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ORIGINAL ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 2  |  Page : 117-122  

Prevalence of osteoarthritis of knee joint among adult population in a rural area of Kanchipuram District, Tamil Nadu


1 Assistant Professor, Department of Preventive and Social Medicine, JIPMER, Pondicherry, Tamil Nadu, India
2 Associate Professor, Department of Community Medicine, PIMS, Pondicherry, Tamil Nadu, India
3 Assistant Professor, Department of Community Medicine, Madurai Medical College, Madurai, Tamil Nadu, India
4 Assistant Professor, Department of Community Medicine, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
5 Lecturer, Department of Physical Medicine and Rehabilitation, PIMS, Pondicherry, Tamil Nadu, India
6 (Rtd) Professor and Head of Community Medicine, PIMS, Pondicherry, Tamil Nadu, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Jayaseelan Venkatachalam
Department of Preventive and Social Medicine, JIPMER, Dhanwanthri Nagar, Pondicherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_344_16

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   Abstract 


Background: Osteoarthritis (OA) is one of the most common degenerative disorders among the elderly population; although aging is the most important cause, research has shown that it is a complex disease with many etiologies. It is not an inevitable part of aging but rather the result of a combination of factors, many of which can be modified or prevented. Objective: The objective of this study was to assess the burden and determinants of OA knee among the adult population. Methods: A community-based, cross-sectional study among 1986 adult persons living in a rural area in Kanchipuram district, Tamil Nadu, South India, was interviewed and examined from January 2014 to December 2014. Data collection was done by the postgraduates, trained health workers under the supervision of principal investigator. Written and informed consent was obtained before data collection. OA was diagnosed using the criteria laid down by the American College of Rheumatology, and it was validated and tested in the study area. Results: A total of 1986 adult respondents were interviewed out of which 27.1% had OA of knee. Age more than 50 years, female gender, tobacco usage, illiteracy, lower socioeconomic class, positive family history of OA, diabetes, and hypertension were found to be associated with OA knee (P < 0.05). Conclusion: The burden of osteoarthritis knee was high in this region. Hence, effective preventive strategy has to be taken to minimize this burden.

Keywords: Determinants, knee joint, osteoarthritis, rural area


How to cite this article:
Venkatachalam J, Natesan M, Eswaran M, Johnson AK, Bharath V, Singh Z. Prevalence of osteoarthritis of knee joint among adult population in a rural area of Kanchipuram District, Tamil Nadu. Indian J Public Health 2018;62:117-22

How to cite this URL:
Venkatachalam J, Natesan M, Eswaran M, Johnson AK, Bharath V, Singh Z. Prevalence of osteoarthritis of knee joint among adult population in a rural area of Kanchipuram District, Tamil Nadu. Indian J Public Health [serial online] 2018 [cited 2020 Dec 1];62:117-22. Available from: https://www.ijph.in/text.asp?2018/62/2/117/234506




   Introduction Top


Arthritis is defined as inflammation of a joint characterized by pain, swelling, and limitation of joint movements. Osteoarthritis (OA), the most common type of arthritis, is a joint failure in which all structures of the joint undergo pathologic changes, often in concert.[1] It is an important cause of disability and the fourth leading cause of years lived with disability.[2] OA affects almost all joints, but the most commonly affected joints are the knee and hip joints. In the world, it is estimated that 10%–15% of all adults aged over 60 have some degree of OA, with prevalence higher among women than men.[3] The prevalence of symptomatic knee OA in the USA, is 12.1% as per NHANES III data and 16.3% in participants aged 55–64 of Johnston County OA project.[4] According to data produced by the Dutch Institute for Public Health, the prevalence of knee OA in those aged 55 and above was 15.6% in men and 30.5% in women, respectively.[5] A study done in Asian countries of India, Pakistan, and Bangladesh showed a higher prevalence of OA knee in rural areas was 13.7% as compared to 6.9% in urban areas.[6] Community survey data in rural and urban areas of India show the prevalence of OA to be in the range of 17%–60.6%.[7]

A study conducted in India among adults had shown a significant difference in the prevalence of OA between rural (56.6%) and urban areas (32.6%).[7] Due to the lifestyle habits, Asians have a higher risk for knee joint arthritis compared to Americans and Europeans.[6] A literature search showed that very few attempts were made to find the prevalence and determinants of OA in south India. Hence, the current study was planned to find the prevalence of knee joint OA and its determinants in rural areas of Kanchipuram district, Tamil Nadu, India.


