Degenerative joint disease in a Jamaican rural population

Is the Planus Foot Type Associated With First Ray Hypermobility?

Background:

Many foot pathologies have been associated with foot type. However, the association of first ray hypermobility remains enigmatic. The purpose of this study was to investigate first ray hypermobility among participants with planus and rectus foot types and its influence on static measures of foot structure.

Methods:

Twenty asymptomatic participants with planus (n = 23 feet) and rectus (n = 17 feet) foot types were enrolled. Several parameters of static foot structure (arch height index, arch height flexibility, first metatarsophalangeal joint flexibility, and first ray mobility) were measured. Participants were further stratified into groups with nonhypermobile (n = 26 feet) and hypermobile (n = 14 feet) first rays. First ray mobility ≥8 mm was used to define “first ray hypermobility”. Generalized estimating equations, best-fit regression lines, and stepwise linear regression were used to identify significant differences and predictors between the study variables

Results:

Overall, 86% of subjects categorized with first ray hypermobility exhibited a planus foot type. Arch height flexibility, weightbearing first ray mobility, and first metatarsophalangeal joint flexibility showed no significant between-group differences. However, weightbearing ray mobility and first metatarsophalangeal joint laxity were associated with partial weightbearing first ray mobility, accounting for 38% of the model variance.

Conclusion:

The planus foot type was found to be associated with first ray hypermobility. Furthermore, weightbearing first ray mobility and first metatarsophalangeal joint laxity were predictive of partial weightbearing first ray mobility, demonstrating an interaction between the translation and rotational mechanics of the first ray.

Clinical Relevance:

Association of first ray hypermobility with foot type and first metatarsophalangeal joint flexibility may help understand the sequela to symptomatic pathologies of the foot.

Prevalence of and risk factors for hallux rigidus: a cross-sectional study in Japan

Background

Hallux rigidus (HR) is a common osteoarthritis of the first metatarsophalangeal joint. However, the epidemiology and risk factors of this pathology have yet to be clarified.

Methods

We have been conducting cohort studies among individuals over 50 years old every 2 years since 1997. This study analyzed data from the 7th to 10th checkups in 2009, 2011, 2013, and 2015. We investigated the prevalence of HR and its risk factors in a total of 604 individuals (mean age, 67.1 ± 6.4 years; 208 men, 396 women). Radiographic HR was defined as Hattrup and Johnson classification grade 1 or higher. Knee osteoarthritis (KOA) was scored according to the Kellgren-Lawrence grading system. Radiographic KOA was defined as grade 2 or higher. Cases with a hallux valgus (HV) angle of 20° or higher were defined as showing HV. Statistical analyses were performed using the Kruskal-Wallis test, Fisher’s exact test, logistic regression modeling, and the Cochran-Armitage trend test. All p-values presented are two-sided and values of p < .05 were considered statistically significant.

Results

The prevalence of HR was 26.7% (161/604). Rates of grade 0, 1, 2, and 3 HR according to the Hattrup and Johnson classification were 73.3% (443/604), 16.4% (99/604), 8.0% (48/604), and 2.3% (14/604), respectively. Overall ratio of symptomatic HR was 8.1%. Univariate analysis revealed KOA, gout attack (GA), and HV as significantly associated with HR. The same factors were confirmed as independent risk factors for HR in multivariate analysis. All parameters were significantly associated with HR. Odds ratios of KOA, HV, and GA for HR were 1.73, 3.98, and 3.86, respectively. The presence or absence of KOA was significantly associated with severity of HR.

Conclusions

This study revealed that the prevalence of HR in the elderly (≥50 years) was 26.7%. KOA, HV, and GA were independent risk factors for HR. KOA was associated with severity of HR.

Distal Metatarsal Segmental Shortening for the Treatment of Chronic Metatarsophalangeal Dislocation of Lesser Toes

BACKGROUND

This retrospective study aimed to describe the techniques and results of distal metatarsal segmental shortening (DMSS) for the treatment of chronic irreducible metatarsophalangeal (MTP) dislocation of lesser toes.

METHODS

We retrospectively reviewed patients who underwent DMSS for chronic dislocation of MTP joints of lesser toes between January 2010 and December 2017 with follow-up of at least 24 months. Demographic data, radiographic measurements, functional outcomes, and complications were analyzed. Furthermore, the results of patients with short segment of shortening (group I, <10 mm) were compared to those with long segment of shortening (group II, ≥10 mm). A total of 43 MTP joints of 30 patients with an average age of 70.4 years were included.

RESULTS

Union was observed in 42 metatarsals (97.7%). Mean American Orthopaedic Foot & Ankle Society scale scores improved significantly from 42.2 (range, 15-65) preoperatively to 79.1 (range, 52-90) (P < .001). Mean visual analog scale pain score improved significantly from 5.0 (range, 1-9) preoperatively to 1.8 (range, 0-6) (P < .001). Complications included 1 nonunion, 1 osteonecrosis, 3 metatarsal angulation, 4 recurrent instability, 4 symptomatic osteoarthritis, 3 transfer metatarsalgia, and 1 floating toe. Group I included 23 MTP joints and group II included 20 MTP joints. There was no significant difference in clinical outcomes and complications between the 2 groups.

CONCLUSION

DMSS was a reliable procedure for the treatment of chronic irreducible dislocated MTP joint of lesser toes. It provided satisfactory surgical outcomes and a low rate of postoperative complications, regardless of length of metatarsal shortening.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Osteoarthritis in England: Incidence Trends From National Health Service Hospital Episode Statistics

Objective

It is typical in epidemiological research of osteoarthritis (OA) to collect data for the hand, hip, and knee. However, little population‐based data exist for this disease in the foot. Thus, we addressed patterns of OA for the foot compared with the hand, hip, and knee spanning 2000/2001 to 2017/2018 in England.

Methods

Secondary‐care data from 3 143 928 patients with OA of the foot, hand, hip, and knee were derived from the National Health Service (NHS) Hospital Episode Statistics (HES) database. Distribution, population prevalence, and incidence of joint‐specific OA were stratified by age and sex.

