level was evaluated using a visual analog scale (VAS). Functionality was evaluated with a TUG test and ATF. The rating of subjectively perceived exertion was measured with the category ratio CR-10 (BORG Scale CR-10), Results: A reduction of pain levels in WBVEG after the intervention (p = 0.001) and intergroups (p = 0.041) was found. A decrease of TUG test time in both groups (p = 0.001) and intergroups (p = 0.045) was found, while no statistical changes were observed in the Borg Scale score. Significant improvements of flexibility in both groups (p = 0.001) and intergroups (p = 0.043) were found. Conclusion: One session of WBV exercise can lead to important improvements in individuals with KOA, possibly triggered by physiological responses. However, more studies are needed, in this clinical context, to confirm these results.

Triaging Total Hip Arthroplasty During the COVID-19 Pandemic

PURPOSE OF REVIEW

The purpose of this review was to evaluate the available literature to determine what may be considered urgent indications for total hip arthroplasty, in the unprecedented setting of the worldwide COVID-19 pandemic.

RECENT FINDINGS

SARS-CoV-2 is a novel coronavirus currently presenting in the form of a global pandemic, referred to as COVID-19. In this setting, multiple states have issued executive orders prohibiting "elective" surgery, including arthroplasty, in order to preserve healthcare resources. However, during this unprecedented reduction in elective surgery, there is likely to be some controversy as to what constitutes a purely "elective" procedure, versus an "urgent" procedure, particularly regarding hip arthroplasty. We reviewed the available literature for articles discussing the most commonly encountered indications for primary, conversion, and revision hip arthroplasty. Based upon the indications discussed in these articles, we further stratified these indications into "elective" versus "urgent" categories. In patients presenting with hip arthroplasty indications, the decision to proceed urgently with surgery should be based upon (a) the potential harm incurred by the patient if the surgery was delayed and (b) the potential risk incurred by the patient in the context of COVID-19 if surgery was performed. The authors present a decision-making algorithm for determining surgical urgency in three patients who underwent surgery in this context. Urgent total hip arthroplasty in the setting of the COVID-19 pandemic is a complex decision-making process, involving clinical and epidemiological factors. These decisions are best made in coordination with a multidisciplinary committee of one's peers. Region-specific issues such as hospital resources and availability of PPE may also inform the decision-making process.

Falling risk in patients with end-stage knee osteoarthritis

Although 25% of patients with end-stage knee osteoarthritis (OA) have reported a fall, there is limited information about risk factors for falling in patients awaiting total knee arthroplasty (TKA). The purpose of this study was to identify clinical and functional measures related to fall risk. A total of 259 participants awaiting TKA for OA participated in this secondary cross-sectional study. Participants were divided into fallers and non-fallers based on falling history in the prior 6 months. Clinical measures (hip and knee pain, neck and low back pain (LBP), knee range of motion, and quadriceps strength) and functional measures (six-minute walk test (6MWT), timed up and go test, and Knee Injury and Osteoarthritis Outcome Score (KOOS)) were assessed in patients 2-4 weeks prior to TKA. Independent t tests were used to examine differences between groups. Odds ratio was calculated to identify clinical risk factors for falling. Of all participants, 47 (18%) reported a fall in the previous 6 months. Fallers had 30% greater LBP (3.0 ± 2.5 vs. 2.1 ± 2.6; p = 0.025). Fallers walked 12% shorter distance in the 6MWT than non-fallers (378 ± 100 vs. 422 ± 105 m; p = 0.010). For every 1-point increase in LBP on a 0-10 scale, there was a 14% greater risk of falling (p = 0.028). For every 10-m increase in 6MWT, there was a 3.8% reduction in fall risk (p = 0.011). Greater LBP and worse walking endurance are associated with falls in individuals with end-stage OA. Future studies should determine if interventions that reduce LBP and improve walking performance also reduce the chance of falling.

Protocol for an embedded pragmatic clinical trial to test the effectiveness of Aliviado Dementia Care in improving quality of life for persons living with dementia and their informal caregivers

INTRODUCTION

Persons living with Alzheimer's disease and related dementias (ADRD) frequently experience pain and behavioral and psychological symptoms of dementia (BPSD) which decrease quality of life (QOL) and influence caregiver burden. Home healthcare professionals however may underrecognize or lack the ability to manage BPSD.

INTERVENTION

This protocol describes an ADRD palliative quality assurance performance improvement program for home healthcare, Aliviado Dementia Care-Home Health Edition. It includes training, mentoring, and a toolbox containing intervention strategies.

METHODS

This embedded pragmatic clinical trial will utilize a multi-site, cluster randomized control design. Recruitment will occur from three home healthcare agencies located in New Jersey, Utah, and Florida. At each agency, care teams will be randomized as clusters and assigned to either the Aliviado Dementia Care program or usual care. We plan to enroll 345 persons living with ADRD and their informal caregiver dyads. The primary outcome will be to measure QOL in both the person living with ADRD and their informal caregiver, and emergency department visits and hospital admissions. Secondary outcomes in the person living with ADRD will include the examination of pain, BPSD, antipsychotic and analgesic use. Secondary outcomes in caregivers include burden, depressive symptoms, functional health and wellbeing, and healthcare utilization.

