Applying the International Classification of Functioning, Disability and Health framework to determine the predictors of falls and fractures in people with osteoarthritis or at high risk of developing osteoarthritis: data from the Osteoarthritis Initiative

Associations of osteoarthritis with risk of future fracture events: prospective study in UK Biobank

BACKGROUND

Researchers have long been interested in the potential relationship between osteoarthritis (OA), falls, and fractures; however, the evidence supporting this relationship has been conflicting. This study aimed to investigate the association between osteoarthritis and future fracture events.

MATERIALS AND METHODS

This study was designed as a prospective cohort study. We recruited a total of 440 476 individuals from the UK Biobank to investigate the impact of OA on the incidence of fracture. Among the total population, there were 54 581 participants diagnosed with OA. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

RESULTS

A total of 26 083 fracture events were documented over a median follow-up period of 13.5 years. After multivariable adjustment, participants with osteoarthritis had an HR (95% CI) of 1.11 (1.08, 1.15) for future fracture events compared to participants without osteoarthritis ( P  < 0.0001). Falls explained 16.34% of the association between osteoarthritis and fracture events and 14.15% of the association between knee osteoarthritis and fracture events. The association was not substantially altered across the series of sensitivity analyses.

CONCLUSION

Osteoarthritis was associated with a greater risk of future fracture events. This finding highlights the importance of preventing future fracture events in people with osteoarthritis.

Falls prevention in people with breast cancer: a survey of current physiotherapist practices

PURPOSE

To examine the current falls prevention knowledge, beliefs and practices of physiotherapists providing clinical care to people with breast cancer.

METHODS

A cross-sectional online survey of currently registered, practising Australian physiotherapists was conducted. The survey was developed and reported using the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist, with data analysed descriptively or using bivariate tests. Free-text responses to open-ended questions were classified into key themes for analysis.

RESULTS

Forty-two physiotherapists completed the survey, of which 55% (23/42) believed that people with breast cancer had a higher risk of falls compared to the general population. Whilst most respondents received prior training in assessing and managing falls risk factors (30/42; 71%), they reported only moderate confidence in assessing and delivering falls prevention care to people with breast cancer (median 6; IQR 4). Only half of respondents (20/38; 53%) routinely asked about falls history although 61% assessed standing balance (23/38) either through an overall functional assessment (16/38; 42%) or using specific balance measures (7/38; 18%).

CONCLUSIONS

Further resources and training for physiotherapists may be required to optimise their skills and confidence, and to embed best-practice falls prevention strategies into the physiotherapy care of people with breast cancer.

Construct Validity and Responsiveness of Performance-based Tests in Individuals With Knee Osteoarthritis

OBJECTIVES

To assess the construct validity and responsiveness of 3 performance-based tests in individuals with knee osteoarthritis (KOA).

DESIGN

This study has a prospective cohort design.

SETTING

Assessments were administered at the Federal University of São Carlos (Brazil) by 3 different raters.

PARTICIPANTS

A total of 107 participants with KOA were aged ≥40 years (N=107).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

This study assessed the construct validity and responsiveness of 3 performance-based tests: 40-meter fast-paced walk test (40-m FPWT), 11-step stair climb test (11-step SCT), and 30-second chair stand test (30-s CST). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), sedentary behavior (activPAL), and numeric pain rating scale (NPRS) were used as comparator instruments. Measurements were obtained at baseline and after 6 months. The construct validity and responsiveness were calculated using Spearman correlation coefficient within predefined hypotheses based on a panel comprising 5 experts in the field of outcome measurement in KOA.

RESULTS

The three performance-based tests showed excellent (ICC>0.9) reliability (intra and inter); however, only the 40-m FPWT and 11-step SCT were considered valid and responsive because both confirmed >75% of the priori hypotheses. The 30-s CST was not considered valid or responsive because it has not confirmed ≥75% of the priori hypotheses.

CONCLUSION

The 3 performance-based tests are reliable for intra and inter assessments. The 40-m FPWT and 11-step SCT are both valid and responsive for measuring physical function in patients with KOA. The 30-s CST was not considered valid or responsive. Therefore, 40-m FPWT and 11-step SCT can detect changes over time and are indicated for functional assessment in clinical practice.

