Дисертації з теми "Osteoarthritis Risk factors"

Purpose: Variation in morphology in the proximal femur and pelvis (e.g. acetabular dysplasia, non-spherical femoral head) can biomechanically compromise the hip joint and predispose to hip osteoarthritis (OA). Such morphological variation may in part explain the heritability of hip OA. The objective of this study was to evaluate a range of 2-dimensional morphological measures on standard radiographs to determine: normal range, right: left symmetry, age and gender differences; and to investigate whether they are associated with the risk of hip OA. Methods: A nested case control study was undertaken in 566 unilateral hip OA cases and 1108 controls in the established Nottingham Genetics of Osteoarthritis and Lifestyle (GOAL) database. Unaffected hips of unilateral hip OA cases were compared to the normal controls, under the assumption that similar morphological features would be observed for the affected hips prior to the development of hip OA. Definition of radiographic hip OA was joint space width (JSW) ~ 2.5 mm. Standardized antero-posterior (AP) radiographs of the pelvis were used to measure the morphological features. Measurements were performed by a single observer and the reproducibility was evaluated at baseline, mid and end of the study. Normal values, thresholds (mean±1.96SD) and symmetry of the features were derived from the control subjects. The intra-observer reliability was examined using intra-class correlation coefficient (ICC). Odds ratio (OR) and 95% confidence interval (Cl) were calculated for association. Logistic regression was used to adjust for age, gender and body mass index (BM!). Measurements were divided into tertiles to examine dose response. ii Results: The intra-observer reliability

Anteromedial osteoarthritis of the knee (AMOA) has been defined anatomically, histologically and radiologically and yet little is known about the epidemiology of the disease or the risk factors involved in the development of the disease. The broad aim of this thesis was to combine clinical insight with the utilisation of modern, large epidemiological datasets to provide information to inform better the clinical management of patients with AMOA. Specifically, the prevalence and incidence of AMOA, the time taken to progress from early disease to severe disease that may require surgical intervention, the radiological characterisation of disease and the assessment of mechanical risk factors implicit in the development of this pattern of disease are investigated. A cross-sectional study of the radiological prevalence of AMOA in a symptomatic cohort in a specialist secondary care knee clinic showed that AMOA was the commonest pattern of knee OA, present in more than 60% of symptomatic subjects. Less than 25% of subjects with AMOA presented with advanced or 'bone-on-bone' disease, emphasising the clinical importance of understanding the progression from earlier stages of disease to this advanced stage. A 20-year longitudinal radiographic study was performed on 1000 women to describe the prevalence, incidence and progression of AMOA. The prevalence of AMOA was 43% and the incidence over 20-years was 0.4. Life table analysis showed that the risk of developing advanced AMOA in a previously normal knee was 2.6%. Of those subjects with early radiological AMOA, 11% progressed to advanced 'bone-on-bone' disease within 10 years and 37% within 20 years. The role of mechanical risk factors in the development of AMOA showed that both anatomical limb and proximal tibial alignment were significantly more varus aligned in those that developed AMOA at 20-years. Assessment of the shape of the medial tibial plateau in a longitudinal MRI study showed that the angle of the upslope at the anterior aspect of the plateau was significantly increased in the group that subsequently developed AMOA. To enable AMOA to be studies in future MRI studies, the MRI description of the disease was defined. In summary, AMOA was shown to be the most common pattern of knee OA both in symptomatic surgical cohorts and in the community. The progression of the disease from an early stage to an advanced stage, which may require surgical intervention, was described for the first time. To enable better the recognition of AMOA in modern epidemiological studies, the MRI description of AMOA was defined and the clinical relevance of modern MRI was discussed. The anatomical alignment of the limb, the alignment of the proximal tibia and the morphology of the tibial plateau were all shown to have a role in the development of AMOA. Addressing these mechanical factors may provide a therapeutic surgical target for the management of patients with AMOA.