   Materials and Methods Top


A community-based, cross-sectional study was carried out in a rural area of Kanchipuram district, Tamil Nadu, South India. The study was conducted from January 2014 to December 2014, and pretested validated questionnaire was administered among adult respondent for diagnosis of OA knee. Persons above 18 years of age and who were permanent residents of the study area were included in the study. The sample size was calculated using OpenEpi Version 3.01 (Atlanta, Georgia, USA) for the assumption of 5% alpha error, the proportion of expected outcome 26%[8] with a design effect of 1.5 and the relative precision of 10% with 20% nonresponsiveness. The maximum sample size required for this study was 1966. However, we interviewed 1986 study respondents. The present study was done in Cheyyur Taluk of Kanchipuram district, in which 118 villages were present out of 118, seven villages (Illedu, Agaram, Kavanoor, Manapakkam, Puthirankottai, Villipakkam, and Vanniyanallur) were selected randomly by lottery method. Assuming equal village population (average size: 2500–3000), we selected 283 study participants from each village. A street was selected randomly in each village after that house was selected by rotating water bottle. The first house was selected in the direction of the water bottle and houses were further sampled continuously from the randomly selected the first house until the required sample size was achieved. One eligible participant was selected randomly and interviewed from each house after written informed consent. Two visits were made before excluding them from the study. Study variables: socio-demographic profile, risk factors for OA, the prevalence of OA, the severity of OA based on Lysholm knee scoring Scale.[9]

Operational definition

Based on the American College of Rheumatology (ACR) criteria,[10] the following procedure was used for diagnosing OA knee joint clinically pain in knee and age >50 years, morning stiffness, crepitus in motion, bony tenderness, bony enlargement, and absence of palpable warmth. Of the above criteria, clinical diagnosis of OA knee was made when the participant had pain in the knee followed by any three of the other criteria. Hypertension (HTN): according to the Joint National Committee 7 guidelines, individuals were diagnosed to have HTN if systolic blood pressure (BP) is >140 mmHg and/or diastolic BP is >90 mmHg on at least two occasions.[11] Diabetes: according to the American Diabetes Association guidelines, two abnormal blood sugar values (fasting blood sugar ≥126 mg/dl or random blood sugar ≥200 mg/dl) with classical symptoms of diabetes (polyphagia, polyuria, and polydipsia) were diagnostic of diabetes.[12] Socioeconomic status of the study respondents was measured based on modified BG Prasad scale, 2014.[13]

Ethical consideration

Ethical committee approval was obtained from the Institute Ethics Committee. Informed written consent was obtained from all participants before data collection. Before obtaining informed consent, the purpose of the study, benefits of participating, the procedure of maintaining confidentiality, and the right not to participate were explained to the participants. The individuals who were found to have comorbid conditions needing further management were given guidance and counseling before referring them to the hospital.

Statistical analysis

Data were entered into Microsoft Office Excel version 2007 (Redmond, Washington, USA) and were analyzed using SPSS for Windows, Version 16.0. (Chicago, SPSS Inc). Frequencies with proportions and means were calculated. Chi-square test was applied to measure the association between two categorical variables, and P < 0.05 was considered statistically significant. Binary logistic multivariable regression models were applied to measure the strength of association, and it was expressed in odds ratio with 95% confidence interval. The outcome variable was OA knee, and the independent variables were tobacco, alcohol drinking, diet, physical activity, family history of OA knee, diabetes, HTN, hypothyroidism, body mass index, age group, education, education, occupation, and socioeconomic status.