Results

OA incidence increased significantly at the foot [3.8% (95% confidence interval [CI] 3.0, 4.6)], hand [10.9% (10.1, 11.7)], hip [3.8% (2.9, 4.7)], and knee [2.9% (2.2, 3.6)] per year from 2000/2001 to 2017/2018. A higher proportion of women were diagnosed with OA, whereas greater incidence in men was estimated for the hand and hip. Foot OA presented comparable diagnosis numbers to the hand. More recently during 2012/2013 to 2017/2018, a significant rise in hip OA was estimated among younger adults, whereas knee OA decreased across all age groups. Incidence of OA in the foot and hand were particularly significant among the 75 or older age group, though bimodal age distributions were observed for both sites.

Conclusion

The significant increase in secondary care records for OA in England underscores the importance of exploring possible causative factors and identifying groups most at risk. Further detailed data may be particularly important for the hip, which represents significant incidence among younger adults. Greater incidence of OA in the foot compared with the knee emphasizes the need for well‐conducted epidemiological research in this area. Monitoring the performance of surgical outcomes at the population‐level for this frequently affected yet understudied site could have substantial potential to reduce the socioeconomic burden it represents to the NHS.

Foot osteoarthritis: latest evidence and developments

Foot osteoarthritis (OA) is a common problem in older adults yet is under-researched compared to knee or hand OA. Most existing studies focus on the first metatarsophalangeal joint, with evidence relating to midfoot OA being particularly sparse. Symptomatic radiographic foot OA affects 17% of adults aged 50 years and over. The first metatarsophalangeal joint is most commonly affected, followed by the second cuneometatarsal and talonavicular joints. Epidemiological studies suggest the existence of distinct first metatarsophalangeal joint and polyarticular phenotypes, which have differing clinical and risk factor profiles. There are few randomized controlled trials in foot OA. Existing trials provide some evidence of the effectiveness for pain relief of physical therapy, rocker-sole shoes, foot orthoses and surgical interventions in first metatarsophalangeal joint OA and prefabricated orthoses in midfoot OA. Prospective epidemiological studies and randomized trials are needed to establish the incidence, progression and prognosis of foot OA and determine the effectiveness of both commonly used and more novel interventions.

Prevalence and Risk Factors of Spine, Shoulder, Hand, Hip, and Knee Osteoarthritis in Community-dwelling Koreans Older Than Age 65 Years

BACKGROUND

Osteoarthritis (OA) is common and disabling among older patients around the world. Data exploring the prevalence and risk factors of OA are of paramount importance in establishing healthcare policies. However, few studies have evaluated these topics among Asian populations.

QUESTIONS/PURPOSES

This study was conducted to determine the prevalence and risk factors of radiographic OA in the spine, shoulder, hand, hip, and knee in Koreans older than age 65 years.

METHODS

A simple random sample (N = 1118) was drawn from a roster of elderly individuals older than age 65 years in Seongnam. Of the 1118 invited subjects, 696 (males = 298, females = 398) participated in this study (a response rate of 62%). The mean age of respondents was 72 ± 5 years (range, 65-91 years). Radiographs of the lumbar spine, shoulder, hand, hip, and knee were taken and afterward evaluated for radiographic OA. The Kellgren-Lawrence grading system was used for all mentioned joints, and radiographic OA was defined as Grade 2 changes or higher. The association of sex, aging, and obesity with OA in each of the mentioned joints was determined with the help of multivariate logistic regression.

RESULTS

The highest prevalence of radiographic OA was seen in the spine (number of subjects with OA/number of whole population = 462 of 696 [66%]) followed by the hand (415 of 692 [60%]), knee (265 of 696 [38%]), shoulder (36 of 696 [5%]), and hip (15 of 686 [2%]). Female sex was associated with knee OA (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.9-8.4; p < 0.001) and hand OA (OR, 2.3; 95% CI, 1.6-3.1; p < 0.001), and male sex was associated with spine OA (OR, 0.7; 95% CI, 0.5-1.0; p = 0.025). Aging was associated with radiographic OA in the spine, knee, and hand (OR per 5-year increments, 1.3 [95% CI, 1.1-1.6; p = 0.001], 1.6 [95% CI, 1.4-1.9; p < 0.001], and 1.4 [95% CI, 1.2-1.7; p < 0.001]), respectively) but not associated with OA in the hip and shoulder. Obesity was associated with knee OA (OR, 3.4; 95% CI, 2.4-5.0; p < 0.001) and spine OA (OR, 1.5; 95% CI, 1.1-2.2; p = 0.014) but not with OA in other joints.

CONCLUSIONS

OA of the spine, hand, and knee is likely to become a major public health problem rather than shoulder and hip OA in Korea. Associations of demographic factors with radiographic OA differed among each joint, and that would be valuable information to assess the role and influence of risk factors of OA in various joints.

LEVEL OF EVIDENCE

Level III, prognostic study.

The population prevalence of symptomatic radiographic foot osteoarthritis in community-dwelling older adults: cross-sectional findings from the clinical assessment study of the foot

OBJECTIVES

To estimate the population prevalence of symptomatic radiographic osteoarthritis (OA) affecting the 1st metatarsophalangeal joint (MTPJ), 1st and 2nd cuneometatarsal joints (CMJs), navicular first cuneiform joint (NCJ) and talonavicular joint (TNJ) in community-dwelling older adults.

METHODS

9334 adults aged ≥50 years registered with four general practices were mailed a health survey. Responders reporting foot pain within the last 12 months were invited to undergo weight-bearing dorso-plantar and lateral radiographs of both feet. OA at the 1st MTPJ, 1st and 2nd CMJs, NCJ and TNJ was graded using a validated atlas. Population prevalence estimates for symptomatic radiographic foot OA overall and for each joint were calculated using multiple imputation and weighted logistic regression modelling to account for missing data and non-response.

RESULTS

5109 health surveys were received (adjusted response 56%). Radiographs were obtained on 557 participants. Overall population prevalence of symptomatic radiographic OA was 16.7% (95% CI 15.3% to 18.0%), 1st MTPJ 7.8% (6.7% to 8.9%), 1st CMJ 3.9% (2.9% to 4.9%), 2nd CMJ 6.8% (5.7% to 7.8%), NCJ 5.2% (4.0% to 6.4%) and TNJ 5.8% (4.8% to 6.9%). With the exception of the 1st CMJ, prevalence was greater in females than males, increased with age and was higher in lower socioeconomic classes. Three-quarters of those with symptomatic radiographic OA reported disabling foot symptoms.