Background: Affecting approximately one in four adults over the age of 50 years in the UK, knee pain is a leading cause of disability in the elderly and bears a significant economic cost. Despite the plethora of studies that have investigated the factors associated with the onset of knee pain and osteoarthritis (OA) in the sedentary population, relatively little is known about the prevalence and factors associated with musculoskeletal pain and OA in an athletic sporting population. Objectives: This study aimed to: (1) describe the injury patterns, the prevalence of pain, and OA in Great Britain’s (GB) Olympians; (2) determine in GB Olympians aged 40 years and older the risk of pain and OA at three joints - the hip, knee and the lumbar spine; and (3) identify the individual risk factors associated with joint pain and OA in GB Olympians aged 40 years and older. Methods: This was a cross-sectional study design with an internal nested-case control study. A web-based and / or paper questionnaire was distributed by email and / or post to 2742 GB Olympians living in 30 different countries. The questionnaire was used to collect data on risk factors associated with the onset of pain and OA. The presence of OA was defined by a self-reported physician-diagnosis. Pain was self-reported using a body manikin, and defined as pain in or around the selected joint on most days for at least one month. The most severe limb was selected as the index joint for data analysis, if bilateral. Three separate models of binary logistic regression were constructed to examine the covariates that were associated with pain at the hip, knee, and the lumbar spine. A further three models were constructed to examine the covariates associated with OA at the aforementioned joints. Covariates were identified for analysis, and those that were associated with pain or OA (P < 0.25) were purposefully fitted into a multivariable regression model. The final regression models were constructed by refitting, one at a time, the covariates that had previously been excluded until all of the covariates and interactions that were clinically relevant or significant at traditional levels (P < 0.05) were included. Relative risk (RR) was estimated using odds ratio (OR), and confounding factors were adjusted (aOR) using logistic regression. The Faculty of Medicine and Health Sciences Research Ethics Committee at the University of Nottingham approved the study. Results: The response rate was 26%, with 714 returns achieved between the 22nd of May 2014 and the 31st of January 2015. The questionnaires were returned from GB Olympians living in 15 different countries, including the UK. The age of the GB Olympians recruited ranged from 19 to 97 years, with a mean age of 58.76 + 16.79 years. Fifty-seven per cent of those recruited were male (n = 405) and 43% were female (n = 309). The age of male GB Olympians recruited ranged from 22 to 97 years, with a mean age of 63.00 + 16.30 years. The age range of female GB Olympians recruited ranged from 19 to 93 years, with a mean age of 53.20 + 15.78 years. A total of 821 significant injuries were reported, resulting in an injury rate of 1150 significant injuries per 1000 registered GB Olympians, with 62% reporting they had sustained at least one significant injury (n = 441). Cartilage injuries, joint sprain (injury of joint and / or ligaments), and ligament ruptures were prominent in those with knee pain and knee OA. Intervertebral disc injuries, contusions and joint related injury were common in those with pain and OA at the lumbar spine. Pain was most prevalent at the lumbar spine (32.7%), knee (25.6%), hip (23.0%), and the ankle (14.1%). Osteoarthritis was most prevalent at the knee (14.2%), hip (11.1%), lumbar spine (5.0%), and the ankle (1.3%). Female gender and older age were significantly associated with lumbar spine OA, and older age and a previous significant hip injury were significantly associated with the prevalence of hip OA. Ageing and body mass index (BMI) (kg/m2), a previous significant knee injury and early-life (20-29 years) generalised joint hypermobility (GJH) (Beighton > 4/9) were found to be significantly associated with the prevalence of knee OA. The strongest factors associated with knee pain were a prior significant knee injury, early-life (20-29 years) varus knee alignment, competing in weight-bearing loading sports, widespread pain, and a higher body mass index (kg/m2). Factors associated with hip pain included a previous significant hip injury and competing in weight-bearing loading sports. A one-unit increase in age and BMI (kg/m2), and a prior significant lumbar spine injury were significantly associated with lumbar spine pain. A one-unit increase in physical well-being was significantly associated with a lower prevalence of pain at the hip and knee. Conclusion: This study found that: 1) injury appeared to be constantly the strongest risk factor for pain at the knee, hip and the lumbar spine, as well as OA at the hip and knee; 2) in GB Olympians aged 40 years and older, the knee was most likely affected by OA, and the lumbar spine by pain; 3) participation in weight-bearing loading sports was associated with hip and knee pain, but not hip and knee OA; and 3) generalised joint hypermobility (Beighton > 4/9) appeared to be not a risk factor for injury, and nor was it a risk factor for all joint pain/OA, except OA at the knee joint. Female GB Olympians with early-life GJH were more vulnerable to knee OA than their male counterparts. Future research is needed to help determine whether or not GJH is a risk factor associated with the onset of knee OA in the general population, particularly among females. As one of the few modifiable risk factors, joint injury prevention should be part of the future initiatives to reduce the risk of OA, along with maintaining a healthy body weight.