CONCLUSION

This study will be the first large-scale embedded pragmatic clinical trial in home healthcare focused on care quality and outcomes in addressing QOL in ADRD. If proven successful, the intervention can then be disseminated to agencies throughout the country to improve the quality of care for this vulnerable, underserved population.

TRIAL REGISTRATION

Clinical Trials.gov: NCT03255967.

Knee Osteoarthritis and the Risk of Medically Treated Injurious Falls Among Older Adults: A Community-Based US Cohort Study

OBJECTIVE

The risk of falls among adults with knee osteoarthritis (OA) has been documented, yet, to our knowledge no studies have examined knee OA and the risk of medically treated injurious falls (overall and by sex), which is an outcome of substantial clinical and public health relevance.

METHODS

Using data from the Health Aging and Body Composition Knee Osteoarthritis Substudy, a community-based study of white and African American older adults, we tested associations between knee OA status and the risk of injurious falls among 734 participants with a mean ± SD age of 74.7 ± 2.9 years. Knee radiographic OA (ROA) was defined as having a Kellgren-Lawrence grade of ≥2 in at least 1 knee. Knee symptomatic ROA (sROA) was defined as having both ROA and pain symptoms in the same knee. Injurious falls were defined using a validated diagnosis code algorithm from linked Medicare fee-for-service claims. Cox regression modeling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

The mean ± SD follow-up time was 6.59 ± 3.12 years. Of the 734 participants, 255 (34.7%) had an incident injurious fall over the entire study period. In the multivariate model, compared with those without ROA or pain, individuals with sROA (HR 1.09 [95% CI 0.73-1.65]) did not have a significantly increased risk of injurious falls. Compared with men without ROA or pain, men with sROA (HR 2.57 [95% CI 1.12-5.91]) had a significantly higher risk of injurious falls. No associations were found for women or by injurious fall type.

CONCLUSION

Knee sROA was independently associated with an increased risk of injurious falls in older men, but not in older women.

Prg4 prevents osteoarthritis induced by dominant-negative interference of TGF-ß signaling in mice

Objective

Prg4, also known as Lubricin, acts as a joint/boundary lubricant. Prg4 has been used to prevent surgically induced osteoarthritis (OA) in mice. Surgically induced OA serves as a good model for post-traumatic OA but is not ideal for recapitulating age-related OA. Reduced expression of the TGF-β type II receptor (TGFβR2) is associated with age-related OA in clinical samples, so we previously characterized a mouse model that exhibits OA due to expression of a mutated dominant-negative form of TGFβR2 (DNIIR). Prg4 expression was significantly reduced in DNIIR mice. Furthermore, we showed that Prg4 was a transcriptional target of TGF-ß via activation of Smad3, the main signal transducing protein for TGF-ß. The objective of the present study was to determine whether maintenance of Prg4, a down-stream transcriptional target of TGF-ß, prevents OA associated with attenuated TGF-ß signaling in mice.

Design

Wild-type, DNIIR, and bitransgenic mice that express both DNIIR and Prg4, were compared. Mice were assessed with a foot misplacement behavioral test, μCT, histology, and Western blot.

Results

Compared to DNIIR mice, bitransgenic DNIIR+Prg4 mice missed 1.3 (0.4, 2.1) fewer steps while walking (mean difference (95% confidence interval)), exhibited a cartilage fibrillation score that was 1.8 (0.4, 3.1) points lower, exhibited cartilage that was 28.2 (0.5, 55.9) μm thicker, and exhibited an OARSI score that was 6.8 (-0.9, 14.5) points lower. However, maintenance of Prg4 expression did not restore levels of phosphorylated Smad3 in DNIIR mice, indicating Prg4 does not simply stimulate TGF-ß signaling.

Conclusions

Our results indicate that maintenance of Prg4 expression prevents OA progression associated with reduced TGF-β signaling in mice. Since there was no evidence that Prg4 acts by stimulating the TGF-ß signaling cascade, we propose that Prg4, a transcriptional target of TGF-ß, attenuates OA progression through its joint lubrication function.

Balance and quality of life after total knee arthroplasty

OBJECTIVE

To evaluate the change in balance and quality of life in patients undergoing total knee arthroplasty for primary gonarthrosis.

METHOD

Patients aged 60 years or older were evaluated in relation to the balance and quality of life before total knee arthroplasty and six months after surgery. To assess balance, this study used the Motor Scale Test for the Elderly; quality of life was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index questionnaire and the Short Form Health Survey. A control group consisting of healthy adults, age- and gender-paired, was used to compare the balance after surgery results.

RESULTS

Twenty-eight patients completed the study, of a total of 37 arthroplasties. The mean age was 70.18 ± 6.17 years. All variables were statistically significant (p ≤ 0.05) for improved balance and quality of life after arthroplasty. It was observed that, after knee arthroplasty, the level of balance does not reach that expected for healthy individuals (p ≤ 0.05).

CONCLUSION

Total knee arthroplasty is effective at improving balance six months after surgery, as well as all domains of quality of life. However, it is not able to restore balance to a level comparable to that of healthy individuals.