CONCLUSIONS

While cautious interpretation due to non-response is warranted, our study suggests that symptomatic radiographic foot OA affects one in six older adults and the majority report associated disability. Clinicians should consider OA as a possible cause of chronic foot pain in older people.

"Generalized osteoarthritis": a systematic review

OBJECTIVES

Given the conflicting definitions of "generalized osteoarthritis" (GOA) in the literature, we performed a systematic review of GOA definitions, risk factors, and outcomes.

METHODS

We searched the MEDLINE literature with the terms osteoarthritis, generalized, polyarticular, multiple joint, and multi-joint to obtain articles related to GOA, following evidence-based guidelines. Titles and abstracts of 948 articles were reviewed, with full-text review of 108. Data were extracted based on pre-specified criteria for 74 articles plus 24 identified through bibliographic review (n = 98).

RESULTS

Twenty-four large cohorts (n ~ 30,000) were represented along with numerous clinical series (n ~ 9000), across 22 countries and 60 years (1952-2012). No less than 15 definitions of GOA were given in 30 studies with a stated GOA definition; at least 6 groups used a summed score of joints or radiographic grades. Prevalence estimates based on these GOA definitions were 1-80%, although most were 5-25%. Increased risk and progression of GOA was associated with age, female sex, and genetic/familial factors. Associations with increased body mass index or bone mineral density were not consistent. A study estimated the heritability of GOA at 42%. Collagen biomarker levels increased with the number of involved joints. Increased OA burden was associated with increased mortality and disability, poorer health, and function.

CONCLUSION

While there remains no standard definition of GOA, this term is commonly used. The impact on health may be greater when OA is in more than one joint. A descriptive term, such as multi-joint or polyarticular OA, designating OA of multiple joints or joint groups is recommended.

Primary osteoarthritis of the hip: a genetic disease caused by European genetic variants

Primary osteoarthritis of the hip is a separate phenotype that occurs at a rate of 3% to 6% in the populations of the world with European ancestry. In all non-European populations, there is a consistent rarity of primary osteoarthritis that suggests a different etiology for these few patients. Family, sibling, and twin studies prove primary osteoarthritis to be a genetic disease with a 50% heritability caused by European genetic variants. The genetic basis is reinforced by the lower rate of primary osteoarthritis in American minorities consistent with their degree of European gene admixture. Whether the mechanism of degeneration of primary osteoarthritis may be secondary through a morphologic deformity, such as femoroacetabular impingement, remains unknown. The virtual absence of the disease in non-Europeans indicates that the European gene component is necessary for the expression of this separate phenotype of osteoarthritis.

Differences in multijoint radiographic osteoarthritis phenotypes among African Americans and Caucasians: the Johnston County Osteoarthritis project

OBJECTIVE

To define and contrast multiple joint radiographic osteoarthritis (OA) phenotypes describing hand and whole-body radiographic OA among African Americans and Caucasians.

METHODS

We conducted a cross-sectional analysis in the Johnston County Osteoarthritis Project, using radiographic data for the hands, tibiofemoral (TF) joints, patellofemoral joints, hips, and lumbosacral (LS) spine. Radiographs were read for OA by a single radiologist using standard atlases. Fisher's exact test, with correction for multiple comparisons, was used to compare phenotype frequencies by race and sex. Logistic regression was used to provide odds ratios, which were adjusted for sex, age, and body mass index (BMI).

RESULTS

Sixteen mutually exclusive hand (n = 2,083) and 32 whole-body (n = 1,419) radiographic OA phenotypes were identified. We found that in comparison to Caucasians, African Americans had significantly less frequent radiographic OA of the distal interphalangeal joints, both in isolation and in combination with other hand joint sites, but had comparable frequencies of radiographic OA for other hand joint sites. Moreover, African Americans had less frequent radiographic OA of the hand, both in isolation and in combination with other joint sites, as compared to Caucasians. In contrast, African Americans had more than twice the odds of isolated OA of the TF joint and 77% higher odds of radiographic OA of the TF joint and LS spine together as compared to Caucasians.

CONCLUSION

Even after adjustment for sex, age, and BMI, African Americans were less likely than Caucasians to have hand radiographic OA phenotypes, but more likely to have knee radiographic OA phenotypes involving the TF joint. African Americans may have a higher burden of multiple large-joint OA involvement not captured by most definitions of "generalized OA."

A systematic review of radiographic definitions of foot osteoarthritis in population-based studies

OBJECTIVE

To identify the methods used in population-based epidemiological studies to diagnose radiographic foot osteoarthritis (OA) and to estimate the population prevalence of radiographic foot OA.

METHOD

Electronic databases searched included Medline, Embase, CINAHL and Ageline (inception to May 2009). The search strategy combined search terms for radiography, OA, foot, and specific foot joints. Predetermined selection criteria were applied. Data extracted from each paper included: sample population, radiographic views taken, foot joints examined, scoring system used, definition of OA applied, reliability of radiographic scoring and prevalence of radiographic OA in the foot.

RESULTS

Titles and abstracts of 1035 papers were reviewed and full-texts of 21 papers were obtained. Fifteen papers met inclusion criteria and a further 12 papers were included after screening references. Radiographic views were frequently not specified (NS) but a combination of antero-posterior (AP) and lateral (Lat) views was most commonly reported. The first metatarsophalangeal (MTP) joint was the most commonly examined joint (n=20, 74%). Nineteen studies (70%) used the Kellgren and Lawrence (K&L) grading system, 95% of which defined OA as K&L grade> or =2. Estimates of the prevalence of radiographic first MTP joint OA (defined as K&L> or =2) in middle-aged to older adults ranged from 6.3 to 39%. Significant statistical heterogeneity prevented pooling of prevalence estimates.

CONCLUSION

There are comparatively few studies examining radiographic foot OA. Existing studies mainly focus on the first MTP joint and use the K&L grading system. Future studies are needed to quantify the prevalence of radiographic OA at the different joint complexes within the foot.