O estudo busca determinar fatores predisponentes para osteoartrite do quadril, por meio da avaliação de parâmetros radiográficos nos quadris de indivíduos idosos. Foram realizadas medições em radiografias de 106 indivíduos com idade acima de 60 anos, sendo um grupo com osteoartrite do quadril e um segundo grupo de indivíduos sem osteoartrite (grupo controle). As incidências radiográficas utilizadas foram ântero-posterior da pelve em ortostase, falso perfil de Lequesne e Dunn a 45 graus de flexão do quadril. Após aplicação de critérios de seleção bem definidos para osteoartrite primária do quadril, o número de quadris avaliados foi 112 quadris de indivíduos normais e 72 quadris de indivíduos com osteoartrite. Os parâmetros radiográficos estudados foram ângulo centro-borda de Wiberg, ângulo de Tönnis, índice acetabular de profundidade por diâmetro, percentual de cobertura da cabeça do fêmur, ângulo colo-diafisário, ângulo centro-borda anterior, offset entre a cabeça e o colo do fêmur, ângulo alfa, esfericidade da cabeça do fêmur e versão do acetábulo. As medidas radiográficas ângulo colo-diafisário, ângulo alfa, índice acetabular de profundidade por diâmetro e percentual de cobertura da cabeça do fêmur apresentaram valores médios significativamente diferentes nos pacientes com osteoartrite primária, quando comparados aos do grupo controle, sugerindo serem fatores predisponentes para a osteoartrite do quadril
This study aimed to determine factors that predispose towards hip osteoarthritis, by means of evaluating the radiographic parameters of elderly individuals hips. Radiographic measurements were made on 106 individuals aged 60 years or over: one group with hip osteoarthritis and another group of individuals without osteoarthritis (control group). The radiographic views used were the antero-posterior view of the pelvis in orthostatic position, Lequesnes false profile and Dunns view with 45 degrees of hip flexion. After applying well-defined selection criteria for primary osteoarthritis of the hip, the numbers of hips evaluated were 112 hips from normal individuals and 72 hips from individuals with osteoarthritis. The radiographic parameters studied were the Wiberg center-edge angle, Tönnis angle, acetabular index of depth to diameter, percentage coverage of the femoral head, neck-shaft angle, anterior center-edge angle, femoral neck-head offset, alpha angle, sphericity of the femoral head and acetabular version. The radiographic measurements of the neck-shaft angle, alpha angle, acetabular index of depth to diameter and percentage coverage of the femoral head presented mean values that were significantly different between the patients with idiopathic osteoarthritis and the control group. This suggests that these factors may predispose towards hip osteoarthritis

UVOD: Artroza šaka predstavlja jednu od najčešćih mišićno-skeletnih bolesti. Manifestuje se bolom, nekada otokom, deformacijom i gubitkom funkcije šaka. Postoje različita mišljenja o povezanosti osteoartroze (OA) i osteoporoze (OP) kao dva najčeša skeletna poremećaja. CILJ: istraživanja je da se utvrde faktori rizika za nastanak OA šaka, uporedi mineralna koštana gustina kod pacijenata sa OA šaka sa kontrolnom grupom i utvrdi značaj metaboličkog sindroma kod pacijenata sa OA šaka. MATERIJAL I METODE: Istraživanje je obavljeno u periodu od jedne godine kod bolesnika sa OA šaka – eksperimentalna grupa, i u kontrolnoj grupi bez OA. OA šaka je definisana na osnovu bola, klinički prisutnih deformiteta šaka kod žena u postmenopauzi starosne dobi od 60-70 godina i radiografskih promena ( drugog do četvrtog stepena prema Kellgren-Lowrencovoj skali). Analizirani su faktori rizika odgovorni za nastanak OA šaka, povezanost OA šaka sa snagom stiska šake, mineralnom koštanom gustinom i metaboličkim sindromom. Analazirirana je i funkcija šake pomoću tri validirana upitnika: Michigan Hand Outcomes Questionnaire (MHQ, Duruoz Hand Indeks (DHI), Health Assessment Questionnaire (PROMIS HAQ). Statistička obrada podataka rađena je u programu SPSS verzija 25. REZULTATI: Prosečna starost pacijentkinja je bila 65,89±3,67 godina. Eksperimentalna i kontrola grupa se statistički razlikuju prema porodičnoj anamnezi o strukturnim promenama zglobova šaka, prema bolnosti šaka u miru, bolnosti šaka pri palpaciji, uzdržavanju od pokreta prstiju šaka, snage stiska šake, metaboličkom sindromu( p<0,001). Kao značajni prediktori za nastanak osteoartroze šaka su se izdvojili pozitivna porodična anamneza o strukturnim promenama za zglobovima šaka i metabolički sindrom ( p<0,001). Utvrđen je veći broj ispitanica sa normalnom koštanom gustinom u kontrolnoj grupi. Eksperimentalna grupa bolesnica imala je lošiju funkciju šake, odnosno lošiji skor primenom validiranih upitnika ( p <0,001). ZAKLJUČAK: Pacijentkinje sa izraženom osteoartrozom šaka imaju smanjenu funkciju šake, češći metabolički sindrom u odnosu na kontrolnu grupu, ali ne i značajno nižu koštanu gustinu.
