Joint impairment and ambulation in the elderly

ACLD patients exhibit additional knee kinematic asymmetries at the speed level of healthy subjects

Anterior cruciate ligament deficiency (ACLD) patients tend to walk slowly but try to catch up with the speed level of healthy subjects daily. Exploring the effects of the walking speed level of healthy subjects on the ACLD patients’ knee kinematics is important to improving non-operative treatments and delaying the progression of posttraumatic knee osteoarthritis. This study aimed to explore whether healthy controls’ walking speed level leads to additional knee kinematic asymmetries in patients with ACLD. 27 ACLD patients and 29 healthy controls were recruited for the study. The ACLD patients walked at two levels of walking speed, including self-selected and healthy controls’ walking speed levels. A three-dimensional gait analysis system was used to collect their knee kinematic data. ACLD patients exhibited more kinematic asymmetries when walking at healthy controls’ walking speed level than at their self-selected speeds. The kinematic asymmetries included increased posterior tibial translation (4.6 mm) and anteroposterior tibial ROM (3.9 mm), abduction angle (1.5°), and distal tibial translation (3.2 mm) asymmetries (p < 0.05). Our findings are meaningful for developing non-operative treatment strategies for patients with ACLD. To get fewer knee kinematic asymmetries, self-selected walking speed could be suggested for patients with ACLD daily rather than the speed levels of healthy subjects.

Effects of transcutaneous electrical nerve stimulation (TENS) in people with knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of Transcutaneous Electric Nerve Stimulation (TENS) on pain, function, walking ability and stiffness in people with Knee osteoarthritis (KOA).

DESIGN

Systematic review and meta-analysis of randomized controlled trials.

METHODS

We searched MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), clinicaltrials.gov and Web of Science (last search November 2021) for randomized controlled trials. The Cochrane Risk of Bias Tool was used for the included studies, and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to interpret the certainty of results. Standardized Mean Differences (SMDs) and 95% confidence interval (CI) were calculated for meta-analysis.

RESULTS

Twenty-nine studies were found (1398 people, age range 54-85, 74% are female) and fourteen were included in this review. Intervention duration was divided as short term (immediately after intervention), medium term (<four weeks) and long term (≥ four weeks). Active TENS showed greater improvement in Visual Analogue Scale (VAS) than sham TENS.Combining TENS with other interventions produced superior outcomes compared with other interventions for VAS in all the terms. In the meanwhile, TENS combined with other interventions was superior to other interventions for the pain subgroup of Western Ontario and McMaster Universities Arthritis Index in the medium term and long term. TENS combined with other interventions was superior to other interventions for function in the medium term and long term.

CONCLUSION

TENS could significantly relieve pain, decrease dysfunction and improve walking ability in people with KOA, but it is not effective for stiffness.

Prevalence of Self-Reported Arthritis Among Elders From Latin America and the Caribbean and Among Mexican Americans From the Southwestern United States

This study examines the prevalence of self-reported arthritis and arthritis symptoms and their relationship to functional limitations in elders from Latin America and the Caribbean and in Mexican Americans from the southwestern United States. This study includes 8,122 elderly aged 60 and older from seven Latin America and Caribbean countries and 2,580 noninstitutionalized Mexican Americans aged 65 or older residing in the southwestern United States. The estimated prevalence of self-reported arthritis ranged from 23.8% in Mexico City to 55.6% in Havana. The prevalence of self-reported pain among arthritic subjects across all countries ranged from 30.7% in older Mexican Americans to 83.7% in Santiago. Arthritis was independently associated with any Activities of Daily Living and any Instrumental Activities of Daily Living limitation across the eight countries after controlling for relevant factors. Self-reported arthritis and arthritis symptoms are highly prevalent among elders from Latin America and the Caribbean and older Mexican Americans and is a significant cause of disability in all studied populations.