A systematic search and narrative review of radiographic definitions of hand osteoarthritis in population-based studies

OBJECTIVE

Currently there is no agreed "gold standard" definition of radiographic hand osteoarthritis (RHOA) for use in epidemiological studies. We therefore undertook a systematic search and narrative review of community-based epidemiological studies of hand osteoarthritis (OA) to identify (1) grading systems used, (2) definitions of radiographic OA for individual joints and (3) definitions of overall RHOA.

METHODS

The following electronic databases were searched: Medline, Embase, Science Citation Index and Ageline (inception to Dec 2006). The search strategy combined terms for "hand" and specific joint sites, OA and radiography. Inclusion and exclusion criteria were applied. Data were extracted from each paper covering: hand joints studied, grading system used, definitions applied for OA at individual joints and overall RHOA.

RESULTS

Titles and abstracts of 829 publications were reviewed and the full texts of 399 papers were obtained. One hundred fifty-two met the inclusion criteria and 24 additional papers identified from screening references. Kellgren and Lawrence (K&L) was the most frequently applied grading system used in 80% (n=141) of studies. In 71 studies defining OA at the individual joint level 69 (97%) used a definition of K&L grade > or = 2. Only 53 publications defined overall RHOA, using 21 different definitions based on five grading systems.

CONCLUSION

The K&L scheme remains the most frequently used grading system. There is a consistency in defining OA in a single hand joint as K&L grade > or = 2. However, there are substantial variations in the definitions of overall RHOA in epidemiological studies.

Prevalence of cervical spondylosis and musculoskeletal symptoms among coolies in a city of Bangladesh

To assess the prevalence of cervical spondylosis and musculoskeletal symptoms among coolies a cross-sectional study was performed in Narayangonj City of Bangladesh on a random sample of 98 male coolies, using a questionnaire and the results of cervical spine X-rays. Statistical associations were investigated using the chi-square test. The results show a considerably higher prevalence of cervical spondylosis among the coolies (39.8%). More than half (51.3%) of the cases of cervical spondylosis were in subjects below the age of 40 yr, and a significant association was found between age group and prevalence of cervical spondylosis. The study also observed a significant association between duration of occupation and prevalence of cervical spondylosis. Coolies who had worked for 10 to 15 yr, or more than 15 yr, had higher rates of cervical spondylosis. In this study it was found that those who carried heavier loads suffered more from cervical spondylosis. Musculoskeletal symptoms in multiple body regions (two or more) were more prevalent (61.2%) than those in single body region (29.6%). Symptoms in the hands/fingers were the most frequent followed by the back and arms/forearms. In conclusion, the high prevalence of cervical spondylosis and musculoskeletal symptoms among professional coolies may be associated with the practice of carrying heavy loads on the head. Further study with a large sample of population is required to investigate this problem and to explore preventive measures.

A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis

OBJECTIVE

To resolve uncertainty regarding sex differences in osteoarthritis (OA) by performing a meta-analysis of sex differences in OA prevalence, incidence and severity.

METHODS

Standard search strategies for population-based studies of OA providing sex-specific data. Random effects meta-analysis to provide pooled male vs female risk and rate ratios for prevalent and incident OA, and standardized mean differences (SMD) for OA severity. Meta-regression was used to investigate sources of heterogeneity.

RESULTS

Males had a significantly reduced risk for prevalent OA in the knee [Risk Ratio (RR) 0.63, 95% CI 0.53-0.75] and hand [RR 0.81, 95% CI 0.73-0.90] but not for other sites. Males aged <55 years had a greater risk of prevalent cervical spine OA [RR 1.29, 95% CI 1.18-1.41]. Males also had significantly reduced rates of incident OA in the knee [Incidence Rate Ratio (IRR) 0.55, 95% CI 0.32-0.94] and hip [IRR 0.64, 95% CI 0.48-0.86], with a trend for hand [IRR 0.65, 95% confidence interval (CI) 0.35-1.20]. Females, particularly those > or = 55 years, tended to have more severe OA in the knee but not other sites. Heterogeneity in the estimates of sex differences in prevalence was substantially explained by age and other study design factors including method of OA definition.

CONCLUSIONS

The results demonstrate the presence of sex differences in OA prevalence and incidence, with females generally at a higher risk. Females also tend to have more severe knee OA, particularly after menopausal age. The site differences indicate the need for further studies to explore mechanisms underlying OA.

Rheumatic diseases in minority populations

Rheumatic diseases are expressed in all ethnic populations, but differ in prevalence, genetic associations, clinical features, and responses to interventions. Most data describing these differences do so in reference to and comparisons with white populations. These are sparse data that evaluate differences within minority populations where there is more homogeneity of external factors, such as social, cultural, and behavioral attitudes. This article reviews the features that are unique to various rheumatic diseases within minority populations.

Attenuation of spinal transients at heel strike using viscoelastic heel insoles: an in vivo study

BACKGROUND

The transients introduced at heel strikes were linked with increased risk for low back pain. The present study was designed to monitor the transients acting on the spinal column at gait, and to find out whether said transients are attenuated by interposition of a viscoelastic heel insoles.

METHODS

A lightweight (2 g) accelerometer was held against the forehead with an elastic strap. The subject was instructed to walk naturally along an 8-m rigid walkway with a built-in, high-frequency (<500 Hz) response Kistler force plate. Seven subjects, shod in leather-soled shoes, were studied sequentially without and with viscoelastic heel insoles (Viscoheel, Bauerfeind). Ground reaction force and vertical acceleration were simultaneously recorded. The data were analog-stored and analyzed with respect to time and frequency domains.

RESULTS

Under the aforementioned conditions, the heel strike introduced a transient that averaged 60% of body weight and lasted for up to 5 ms. Maximal deceleration was recorded in the order of 5G, with a frequency spectrum of 100 Hz. Interposition of silicone heel insoles attenuated the ground reaction force by one third and deceleration by two thirds, the highest frequency components having been eliminated.

CONCLUSION

Viscoelastic heel insoles significantly attenuate the strain on the spinal column that is caused by walking.

Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester

OBJECTIVE

To assess the prevalence of musculoskeletal symptoms among the major ethnic minority populations of Greater Manchester.

