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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 15
| Issue : 2 | Page : 144-150 |
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Magnitude of knee osteoarthritis and associated risk factors among adult patients presenting in a family practice clinic in Nigeria
Lawrence A Adebusoye1, Adetola M Ogunbode1, Temitope O Alonge2
1 Consultant Family Physician, University College Hospital, Ibadan, Nigeria
2 Consultant Orthopaedic and Trauma Surgeon, University College Hospital, Ibadan, Nigeria
| Date of Web Publication | 24-Dec-2013 |
Correspondence Address:
Adetola M Ogunbode
Family Medicine Department, University College Hospital, Ibadan
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2276-7096.123607
Background: Knee osteoarthritis is a chronic medical condition of public health importance in this setting. It is mostly diagnosed when preventive measures are no longer practicable due to reliance on the radiological diagnosis.
Objectives: To determine the magnitude and risk factors associated with knee osteoarthritis among adult patients presenting at the University College Hospital, Ibadan, Nigeria.
Materials and Methods: This cross-sectional study used a semi-structured questionnaire to interview 400 respondents. Knee osteoarthritis was diagnosed clinically using the American College of Rheumatology (ACR) criteria.
Results: The point prevalence of knee osteoarthritis was 11.5%. Increasing age, female gender, marital status, low educational status, financial dependency, poor income, obesity, previous knee injury, epigastric pain, peptic ulcer disease, varus deformity of the knee, and poor health status were significantly associated with knee osteoarthritis. Logistic regression analysis showed increasing age (OR = 2. 874, CI = 1. 294-6.381), history of epigastric pain (OR = 57. 044, CI = 1. 693-192.24) and varus deformity of the left knee (OR = 3. 012, CI = 1. 063-8.547) to be the most significant factors associated with knee osteoarthritis.
Conclusion: The magnitude of clinical knee osteoarthritis is high among respondents in this hospital-based study. Doctors in primary care should screen patients at first-contact to detect osteoarthritis early and manage appropriately. Keywords: Family practice clinic, knee osteoarthritis, Nigeria, risk factors
How to cite this article:
Adebusoye LA, Ogunbode AM, Alonge TO. Magnitude of knee osteoarthritis and associated risk factors among adult patients presenting in a family practice clinic in Nigeria. J Med Trop 2013;15:144-50 |
How to cite this URL:
Adebusoye LA, Ogunbode AM, Alonge TO. Magnitude of knee osteoarthritis and associated risk factors among adult patients presenting in a family practice clinic in Nigeria. J Med Trop [serial online] 2013 [cited 2023 Jun 6];15:144-50. Available from: https://www.jmedtropics.org/text.asp?2013/15/2/144/123607 |
| Introduction | |  |
Osteoarthritis in general is defined as a constellation of symptoms and signs in the joints which had evolved as a result of defective integrity of the articular cartilage with or without changes in the underlying bone and the joint margins. [1] It is a common disease of the aged population and one of the leading causes of disability. [2] Knee osteoarthritis (OA) is one of the frequent and functionally impairing disorders of the musculoskeletal system, [3] and it is one of the most common non-communicable conditions worldwide. [4]
The incidence of knee OA is rising with the increasing average age of the general population. [2] In the report by Akinpelu et al., in 2009, the first community-based study on symptomatic knee OA in English medical literature, among 1044 participants recruited through a multi-stage cluster sampling technique, the estimated point prevalence of knee OA was 19.6%. [5] In the study, the highest prevalence of knee OA (48.3%) was observed among the elderly with a female preponderance (1.2:1). [5] Similarly, another Nigerian study in 2005 reported a higher proportion of knee OA among female participants. [6]
The aetiology of knee OA is believed to be multifactorial, and the following (modifiable and non-modifiable) risk factors have been identified: Heredity, physical workload and obesity. [7] A retrospective study in 2005 on 164 patients attending the Orthopaedic clinic revealed a significant association of OA with the female gender and body mass index. [6] In the prospective cohort study by Lohmander et al., in 2009, among 27 960 participants, the authors concluded that body mass index (BMI) was significantly associated with severe knee osteoarthritis and had the strongest relative risk gradient with the adjusted relative risk being 8.1 (95% CI 5.3-12.4). [8] Other risk factors include trauma to the joint due to repetitive movements, in particular squatting and kneeling. [2] Advanced age [9] and occupational risk factors [3] such as heavy lifting and carrying of weights are also strongly related to the development and progression of diseases of the knee joint.