Evaluation of Gait Speed after Applying Kinesio Tape on Quadriceps Femoris Muscle in Patients with Knee Osteoarthritis

BACKGROUND:

Knee osteoarthritis is a chronic degenerative disease, known as the most common cause of difficulty walking in older adults and subsequently is associated with slow walking. Functional decline, increased risk of falls and the presence of pain are, in many studies, related to the muscle weakness caused by osteoarthritis especially weakness of the quadriceps muscles. Many studies have shown that the strength of the quadriceps femoris muscle can affect gait, by improving or weakening it. Kinesio Tape is a physiotherapeutic technique, which reduces pain and increases muscular strength by irritating the skin receptors.

AIM:

This study aimed to verify if the application of Kinesio Tape on quadriceps femoris muscle increases gait speed while decreasing the time needed to accomplish the 10-meter walk test in patients with knee osteoarthritis and also in subjects without knee osteoarthritis.

METHOD:

In this study, we observed the change of gait speed with the help of the 10-meter walk test before, one day and three days after the application of Kinesio Tape in quadriceps femoris muscle. We compared the results of the time needed to perform the 10-meter walk in two groups. In the first group, the Patients group, participated 102 out-patients with a clinical diagnosis of primary knee osteoarthritis, while in the second group, the Control group, participated 73 subjects with a main excluding criterion a clinical diagnosis of primary knee osteoarthritis.

RESULTS:

Our results indicated that there was a significant decrease of time needed to perform the 10-meter walk test in both groups three days after application of Kinesio Tape on quadriceps femoris muscle. However, there was not a significant change one day after the application of Kinesio Tape compared before its application in both groups.

CONCLUSIONS:

Our results indicated that there was a significant decrease in time needed to accomplish the 10-meter walk test. Kinesio Tape is a technique that can be used especially when changing walking stereotypes is a long-term goal of the treatment.

Alterations in body lean angle in lame horses before and after diagnostic analgesia in straight lines in hand and on the lunge

Altered body lean has been subjectively observed during lungeing in lame horses. The objectives were to quantify the influence of lameness on body lean in trot on the lunge and to investigate the influence of improvement in lameness on the differences in body lean between reins. Thirteen lame horses were trotted in straight lines and lunged on a 10m-diameter circle on both reins before and after lameness was subjectively substantially improved by diagnostic analgesia. A global position system-aided inertial measurement unit attached to the tubera sacrale quantified body lean. Differences between reins in body lean before and after diagnostic analgesia were calculated and means were determined. Five and eight horses had unilateral and bilateral hindlimb lameness, respectively. Two of five horses with unilateral and three of eight horses with bilateral lameness leaned more on the rein with the lame or lamer hindlimb on the inside of the circle (difference between reins 5-8°). Two of five horses with unilateral and two of eight horses with bilateral lameness leaned more on the rein with the lame or lamer hindlimb on the outside of the circle (4-10°). Four horses, one with unilateral and three with bilateral lameness, had only 1° difference in body lean angle between left and right reins. When lameness was improved by diagnostic analgesia, the body lean changed significantly towards similar leaning on left and right reins (mean angle changed from 8.8° to 10.0° (P=0.03) on one rein and 13.4° to 10.8° (P=0.002) on the other rein). It was concluded that body lean becomes more symmetrical between reins after improvement in lameness using diagnostic analgesia.

Primary knee osteoarthritis increases the risk of falling

OBJECTIVES

The aim of this study was to investigate the effect of primary knee osteoarthritis on the risk of falling.

MATERIALS AND METHODS

One hundred participants (50 with knee osteoarthritis and 50 healthy controls) were included in this study. Primary knee osteoarthritis was diagnosed according to the American College of Rheumatology (ACR) criteria. Patients who were grade 2 or 3 by Kellgren-Lawrence criteria according to weight-bearing knee radiographs were included in this study. The risk of falling was evaluated by the interactive balance and coordination device both in the osteoarthritis and control groups. The functional status and pain were evaluated with respectively Lequesne Index and Visual Analogue Scale.

RESULTS

No statistically significant differences were found between the group of primary knee osteoarthritis and control in terms of age, BMI, and gender. The median falling index was 52 in the group with knee OA, whereas it was 31 in the control group. It was determined that primary knee osteoarthritis increased the risk of falling significantly and grade 3 primary knee osteoarthritis was statistically significantly higher than grade 2 (p < 0.001). The pain and functional status did not appear to be effective on the risk of falling in those patients (p > 0.05).

DISCUSSION

Falling is among the important causes of mortality and morbidity in advanced age. Therefore, assessment of risk factors for falling and the strategies to prevent it are important. Primary knee osteoarthritis is one of the risk factors associated with falling. Therefore, medical approaches, proprioception training, balance-gait training, muscle strengthening exercises, and arrangements to prevent domestic injurious falling should be planned to reduce the risk of falling in the presence of primary knee osteoarthritis.