METHOD

The study group was a community sample of 2117 adults from the Indian, Pakistani, Bangladeshi, and African Caribbean communities. Questionnaires administered by post and by an interviewer were used to assess the presence of any musculoskeletal pain, pain in specific joints, and the level of physical function. Ethnicity was self assigned. The results were compared with those from a recent study in the local white population using the same methodology.

RESULTS

Overall response rate was 75% among the south Asian (Indian, Pakistani, and Bangladeshi community and 47% among the African Caribbean community. The profile of musculoskeletal pain among the ethnic minority groups differed from that in the white population. Although musculoskeletal symptoms were slightly more prevalent among people from ethnic minority groups than among the white population, pain in multiple sites was considerably more common among ethnic minorities.

CONCLUSIONS

The finding that musculoskeletal pain is more widespread among ethnic minority communities in the UK has not previously been reported. This may reflect social, cultural, and psychological differences. The cause of the differences in the profile of pain and the health needs that follow need further investigation.

Clinical, radiologic, demographic, and occupational aspects of hand osteoarthritis in the elderly

OBJECTIVE

Osteoarthritis (OA) of the hand is common in elderly patients. The aim of this study was to characterize OA frequency, severity, and distribution and to trace interrelationships between these findings and the demographic, occupational, and medical data from elderly Jewish nonrheumatologic patients.

METHODS

Study participants were 253 consecutive patients admitted to a geriatric center for a variety of nonrheumatic medical conditions. Excluded patients were those with rheumatoid arthritis; neurologic, orthopedic, or other conditions that would interfere with symmetric hand function; and mental or medical states that would interfere with history taking and radiographic studies. Patient occupations were graded as workload degree (on a scale of 1 to 3) and as the total occupational score (workload degree multiplied by the duration of each job). Clinical findings of Heberden nodes, Bouchard nodes, and malignment, graded on a scale of 0 to 3, were summed as the clinical OA score. Hand radiographs were independently read (modified Altman method), grading 5 parameters in each joint on a scale of 0 to 3, summed as a radiologic OA score. Statistical analyses included the Student t test, chi(2) test, ANOVA, Pearson correlation, and partial correlation coefficients.

RESULTS

Among 253 elderly patients (171 women, 82 men; mean age, 79 years) OA was frequent (occurring in about 80% of patients), involving most severely the second and third distal interphalangeal, right first interphalangeal, and both first carpometacarpal joints. The prevalence of OA was similar in women and men, with higher scores in women, and reached significance only in the distal interphalangeal joints. Metacarpophalangeal joints were more involved in men. Age had a clear influence on OA scores. Ethnicity affected OA severity, with Ashkenazi Jews having significantly higher scores than Sepharadi Jews. Dominant hands had significantly higher global OA scores as well as isolated joint scores (except for the first carpometacarpal joint). Occupational load, housekeeping tasks, and the number of children did not influence the total or specific joint OA scores. Associated conditions such as obesity, diabetes, hypothyroidism, and chondro calcinosis were not associated with more pronounced OA.

CONCLUSIONS

Hand OA was prevalent in our elderly cohort, and its severity was influenced by inherent traits such as age, female gender, ethnicity, and handedness. In contrast, acquired factors such as workload, number of children, and associated diseases did not appear to influence OA expression.

Total hip replacement rates are higher among Caucasians than Asians in Hawaii

The etiology of hip osteoarthritis remains unknown but may involve genetic or lifestyle factors. Most cases of total hip replacement are performed because of osteoarthritis. To examine possible ethnic differences, hospital records in Hawaii from 1985 to 1989 were reviewed. Preoperative radiographs were reviewed for a subset of patients to ascertain the reason for total hip replacement. Osteoarthritis accounted for a greater percentage of total hip replacements among whites (59% for women and 66% for men) than among Japanese (36% of women and 30% of men). The incidence of total hip replacement for whites was three to 25 times greater than that of other ethnic groups (Japanese, Chinese, Filipino, and Hawaiians). For example, the risk of total hip replacement for white women 40 years to 84 years of age was 4.4%, compared with 1.1% for Japanese women and 1.7% for Chinese women of the same age group. Compared with published data, the incidence was similar for Chinese in Hawaii and San Francisco; however; whites in Hawaii had a total hip replacement incidence less than half that of whites in San Francisco. Lifestyle differences might account for the lower incidence of total hip replacement for whites in Hawaii, compared with those in San Francisco. The lower incidence among Asians suggests a possible genetic basis for osteoarthritis.

The epidemiology of low back pain in the rest of the world. A review of surveys in low- and middle-income countries

STUDY DESIGN

A criteria-based review of the literature.

SUMMARY OF BACKGROUND DATA

The literature on the epidemiology of low back pain is accumulating, but for the most part studies are restricted to high-income countries, which comprise less than 15% of the world's population. Little is known about the epidemiology of low back pain in the rest of the world.

OBJECTIVES

To address the imbalance in the literature and to review the relatively few studies on the epidemiology of low back pain in low- and middle-income countries. Rates from these studies are contrasted with rates from selected high-income countries. In reviewing the literature, a hypothesis is tested: low back pain rates are higher in low-income countries than in high-income countries, not only because hard physical labor is more prevalent in low-income countries, but also because, unlike high-income countries, hard physical labor for older workers in low-income countries often is unavoidable.

METHODS

Among other sources, articles for the review come from a search of the MEDLINE bibliographic database, with "back pain" and individual low- and middle-income countries entered as key words. To avoid recall biases, findings specifically on point prevalence are reviewed.

RESULTS

Within the categories of low-income and high-income countries, low back pain rates vary twofold or more. In comparisons between these categories of countries, rates on the whole are higher among the general populations of selected high-income countries than among rural low-income populations; specifically, rates are 2-4 times higher among Swedish, German, and Belgium general populations than among Nigerian, southern Chinese, Indonesian, and Filipino farmers. Within low income countries, rates are higher among urban populations than among rural populations and still higher among workers in particular worksites, referred to as "enclosed workshops."