Comprehensive review of deep learning in orthopaedics: Applications, challenges, trustworthiness, and fusion

Deep learning (DL) in orthopaedics has gained significant attention in recent years. Previous studies have shown that DL can be applied to a wide variety of orthopaedic tasks, including fracture detection, bone tumour diagnosis, implant recognition, and evaluation of osteoarthritis severity. The utilisation of DL is expected to increase, owing to its ability to present accurate diagnoses more efficiently than traditional methods in many scenarios. This reduces the time and cost of diagnosis for patients and orthopaedic surgeons. To our knowledge, no exclusive study has comprehensively reviewed all aspects of DL currently used in orthopaedic practice. This review addresses this knowledge gap using articles from Science Direct, Scopus, IEEE Xplore, and Web of Science between 2017 and 2023. The authors begin with the motivation for using DL in orthopaedics, including its ability to enhance diagnosis and treatment planning. The review then covers various applications of DL in orthopaedics, including fracture detection, detection of supraspinatus tears using MRI, osteoarthritis, prediction of types of arthroplasty implants, bone age assessment, and detection of joint-specific soft tissue disease. We also examine the challenges for implementing DL in orthopaedics, including the scarcity of data to train DL and the lack of interpretability, as well as possible solutions to these common pitfalls. Our work highlights the requirements to achieve trustworthiness in the outcomes generated by DL, including the need for accuracy, explainability, and fairness in the DL models. We pay particular attention to fusion techniques as one of the ways to increase trustworthiness, which have also been used to address the common multimodality in orthopaedics. Finally, we have reviewed the approval requirements set forth by the US Food and Drug Administration to enable the use of DL applications. As such, we aim to have this review function as a guide for researchers to develop a reliable DL application for orthopaedic tasks from scratch for use in the market.

Association of knee and hip osteoarthritis with the risk of falls and fractures: a systematic review and meta-analysis

OBJECTIVE

Studies evaluating the association of knee and hip osteoarthritis (OA) with falls and fractures have inconsistent findings. We aimed to investigate associations of symptomatic and radiographic knee and hip OA with risk of falls, recurrent falls, and fractures.

METHODS

We conducted an electronic search of databases from inception to February 2023. Two authors independently screened studies, extracted data, and assessed the risk of bias using the Newcastle-Ottawa Scale tool in eligible studies. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects models.

RESULTS

Of 17 studies included (n = 862849), 2 had a high risk of bias. Among studies that evaluated falls or fractures as outcomes, 7/8 (87.5%) and 5/11 (45.5%) were self-reported, respectively. Both symptomatic knee and hip OA were associated with increased risk of recurrent falls (knee: OR = 1.55, 95% CI 1.10 to 2.18; hip: OR = 1.50, 95% CI 1.28 to 1.75) but not falls or fractures. Radiographic knee OA increased risk of falls (OR = 1.28, 95% CI 1.03 to 1.59) and did not significantly increase risk of recurrent falls (OR = 1.39, 95% CI 0.97 to 1.97) or fractures (OR = 1.22, 95% CI 0.99 to 1.52). Radiographic hip OA decreased the risk of recurrent falls (OR = 0.70, 95% CI 0.51 to 0.96) but had no statistically significant association with fractures (OR = 1.16, 95% CI 0.79 to 1.71).

CONCLUSION

Symptomatic knee and hip OA were both associated with an increased risk of recurrent falls, and radiographic knee OA was associated with an increased risk of falls. No statistically significant associations of radiographic and symptomatic knee or hip OA with fractures were found.

Age and Gender Differences in Fall-Related Factors Affecting Community-Dwelling Older Adults

BACKGROUND

Falls are one of the major adverse events affecting older adults that can result in serious injuries. Hospitalizations and deaths because of fall-related injuries have been increasing. Nevertheless, there is a dearth of studies examining the physical condition and current exercise habits of older adults. Moreover, studies analyzing the role of factors related to fall risk by age and gender in large populations are also scarce.

PURPOSE

This study was designed to investigate the prevalence of falls among community-dwelling older adults and elucidate the effects of age and gender on the related factors using a biopsychosocial model.