Knee osteoarthritis at the early stage: The four-week effect of lateral wedge insole on pain and risk of falls

Background: Knee osteoarthritis (KOA) is associated with a decrease in function, increase in pain and risk of falls. Lateral wedge insole (LWI) is commonly prescribed in KOA to improve pain and function. Our study aimed to 1) evaluate the clinical symptoms and risk of falls in early KOA and compare with controls; 2) evaluate the immediate and four-week effect of LWI. Methods: A sample of 20 Persian dwelling individuals with early KOA and 19 matched controls were recruited. Pain with Visual Analogue Scale (VAS), Quality of life (QOL) with the knee injury and osteoarthritis outcome score, risk of falls with the Timed Up and Go (TUG) and static One-leg Balance (OLB) tests were assessed. The four-week effect of 5º LWI was considered for individuals with KOA. Independent t-test was done to report the between-group differences, and paired t-test was used to report the four-week effect of LWI. Results: At baseline, statistically significant higher scores for pain, lower scores for QOL, and higher risk of falls were observed in KOA compared to controls (p< 0.001). A significant statistical decrease was observed in pain, and risk of falls, and an increase in QOL in KOA after four-week effect of LWI compared to baseline (p< 0.001). Conclusion: People with early KOA showed higher pain and lower level of QOL that were associated with higher risk of falls. LWI may have the potential to improve clinical symptoms and reduce the risk of falls at the early stage of KOA.

A manual physical therapy intervention for symptoms of knee osteoarthritis and associated fall risk: A case series of four patients

BACKGROUND AND PURPOSE

Patients with knee osteoarthritis (OA) are at an increased risk of falling. Further, the symptoms associated with knee OA are correlated with fall risk. A manual physical therapy (MPT) approach consisting of mobilizing techniques and reinforcing exercise improves the symptoms and functional limitations associated with knee OA. The purpose of this case series is to evaluate an MPT intervention of mobilization techniques and exercise for knee OA on improving symptoms and quantify the secondary benefit of improving stumble recovery.

CASE DESCRIPTION

Four patients with symptomatic knee OA and four matched controls completed a fall risk assessment. Following 4 weeks of intervention, patients were reevaluated.

OUTCOMES

Initial Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores indicated notable symptoms and functional limitations in all patients. In addition, all patients displayed elevated fall risk and/or impaired stumble responses. Following 4 weeks of intervention, all patients reported meaningful reductions in all three WOMAC subscales and demonstrated improvements in at least two of the three fall risk measures.

DISCUSSION

We identified potential connections between symptom relief in patients with knee OA, stumble response, and ultimately fall risk. The results suggest that MPT intervention designed to improve the signs and symptoms of knee OA may lead to a secondary benefit of improved gait stability and stumble response.

Longitudinal associations between serum 25-hydroxyvitamin D, physical activity, knee pain and dysfunction and physiological falls risk in community-dwelling older adults

AIMS

To describe the longitudinal associations between physiological falls risk, and between-person and within-person effects of 25-hydroxyvitamin D (25OHD), physical activity (PA), knee pain and dysfunction in community-dwelling older people.

METHODS

Data for 1053 participants (51% women; mean age 63 ± 7.4 years) studied at baseline, 2.5, 5, and 10 years were analysed. Falls risk (Z-score) was measured using the Physiological Profile Assessment. Knee pain and dysfunction were assessed using the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC). Moderate-to-vigorous PA (MVPA) was measured using accelerometer. Linear mixed-effect regression models, with adjustment for confounders, were used to estimate the association between physiological falls risk and between-person and within-person effects of PA, 25OHD and WOMAC score.

RESULTS

Between-person effects showed that 10-year average physiological falls risk was lower in participants who had a higher 10-year average 25OHD (β = -0.005 per nmol/l, 95% CI: -0.008, -0.002), log-MVPA (β = -0.16 per minute, 95% CI: -0.22, -0.10) and lower mean WOMAC score (β = 0.005 per-unit score, 95% CI: 0.003, 0.01). Within-person effects showed that a higher physiological falls risk at any time-point was associated with higher than average WOMAC score (β = 0.002 per-unit score, 95% CI: 0.0003, 0.004) and lower than average log-MVPA (β = -0.15 per minute, 95% CI: -0.24, -0.06), but not 25OHD, at the same time-point.

CONCLUSION

Having higher WOMAC global score above an individual's average increases the risk of falling, whereas, increasing one's own MVPA level further reduces their risk of falling. The presence of between-person but not within-person associations for 25OHD suggests the former may be confounded by other factors.

Reliability and validity of the Turkish version of Activities-specific Balance Confidence scale in symptomatic knee osteoarthritis

BACKGROUND

Activities-specific Balance Confidence (ABC) scale is a well known tool to evaluate the functional balance. Balance impairment may accompany to knee osteoarthritis.

OBJECTIVE

The aim was to investigate the reliability and validity of the Turkish version of ABC in knee osteoarthritis.

METHODS

Forty-nine patients with knee osteoarthritis were included. All the participants were evaluated by ABC and Berg Balance Scale (BBS). Knee Injury and Osteoarthritis Outcome Score (KOOS) was used for the assessment of the knee related condition.

RESULTS

Mean age was 64.7 ± 9.2. Eighty-five percent was women. Mean ABC score was 53.5% and BBS score was 40. Interclass correlation coefficient was 0.95. There was a statistically significant positive correlation between the test-retest results (t= 1.90, p= 0.063). Correlation coefficient was high (p= 0.001, r= 0.953). Cronbach's alpha was 0.97. There was a significant positive correlation between ABC-T and BBS, the symptoms, daily living activities and quality of life subscales of KOOS (r= 0.555, p< 0.001; r= 0.424, r= 0.379, r= 0.621, p< 0.01). ABC-T correlated negatively with the radiological severity (r = -0.316, p< 0.05).