CONCLUSIONS

The disparity in low back pain rates within categories of countries, high-income and low-income, calls attention to the high proportion of studies on the epidemiology of low back pain that are methodologically questionable. Recommendations are offered to improve the methodologic quality of this type of study. Conclusions may be drawn from comparisons between studies, although, in the absence of set methodologic standards, they are tentative. The considerably lower rates among populations of low-income farmers compared with rates of the affluent populations of selected northern European countries indicate that, contrary to the hypothesis proposed here, hard physical labor itself is not necessarily related to low back pain. The higher rates in urban low-income populations as compared with rates in rural low-income populations and the sharply higher rates among workers in enclosed workshops of low-income countries suggest a disturbing trend: low back pain prevalence may be on the rise among vast numbers of workers as urbanization and rapid industrialization proceed.

Epidemiological and aetiological aspects of low back pain in vibration environments - an update

The article reviews the substantial body of epidemiological evidence linking vibration exposure and low back pain. Drivers appear to be at particular risk if exposures exceed those recommended by the ISO exposure limit. Various aetiological factors associated with vehicular vibration, flattening of the lumbar lordosis, increased motion segment flexibility, disc pressure and mechanical softening are discussed. Vibration studies of functional spinal units are also discussed, as are in vivo whole-body vibration experiments. Animal models have shown that vibration leads to compromised nutrition, higher disc pressures, release of neuropeptides, increased creep and histological changes.

The epidemiology of hip osteoarthritis and rheumatoid arthritis in the Orient

The prevalence of hip osteoarthritis and rheumatoid arthritis has been found to be lower in Chinese, Japanese, and other Asian populations than in whites. The low prevalence of osteoarthritis hip in the Chinese and Japanese populations cannot be explained by the rarity of hip dysplasia, which is as prevalent in those two populations as in whites. As in other populations, rheumatoid arthritis in the Chinese is associated with the shared epitope of the third hypervariable region of the DR gene. However, the low prevalence of rheumatoid arthritis in the Chinese cannot be accounted for entirely by genetic factors.

Osteoarthritis

There are few studies on the prevalence, pattern or clinical course of osteoarthritis (OA) in the tropics. The studies that have been carried out, however, indicate that on the whole there is a lower prevalence of OA than found in Western countries. In addition, the pattern of joint involvement may be different with less common involvement of the hip relative to the knee and polyarticular OA is uncommon in many parts of the tropics. It also seems likely that a significant number of these patients in the tropics have OA secondary to various infections including pyogenic, tuberculous and parasitic infections. There is an urgent need to confirm these observations and to identify possible genetic, developmental or environmental factors influencing the expression of OA in the tropics. In addition degenerative arthropathies, such as Mseleni's disease, present in some parts of the tropics, merit further study. With increasing life-expectancy and improved health-care in many parts of the tropics, OA will become an increasingly prevalent and important condition with associated morbidity and socio-economic implications for these countries.

Extreme variations in racial rates of total hip arthroplasty for primary coxarthrosis: a population-based study in San Francisco

OBJECTIVES

To compare the incidence of all total hip arthroplasty, and total hip arthroplasty for primary coxarthrosis, among the Asian, black, Hispanic, and white populations living in one locale.

METHODS

We identified all San Francisco residents who underwent total hip replacements (THR) in the 17 hospitals for adults within or near San Francisco County during a five year period. Preoperative pelvic radiographs were read without prior knowledge of the gender or race of the subject, to diagnose the specific hip diseases. Age standardised THR incidence by race and gender was determined, as was the comparative THR incidence for specific diagnosis (primary and secondary osteoarthritis).

RESULTS

The greatest annual rate of total hip replacement occurred in white women (97 per 100,000 population), followed by white men, black women, black men, Hispanic women, and Hispanic men. The smallest numbers were found in Asians, whose THR rate was 10% that of whites. A primary coxarthrosis diagnosis was greatest among white subjects (66%), followed by black subjects (54%), Hispanics (53%), and Asians (28%). Age standardised THR rates for primary coxarthrosis per 100,000 population were likewise greatest among whites (43.0) and least among Asians (1.3 for Chinese). Mean age of patients undergoing THR for primary coxarthrosis was 70 years for white subjects and almost a decade younger in all other groups.

CONCLUSIONS

THR rates are much lower for Asians, Hispanics, and black subjects than for the white population living in San Francisco. The low rates of total hip arthroplasty in the non-white groups was related to the much lower incidence of THR for primary coxarthrosis among non-whites than among whites. The racial distribution of primary coxarthrosis among patients who underwent THR is consistent with distribution patterns reported internationally.

Utilisation of joint movement range in arboreal primates compared with human subjects: an evolutionary frame for primary osteoarthritis

OBJECTIVE

To determine whether an arboreal lifestyle required full use of movement ranges underutilised in nine joint groups in humans, because under-utilisation of available movement range may be associated with susceptibility to primary osteoarthritis.

METHODS

Utilisation of the nine joint groups was studied in two species of primate exercising in a simulated arboreal environment, using 'focal animal' observation techniques supplemented by telephoto photography and by review of archival material from other sources. Fifteen apes were observed over a total observation period of 20.2 man-hours and 152 films were analysed for utilisation of movement range.

RESULTS

With one exception, all the movement ranges reported to be under-utilised in humans were fully utilised by the apes in climbing activities. The exception, metacarpophalangeal extension, was an essential component of the chimpanzee ground progression mode of knuckle walking.

CONCLUSIONS

The underused movement range in several human joints is explicable as residual capacity from a semiarboreal lifestyle. If the correlation with primary osteoarthritis is confirmed, it suggests that the disease may reflect a disparity between inherited capacity and current need. The significance of the result lies in its implication that primary osteoarthritis may be preventable.