As a disability-causing chronic medical condition, knee OA has recently acheived great public health importance in developing countries. Healthcare workers see patients with knee OA at first-contact when measures of prevention are no longer practicable due to reliance on radiological techniques. In the past, the diagnosis of OA had been based on radiologic features rather than clinical features. [1] This led to the formation of a subcommittee on classification criteria of OA with a mandate to develop a criteria based on the medical history, physical examination, laboratory findings, and radiological examinations. [1] For resource constrained developing countries like Nigeria, dependence on radiological methods for the diagnosis of knee OA would not be economically feasible, hence the need to rely on clinical-based diagnostic criteria such as the American College of Rheumatology (ACR) as well as physical examination of the knee. [5]
To the best of our knowledge, this is the first hospital-based study on the clinical diagnosis of knee OA in Nigeria. The aim of this study was to determine the prevalence and the risk factors which are associated with knee OA among adult patients attending the General Outpatient clinic, University College Hospital (UCH), Ibadan, Nigeria.
| Materials and Methods | | |
Study Site
General Outpatient (G.O.P) clinic of the Family Medicine Department of the University College Hospital (UCH), Ibadan, Nigeria was the site of this study. UCH is the oldest tertiary hospital in Nigeria and has patients referred from all parts of Nigeria. However, many come without referrals and these are triaged and managed by family physicians, while those requiring further specialist care are referred to other specialty clinics within the health facility.
Study Design
This was a cross-sectional study.
Study Population
Four-hundred patients aged 18 years and above were recruited between January 15 th and March 30 th , 2012 at the G.O.P clinic, UCH. Only those who gave their informed consent were included, while those who were too ill to participate in the study were excluded.
Sampling Technique
Respondents were selected consecutively.
Procedure
A semi-structured questionnaire was used to conduct the interview. The questionnaire was pre-tested to determine its clarity and comprehensiveness to address the set objectives of the study and necessary amendments were then made. Information on the respondents' socio-demographic characteristics, physical, and lifestyle habits were obtained. Their past medical history and self-rated health were also obtained. Anthropometric measurements of height, weight, knee-height, right and left leg lengths were carried out. Also included were the body circumferences of waist, hip, calf and both knees.
The American College of Rheumatology (ACR) clinical classification of knee osteoarthritis was used to make the clinical diagnosis of osteoarthritis. ACR has been used in studies in many countries including Nigeria. [5] It has a sensitivity of 94% and specificity 93%. [10] ACR comprised five criteria which are: (1) Knee pain for most days of last month, (2) Crepitus on active joint motion (Noisy/crackling noise in the knee), (3) Morning stiffness of at least 30 min in duration, (4) Age > 38 years and (5) Bony enlargement of the knee on examination. Respondents were diagnosed with clinical osteoarthritis if items 1, 2, 3, 4, or 1, 2, 5 or 1, 4, 5 were present. [11]
Anthropometric Measurements
Height was recorded to the nearest 0.1 meters with a measurement stand (stadiometer) which was positioned on a flat surface. The respondents were asked to remove their shoes, and their heels were positioned against the vertical calibrated stand with their scapula, buttocks and heels resting against the wall and the female respondents were asked to remove their headwear. Weight was measured with a weighing scale manufactured by Hana, China and was recorded to the nearest 0.1 kg. Respondents stood on the weighing scale which was placed on a flat horizontal surface, after the removal of any weighty garments and shoes. The readings were made by the researcher standing in front of the respondents and the zero mark was checked after every reading for accuracy.
Ethical Consideration
This study was not invasive. Permission was received from the head of Family Medicine Department, UCH, Ibadan, while written informed consent was obtained from each respondent before administration of questionnaires.
Follow-Up
The primary health complaints of the respondents were addressed before the interview and those needing further treatment were referred to other specialty clinics within the facility.
Data Analysis
Administered questionnaires were checked, sorted and coded serially after each study day. SSPS (version 16) was used for data entering, cleaning and analysis. Descriptive statistics were employed for the socio-demographic, lifestyle, and self-reported health status of the respondents. Chi-square statistics was used to assess the association between categorical variables. The P-value of significance was set at < 0.05. Logistic regression was used to explore the relationship between the socio-demographic, lifestyle and other risk factors associated with knee OA.
| Results | | |
There were 238 (59.5%) female and 162 (40.5%) male respondents, with female to male ratio of 1.5 to 1. The respondents mean age were 47.3 ± 16.4 years (range 18-90 years). Their median monthly income was 20 000 Naira ($133.33) with Inter-quartile range (IQR) of 36 000 Naira ($240.00). The median number of children of the respondents was 4 with IQR of 4 (range 0 - 16). The mean duration of time spent in the present occupation by the respondents was 16.1 ± 11.9 months (range 1-60 months) and on average, they walked 350 metres daily (range 50-1250 metres).