CONCLUSIONS

ABC-T is a reproducible test with excellent internal consistency and construct validity in knee osteoarthritis. Balance confidence was moderate and related with the symptoms, daily living activities, disease severity and quality of life.

The mediating role of psychological symptoms on falls risk among older adults with osteoarthritis

The purpose of this study was to investigate the role of fear of falling (FoF) and psychological symptoms in explaining the relationship between osteoarthritis (OA) symptom severity and falls. Individuals aged ≥65 years with ≥2 falls or ≥1 injurious fall over the past 12 months were included in the falls group, while volunteers aged ≥65 years with no history of falls over 12 months were recruited as controls. The presence of lower extremity OA was determined radiologically and clinically. Severity of symptoms was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. FoF and psychological status were measured with the shortened version of the Falls Efficacy Scale-International and the 21-item Depression, Anxiety and Stress Scale (DASS-21), respectively. Of 389 (229 fallers, 160 non-fallers) potential participants, mean (SD) age: 73.74 (6.60) years, 141 had clinical OA and 171 had radiological OA. Fallers with both radiological OA and clinical OA had significantly higher FoF and DASS-21 scores than non-fallers. FoF was significantly positively correlated with symptom severity in fallers and non-fallers with radiological and clinical OA. Depression, anxiety, and stress scores were only significantly correlated with symptom severity among fallers but not non-fallers in both clinical and radiological OA. The relationship between mild symptoms and reduced risk of falls compared to no symptoms in those with radiological OA was attenuated by increased anxiety. The increased falls risk associated with severe symptoms compared to mild symptoms in clinical OA was attenuated by FoF. FoF may, therefore, be a potentially modifiable risk factor for OA-associated falls which could be considered in future intervention studies.

Symptoms of Knee Instability as Risk Factors for Recurrent Falls

OBJECTIVE

Whether knee instability contributes to the increased risk of falls and fractures observed in persons with knee osteoarthritis (OA) has not been studied. We examined the association of knee buckling with the risk of falling and fall-related consequences in older adults with, or at high risk for, knee OA.

METHODS

At the 60-month visit of the Multicenter Osteoarthritis Study, men and women ages 55-84 years were asked about knee buckling in the past 3 months and whether they fell when a knee buckled. Falls and fall-related injuries in the past 12 months and balance confidence were assessed at 60 and 84 months. Multivariate logistic regression was used to assess the association of knee buckling with falls and their consequences.

RESULTS

A total of 1,842 subjects (59% women, mean ± SD age 66.9 ± 7.8 years, and body mass index 30.3 ± 5.7) were included. At 60 months 16.8% reported buckling and at 84 months 14.1% had recurrent (≥2) falls. Bucklers at 60 months had a 1.6- to 2.5-fold greater odds of recurrent falls, fear of falling, and poor balance confidence at 84 months. Those who fell when a knee buckled at baseline had a 4.5-fold, 2-fold, and 3-fold increased odds 2 years later of recurrent falls, significant fall injuries, and fall injuries that limited activity, respectively, and were 4 times more likely to have poor balance confidence.

CONCLUSION

Interventions that reduce knee buckling may help prevent falls, fall-related injuries, and adverse psychological consequences of falls in persons with knee OA.

Older men with severe disc degeneration have more incident vertebral fractures-the prospective MINOS cohort study

OBJECTIVE

Data on the relationship between disc degeneration (DD) and fragility fractures in men are limited. The aim of this study was to prospectively analyse the risk of vertebral and non-vertebral fractures in men with thoracolumbar DD according to the severity of its radiological signs: disc space narrowing (DSN), osteophytes and endplate sclerosis.

METHODS

Men >50 years of age (n = 765) had lateral spine radiographs and DXA and were monitored prospectively. We analysed the risk of incident vertebral (7.5 years) and non-vertebral fractures (10 years) in men according to the severity of DD.

RESULTS

After adjustment for age and weight, BMD increased with increasing total DSN score, endplate sclerosis and osteophytosis. Over 7.5 years, 28 incident vertebral fractures occurred in 27 men. After adjustment for age, BMI, spine BMD, prior fractures and abdominal aortic calcifications, the vertebral fracture risk was 3-fold higher in the upper DSN quartile vs men without DSN. After adjustment for the same confounders, vertebral fracture risk was also nearly 3-fold higher in the upper DSN quartile vs the three lower quartiles combined. Over 10 years, 61 men sustained non-vertebral fragility fractures. After adjustment for age, BMI, hip BMD, abdominal aortic calcifications and prior falls and fractures, the non-vertebral fracture risk decreased with increasing DSN score. The risk of non-vertebral fracture was half as high in men above the median total DSN score vs men below the median.

CONCLUSION

In older men, severe DD is associated with higher BMD. Multilevel severe DSN is associated with higher vertebral fracture risk and lower non-vertebral fracture risk.