Utilization of upper limb joint replacements during 1972-90: the Mayo Clinic experience

Increasing application of expensive medical technologies, including joint replacement, is of concern in the current economic climate. Successful upper limb joint replacements (ULJRs) are being performed, but few detailed data about their utilization are available. To explore the resource implications of such surgery, the utilization of total shoulder replacement (TSR), total elbow replacement (TER) and total wrist replacement (TWR) were examined from the time these procedures first became available at the Mayo Clinic up to 1990. The age- and sex-adjusted utilization rate for TSR among Olmsted County, Minnesota, residents was 1.8 per 100,000 person-years (p-y), 0.8 per 100,000 p-y for TER and 1.1 per 100,000 p-y for TWR. Overall utilization of primary ULJR among Olmsted County residents during the 19-year study period was 3.8 per 100,000 p-y. The commonest indication for TSR was osteoarthritis (46 per cent) and for TER and TWR was rheumatoid arthritis (50 and 81 per cent respectively). There was no consistent trend in the utilization of these procedures among Olmsted County residents, but the number of referral patients receiving a ULJR at the Mayo Clinic increased steadily during the study period. The Mayo Clinic experience suggests an increasing demand for ULJR, particularly TSR and TER. With continued advances in, and diffusion of, the technology this demand may increase further.

Trends in the utilization of primary total hip arthroplasty, 1969 through 1990: a population-based study in Olmsted County, Minnesota

Using the unique data resources of the Rochester Epidemiology Project, we identified the residents of Olmsted County, Minnesota, who underwent total hip arthroplasty (THA) between 1969, when this technique was introduced, and 1990. During this period, 735 residents underwent 859 primary THAs. An initial dramatic upsurge in utilization of THA soon after its introduction was followed by a lower rate of increase, to an age- and sex-adjusted rate of 59.9 per 100,000 person-years in 1987 through 1990. In Olmsted County, the procedure was used more often in women than in men, but men underwent THA at a younger age than did women. THAs were performed for various conditions of the hip, but the increased utilization during the last decade of the study was mainly attributable to its application in primary degenerative hip disease among patients (male more often than female) from a wider age range; utilization of THA for hip fractures decreased during the study period. Most THAs were of the cemented variety (86.1%); however, the rate of use of noncemented THAs, first performed in 1984, is increasing. The overall upward trend in Olmsted County was consistent with European data but less than the rate of increase observed for the United States as a whole between 1983 and 1987. Olmsted County utilization rates, if projected nationally, suggest a need for more than 139,000 primary THAs each year at an annual direct cost of more than $2.7 billion. An urgent need exists for detailed examination of national utilization patterns and clarification of the role of cementless implants and of THA for hip fractures.

A longitudinal study of osteoarthritis of the hand: the effect of age

Osteoarthritis is the most ubiquitous rheumatic disease worldwide. Although its prevalence in various populations has been well documented, few studies have evaluated the longitudinal radiographic progression of the disease, especially as it is expressed in the interphalangeal joints of the hand. In this longitudinal study, left hand-wrist X-rays of 386 white male participants of the Baltimore Longitudinal Study of Aging followed for at least 5 years with two or more visits were examined for prevalence and progression of osteoarthritis of the distal and proximal interphalangeal joints of the hand. As other studies have shown, we found that the prevalence of osteoarthritis in both distal and proximal interphalangeal joints becomes progressively higher as the age of the subjects increases. Using the life table method of analysis we studied the progression of osteoarthritis as defined by the following criteria: (1) an increase in the severity of radiographic changes of the joints previously affected and (2) an increase in the number of new joints affected. The results indicated that osteoarthritis in both the distal and proximal interphalangeal joints progresses at a faster rate in the older population than in individuals less than 60 years of age. Furthermore, osteoarthritis in the interphalangeal joints progresses at the same rate whether the starting point was a Kellgren grade of 0 (no disease) or 1 (doubtful). We therefore conclude that grade 1 is an intermediate step in the inexorable progression of osteoarthritis of the interphalangeal joints and not synonymous with grade 0, as it has been customarily interpreted.

Idiopathic symptomatic osteoarthritis of the hip and knee: a population-based incidence study

We identified all residents of Rochester, Minnesota, who sought medical assistance for the first time in 1985 because of symptomatic osteoarthritis of the hip or knee that was unrelated to a specific disease. Of these residents, 98 (59 women and 39 men) had 122 symptomatic joints (95 knees and 27 hips), for age- and sex-adjusted incidence rates of 205 new patients and 255 newly affected joints per 100,000 person-years. The incidence of osteoarthritis of the hip was greater in women than in men, whereas the sex ratio for occurrence of osteoarthritis of the knee approached unity. Rates at both sites increased steadily with aging in men but plateaued after the menopause in women; similar patterns were seen whether or not grade 1 disease was included. Projected nationally, these first population-based data indicate that as many as approximately half a million new symptomatic cases of idiopathic osteoarthritis of the knee and hip may arise annually in the white population of the United States. With increasing longevity, osteoarthritis may exact an even greater toll in the future.

Osteoarthritis of the hip and knee in Saudi Arabia

The records of 4721 patients, who were registered at a Primary Health Care Centre in the Eastern Province of Saudi Arabia during a 18 month period, were reviewed. One hundred and sixty-six (3.5%) had osteoarthritis of the hip or knee. The ratio of hip to knee was 1:80 which is very low compared to other populations, and the possible causes for this are discussed.

Descriptive epidemiology and public health aspects of low back pain

The prevalence of low back syndrome and its consequences in terms of disability, handicap, and need for medical care were studied as part of "the Mini-Finland Health Survey". A sample of 8000 persons representative of the Finnish population aged 30 or over was invited for examination, and 7217 (90%) participated. At interview 75% of the participants reported that they had experienced at least one episode of low back pain. Six or more episodes were reported by half of the population, and about 20% had suffered from pain during the previous month. On the basis of a standardised clinical examination, a physician diagnosed low back syndrome in 17.5% of men and 16.3% of women. The prevalence was highest in those aged 55-64 years. The use of health services was frequent among those suffering from low back pain. Nevertheless, their need for care was commonly unmet. Some disability was found in almost 60% of the subjects with low back pain, although severe functional limitations were rare. It was estimated that of the work disability the reduced capacity for everyday duties apart from work, and the reduced capacity for leisure time activities, in the population 18%, 16%, and 17%, respectively, were attributable to the low back syndrome. Thus low back syndrome has a strong impact on individuals and on society as a whole.