   Results Top


The present study showed that the prevalence of OA knee among respondents was 27.1% and 95% confidence interval (CI) (25.2–29.1) and more common among people aged >50 years. This study also observed that there was statistically significant association between age versus OA and age more than 50 years. The odds of having OA knee among participants with age >50 years was 7.7 (6.2–9.6) times compared to age <50 years. Similarly, female gender had 1.4 times more odds of having OA knee compared to males, and this was statistically significant (P < 0.05). OA knee was significantly (P < 0.01) higher in illiterates compared to graduates, and it was observed in the study with increased literacy and there was decreased trend of OA knee. With respect to occupation versus OA knee, homemakers are more prone for OA knee compared to professional group, and this was statistically significant (P > 0.001). OA knee was 2.6 times higher in lower socioeconomic group (Class 5) compared to Class 1 [Table 1].
Table 1: Association between sociodemographic variables and osteoarthritis knee joint (n=1986)

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Association between lifestyle versus OA knee: The study revealed that the proportion of OA knee was high among tobacco users compared to nonusers. This difference was statistically significant, and the odds ratio was 2.9 (95% CI: 2.4–3.6). Similarly, people with no physical activity were at more risk for OA knee compared to people who did light-physical activity. The present study also found that there was association between diabetes mellitus (DM), HTN versus OA knee. The participants with diabetes had 2.1 times odds of developing OA knee compared to respondents without diabetes. Respondents with positive family history were more likely to develop OA knee as compared to those without family history [Table 2]. Multivariable analysis was also done to control the confounders after adjusting with age, gender, literacy, socioeconomic class, positive family history of OA, diabetes, and HTN. Model was well fitted as evident from significant Chi-square test (Chi-square value 19.03 and the P = 0.015). The above model explains Cox and Snell r2 = 0.269, Nagelkerke r2 = 0.39; and it means that 26.9%–39% of the variation in the dependent variable is explained by this model. The study concluded that age >50 years, female gender, illiterate, positive family history, tobacco use, history of chikungunya, and HTN, and diabetes were found to be independent risk factors for knee joint OA [Table 3]. Among the total study participants, 538 (27%) participants were diagnosed to have OA, and the severity of this OA was graded based on Lysholm knee scoring. Of 538 OA knee participants, 357 (66.4%) of the knee joint was found to be a poor grade. Based on this scoring, 176 (32.7%) of patients had calf muscle wasting on the left side and 162 (32.6%) on the right side. Similarly, 181 (33.6%) of respondents had quadriceps wasting on the left side and 161 (29.9) on the right side. Around half of them had some muscle weakness on either side. About one-fifth, 114 (21.2%) of the patients had restricted flexion movements on the left side, 112 (20.8%) of study participants on the right side while one-fourth 139 (25.8%) had restricted extension movements of the knee joint.
Table 2: Association between lifestyle factors and osteoarthritis knee joint (n=1986)

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Table 3: Multivariable logistic regression model for determinants of osteoarthritis knee

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   Discussion Top


In our study, the overall prevalence of OA is based on ACR clinical criteria in the rural population of Kanchipuram district as 27.1% and prevalence among men (22.3%) and women (29.8%). Similarly, a study which was done in rural areas of Bengaluru (n = 342) also showed that the overall prevalence was 17%, among men 15.5% and women 18.8% based on ACR.[14] The above difference in the prevalence of OA Knee might be different demographical region and also the former study was used ACR criteria; and later, the study was used old ACR criteria. In the present study, as the age increases the proportion of OA was of increasing trend (age >50 years 52%, <50 years 12.3%). Similar results were also observed by Ajit et al.[14] In another study done in a rural area of Bangladesh, the prevalence of knee joint OA was found as 14% (n = 2601) among persons aged above 15 years.[15] The reason for the high prevalence in our study might be attributed to the predominance of females among the study participants (63.4%), study respondents age more than 18 years, and the main occupation among the rural population was agriculture which inevitably involves tedious work such as heavy weight lifting. Although we found the general prevalence to be 27.1% in our study [Table 1], OA was found to be more prevalent in the elderly age group, age group above 50 with a prevalence of 52% (odds ratio = 7.7). A similar study was done in Chandigarh among elderly (above 65 years) in both rural and urban areas had shown the prevalence of knee joint OA as 56.6% (n = 362).[16] Another review article by Felson et al. stated that 50% of people over the age of 65 have arthritis in at least one joint and over 80% of people over the age of 75 have arthritis in at least one joint.[17]