METHODS

This cross-sectional study utilized data from the 2017 National Survey of Older Koreans. On the basis of the biopsychosocial model, the biological factors related to falls included chronic diseases, number of medications, visual difficulties, activity of daily living (ADL) dependence, lower-limb muscle strength, and physical performance; psychological factors included depression, cognitive ability, regular smoking, alcohol consumption, nutritional status, and exercise; and the social factors included educational level, annual income, living conditions, and instrumental ADL dependence.

RESULTS

Of the 10,073 older adults surveyed, 57.5% were women and approximately 15.7% had experienced falls. The results of the logistic regression showed that, in men, falls were significantly associated with taking more medications and being able to climb 10 stair steps; in women, falls were significantly associated with poor nutritional status and instrumental ADL dependence; and in both genders, falls were significantly associated with greater depression, ADL dependence, and the presence of more chronic diseases and negatively associated with physical performance.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The results suggest that practicing kneeling and squatting is the most effective strategy for reducing fall risk in older adult men and that improving nutritional status and strengthening physical ability is the most effective strategy for reducing fall risk in older adult women.

Falls prevention and osteoarthritis: time for awareness and action

Osteoarthritis (OA) and falls both commonly affect older people. While high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management. OA care and falls prevention have for too long been considered as separate clinical constructs. In the context of ageing populations and growing numbers of people with OA, the time to raise awareness and enact appropriate action is now. This Perspectives on Rehabilitation article draws on the findings from a comprehensive mixed-methods falls and OA research program (which uniquely spanned population, clinician, and consumer perspectives) to better understand existing evidence-practice gaps and identify key opportunities for improvements in clinical care.IMPLICATIONS FOR REHABILITATIONWhile high-level evidence exists to prevent falls in older people, falls prevention is rarely considered within contemporary OA management and this represents a concerning knowledge-to-practice gap.Given ageing populations and growth in the number of people with OA, it is time for falls prevention to be incorporated within routine OA care for older people.To achieve this, we need to re-shape current messaging around falls prevention and develop targeted resources to optimise clinician knowledge and skills in this area.

Derivation of a screening tool for predicting the risk of falls in community-dwelling older adults with knee osteoarthritis

The aim of this study was to derive a screening tool for predicting the risk of falls in community-dwelling older adults with knee osteoarthritis. This prospective cohort study was conducted in four orthopedic clinics. The main outcome measure was falls or nonfalls for 5 months, and the predictors were sex, age, BMI, Kellgren-Lawrence grade, laterality, number of comorbidities, pharmacotherapy, physical therapy period, use of a cane, household, previous history of falls, visual analog scale for pain, one-leg standing test (OLST), five times sit-to-stand test (FTSST), and Frenchay activities index. Ninety outpatients (74 females and 16 males) with a mean (SD) age of 73.1 (9.3) years completed a 5-month follow-up. According to the binomial logistic regression analysis, previous history of falls [odds ratio (OR), 6.85; P = 0.019], OLST (OR, 5.97; P = 0.048), and FTSST (OR, 12.93; P = 0.034) were identified as risk factors for falls, and the clinical prediction rule was derived from these variables. The pretest probability of fallers in this study was 21.1% (19 of 90 participants). When the total screening tool score was three points (the participant scored one point for each item: previous history of falls, yes; OLST, ≤6.84 s; FTSST, ≥8.77 s), the positive likelihood ratio was 16:19, and the posttest probability increased to 81.3%. Therefore, this simple screening tool possesses potential clinical utility for identifying patients with knee osteoarthritis at high risk of falls in the future because it demonstrated sufficient diagnostic test accuracy.

Classification of Center of Mass Acceleration Patterns in Older People with Knee Osteoarthritis and Fear of Falling