Epidemiology of osteoarthritis: Zoetermeer survey. Comparison of radiological osteoarthritis in a Dutch population with that in 10 other populations

The prevalence of mild and severe radiological osteoarthritis was investigated in a random sample of 6585 inhabitants of a Dutch village. Radiographs were graded 0-4 according to the criteria described by Kellgren and Lawrence. The prevalence of radiological osteoarthritis increased strongly with age and was highest for cervical spine (peak: men 84.8%, women 84.3%), lumbar spine (peak: 71.9%, women 67.3%), and distal interphalangeal joints of the hands (peak: men 64.4%, women 76%). Prevalence did not exceed 10% in sacroiliac joints, lateral carpometacarpal joints, and tarsometatarsal joints. Severe radiological osteoarthritis (grade 3 or grade 4) was uncommon under age 45; in elderly persons the prevalence of severe radiological osteoarthritis did not exceed 20% except for the cervical and lumbar spine, distal interphalangeal joints of the hands and, in women only, metacarpophalangeal joints, first carpometacarpal joints, first metatarsophalangeal joints, and knees. Overall, differences between men and women were small except for hips and knees; however, severe radiological osteoarthritis was found in a higher proportion in most of the joints in women. Our data were compared with data from similar population surveys. The slope between joint involvement and age was strikingly constant for most of the joints. Differences between populations were mainly differences in level. These differences of prevalence of radiological osteoarthritis may be attributed to interobserver differences--that is, different criteria used to establish radiological osteoarthritis, in addition to genetic or environmental factors, or both.

Primary osteoarthritis: epidemiology, clinical aspects, and general management

The etiology of osteoarthritis, the most common articular disorder, is still unknown. Epidemiologic studies demonstrate a relationship to aging and to certain occupations; relationships to obesity as an etiologic factor remain controversial. An inverse relationship of osteoarthritis and bony density has been observed. Medical management is primarily symptomatic; surgery, particularly of the hip or knee, restores function and relieves pain at late stages of the disease. Investigational trials of specific therapeutic agents suggest possible forthcoming interventions to prevent, retard, or reverse the disease process.

Prevalence rates and odds ratios of shoulder-neck diseases in different occupational groups

The aim of the present study was to evaluate the association and impact of occupational exposure and diseases of the shoulder and neck. Prevalence rates, odds ratios, aetiological fractions, and their confidence intervals were computed for pooled and non-pooled data of previous published reports. By comparison with office workers and farmers, dentists had an increased odds ratio for cervical spondylosis (two studies) and for shoulder joint osteoarthrosis. Meat carriers, miners, and "heavy workers" also had significantly higher rates of cervical spondylosis compared with referents. Compared with iron foundry workers, civil servants had a significant odds ratio (4.8) of cervical disc disease and a 0.79 aetiological fraction. Whether this was due to exposure or healthy worker effect was not clear. In four occupational groups with high shoulder-neck load an odds ratio of 4.0 was found for thoracic outlet syndrome with an aetiological fraction of 0.75. Rotator cuff tendinitis in occupational groups with work at shoulder level (two studies) showed an odds ratio of 11 and an aetiological fraction of 0.91. Keyboard operators had an odds ratio of 3.0 for tension neck syndrome (five studies). Unfortunately, owing to the scanty description of the work task, the exposure could be analysed only by job title. Examination of published reports shows clearly that certain job titles are associated with shoulder-neck disorders. High rates and aetiological fractions for rotator cuff tendinitis and tension neck syndrome suggest that preventive measures could be effective. Although job descriptions are brief, the associations noted suggest that highly repetitive shoulder muscle contractions, static contractions, and work at shoulder level are hazardous exposure factors. In reports of cross sectional studies of occupational shoulder-neck disorders presentation of age, exposure, and effect distribution may help for future meta-analysis.

Osteoarthrosis in a rural South African Negro population

The prevalence and distribution of osteoarthrosis has been studied in a South African Negro population. One or more joints were affected in 60% of the males and 48% of the females, compared with a prevalence of 55% in males and 63% in females in a comparable English population. Multiple osteoarthrosis was significantly less common in the African than in the English population, the difference here being greatest in females. Clinical Heberden's nodes were also very infrequent in the African population. However, the Tswana males had significantly more osteoarthrosis of the metacarpophalangeal and proximal interphalangeal joints than was encountered in English males. This is attributed to the traumatic effect of hard manual work which is carried on into old age among most African populations.

Rheumatism in industry: a review

Anderson, J. A. D. (1971).Brit. J. industr. Med.,28, 103-121. Rheumatism in industry: a review. Information about causes, effects, and prevention of rheumatic disease among industrial workers lacks standardization, as shown by the literature in this field; one reason for this is that there are discrepancies about the range of diseases and syndromes which should be included under this heading. The Industrial Survey Unit of the Arthritis and Rheumatism Council defined a rheumatic complaint as musculo-skeletal pain not related to recent (i.e., within six weeks) trauma. A study by the Unit of the social and economic effects of rheumatism among 2 684 male employees from a range of manual occupations is considered in relation to the observations made by other investigators. Sickness absence (at present estimated to be about 29·8 million working days per annum in Britain) and premature retirement can be shown to result directly from rheumatic complaints, especially rheumatoid arthritis and disc disease; furthermore, there seems to be general agreement that sickness absence is more marked in heavy manual occupations than in light ones. However, the extent to which job changes ascribed to rheumatic complaints are in fact caused by them is more doubtful. Evidence supporting the view that occupational factors are related to the aetiology of some chronic rheumatic diseases is fairly strong. Chronic tenosynovitis, bursitis, osteoarthrosis, and, to a lesser extent, disc disease are among those in which such a relationship can be demonstrated; however, the reason why some men are more prone to develop these conditions than others working in similar jobs is still in doubt, suggesting that the aetiology is multifactorial. In other rheumatic diseases, notably rheumatoid arthritis, a fairly extensive study of the literature does not indicate any clear correlation between occupation and aetiology. A system of job analysis for individual workers based on effort, posture, and climatic conditions at work is suggested. Its use as an alternative to grouping employees under their occupational titles might help to clarify these points. Prevention of rheumatic disease (including the use of pre-employment medical examinations) seems impracticable at the present time, but some progress in tackling the problems of rheumatism among industrial workers might be possible by improving rehabilitative services. These improvements would depend on closer collaboration not only between government departments but among doctors themselves and between them and others working in this field.