A classification study of kinematic gait trajectories in hip osteoarthritis

The clinical evaluation of patients in hip osteoarthritis is often done using patient questionnaires. While this provides important information it is also necessary to continue developing objective measures. In this work we further investigate the studies concerning the use of 3D gait analysis to attain this goal. The gait analysis was associated with machine learning methods in order to provide a direct measure of patient control gait discrimination. The applied machine learning method was the support vector machine (SVM). Applying the SVM on all the measured kinematic trajectories, we were able to classify individual patient and control gait cycles with a mean success rate of 88%. With the use of an ROC curve to establish the threshold number of cycles necessary for a subject to be identified as a patient, this allowed for an accuracy of higher than 90% for discriminating patient and control subjects. We then went on to determine the importance of each trajectory. By ranking the capacity of each trajectory for this discrimination, we provided a guide on their order of importance in evaluating patient severity. In order to be clinically relevant, any measure of patient deficit must be compared with clinically validated scores of functional disability. In the case of hip osteoarthritis (OA), the WOMAC scores are currently one of the most widely accepted clinical scores for quantifying OA severity. The kinematic trajectories that provided the best patient-control discrimination with the SVM were found to correlate well but imperfectly with the WOMAC scores, hence indicating the presence of complementary information in the two.

Prospective study of gait function before and 2 years after total knee arthroplasty

PURPOSE

To perform a prospective evaluation of gait before and 2 years after total knee arthroplasty (TKA) and examine the influence of comorbidity and other joint problems on gait characteristics and their improvement after TKA.

METHODS

One hundred and eleven patients scheduled for TKA took part (34 men, 65 ± 10 y; 77 women, age 68 ± 9 y). Gait velocity, cadence, and ground reaction force parameters were measured before and 2 years after surgery. Patients completed a questionnaire to rate their pain and other joint problems. Comorbidity was measured with the American Society of Anaesthesiologists (ASA) score.

RESULTS

Two years after TKA there were significant improvements (each p<0.05) in gait velocity and cadence and most of the ground reaction parameters, though forces during loading/unloading remained lower for the operated leg than for the contralateral leg. Higher comorbidity and other painful joints of the lower extremities/spine had a consistent, negative influence (p<0.05) on the absolute values achieved for the gait parameters although their improvement compared with baseline was independent of these factors.

CONCLUSIONS

Comorbidity and other joint problems negatively influenced gait performance. These confounders should be taken into account when setting realistic patient expectations and when interpreting the success of TKA in the individual patient. Improvement in gait is however still possible, within the bounds of concomitant comorbidity.

Test-retest reliability of 3D kinematic gait variables in hip osteoarthritis patients

OBJECTIVES

(1) to investigate the test-retest reliability of 3D gait analysis (3DGA) in hip Osteoarthritis (OA) patients; (2) to find the minimum number of gait trials needed to overcome intrinsic variability; (3) to check the accuracy of angles measured by the 3D system.

DESIGN

23 Patients suffering from hip OA with no other major disease were recruited. We evaluated the reliability of spatio-temporal variables and body angles (lower-limb joints, trunk and pelvis angles) during two sessions of 3DGA using intra-class correlation coefficients (ICC). The minimum number of trials needed to overcome intrinsic variability was evaluated using an exponential fit model and the Bland and Altman coefficient of repeatability (CoR). The accuracy of measurement was evaluated using a manual goniometer and the recording of 18 different angles.

RESULTS

Spatio-temporal variables and most of the kinematic joint and trunk angles calculated demonstrated good to excellent reliability (ICC from 0.77 to 0.97). This was not the case for pelvic angles. The fitting model combined with the CoR showed that 5-10 trials are sufficient to obtain good reliability [ICC>0.7; CoR<2 standard deviation (SD)] for most of the spatio-temporal variables. All body angles showed good reliability (ICC>0.7) and low CoR (<2 SD) after five trials except for the pelvic angles. The reliability of marker positioning was found to be good (ICC>0.7) to excellent (ICC>0.9). Differences between angles measured using 3DGA and angles measured with a manual goniometer were found to be less than one percent.

CONCLUSION

The present study shows that most of variables obtained using 3DGA in hip OA patients are reliable. Moreover, for most variables, 5-10 trials are needed to obtain good reliability and to overcome intrinsic variability, rather than 30 or more, thus improving the feasibility of measurement.