INTRODUCTION: Arthritis of the hand is one of the most common musculoskeletal disorders. It manifests as pain, sometimes accompanied by swelling and deformities, which may lead to the loss of hand function. However, there is no consensus on the relationship between osteoarthritis (OA) and osteoporosis (OP) as the two most common skeletal disorders. AIMS: The study aim was to determine the risk factors related to the development of OA in the hand, as well as compare the bone density in patients with hand OA (HOA) with that measured in the control group and establish the significance of metabolic syndrome in the HOA group. MATERIAL AND METHODS: The study was conducted over a 12-month period and included a sample comprising of the experimental (patients affected by HOA) and the control (individuals with no evidence of HOA) group. HOA was diagnosed based on the reported pain, clinical evidence of hand deformities in postmenopausal women aged 60−70, and radiological evidence of physiological changes (Grade II to IV, based on the Kellgren-Lowrence scale). The risk factors for the development of HOA were analyzed, along with the link between HOA and hand grip strength, bone mineral density and metabolic syndrome. Analyses also included had function, as determined by three validated questionnaires: Michigan Hand Outcomes Questionnaire (MHQ), Duruoz Hand Index (DHI), and Health Assessment Questionnaire (PROMIS HAQ). Statistical analyses were performed using the SPSS version 25 computer software. RESULTS: The average age of the sample was 65.89±3.67 years. There were statically significant differences between the experimental and the control group with respect to the family history of structural changes in the hand joints, perceived hand pain at rest and when palpated, reluctance to utilize fingers, hand grip strength, and metabolic syndrome (p < 0.001). Family history of structural changes to the hand joints and metabolic syndrome emerged as the strongest predictors of the osteoarthritis of the hand development (p < 0.001). A greater number of the control group members had normal bone mineral density, while the patients assigned to the experimental group had inferior hand function, as determined by the score on the aforementioned validated questionnaires (p < 0.001). CONCLUSION: Postmenopausal women with pronounced osteoarthritis of the hand have reduced hand function, and are more likely to suffer from a metabolic syndrome relative to the control group, while the differences in bone mineral density are not statistically significant.

Objective: To determine the association between cumulative occupational physical load (COPL) to the knee and the presence of symptomatic osteoarthritis (SOA) and magnetic resonance imaging–defined osteoarthritis (MRI-OA). Methods: Cross-sectional analyses of symptomatic and asymptomatic (n=327) individuals were performed. Inclusion criteria for the symptomatic participants were: 1) having pain, aching, or discomfort in or around the knee on most days of the month at any time in the past; 2) having any pain, aching, or discomfort in or around the knee in the past 12 months. Asymptomatic participants responded “no” to both knee pain questions. COPL was calculated using a self-reported level of activity (five levels) and participation in knee bending/kneeling tasks (three levels) for each occupation held. SOA was defined by the Kellgren Lawrence x-ray grade ≥2, plus the presence of knee pain, as defined by the study inclusion pain criteria. MRI-OA was defined using the criteria specified by Hunter and associates. Logistic regression analyses, adjusted with population weights, were used to examine the associations between COPL (reference group=the lowest COPL quarter) and the presence of SOA and MRI-OA, respectively, after controlling for age, female sex, body mass index, and two-way interactions. Results: Participants (women=167, men=160) were on average 58.5 (SD=11.0) years old with a BMI of 26.3 (SD=4.7). Of those, 102 (31.2%) participants had SOA. For SOA, a monotonic statistically significant relationship was found between COPL 4 (highest quarter; odds ratio (OR)=8.16; 95% CI=1.89, 35.27) and COPL 3 (OR=5.73; 95% CI=1.36, 24.12) versus COPL 1. For MRI-OA, monotonic and statistically significant associations were found in COPL 4 versus 1 (OR=9.54; 95% CI=2.65, 34.27); COPL 3 versus 1 (OR=9.04; 95% CI=2.65, 30.88); COPL 2 versus 1 (OR=7.18; 95% CI=2.17, 23.70). Conclusion: COPL is a significant risk factor for knee OA. Dose response relationships between COPL and both SOA and MRI-OA were found. This study provides new insight into the role of occupation in knee OA, although the results should be interpreted cautiously due to limitations associated with the cross-sectional study design.