Change in knee structure and change in tibiofemoral joint space width: a five year longitudinal population-based study

Background

Change in knee cartilage volume is frequently used as a proxy for change in knee joint space width over time, but longitudinal data on these associations is limited. We aimed to determine whether change in knee cartilage volume, new or worsening meniscal extrusion (ME), meniscal tears and cartilage defects over 2.4 years correlated with change in joint space width (JSW) over 5 years in older community dwelling adults.

Methods

Participants (n = 153) had their right knee imaged using MR imaging and x-ray at baseline, and after 2.4 years (MRI) and 5 years (x-ray). Cartilage volume, cartilage defects, meniscal extrusions and meniscal tears were assessed on sagittal T1-weighted fat-suppressed MRI. JSW was assessed using standard fixed semi-flexed view radiographs, and scored on those with adequate alignment.

Results

Participants were 51–79 (mean 62) years old; 48 % were female. Cartilage volume reduced over time (medial −134 ± 202 μL/year, lateral −106 ± 165 μL/year, p < 0.001), as did JSW (medial −0.05 ± 0.16 mm/year, lateral −0.12 ± 0.24 mm/year, p < 0.001). In multivariable analysis, the only consistent predictor of change in JSW was new or worsening ME (medial tibia R² 3.1 %, p = 0.031; medial femur R² 3.2 %, p = 0.024); change in cartilage volume correlated with change in JSW laterally (R² 4.8 %, p = 0.007) and was borderline medially (R² 2.2 %, p = 0.064); there was no association for meniscal tears or cartilage defects. The magnitude of these associations were similar albeit somewhat greater for ME in participants with radiographic OA (R² 6.2 %, p = 0.017).

Conclusion

Change in ME and cartilage volume weakly predict change in JSW, but the vast majority of the variation remains unexplained. Since MRI examines cartilage directly while radiographs examine it indirectly, these results cast doubt on the validity of using JSW as a proxy measure of cartilage loss.

Center of Pressure Displacement of Standing Posture during Rapid Movements Is Reorganised Due to Experimental Lower Extremity Muscle Pain

Background

Postural control during rapid movements may be impaired due to musculoskeletal pain. The purpose of this study was to investigate the effect of experimental knee-related muscle pain on the center of pressure (CoP) displacement in a reaction time task condition.

Methods

Nine healthy males performed two reaction time tasks (dominant side shoulder flexion and bilateral heel lift) before, during, and after experimental pain induced in the dominant side vastus medialis or the tibialis anterior muscles by hypertonic saline injections. The CoP displacement was extracted from the ipsilateral and contralateral side by two force plates and the net CoP displacement was calculated.

Results

Compared with non-painful sessions, tibialis anterior muscle pain during the peak and peak-to-peak displacement for the CoP during anticipatory postural adjustments (APAs) of the shoulder task reduced the peak-to-peak displacement of the net CoP in the medial-lateral direction (P<0.05). Tibialis anterior and vastus medialis muscle pain during shoulder flexion task reduced the anterior-posterior peak-to-peak displacement in the ipsilateral side (P<0.05).

Conclusions

The central nervous system in healthy individuals was sufficiently robust in maintaining the APA characteristics during pain, although the displacement of net and ipsilateral CoP in the medial-lateral and anterior-posterior directions during unilateral fast shoulder movement was altered.

Analyzing the History of Falls in Patients with Severe Knee Osteoarthritis

BACKGROUND

One out of three adults over the age of 65 years and one out of two over the age of 80 falls annually. Fall risk increases for older adults with severe knee osteoarthritis, a matter that should be further researched. The main purpose of this study was to investigate the history of falls including frequency, mechanism and location of falls, activity during falling and injuries sustained from falls examining at the same time their physical status. The secondary purpose was to determine the effect of age, gender, chronic diseases, social environment, pain elsewhere in the body and components of health related quality of life such as pain, stiffness, physical function, and dynamic stability on falls frequency in older adults aged 65 years and older with severe knee osteoarthritis.

METHODS

An observational longitudinal study was conducted on 68 patients (11 males and 57 females) scheduled for total knee replacement due to severe knee osteoarthritis (grade 3 or 4) and knee pain lasting at least one year or more. Patients were personally interviewed for fall history and asked to complete self-administered questionnaires, such as the 36-item Short Form Health Survey (SF-36) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and physical performance test was performed.

RESULTS

The frequency of falls was 63.2% for the past year. The majority of falls took place during walking (89.23%). The main cause of falling was stumbling (41.54%). There was a high rate of injurious falling (29.3%). The time patients needed to complete the physical performance test implied the presence of disability and frailty. The high rates of fall risk, the high disability levels, and the low quality of life were confirmed by questionnaires and the mobility test.

CONCLUSIONS

Patients with severe knee osteoarthritis were at greater risk of falling, as compared to healthy older adults. Pain, stiffness, limited physical ability, reduced muscle strength, all consequences of severe knee osteoarthritis, restricted patient's quality of life and increased the fall risk. Therefore, patients with severe knee osteoarthritis should not postpone having total knee replacement, since it was clear that they would face more complicated matters when combining with fractures other serious injuries and disability.