Physical and mental health of homebound older adults: an overlooked population

There are currently more than 38.9 million people aged 65 an older in the United States. Up to 3.6 million of these people are considered housebound and in need of home-based care. Although homebound status is not defined specifically, with a broad range of disability levels, it is evident that people who are homebound suffer from a multitude of medical and psychiatric illnesses. This review examines the current literature to identify the specific physical and psychiatric factors most responsible for older adults becoming and remaining housebound. Homebound older adults suffer from metabolic, cardiovascular, cerebrovascular, and musculoskeletal diseases, as well as from cognitive impairment, dementia, and depression, at higher rates than the general elderly population. The information in this review will explain the specific types of care the homebound population needs and discuss the care that could help ease their suffering and delay their entry into a nursing home or hospital.

Gait analysis as a quantifiable outcome measure in hip or knee osteoarthritis: a systematic review

OBJECTIVES

Kinematic gait analysis consisting of measuring gait parameters (stride length, gait speed, dynamic joint angles) is a potential outcome measure in osteoarthritis (OA). The aim of this study was to evaluate its psychometric properties.

METHODS

A systematic literature search was performed in PUBMED and the Cochrane database until January 2008 by selecting manuscripts assessing any psychometric property of gait analysis in knee or hip OA. Were assessed feasibility (cost, time and access); reliability; discriminant capacity by differences between OA and non-OA patients; construct validity by correlation between gait analysis and OA symptoms: pain or functional disability (Lequesne/WOMAC); and responsiveness by improvement of gait analysis after treatment of OA using effect size.

RESULTS

Among the 252 articles identified, the final analysis included 30 reports (i.e., 781 knee OA patients and 343 hip OA patients). Gait analysis presents various feasibility issues and there was limited evidence regarding reliability (three studies, 67 patients). Discriminant capacity showed significant reduction of gait speed, stride length and knee flexion in OA patients compared to healthy subjects. Few data were available concerning construct validity (three studies, 79 patients). Responsiveness of gait speed was moderate to large with effect size ranging respectively from 0.33 to 0.89 for total knee replacement, and from 0.50 to 1.41 for total hip replacement.

CONCLUSION

Available data concerning validity and reliability of kinematic gait analysis are insufficient to date to consider kinematic parameters as valuable outcome measures in OA. Further studies evaluating a large number of patients are needed.

Epidemiology of gait disorders in community-residing older adults

OBJECTIVES

To study the epidemiology of gait disorders in community-residing older adults and their association with death and institutionalization.

DESIGN

Community-based cohort study.

SETTING

Bronx County and the research center at Albert Einstein College of Medicine.

PARTICIPANTS

The Einstein Aging study recruited 488 adults aged 70 to 99 between 1999 and 2001. At entry and during annual visits over 5 years, subjects received clinical evaluations to determine presence of neurological or nonneurological gait abnormalities.

MEASUREMENTS

Prevalence and incidence of gait disorders based on clinical evaluations and time to institutionalization and death.

RESULTS

Of 468 subjects (95.9%) with baseline gait evaluations, 168 had abnormal gaits: 70 neurological, 81 nonneurological, and 17 both. Prevalence of abnormal gait was 35.0% (95% confidence interval (CI) = 28.6-42.1). Incidence of abnormal gait was 168.6 per 1,000 person-years (95% CI = 117.4-242.0) and increased with age. Men had a higher incidence of neurological gait abnormalities, whereas women had a higher incidence of nonneurological gaits. Abnormal gaits were associated with greater risk of institutionalization and death (hazard ratio (HR) = 2.2, 95% CI =1.5-3.2). The risk was strongly related to severity of impairment; subjects with moderate to severe gait abnormalities (HR = 3.2, 95% CI = 1.9-5.2) were at higher risk than those with mild gait abnormalities (HR = 1.8, 95% CI = 1.0-2.8).

CONCLUSION

The incidence and prevalence of gait disorders are high in community-residing older adults and are associated with greater risk of institutionalization and death.