L’artrosi és una malaltia plurifactorial. En els darrers anys s’ha relacionat tant amb els factors de risc cardiovasculars clàssics com amb fenòmens d’inflamació, canviant el paradigma de la malaltia. En el primer treball s’avalua l’associació de l’artrosi simptomàtica de mans o genolls amb els factors de risc cardiovasculars clàssics i la síndrome metabòlica respecte un grup control. Es realitza una aproximació a la definició de síndrome metabòlica, donat es tracta d’un estudi transversal observacional. S’observa que tant l'obesitat com la hipertensió arterial són més freqüents en el grup de pacients amb artrosi. Igualment aquests pacients tenen una major presència de síndrome metabòlica. Quan es comparen els episodis cardiovasculars, el grup amb artrosi presenta un major nombre, però l’artrosi, tot i ser influent, no esdevé un factor de risc independent per la seva aparició. Es conclou que els pacients amb artrosi tenen una freqüència augmentada de factors de risc cardiovasculars i síndrome metabòlica. En el segon treball es valora un grup homogeni de pacients amb artrosi de genoll, donades quatre característiques peculiars. La primera és que totes són dones. La segona, totes les pacients presenten artrosi de genoll amb vessament associat. La tercera és que totes tenen elevats índex simptomàtics per dolor i/o discapacitat funcionals a nivell del genoll, i en darrer lloc, les pacients es distribueixen en els diferents graus d’afectació radiològica a diferència d’altres estudis on només s’avaluen pacients en estadi final protèsic. En aquest grup de pacients, es pretenia avaluar la relació dels factors de risc cardiovascular, la síndrome metabòlica i les adipoquines en líquid articular amb la severitat clínica de l’artrosi de genoll, valorada per un qüestionari que presenta dominis tant de dolor com de capacitat funcional com és l’índex de Lequesne. Com a variables de control s’utilitzen el grau d’afectació radiològic, la realització d’exercici físic, marcadors clàssics de la inflamació com el factor de necrosi tumoral, i mesures antropomètriques com el perímetre de cintura. Es determinen set adipoquines en líquid articular, leptina, adiponectina, resistina, osteopontina, visfatina, omentina i quemerina. Els nostres resultats mostren una associació significativa entre la leptina, la resistina i l’osteopontina amb la severitat clínica en artrosi de genoll amb vessament. De tota manera quan s’avalua aquesta associació sota l’efecte de les variables de confusió i de totes les adipoquines, només la resistina s'associa de forma directa i significativa amb l’índex de Lequesne, mentre que la visfatina mostra una associació significativa i inversa amb la severitat clínica. Entre les variables de confusió, el perímetre de cintura i el grau d’afectació radiològica tenen també una associació significativa i independent amb la severitat clínica, mentre que la realització d’exercici físic es relaciona de forma inversa i independent amb l’índex de Lequesne. Els nostres resultats mostren una associació entre diferents adipoquines en líquid articular i la severitat clínica, evidenciant la influència de factors proinflamatoris en l’artrosi de genoll, però també posen de manifest la presència de possibles interaccions biològiques entre les diferents adipoquines respecte la gravetat clínica, donat que les diferents associacions poden variar en funció de les adipoquines avaluades.
Osteoarthritis is a multifactorial disease. In last few years, ostearthritis has been related to classical cardiovascular risk factors and to inflammatory features, leading to a conceptual change of the disease. The first work was addressed to evaluate the association between symptomatic knee or hand osteoarthritis with cardiovascular risk factors and metabolic syndrome versus a control group. Due to the transversal design of the study, an approximation to the definition of metabolic syndrome was made. Patients with osteoarthritis had a high frequency of obesity, hypertension and metabolic syndrome. Unless the number of cardiovascular events was higher in the osteoarthritis group, no significant statistical differences were found, and although osteoarthritis had an influence, it was not independently associated to the presence of cardiovascular events. We concluded that patients with osteoarthritis had a high frequency of cardiovascular risk factors and metabolic syndrome. The second work was carried out in a homogeneous group of knee osteoarthritis with four disctintive features. First, all patient were women. Second, all patient had synovial effusion at the moment of evaluation. Third, the symptomatic levels regarding knee pain or disability were high. Lastly, patients were not in a final radiographic stage and the study was not addressed to patients who underwent prosthetic surgery. We aimed to assess the association between clinical severity with cardiovascular risk factors, metabolic syndrome and synovial fluid adipokines. Clinical severity was evaluated with the Lequesne index, which included pain and disability questions. The confusion factors assessed included radiological degree, physical exercise, classical inflammatory markers like tumour necrosis factor alpha, and anthropometric measurements like waist circumference. Seven adipokines in synovial fluid were determined (leptin, adiponectin, resistin, osteopontin, visfatin, omentin and chemerin). Our results showed a significant association between leptin, resistin and ostepontin with clinical severity in patients with knee osteoarthritis and joint effusion. When the association was evaluated with all confounders and all adipokines, only resistin was associated independently and directly to the Lequesne index, while visfatin was inversely and independently related to clinical severity. Between confounders, waist circunference and radiographic degree were independently and directly associated to clinical severity, while physical exercise was independently and inversely related to Lequesne index. An association between different adipokines and clinical severity was shown in our study, so proinflammatory factors in synovial fluid are important in the clinical evaluation of knee osteoarthritis. Another highlighted point derived from our results were the biological interactions between adipokines regarding knee osteoarthritis clinical severity, because the adipokine association may change depending on which of them were evaluated. This, in our opinion, is an important point for future studies.