Mild Joint Symptoms Are Associated with Lower Risk of Falls than Asymptomatic Individuals with Radiological Evidence of Osteoarthritis

Osteoarthritis (OA) exacerbates skeletal muscle functioning, leading to postural instability and increased falls risk. However, the link between impaired physical function, OA and falls have not been elucidated. We investigated the role of impaired physical function as a potential mediator in the association between OA and falls. This study included 389 participants [229 fallers (≥2 falls or one injurious fall in the past 12 months), 160 non-fallers (no history of falls)], age (≥65 years) from a randomized controlled trial, the Malaysian Falls Assessment and Intervention Trial (MyFAIT). Physical function was assessed using Timed Up and Go (TUG) and Functional Reach (FR) tests. Knee and hip OA were diagnosed using three methods: Clinical, Radiological and Self-report. OA symptom severity was assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). The total WOMAC score was categorized to asymptomatic, mild, moderate and severe symptoms. Individuals with radiological OA and ‘mild’ overall symptoms on the WOMAC score had reduced risk of falls compared to asymptomatic OA [OR: 0.402(0.172–0.940), p = 0.042]. Individuals with clinical OA and ‘severe’ overall symptoms had increased risk of falls compared to those with ‘mild’ OA [OR: 4.487(1.883–10.693), p = 0.005]. In individuals with radiological OA, mild symptoms appear protective of falls while those with clinical OA and severe symptoms have increased falls risk compared to those with mild symptoms. Both relationships between OA and falls were not mediated by physical limitations. Larger prospective studies are needed for further evaluation.

Effects of noxious stimulation to the back or calf muscles on gait stability

Gait stability is the ability to deal with small perturbations that naturally occur during walking. Changes in motor control caused by pain could affect this ability. This study investigated whether nociceptive stimulation (hypertonic saline injection) in a low back (LBP) or calf (CalfP) muscle affects gait stability. Sixteen participants walked on a treadmill at 0.94ms(-1) and 1.67ms(-1), while thorax kinematics were recorded using 3D-motion capture. From 110 strides, stability (local divergence exponent, LDE), stride-to-stride variability and root mean squares (RMS) of thorax linear velocities were calculated along the three movement axes. At 0.94ms(-1), independent of movement axes, gait stability was lower (higher LDE) and stride-to-stride variability was higher, during LBP and CalfP than no pain. This was more pronounced during CalfP, likely explained by the biomechanical function of calf muscles in gait, as supported by greater mediolateral RMS and stance time asymmetry than in LBP and no pain. At 1.67ms(-1), independent of movement axes, gait stability was greater and stride-to-stride variability was smaller with LBP than no pain and CalfP, whereas CalfP was not different from no pain. Opposite effects of LBP on gait stability between speeds suggests a more protective strategy at the faster speed. Although mediolateral RMS was greater and participants had more asymmetric stance times with CalfP than LBP and no pain, limited effect of CalfP at the faster speed could relate to greater kinematic constraints and smaller effects of calf muscle activity on propulsion at this speed. In conclusion, pain effects on gait stability depend on pain location and walking speed.

The association between antagonist hamstring coactivation and episodes of knee joint shifting and buckling

OBJECTIVE

Hamstring coactivation during quadriceps activation is necessary to counteract the quadriceps pull on the tibia, but coactivation can be elevated with symptomatic knee osteoarthritis (OA). To guide rehabilitation to attenuate risk for mobility limitations and falls, this study evaluated whether higher antagonistic open kinetic chain hamstring coactivation is associated with knee joint buckling (sudden loss of support) and shifting (a sensation that the knee might give way).

DESIGN

At baseline, median hamstring coactivation was assessed during maximal isokinetic knee extensor strength testing and at baseline and 24-month follow-up, knee buckling and shifting was self-reported. Associations between tertiles of co-activation and knee (1) buckling, (2) shifting and (3) either buckling or shifting were assessed using logistic regression, adjusted for age, sex, knee OA and pain.

RESULTS

1826 participants (1089 women) were included. Mean ± SD age was 61.7 ± 7.7 years, BMI was 30.3 ± 5.5 kg/m(2) and 38.2% of knees had OA. There were no consistent statistically significant associations between hamstring coactivation and ipsilateral prevalent or incident buckling or the combination of buckling and shifting. The odds ratios for incident shifting in the highest in comparison with the lowest tertile of coactivation had similar magnitudes in the combined and medial hamstrings, but only reached statistical significance for lateral hamstring coactivation, OR(95%CI) 1.53 (0.99, 2.36).

CONCLUSIONS

Hamstring coactivation during an open kinetic chain quadriceps exercise was not consistently associated with prevalent or incident self-reported knee buckling or shifting in older adults with or at risk for knee OA.

Prevalence and burden of osteoarthritis amongst older people in Ireland: findings from The Irish LongituDinal Study on Ageing (TILDA)

OBJECTIVE

To investigate the prevalence of osteoarthritis (OA) in a population aged ≥50 years in Ireland, and to determine its relationship with demographic and health-related variables.

METHODS

Cross-sectional data from Wave 1 of The Irish Longitudinal Study on Ageing (TILDA), a population-based study of 8175 people aged ≥50 years were analyzed. Logistic regression was used to determine associations between the presence of OA and a range of demographic and health-related variables.