Osteoarthritic knee or hip pain: possible indicators in elderly adults with cognitive impairment

Many elderly individuals with cognitive impairment (CI) suffer from chronic pain resulting from osteoarthritis (OA). They have diminished ability to communicate their pain to health care providers, and when pain is undetected, it may be untreated. A method of detecting chronic OA pain in elderly individuals with Cl and measuring treatment outcomes is thus urgently needed. This article examines indicators of chronic OA pain in cognitively intact elderly individuals that could be used to identify pain in elderly individuals with Cl. The review suggests that patients with severe knee or hip OA pain tend to show specific motor patterns, disturbances of gait patterns, and reduction of activity level. Therefore, these behaviors could serve as alternatives to verbal report of chronic pain in elderly individuals with Cl and knee or hip OA.

Pain, lower-extremity muscle strength, and physical function among older Mexican Americans

OBJECTIVE

To examine the relation between pain on weight bearing, lower-extremity muscle strength, and physical function among older Mexican Americans.

DESIGN

Cross-sectional study.

SETTING

Five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS

A population-based sample of 544 noninstitutionalized Mexican-American men and women age 71 years and older.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain on weight bearing, lower-extremity muscle strength, and physical function.

RESULTS

Of the 544 subjects, 244 (44.9%) reported pain on weight bearing. Mean muscle strength in men ranged from 9.3 kg for knee extension, 12.8 kg for hip flexion, to 13.0 kg for hip abduction. In women, mean strength ranged from 6.6 kg for knee extension, 9.5 kg for hip flexion, to 8.6 kg for hip abduction. Mean of physical function score was 70.7 for men and 60.6 for women. Pain on weight bearing was negatively associated with summary lower-extremity muscle strength only in women (-.05, P < .001) after controlling for all covariates. Pain on weight bearing was negatively associated with physical function in both men (-15.33, P < .001) and women (-11.03, P < .001), and lower-extremity muscle strength was positively associated with physical function in both men (37.77, P < .001) and women (73.50, P < .001), after controlling for all covariates.

CONCLUSIONS

Among older Mexican Americans, the presence of pain was associated with decreased muscle strength in women and decreased physical function in both men and women. High muscle strength was associated with high physical function in both men and women.

Neurological examination findings to predict limitations in mobility and falls in older persons without a history of neurological disease

PURPOSE

To estimate the prevalence of neurological signs and their association with limitations in mobility and falls in a sample of older persons without known neurological disease.

METHODS

A neurologist examined 818 participants from the InCHIANTI study who were aged > or =65 years and who did not have cognitive impairment, treatment with neuroleptics, and a history of neurological disease. Mobility was assessed as walking speed and self-reported ability to walk at least 1 km without difficulty. Participants were asked to report falls that had occurred in the previous 12 months.

RESULTS

Less than 20% (160/818) of participants had no neurological signs. Neurological signs were more prevalent in older participants and those with impaired mobility. When all neurological signs were included in sex-and age-adjusted multivariate models, 10 were mutually independent correlates of poor mobility. After adjusting for age and sex, the number of neurological signs was associated with progressively slower walking speed (P <0.001), a higher probability of reported inability to walk 1 km (P <0.001), and a history of falls (P <0.05).

CONCLUSION

Neurological signs are independent correlates of limitations in mobility and falls in older persons who have no clear history of neurological disease.

The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation

OBJECTIVES

To examine the relative effectiveness of electro-acupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) in alleviating osteoarthritic (OA)-induced knee pain.

DESIGN

Single-blinded, randomized controlled study.

SUBJECTS

Twenty-four (24) subjects (23 women and 1 man), mean age 85, were recruited from eight subsidized Care & Attention Homes for the elderly.

INTERVENTIONS

Subjects were randomly assigned to the EA, TENS, or control groups. Subjects in the EA group (n = 8) received low-frequency EA (2 Hz) on two acupuncture points (ST-35, Dubi and EX-LE-4, Neixiyan) of the painful knee for 20 minutes. Subjects in the TENS group (n = 8) received low-frequency TENS of 2 Hz and pulse width of 200 micros on the same acupuncture points for 20 minutes. In both treatment groups, electrical treatment was carried out for a total of eight sessions in 2 weeks. Eight subjects received osteoarthritic knee care and education only in a control group. All subjects were evaluated before the first treatment, after the last treatment, and at 2-week follow-up periods.