The largest proportion of respondents 93 (23.2%) were aged above 60 years. Marital status showed that the majority 257 (64.2%) were married and 232 (58.0%) had completed the 9 years mandatory basic education (that is primary and junior secondary school) in Nigeria. Elementary occupations such as cleaners and helpers; agricultural, forestry and fishery labourers; labourers in construction, manufacturing and transport; food preparation assistants; street and related sales and service workers and refuse workers were the commonest occupational activities among the respondents. The largest proportion of respondents 195 (48.8%) were engaged in employment and a few 44 (11.0%) were unemployed. The minority 92 (23.0%) was living below the World Bank's defined poverty line of $1.25 per day. [12] The majority of the respondents 240 (60.0%) lived with their spouses and more of the men were financially self-supporting whilst more of the women got support from their children and grandchildren. This is shown in [Table 1].
Forty-six (11.5%) respondents were diagnosed with clinical knee osteoarthritis using the ACR criteria. [Table 2] shows the socio-demographic characteristics of the respondents by clinical knee osteoarthritis. The proportion of respondents with clinical knee osteoarthritis rose significantly from 1.3% in those less than 30 years to 26.9% in respondents aged 60 years and above (χ2 = 38.864, P < 0.0001). Knee OA in female respondents was significantly higher compared with their male counterparts 15.1% vs. 6.2% (χ2 = 7.592, P = 0.006). There was a significant association between marital status and clinical knee osteoarthritis with highest proportion found in 26.6% of those who were separated, divorced or widowed (χ2 = 22.489, P < 0.0001). Significantly, the proportion of respondents with clinical knee osteoarthritis decreased with educational status from 26.8% in those with no formal education to 2.1% in those with tertiary education (χ2 = 29.443, P < 0.0001). Respondents living below the poverty line had a higher proportion of clinical knee osteoarthritis compared with those living above the poverty line 22.8 vs. 7.5% (χ2 = 11.784, P = 0. 001). The highest proportion of clinical knee osteoarthritis was observed in respondents who lived (25.0%) (χ2 = 16.164, P = 0.001) and depended financially (28.0%) (χ2 = 40.434, P < 0.0001) on their children/grandchildren. Respondents with the family history of knee pain had a higher proportion of clinical knee osteoarthritis compared with those with no family history of knee osteoarthritis without a statistical difference 14.0 vs. 9.5% (χ2 = 2.041, P = 0.153). | Table 2: Socio-demographic characteristics of respondents with clinical knee osteoarthritis
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The risk factors associated with clinical knee osteoarthritis were depicted in [Table 3]. The highest proportion of respondents (22.9%) with clinical knee OA who were obese confirms a strong statistical association between BMI and clinical knee osteoarthritis (χ2 = 18.082, P < 0.0001). Respondents with a history of a previous knee injury and previous knee procedure/surgery had a higher proportion of clinical knee osteoarthritis compared with those without these histories (20.6 vs. 9.6%; χ2 = 6.649, P = 0. 010) and (17.6 vs. 10.9%; χ2 = 1.380, P = 0.240), respectively. Higher proportion of respondents who presented with the history of first episode of knee pain were diagnosed with clinical knee OA compared with those not reporting this history (21.5 vs. 9.6%) (χ2 = 7.685, P = 0. 006). Similarly, those who presented with, upper abdominal pain (41.7% vs 10.6%) and treatment for peptic ulcer disease [PUD] (20.0 vs. 10.3%) had a significantly higher proportion of clinical knee OA compared with those without these histories, (χ2 = 11.062, P = 0. 001) and (χ2 = 4.057, P = 0. 044), respectively. However, respondents who did not drink alcohol (11.5%), smoke tobacco (11.6%), take vitamins (15.3%) and who were not engaged in regular exercise (14.7%) had a higher proportion of clinical knee OA than those who engaged in these habits. Respondents with varus deformity of the knees had the highest proportions of clinical knee osteoarthritis of right (28.%) and left (70.0%) legs compared with those with straight or valgus deformity. There was a strong significant association between varus deformity of the knees and clinical osteoarthritis (Right; χ2 = 16.926, P < 0.0001 and Left; χ2 = 39.597, P < 0.0001).
Logistic regression analysis showed past history of abdominal pain (OR = 57.044, CI = 1.693 - 192.20; P = 0.024), increasing age (OR = 2.874, CI = 1.294 - 6.381: P =0.010) and left varus deformity (OR = 3.012, CI = 1.063 - 8.547; P = 0.038) were the most significant risk factors to developing clinical knee OA. [Table 4]. | Table 4: Logistic regression analysis of significant factors associated with knee osteoarthritis
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| Discussion | | |
In resource-constrained countries, making the diagnosis and caring for persons with knee osteoarthritis is an arduous task due to the reliance on radiologic diagnosis. Most studies in these settings used the radiologic criteria in estimating the burden of knee OA. Conservatively, to make a radiologic diagnosis of knee OA in this resource constrained setting cost $15 in a country where the minimum wage is $4 per day, thus it is difficult to request for one. Therefore, it is not surprising that most sufferers present late to the clinic. Highly sensitive and specific clinical diagnostic tools like the American College of Rheumatology (ACR) criteria are very useful in making an early diagnosis of knee OA, hence its use in our study.