(1) Background: The preoccupation related to the fall, also called fear of falling (FOF) by some authors is of interest in the fields of geriatrics and gerontology because it is related to the risk of falling and subsequent morbidity of falling. This study seeks to classify the acceleration patterns of the center of mass during walking in subjects with mild and moderate knee osteoarthritis (KOA) for three levels of FOF (mild, moderate, and high). (2) Method: Center-of-mass acceleration patterns were recorded in all three planes of motion for a 30-meter walk test. A convolutional neural network (CNN) was implemented for the classification of acceleration signals based on the different levels of FOF (mild, moderate, and high) for two KOA conditions (mild and moderate). (3) Results: For the three levels of FOF to fall and regardless of the degree of KOA, a precision of 0.71 was obtained. For the classification considering the three levels of FOF and only for the mild KOA condition, a precision of 0.72 was obtained. For the classification considering the three levels of FOF and only the moderate KOA condition, a precision of 0.81 was obtained, the same as in the previous case, and finally for the classification for two levels of FOF, a high vs. moderate precision of 0.78 was obtained. For high vs. low, a precision of 0.77 was obtained, and for the moderate vs. low, a precision of 0.8 was obtained. Finally, when considering both KOA conditions, a 0.74 rating was obtained. (4) Conclusions: The classification model based on deep learning (CNN) allows for the adequate discrimination of the acceleration patterns of the moderate class above the low or high FOF.

Analysis of the Associations between Arthritis and Fall Histories in Korean Adults

(1) Background: the purpose of the present study was to analyze the associations between arthritis and fall histories in Korean adults. (2) Methods: data from the 2015 and 2017 Korean Community Health Survey were analyzed. In total, 322,962 participants aged ≥40 years were included. The participants were divided into two different groups. First, the participants were divided into the ‘arthritis (osteoarthritis or rheumatoid arthritis) for entire life’ and ‘nonarthritis for entire life (comparison I)’ groups. Subsequently, the participants were divided into the ‘current arthritis’ and ‘noncurrent arthritis (comparison II)’ groups. Afterwards, we analyzed the prevalence odds ratios (pORs) of the fall histories of the participants using a logistic regression analysis with the 95% confidence interval (CI). The variables of income, education level, region of residence, smoking status, alcohol consumption, obesity, subjective health status, stress level, physical activity, and sleep hours were adjusted for as covariates. (3) Results: both the arthritis for entire life and current arthritis groups had higher prevalence rates of falls than the comparison I and comparison II groups, respectively (each p < 0.001). The pORs of falling ≥1 time and ≥2 times per year in the arthritis for the entire life group were 1.42 (95% CI = 1.38–1.46) and 1.69 (95% CI = 1.62–1.76), respectively. The adjusted pORs for falling ≥1 time and ≥2 times per year in the current arthritis group were 1.35 (95% CI = 1.31–1.39) and 1.56 (95% CI = 1.50–1.63), respectively. (4) Conclusions: previous arthritis has a significant impact on the risk of falling.

Does screening for depressive symptoms help optimize duloxetine use in knee OA patients with moderate pain? A cost-effectiveness analysis

OBJECTIVE

Duloxetine is an FDA-approved treatment for both osteoarthritis (OA) pain and depression, but uptake of duloxetine in knee OA management varies. We examined the cost-effectiveness of adding duloxetine to knee OA care with or without depression screening.

METHODS

We used the Osteoarthritis Policy Model, a validated computer microsimulation of knee OA, to examine the value of duloxetine for knee OA patients with moderate pain by comparing three strategies: 1) usual care (UC); 2) duloxetine for those who screen positive for depression on the Patient Health Questionnaire 9 (PHQ-9) + UC; and 3) universal duloxetine + UC. Outcomes included quality-adjusted life years (QALYs), lifetime direct medical costs, and incremental cost-effectiveness ratios (ICERs), discounted at 3% annually. Model inputs, drawn from published literature and national databases, included: annual cost of duloxetine, $721-$937; average pain reduction for duloxetine, 17.5 points on the WOMAC pain scale (0-100); likelihood of depression remission with duloxetine, 27.4%. We considered two willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY. We varied parameters related to the PHQ-9 and duloxetine's cost, efficacy, and toxicities to address uncertainty in model inputs.

RESULTS

The screening strategy led to an additional 17 QALYs per 1,000 subjects and increased costs by $289/subject (ICER=$17,000/QALY). Universal duloxetine led to an additional 31 QALYs per 1,000 subjects and $1,205/subject (ICER=$39,300/QALY). Under the majority of sensitivity analyses, universal duloxetine was cost-effective at the $100,000/QALY threshold.

CONCLUSION

Adding duloxetine to usual care for knee OA patients with moderate pain, regardless of depressive symptoms, is cost-effective at frequently-used WTP thresholds.

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

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