碩士
國立臺北大學
統計學系
101
The aging problem is become a global problem. Once people in middle age, the physical function will gradually degenerate, and the occurrence of all chronic diseases or other aging diseases will increase apparent. Thus, the impact of the aging world should be studied more carefully. Osteoarthritis, also known as degenerative Joint Disease, is one of the most troublesome diseases among all of the most common elderly diseases. It not only induces pain constantly, but also causes the physical movement uncomfortably. Up to now, hand osteoarthritis disease symptoms and the patients’ own situation are studied rarely by researches studied osteoarthritis in Taiwan. If osteoarthritis can be diagnosed earlier by the clinical observation, it can effectively avoid the subsequent pain symptoms, possible loss of the physical function and even disability. This study utilized the data from Genome-Wide Study for Disease Susceptibility Genes in Patients with Hand Osteoarthritis (HOA) of the Han-Chinese Population involving a collection of eight hospitals. 497 eligible participants were classified into three groups. There were 182 participants who had hand osteoarthritis, and 115 participants who were treated as a disease control group and a normal control group of 200 participants. The demographics of participants, the family’s ancestral history and related disease history, profession and lifestyle, the medical history and drug history, the clinical physical examination, the clinical physical assessment, the grip strength, and pinch strength measurements were collected. Many clinical variables were grouped into many constructs established by the factor analysis and reliability analysis. The chi-square and Kruskall Wallis test were used to assess the association between the categorical variable and the continuous explanatory variable and the classification of the participants. The overall association between associated clinical variables and the classification of participants were assessed by the multinomial logit model. Age at screening, weight, finger joints swollen, gender, hospital classification have the greatest influence in predicting the classification of participants. More specifically, the study shows that people with swelling on finger joints suffer higher probability of hand osteoarthritis, and older age is an important risk of hand osteoarthritis. The results of this study provide clinical preliminary judgment in hand osteoarthritis. The health agencies can use such information to develop health policy in this area. As a result, people can effectively prevent from suffering hand osteoarthritis or reduce the risk having this disease.

碩士
中山醫學大學
醫學研究所
106
Abstract Objective： Dementia is one of the most common neurological diseases around the world, but it remains unclear whether there is an association between dementia and general anaesthesia. This study aimed to investigate the association between anaesthesia and dementia in osteoarthritis patients by analyzing a nation-wide population-based database. Methods and Materials： Using the claims data of 1 million insured residents covered by Taiwan’s universal health insurance from 2000 to 2013, we included 2171 newly diagnosed dementia patients for the study group. The control group, which consisted of 4342 individuals without dementia, was matched for age and gender. Data were analyzed using logistic regression. Results： There were no difference between Individuals exposed to general anaesthesia and those exposed to regional anaethesia (OR = 1.11, 95%CI 0.73-1.70) after adjusted for age, sex and Co-morbidities. In addition, no significant association was found when exposure was quantified as anaesthesia duration(OR = 0.91, 1.21, and 0.39 for <2 hours, 2-4hours, >4hours exposures compared to none, respectively) or replacement time(OR = 0.72 for twice compared to once). Conclusion and Suggestion： The results of our nationwide, population-based study show that there is no significant difference of dementia risk after either general or regional anaesthesia.

With increasing rates of obesity, research has begun to focus of co-morbidities of obesity such as osteoarthritis. The majority of existing research has focused on older adults as the group most likely to suffer from osteoarthritis. The purpose of this study was to determine if overweight and obese young adults exhibit biomechanical risk factors for knee osteoarthritis, and to determine if young adults with biomechanical risk factors of osteoarthritis can modify these with instruction. This purpose was divided into two separate studies. Study 1: Thirty adults between 18-35 years old were recruited into three groups according to body mass index: normal, overweight, and obese. Participants walked through the lab while we collected 3-d kinematic and kinetic data. Overweight and obese young adults walked with similar gait compared to normal weight young adults. Study 2: Nine young adults between 18-35 years were recruited who walked with stiff-knee gait. Baseline measures of gait were collected in the form of 3-d kinematics and kinetics as participants walked through the laboratory. They then completed the gait instruction program which consisted of four blocks of training. Each block included ten single steps where the participant was provided feedback, followed by 100 practice steps around the laboratory. Participants were successful in increasing sagittal plane kinematics and kinetics of interest in the study. Conclusion: Identifying individuals who had biomechanical risk factors of osteoarthritis according to body mass index was not possible. According to the results of our study, obese and overweight young adults are not at increased risk of osteoarthritis compared to normal weight young adults. Individuals who may be at increased risk due to stiff-knee gait were able to improve their gait following instruction.

This study examines the possible correlations between vertebral osteoporosis, spondylolysis, spondylolisthesis, Schmorl’s nodes, vertebral osteoarthritis, osteophytosis, and laminal spurs. Further, this study examines the effects of sex, age, ancestry, and occupation on the vertebral pathologies. A total of 238 individuals (54 African Americans and 184 randomly selected European Americans) from the William M. Bass Donated Skeletal Collection at the University of Tennessee, Knoxville, were analyzed. Vertebral pathologies and anomalies were assessed using visual morphometric scoring methods outlined in previous research. It is hypothesized that positive correlations exist between osteoporosis and other vertebral pathologies and a positive correlation exists between vertebral pathologies and strenuous occupations. It is also hypothesized that there is a difference in the prevalence of vertebral pathologies between European American and African American ancestries due to African Americans generally showing higher bone mineral density than European Americans (Aloia 2008). The results of this research demonstrate numerous relationships: females are correlated with more severe osteoarthritis, osteoporosis, and spondylolisthesis, while males correlate with Schmorl’s nodes; European Americans are correlated with osteoporosis, osteoarthritis, osteophytosis, and Schmorl’s nodes, while African Americans are correlated with laminal spurs; individuals 40 years or older are correlated with osteoporosis, osteoarthritis, Schmorl’s nodes, and laminal spurs; and lastly, labor intensive occupations (i.e., construction worker) are correlated with osteoarthritis, osteophytosis, and Schmorl’s nodes, all with p-values less than 0.05. The majority of the pathological conditions also correlate with each other, for example, osteoporosis and osteoarthritis. This research demonstrates how pathological conditions correlate with sociodemographic risk factors and with other pathological conditions, which can help with the identification process of skeletal remains in archaeological and forensic contexts.