RESULTS

After eight sessions of treatment, there was significant reduction of knee pain in both EA group and TENS group, as measured by the Numeric Rating Scale (NRS) of pain (p < 0.01). Prolonged analgesic effect was maintained in the EA and the TENS groups at a 2-week follow-up evaluation. The Timed Up-and-Go Test (TUGT) score of the EA group was significantly lower than that of the control group (p < 0.05), but such change was not observed in the TENS group.

CONCLUSIONS

Both EA and TENS treatments were effective in reducing OA-induced knee pain. EA had the additional advantage of enhancing the TUGT results as opposed to TENS treatment or no treatment, which did not produce such corollary effect.

Brain white matter lesions detected by magnetic resonance [correction of resosnance] imaging are associated with balance and gait speed

OBJECTIVE

To investigate the relations between premorbid and current mental ability, mood, and white matter signal abnormalities detected by T2 weighted brain magnetic resonance imaging (MRI) and impairment of balance and mobility in older adults.

METHODS

97 subjects from the Aberdeen 1921 birth cohort underwent brain MRI, evaluation of balance, and measurement of gait speed. White matter hyperintensities detected on T2 weighted MRI scans were rated by three independent raters on three variables: white matter lesions; periventricular lesions; and brain stem lesions.

RESULTS

Decreased gait speed was correlated with impaired visual acuity (p = 0.020), shorter stature (p = 0.008), a lower childhood IQ (p = 0.030), a lower current Raven's progressive matrices score (Raven score) (p < 0.001), a higher hospital anxiety and depression scale (HADS) score (p = 0.004), and an increased grade of brain stem lesions on MRI. Inability to balance was correlated with Raven score (p = 0.042), brain stem lesions (p = 0.003), white matter lesions (p = 0.003), and periventricular lesions (p = 0.038). Binary logistic regression identified brain stem lesions (odds ratio (OR) 0.22; 95% confidence interval 0.09 to 0.54) and HADS depression score (OR 0.75; 0.58 to 0.97) as the only significant associations with balance. Structural equation modelling detected an association between two latent traits representing white matter disease and an integrating function, respectively.

CONCLUSIONS

In this cohort, white matter lesions, periventricular lesions, and brain stem lesions were associated with impaired balance. Current mental ability was strongly related to gait speed. There appears to be a concordance between motor skills and intellect in old age, which is degraded by white matter disease.

Common chronic diseases and general impairments as determinants of walking disability in the oldest-old population

OBJECTIVES

Walking disability affects older people's autonomy and well-being. We investigated the relative effect of common chronic diseases and general impairments on walking disability in the general oldest-old population.

DESIGN

Population-based cohort study.

SETTING

Leiden 85-plus Study, the Netherlands.

PARTICIPANTS

Five hundred ninety-nine persons aged 85, response rate 87%.

MEASUREMENTS

Walking disability was assessed using a 6-meter walking test. Persons with a walking time below the 25th percentile and those who were physically unable to perform the walking test were categorized as having a walking disability. Information on common chronic diseases was obtained from records of subjects' general practitioners and pharmacies. General impairments were assessed with functional tests and standardized questions during face-to-face interviews. We expressed the effect of common chronic diseases and general impairments as the population attributable risk (PAR), indicating how much disability can be prevented when the identified risk factor is eliminated from the population.

RESULTS

One hundred ninety-two persons (33%) had a walking disability. This disability was highly associated with poor mobility in daily life, recurrent falls, and poor well-being (all P <.001). Of the common chronic diseases, stroke, angina pectoris, diabetes mellitus, and hip fracture but not arthritis contributed most (PARs from 6% to 15%) to walking disability in the population at large. General impairments had higher prevalence rates and higher PARs than common chronic diseases. Cognitive impairment, depressive symptoms, and dizziness upon rising contributed most (PARs between 22 to 27%) to walking disability. In multivariate regression analyses of all common chronic diseases and general impairments, associations remained significant.