This hospital-based study found 11.5% of respondents with clinical knee OA. This proportion was lower than that of a Nigerian community based study (19.6%) in which symptomatic diagnostic criteria were used. [5] Like in most studies on knee OA, age was a significant factor for developing the disease. [13] The proportion of respondents with clinical knee OA increased significantly from 1.3 to 26.9% from those less than 30 years to those above 60 years. Akinpelu et al., in 2007, in a study carried out among 1029 patients referred to physiotherapy out-patient clinics, reported similar findings. [14] Hinton et al., 2002 also reported that age older than 50 years was a risk factor for osteoarthritis. [9] This is not surprising as risk of knee joint damage due to the repetitive wear and tear would increase with advancing age. Most patients noticed and reported pain and other symptoms of knee OA after the fifth decade of life. [15],[16] Clinical knee OA was significantly more prevalent among the female respondents in this study by a ratio 2.4 to 1. This was also observed in other Nigerian studies in which Oyemade [15] and Akinpelu et al.[14] reported a female to male ratio of 3 to 2 and 3.5 to 1, respectively. The reasons for the female preponderance could be attributed to a myriad of factors including hormonal factors. [17] The loss of oestrogen during menopause has been found to contribute significantly to the development of knee OA in these women. [17] Insulin-like growth factor 1 (IGF-1) is important in maintaining muscle function via protein synthesis, bone density, and regulation of fat metabolism. The level of IGF-1 has been observed to decline more significantly in women with knee OA compared with those without the disease. [17]
We found marital status to be a significant risk factor associated with clinical knee OA with the greatest proportion seen in those who were either separated, divorced or widowed, P <0.0001. This observation may be due to increased age as respondents who were either divorced or widowed are likely to be much older than those who were single. Significantly in this study, low educational level was found to be a risk factor to developing knee OA. The proportion of respondents with clinical knee OA decreased from 26.8% in those with no formal education to 2.1% in those with tertiary education. Sahyoun et al., 1999 reported an association between arthritis and education with the risk of developing arthritis being nearly 50% higher for women with less than a high school education (RR = 1.48, 95% CI 1.21-1.81). [18] Individuals with low education are more likely to be older, poorer, smoke tobacco and engaged in more physically demanding occupations requiring lifting of heavy loads and repetitive joint movements. [19] The finding of the highest proportion of respondents with knee OA living their children/grandchildren may be due to the fact that knee OA commonly affect women who often live their children/grandchildren in their old age.
Obesity was strongly associated with clinical knee OA among the respondents.The risk of osteoarthritis increased in people with body mass index (BMI) above 25 kg/m 2 , but was greatest in women whose BMI values were above 32 kg/m 2 . [18] Ojoawo, 2002 also reported that using BMI, more patients above 51 years were affected with knee OA. [20] Similarly, Lin et al., 2010 recorded a strong association between BMI and knee OA. [7] Obesity places a heavy load on the knee joints which leads to increased stress and possible breakage of the articular cartilage. [21] It has been estimated that a force of 3 to 6 times the body weight is placed on the knee joints while walking, therefore an increase in one's body weight will increase the force on the knee joints tremendously. [21]
A higher proportion of respondents in this study with previous knee injury and knee procedure/surgery had clinical knee OA. Knee injury was found to be associated with lateral and medial compartment knee OA in the report by Lin et al., 2010. [7] Of the respondents, 15.7% reported previous knee injury. Respondents who did not consume alcohol, smoke tobacco, take vitamins and did not engage in regular exercise had more of clinical knee OA than those who engaged in these habits. Surprisingly, respondents in this study those who did not smoke tobacco were found to have more clinical knee OA than those who smoked tobacco. This is in tandem with Sahyoun's 1999 report in which smoking was not found to be significantly associated with arthritis. [18] Varus deformity of the knees was the commoner deformity seen among respondents with knee OA in this study compared with those with valgus deformity. This was similar to an African study using ACR criteria in which varus knee malalignment was a risk factor for the knee OA. [22] The abdominal pains and PUD in the respondents may be related because treatment of knee OA includes the use of NSAIDS that cause gastritis. Increasing age, history of abdominal pain, and left varus deformity were the most significant risk factors for developing clinical knee osteoarthritis using logistic regression analysis.
| Conclusion | | |
This study has shown modifiable factors such as poverty, low education, obesity, peptic ulcer disease, and non-engagement in physical exercise to be significantly associated with knee OA.
| Recommendations | | |
The use of clinical diagnostic criteria for knee OA especially in the primary care setting would afford early diagnosis of osteoarthritis. Healthcare workers should encourage their patients to adopt lifestyle modifications such as engagement in regular exercise and weight moderation.
| References | | |
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[Table 1], [Table 2], [Table 3], [Table 4]
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