In our study [Table 1], OA was present in 29% of females, whereas it was present in only 22% of males of the study participants (odds ratio = 1.4). Similar observation also noted by Srikanth et al. in their meta-analysis found that women are more likely to have OA under age 45, while over the age of 55, more women than men had OA. However, overall, males have a significantly reduced risk for the prevalence of OA in the knee.[18] The high incidence of OA in women, especially after menopause, has suggested that estrogen deficiency plays a role in causing disease. Cohort studies have reported that women taking estrogen have a decreased prevalence.[19]

People who consumed tobacco were found to be at a higher risk of developing OA [Tab 2]. It was found that 42.8% of people who had tobacco in various forms had OA, contrary to the 20.1%, who have never used the substance (odds ratio = 2.9). Studies show that cigarette smoking is a risk for cartilage loss and so people with cigarette smoking sustain more cartilage loss have more severe pain than who do not smoke.[20]

Although statistically insignificant, our study showed that the prevalence of OA was less among those who consumed alcohol when compared with participants not taking alcohol. Almost 27.6% of the people who never consumed alcohol had OA, whereas only 21.4% of people who did were found to have the condition (odds ratio = 0.8). A study by Huidekoper et al. conducted on arthritis and alcohol, has shown rather surprising but similar results; arthritis patients consume less alcohol than normal people. This may suggest that alcohol may protect the individual from arthritis or there is an inverse relationship.[21] We also found that about 42% of the diabetics in our study were suffering from OA. This proved a significant association between diabetes and OA (odds ratio = 2.1), Carnevale et al. hypothesized that the reason for this could be that DM patients (both Type 1 and Type 2) have increased risk for fracture and their bone mineral density is deranged due to metabolic alterations such as increased calcium excretion, insulin release, growth factor resistance, advanced glycosylated end products in Extracellular fluid (ECF), and microangiopathic and neuropathic complications.[22] In another study conducted by Nieves-plaza among 202 participants (100 adult DM patients as per the National Diabetes Data Group Classification and 102 nondiabetic participants), it was found that the prevalence of OA in patients with DM and nondiabetic participants was 49.0% and 26.5%, respectively.[23] Almost 50% of hypertensives were suffering from and it found to be statistically significant (odds ratio = 3.1). The presence of coexistent chronic conditions, particularly heart disease, pulmonary disease, and obesity, increased the likelihood of subsequent disability. These findings suggest that knee OA is associated with long-term physical disability and that the presence of coexistent chronic disease may increase the amount of long-term disability from knee OA.[24] In the Present Study found that participants who did no physical activity were at a higher risk of developing OA knee, compared to those who did some amount of physical activity (odds ratio = 1.5). However study done by Felson et al found that increases physical activity score not associated with OA knee.[25] OA was found to be more common among obese persons (29.1%), but the association was not significant (P = 0.4), but a case–control study by Holliday et al. assessed the risks associated with high BMI and other anthropometric measures of obesity.[26] The possible reason might be obesity was less prevalent in our study. In our study, concludes with multivariate regression analysis showed that the following factors such as age more than 50 years, female gender, tobacco usage, illiterates, socioeconomic Class 5, positive family history of OA, diabetes, and HTN were found to be risk factors for knee joint OA, Heidari also found that that old age, obesity, female gender, and positive family history will lead to OA knee.[27]

The strength of the study is large population-based study with diagnosis OA knee based on ACR criteria along with the clinical examination. Limitation is ACR criteria highly sensitive but less specific this may lead to slight overestimation of OA in this region.


   Conclusion Top


The burden of OA knee was high in this region and the risk factor were age more than 50 years, female gender, tobacco usage, illiteracy, lower socioeconomic class, positive family history of OA, diabetes, and HTN were found to be associated with OA knee (P < 0.05).

Financial support and sponsorship

This study was supported by Pondicherry Institute of Medical Sciences, Puducherry, India.

Conflicts of interest

There are no conflicts of interest.



 
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