CONCLUSION

Within the general oldest-old population, general impairments contribute more substantially to walking disability than do common chronic diseases. The diagnosed diseases did not explain the impairments that led to walking disability. Especially in the oldest old, clinicians should focus not merely on common chronic diseases but particularly on general impairments as targets for diagnostic analysis and treatment to decrease walking disability.

Characteristics of housebound elderly by mobility level in Japan

The purpose of the present study was to describe characteristics of the housebound elderly by their mobility levels. Disabled elderly people in Japan were interviewed at home by nurses. Housebound status was defined as people who left the house less than once a week. Characteristics of housebound elderly were compared with non-housebound elderly by three mobility levels: (i) Non-walking group (n=72); 5 m-walking group (n=153); going-by-bus group (n=96). Housebound elderly were not found in the going-by-bus group. Among the elderly in the non-walking group, the cognitive function of the housebound elderly was significantly lower and the housebound elderly were less well cared for; however, their caregivers rated their caregiving burden significantly lower than did caregivers of the non-housebound elderly. Among those in the 5 m-walking group, the autonomy and social networks of the housebound elderly were significantly less than for the non-housebound. The characteristics of housebound elderly showed differences by mobility levels.

Impact of pain on disability among older Mexican Americans

BACKGROUND

Joint pain is a very common complaint among elderly persons and may lead to functional disability. The purpose of this study is to estimate the prevalence of self-reported pain on weight bearing and its impact on the 2-year incidence of limitation in lower-body activities of daily living (ADL) in initially nondisabled Mexican American elderly subjects.

METHODS

We studied a probability sample of 2167 noninstitutionalized Mexican American men and women aged 65 or older residing in five Southwestern states. Subjects were asked about pain on weight bearing, ADL, depressive symptomatology, and the presence of chronic diseases. The body mass index was computed using measured height and weight. Finally, a three-task (tandem balance, 8-foot walk, and repeated chair stands), performance-based, lower-body function test was performed.

RESULTS

The overall prevalence of pain on weight bearing in the sample was 31.9%, with 37.7% for women versus 24.0% for men (p <.001). The most prevalent sites of pain were knees (14.7%), followed by ankle/feet (12.1%). In a logistic regression analysis, pain was a significant independent predictor of subsequent disability and of the inability to perform tandem balance, 8-foot walk, and repeated chair stands.

CONCLUSIONS

Pain on weight bearing is prevalent among older Mexican Americans and is a major independent risk factor for subsequent disability.

Chronic pain in the elderly: occupational adaptation as a means of coping with osteoarthritis of the hip and/or knee

OBJECTIVE

To determine whether elderly individuals with chronic pain as a result of osteoarthritis of the hip and/or knee would report adaptations to their activities, or occupational adaptations, as a coping response to pain and, if so, to describe these adaptations and their relation to chronic pain, functional difficulty, depression, social support, and life satisfaction.

DESIGN

Thirty elderly individuals completed rating scales and a structured questionnaire designed to measure occupational adaptation and the importance of activity.

SETTING

Participants were community-dwelling elderly individuals and were interviewed in their homes or in a research office setting.

PATIENTS

Consecutive orthopedic surgeon, family physician, or Arthritis Society patients, whose names were provided with the patient's consent, to the researcher.

RESULTS

Individuals reported two approaches to occupational adaptation: they changed how they performed personal activities of daily living that they rated as most important and they stopped performing a number of avocational activities that they rated as less important. Statistically significant correlations were found among occupational adaptation, pain, depression, and difficulty with functioning. These variables were inversely related to life satisfaction.

CONCLUSIONS

This sample of elderly individuals with chronic pain described occupational adaptations, or adaptations to "doing," as a means of coping with their chronic pain. There appeared to be a relation among pain, functional difficulty, depression, social support, and occupational adaptation. Additional research to increase the understanding of occupational adaptation as a means of coping with chronic pain is warranted.

Osteoarthritis in older adults

OBJECTIVE

This review highlights the clinical and pathophysiologic features of osteoarthritis (OA) of the peripheral joints and discusses the current and future management options for this common but potentially disabling disease. This article also addresses the contribution of osteoarthritis to falls and functional impairment in older people.