BACKGROUND: Knee osteoarthritis is a chronic disease that frequently results in pain, activity limitations and difficulties performing social and community activities. Despite the growing prevalence of arthritis and associated participation restrictions, few studies have measured the long-term impact of the environment and psychological factors on participation restriction in this population. METHODS: Participants from the Multicenter Osteoarthritis Study (MOST) self-reported participation at baseline, 30, 60, and 84 months using the Instrumental Role subscale of the Late Life Disability Index. For study 1, participants’ environmental features were assessed at baseline from the Home and Community Environment questionnaire administered in the MOST-Knee Pain & Disability study, an ancillary study of MOST. The relative risk of participation restriction at 60 months due to community mobility barriers and transportation facilitators was calculated using binomial regression, adjusting for covariates. For study 2, baseline levels of positive and negative affect were assessed with the Center for Epidemiological Studies Depression Scale. The relative risk of incident participation restriction over 84 months due to 1) low positive affect (vs. high positive affect), 2) high negative affect (vs. low negative affect), and 3) combinations of low/high positive and negative affect (vs. high positive affect/low negative affect) were calculated in separate analyses using binomial regression, adjusting for covariates. RESULTS: In study 1, 69 (27%) of the 322 participants developed participation restriction by 60 months. Participants reporting high community mobility barriers at baseline had 1.8 times the risk [95% CI: 1.24, 2.73] of participation restriction at 60 months, after adjusting for covariates, whereas the risk due to high transportation facilitators was not significant. In study 2, 470 participants (26%) had incident participation restriction over 7 years. The adjusted relative risks of incident participation restriction over 7 years across the three analyses were: 1) low positive affect (vs. high positive affect): RR: 1.2 [95% CI: 1.0, 1.4], 2) high negative affect (vs. low negative affect): RR: 1.5 [95% CI: 1.3, 1.7], 3) low positive affect and high negative affect (vs. high positive and low negative affect): RR: 1.8 [95% CI: 1.4, 2.1]. CONCLUSIONS: These studies highlight that people with knee osteoarthritis who have certain contextual features, such as environmental barriers or low positive and high negative affect, are at increased risk of participation restriction over time.
2018-07-07T00:00:00Z

Research Doctorate - Doctor of Philosophy (PhD)
Musculoskeletal conditions, such as spinal pain and osteoarthritis (OA) have a high global burden. Although evidence suggests that musculoskeletal conditions are linked with both chronic diseases and lifestyle risk factors, there are significant evidence gaps in our understanding of these relationships. This thesis attempts to explore the relationship between musculoskeletal conditions and chronic diseases and assess the management of lifestyle risk factors in patients with common musculoskeletal conditions including chronic low back pain and knee OA. Chronic diseases and musculoskeletal conditions have a significant global burden and frequently co-occur. Emerging evidence suggests musculoskeletal conditions may contribute to the development of chronic disease and several mechanisms have been proposed to explain these links. However, the available studies have not been systematically synthesised, and longitudinal relationships have not been assessed. In Chapter Two, a systematic review was performed to investigate whether the most common musculoskeletal conditions contribute to the development of non-communicable chronic diseases. Electronic databases were searched for cohort studies reporting adjusted estimates of the association between musculoskeletal conditions (neck or back pain or osteoarthritis of the knee or hip) and subsequent development of chronic disease (cardiovascular disease, cancer, diabetes, chronic respiratory disease or obesity). Thirteen eligible cohort studies following 3,086,612 people were identified. In the primary meta-analysis of adjusted estimates, osteoarthritis was the exposure in eight studies and back pain in two studies and cardiovascular disease was the outcome in eight studies, cancer in one study, and diabetes in one study. Pooled adjusted estimates from these ten studies showed that people with a musculoskeletal condition, have a 17% increase in the risk of developing a chronic disease, compared to people without a musculoskeletal condition (hazard ratio 1.17, 95%CI 1.13 to 1.22; I2 52%, total n=2,686,113). The meta-analysis found musculoskeletal conditions may increase the risk of chronic disease. The results highlight that musculoskeletal conditions could be important in the prevention of chronic disease. There is evidence to suggest that the persistence of low back pain is linked to lifestyle risk factors, such as overweight and obesity. Although there is widespread suggestion that managing lifestyle risks such as weight, should be part of management for patients with low back pain, there is currently no evidence about the effectiveness of lifestyle management to guide clinical practice. Chapter Three presents a study protocol (Part A) and statistical analysis plan (Part B) for the first high quality randomised controlled trial (RCT) testing whether targeting lifestyle risk factors could improve outcomes for patients with chronic low back pain. Eligible patients (n=160) were randomly allocated, using a central concealed random allocation process, to receive advice and education and referral to a 6-month telephone-based healthy lifestyle coaching service, or usual care. Chapter Four presents the results of the trial