RESULTS

A total of 8175 people ≥50 years in Ireland were identified from the TILDA database of whom 45.7% (n = 2941) were male and 54.3% (n = 4431) were female. The overall prevalence of OA was 12.9% (women-17.3%; men-9.4%). Prevalence increased with age, with prevalence in those aged ≥ 80 years twice that [17.7%; 95% confidence interval (CI) 13.97, 21.54] of those aged 50-60 years (8.23, 95% CI 7.32, 9.13). On multivariable analysis, OA was significantly associated (P < 0.02) with female gender, older age, pain severity, higher body mass index (BMI), fear of falling, greater number of physical limitations and medication use. In particular, there was a strong association between the use of NSAIDS and the presence of OA [adj odd ratio (OR) = 5.88, 95% CI 4.16, 8.31]. A significant association was also found between OA and increasing number of chronic diseases (adj OR = 2.75 9, 95% CI = 2.44, 3.09).

CONCLUSIONS

OA is a common and multifaceted condition, with comparable prevalence of self-reported OA in Ireland with similar populations. Assessment and management should focus on potentially modifiable factors such as BMI, pain, physical limitations, polypharmacy and fear of falling. More research is required to understand the complex inter-relationships between these and other risk-associated variables.

Knee Pain and a Prior Injury Are Associated with Increased Risk of a New Knee Injury: Data from the Osteoarthritis Initiative

OBJECTIVE

We explored whether knee pain or a history of knee injury were associated with a knee injury in the following 12 months.

METHODS

We conducted longitudinal knee-based analyses among knees in the Osteoarthritis Initiative. We included both knees of all participants who had at least 1 followup visit with complete data. Our first sets of exposures were knee pain (chronic knee symptoms and severity) at baseline, 12-month, 24-month, and 36-month visits. Another exposure was a history of injury that we defined as a self-reported injury at any time prior to baseline, 12-month, 24-month, or 36-month visit. The outcome was self-reported knee injury during the past year at 12-month, 24-month, 36-month, and 48-month visits. We evaluated the association between ipsilateral and contralateral knee pain or history of injury and a new knee injury within 12 months of the exposure using generalized linear mixed model for repeated binary outcomes.

RESULTS

A knee with reported chronic knee symptoms or ipsilateral or contralateral history of an injury was more likely to experience a new knee injury in the following 12 months than a knee without chronic knee symptoms (OR 1.84, 95% CI 1.57-2.16) or prior injury (prior ipsilateral knee injury: OR 1.81, 95% CI 1.56-2.09. Prior contralateral knee injury: OR 1.43, 95% CI 1.23-1.66).

CONCLUSION

Knee pain and a history of injury are associated with new knee injuries. It may be beneficial for individuals with knee pain or a history of injury to participate in injury prevention programs.

Lower-extremity osteoarthritis and the risk of falls in a community-based longitudinal study of adults with and without osteoarthritis

OBJECTIVE

Knee and hip osteoarthritis (OA) are known risk factors for falls, but whether they together additionally contribute to falls risk is unknown. This study utilizes a biracial cohort of men and women to examine the influence of lower-extremity OA burden on the risk for future falls.

METHODS

A longitudinal analysis was performed using data from 2 time points of a large cohort. The outcome of interest was falls at followup. Covariates included age, sex, race, body mass index, a history of prior falls, symptomatic OA of the hip and/or knee, a history of neurologic or pulmonary diseases, and current use of narcotic medications. Symptomatic OA was defined as patient-reported symptoms and radiographic evidence of OA in the same joint. Logistic regression analyses were used to determine associations between covariates and falls at followup.

RESULTS

The odds of falling increased with an increasing number of lower-extremity symptomatic OA joints: those with 1 joint had 53% higher odds, those with 2 joints had 74% higher odds, and those with 3-4 OA joints had 85% higher odds. When controlling for covariates, patients who had symptomatic knee or hip OA had an increased likelihood of falling (adjusted odds ratio [aOR] 1.39, 95% confidence interval [95% CI] 1.02-1.88 and aOR 1.60, 95% CI 1.14-2.24, respectively).

CONCLUSION

This study reveals the risk for falls increases with additional symptomatic OA lower-extremity joints and confirms that symptomatic hip and knee OA are important risk factors for falls.

Gait variability before surgery and at discharge in patients who undergo total knee arthroplasty: a cohort study

This study aimed to determine gait ability at hospital discharge in patients undergoing total knee arthroplasty (TKA) as an indicator of the risk of falling. Fifty-seven patients undergoing primary TKA for knee osteoarthritis participated in this study. Gait variability measured with accelerometers and physical function including knee range of motion (ROM), quadriceps strength, walking speed, and the Timed Up and Go (TUG) test were evaluated preoperatively and at discharge from the hospital (1 month before and 5 days after surgery). All patients were discharged directly home at 5 days after surgery. Knee flexion of ROM, quadriceps strength, walking speed, and the TUG test results were significantly worse at hospital discharge than preoperatively (p < 0.001). However, gait variability was not significantly different before and after TKA. This result indicated that patients following TKA surgery could walk at hospital discharge as stably as preoperatively regardless of the decrease in physical function, including knee ROM, quadriceps strength, and gait speed after surgery.