DESIGN

A critical assessment of current data regarding the pathogenesis of osteoarthritis, current and future therapies, and the potential role of OA in falls and functional impairment in older people.

CONCLUSIONS

Osteoarthritis is the most prevalent articular disease in older adults. Disease markers that will detect early disease and allow early intervention with pharmacologic agents that modify, if not halt, disease progression are much needed, but they are presently unavailable. Current management should include safe and adequate pain relief using systemic and local therapies and should also include medical and rehabilitative interventions to prevent, or at least compensate for, functional deficits. Although OA can result in impaired mobility and lower extremity function, its contribution as a cause of recurrent falls or impaired self-care, relative to other comorbid conditions, remains ill-defined. Further analysis of the determinants of disability, loss of mobility and falls in older patients with OA is needed.

Predictors of decline in manual performance in older adults

OBJECTIVE

To determine factors that predict decline in manual performance using a multivariate model of determinants of functional limitation.

DESIGN

Longitudinal observational study.

SETTINGS

Ambulatory general medicine clinics, residences of homebound individuals, and a continuing care retirement community.

PARTICIPANTS

Subjects were 485 persons more than 60 years of age and included continuing care retirement community (CCRC) residents (n = 215), chronically homebound older persons (n = 65), and ambulatory older adults (n = 205). Mean age at baseline was 78 years.

MEASUREMENT

Independent variables included demographics, physician measures of upper-extremity joint impairment, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variable was 2-year decline in timed manual performance below a threshold associated with need for long-term care services.

RESULTS

The proportion of subjects who exceed a Timed Manual Performance Test threshold of 350 seconds increased slowly from baseline through Year 4 for all age groups but rose rapidly from Year 4 to Year 6 for the oldest group (> 85 years at baseline). Using a discrete survival model, we found that age, education, grip strength, and psychological status predicted crossing the manual performance threshold within a 2-year period.

CONCLUSIONS

The findings, coupled with earlier findings that upper extremity joint impairment predicted both grip strength and manual performance, suggest that joint impairment may be an important risk factor for future functional limitation. Since diminished hand function has been shown to predict dependency, development and testing of interventions to maintain or restore upper extremity joint function and reduce pain would appear to be a high research priority.

Predictors of change in walking velocity in older adults

OBJECTIVE

To determine factors that predict change in walking velocity in older people using a multivariate model.

DESIGN

Longitudinal observational study.

SUBJECTS

A total of 588 persons older than age 60, including subjects residing in a continuing care retirement community (CCRC) (n = 248), and homebound (n = 79) and ambulatory (n = 261) subjects. Mean age at baseline = 77.

MEASUREMENT

Independent variables included demographics, physician measures of lower-extremity joint impairment and other musculoskeletal and neurological variables, comorbidities derived from physical examination and chart abstract, self-assessed arthritis pain, depression, and anxiety. The major dependent variables were 2- and 4-year decline in walking velocity below a threshold associated with nursing home placement.

MAIN RESULTS

From baseline to Year 4, median walking velocity declined from 61.8 to 53.0 m/min, and the proportion of subjects above a threshold value of 11.5 m/min declined from 95.3% to 80.4%. Age, joint impairment, and weakness of quadriceps, measured at baseline, predicted 2-year and 4-year decline in walking velocity.

CONCLUSIONS

The findings indicate that joint impairment and quadriceps strength contribute significantly to crossing a clinically significant threshold in walking velocity among older people over time. Future research is needed to determine whether these risk factors can be modified through preventive interventions such as muscle-strengthening exercises and pain medication.

The prevalence and impact of arthritis in older persons

OBJECTIVE

To review that what is known about the prevalence and impact of arthritis on disability and health care expenditures incurred by older persons.

METHODS

The current prevalence estimates of osteoarthritis and osteoporosis in the US are examined, and what is known about the relationship of arthritis, broadly defined to disability, and the impact of arthritis-specific disability on home care and nursing home use by older persons are reviewed.