and showed that there were no differences between groups for pain intensity over six months (area under the curve, mean difference 6.5, 95%CI -8.0 to 21.0; p=0.38) or any secondary outcome. The lifestyle intervention did not reduce self-reported weight, the hypothesised mechanism to influence important patient outcomes such as pain and disability. The results suggest that clinical education and advice coupled with referral to generic, non-disease specific telephone-based healthy lifestyle coaching may not adequately support patients with chronic low back pain. Standard analyses of RCTs estimate whether an intervention is effective or not. However, these analyses cannot provide explanations for how an intervention works, or why it does not work. Causal mediation analysis of RCTs can be used to determine if intervention effects worked through the hypothesised targets or if they are explained by other mechanisms. When there are no intervention effects, causal mediation analysis can help to determine if changing the targets is likely to lead to the outcome of interest. Chapter Five and Six presents an a priori protocol and results of a causal mediation analysis, respectively, of aggregated data from two RCTs; one which included 160 patients with chronic low back pain (the RCT presented in Chapters Three and Four), and another which included 120 patients with knee OA. In both trials the intervention consisted of brief advice and referral to a 6-month telephone-based healthy lifestyle coaching service. In the back pain trial participants were also offered a single physiotherapy consultation. The hypothesised primary mediator was self-reported weight and alternative mediators were diet, physical activity and pain beliefs. Outcomes were pain, disability and quality of life (QoL). Data were analysed using causal mediation analysis with sensitivity analyses for sequential ignorability. The intervention had no effect on pain intensity, disability or physical QoL. The intervention significantly improved mental QoL however, the intervention effect was not channeled via the selected mediators. The intervention did not reduce weight, or the alternative mediators (diet, physical activity, pain beliefs), and these mediators were not associated with the outcomes (with one exception; poor diet was associated with lower mental QoL). Although clinical guidelines advocate focusing on lifestyle risk factors and erroneous pain beliefs in patients with chronic low back pain or knee OA, there is uncertainty about whether they are causes of pain, disability, and poor QoL. These findings suggest that addressing lifestyle risk factors and erroneous pain beliefs may not be appropriate targets to improve pain, disability and quality of life in these patients. Decision makers often have limited funds and are required to choose between health care interventions. Economic analysis of RCTs provide decision makers with information to help guide allocation of scarce resources. Chapter Six presents an economic evaluation of a healthy lifestyle intervention for patients with chronic low back pain, compared with usual care (the RCT presented in Chapters Three and Four). The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight, and body mass index. Costs included intervention costs, healthcare utilisation costs and work absenteeism costs. The primary analysis was conducted from the societal perspective and included all of these cost categories. Mean total costs were lower in the intervention group than the control group (-$614, 95%CI -3133 to 255). For all outcomes, the intervention was on average less expensive and more effective than usual care and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e. 0.81) at a willingness-to-pay of $0/unit of effect. For QALYs, this probability increased to 0.90 at a willingness-to-pay of $17,000/QALY and reached a maximum of 0.96 at $67,000/QALY. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses. These findings suggest that the healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicate caution is needed when interpreting these findings. Overall, the studies included in this thesis have advanced the evidence-base regarding the relationship between musculoskeletal conditions and chronic disease, and the management of lifestyle risk factors. A systematic review of the literature suggests that musculoskeletal conditions should be considered in the prevention of chronic disease. However, a better understanding of the relationships between musculoskeletal conditions and chronic diseases is required to support inclusion of musculoskeletal conditions in the current chronic disease prevention agenda. To improve understanding about causal relationships, use of contemporary analytical methods in the assessment of longitudinal data is needed. Other aspects of this thesis explore management of lifestyle risk factors in patients with musculoskeletal conditions. Using existing population health services might be a scalable and cost-effective model to support clinicians to provide lifestyle-focused care for patients with musculoskeletal conditions. However, in their generic form, they do appear to produce clinically meaningful benefit to patients. Given the high prevalence of musculoskeletal conditions, a dedicated line of research would be warranted to support adaptation of available services for patients with musculoskeletal conditions and concomitant health risks. To maximise knowledge gained from the investment in research, clinical trialists should routinely plan and use supplementary analyses, such as causal mediation analyses and economic evaluations, in addition to standard analyses of treatment effectiveness. These methods of analysis extend knowledge from RCTs to guide intervention refinement and can inform decisions about resource allocation for clinical or policy decision-makers.