RESULTS

Arthritis is a major contributor to disability among older people and is especially disabling for older women, who have higher prevalence rates and greater disability than their male counterparts. Studies of the relationship of arthritis to long-term care use indicate that arthritis can be a risk factor insofar as it can cause disability that results in homeboundedness, which, in turn is a risk factor for nursing home use. It is possible that previous analyses that included arthritis and disability as competing risk factors for nursing home use underestimate the contribution of arthritis because arthritis is a risk factor for disability; thus, the two variables may be strongly correlated.

CONCLUSIONS

More study is needed to understand the contribution of sex to prevalence of arthritis and severity of arthritis-specific disability. The route through which arthritis affects long-term care use also needs careful longitudinal study. If arthritis is confirmed to be a major risk factor for disability that leads to long-term care use, the development and testing of interventions to prevent/minimize arthritis-specific disability should be a major research priority.

A method for scoring the pain map of the McGill Pain Questionnaire for use in epidemiologic studies

Identifying and quantifying the location of pain may be important for understanding specific functional impairments in elderly populations. The purpose of the present analysis was two-fold: first, to describe the reliability of a scoring method for the McGill Pain Map (MPM), and second, to validate the method of scoring the MPM as a tool for assessing areas of body pain in an epidemiologic study. In interviews performed at the subjects' homes, 411 community dwelling Mexican-American and non-Hispanic white subjects aged 65-74 from the San Antonio Longitudinal Study of Aging (SALSA) were asked to describe the location of their pain on the map of the human body included in the McGill Pain Questionnaire. The location of pain was scored by overlaying the survey figures with a MPM template divided into 36 anatomical areas. Inter- and intra-rater agreement among three raters was measured by calculating a kappa statistic for each of the body areas, and an intraclass correlation coefficient for the total number of painful areas (NPA). Internal validity was measured by Spearman's rho between the NPA and the Present Pain Index (PPI) and Pain Rating Index (PRI) of the McGill Pain Questionnaire, and external validity by correlation between NPA and the Perceived Health (PH), Amount of Bodily Pain (APB), and Pain Interference with Work (PIW) items of the Medical Outcomes Study, and the Perceived Physical Health (PPH) question of the San Antonio Heart Study. Average inter-rater agreement for individual MPM areas was 0.92 +/- 0.01, and average agreement for NPA was 0.96 +/- 0.01. Intra-rater agreement for individual areas averaged 0.94 +/- 0.01, and for NPA = 0.99 +/- 0.001. Pain in one or more areas was present in 47.7% of the subjects. For the whole sample, correlations between NPA and the validation indices were: PPI (0.91), PRI (0.89), PH (0.25), ABP (0.64), PIW (0.49), and PPH (0.20). Among the 196 subjects with pain, correlations were: PPI (0.34), PRI (0.34), PH (0.19), ABP (0.21), PIW (0.38), and PPH (0.19)-p < 0.01 for all correlations. In conclusion, we have developed a reliable method of scoring the MPM and have shown evidence of its validity in a community-based sample of elderly subjects. Patterns of painful body areas may be associated with specific diseases and functional impairments.

The determinants of walking velocity in the elderly. An evaluation using regression trees

OBJECTIVE

To determine predictors of walking velocity in the elderly.

METHODS

Five hundred thirty-two persons from 3 cohorts of elderly persons (retirement community, ambulatory care medical clinic, or chronically homebound population) performed a 10-foot (for the homebound subjects) or 50-foot (for all other subjects) walk time test and underwent a standardized interview, chart review, and clinical examination. The 73 independent variables that were evaluated included demographic, musculoskeletal, neurologic, psychologic, and other comorbidity items. Least-squares and least-absolute-deviation regression tree analyses were performed to determine the strongest predictive factors associated with walking velocity.

RESULTS

Sampling cohort (homebound versus non-homebound), quadriceps strength, hip flexion strength, lumbosacral spine impairment, lower joint impairment, and education were found to be associated with walking velocity. Joint pain measures were not associated with walking velocity.

CONCLUSION

Muscle strength variables are better predictors of walking velocity than are joint pain variables. Thus, clinical trials and observational studies using walking velocity as an outcome need to take into consideration the influence of muscle strength on this outcome variable.