w w w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Original
article
Comparative
study
of
functional
capacity
and
quality
of
life
among
obese
and
non-obese
elderly
people
with
knee
osteoarthritis
Mansueto
Gomes-Neto
a,b,c,∗,
Anderson
Delano
Araujo
a,c,
Isabel
Dayanne
Almeida
Junqueira
c,
Diego
Oliveira
c,
Alécio
Brasileiro
c,
Fabio
Luciano
Arcanjo
a,caDepartmentofBiofunction,PhysicalTherapyCourse,UniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil
bPost-GraduatePrograminMedicineandHealth,UniversidadeFederaldaBahia(UFBA),Salvador,BA,Brazil
cPhysicalTherapyCourse,UniãoMetropolitanadeEducac¸ãoeCultura,Salvador,BA,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received19August2014 Accepted31May2015
Availableonline26September2015
Keywords: Elderly Osteoarthritis Obesity Qualityoflife
a
b
s
t
r
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c
t
Introduction:Theassociationbetweenosteoarthritis(OA)andobesitycanleadtoareduced functionalcapacity,compromisingthequalityoflife(QoL)oftheelderly.
Objective:TocomparethefunctionalcapacityandQoLofobeseandnon-obeseolderadults withkneeOA.
Methods:Thesampleconsistedof35subjectswithOAdividedintotwogroups,obeseand non-obesesubjects,accordingtotheirbodymassindex.Toassessfunctionalcapacity, per-formancetestssuchasTimedUpandGo(TUG),gaitspeedtest,andthesix-minutewalktest (6MWT)werecarriedout.ToassessQoL,WOMACandSF-36questionnaireswere admin-istered.Weperformeddescriptive andinferentialstatisticsusingSPSSsoftwareversion 20.0.
Results:ElderlypatientswithOAweredividedintotwogroups(obese,n=16;non-obese, n=19).Socio-demographiccharacteristicsweresimilarbetweengroups(p>0.05).Theobese groupshowedaworstperformanceinTUG,briskwalkingspeedand6MWT.Amoresevere painwasfoundinthefollowingitems:“performingheavyhouseworkchores”,“goingdown stairs”,“bendingtofloor”and“gettingupfrombed”intheobesegroup(p<0.05).Inaddition, theobesegrouphadmoredifficultytoperformtasksforthefollowingitems:“goingdown stairs”,“risingfromachair”,“standing”and“gettingon/offtoilet”(p<0.05).Therewasno statisticallysignificantdifferenceintheassesseddomainsofSF-36betweengroups(p>0.05). Conclusion:OAassociatedwithobesitycausedanegativeimpactonfunctionalcapacity; however,qualityoflifescoreswerelow,andnodifferenceinobeseandnon-obesesubjects wasfound.
©2015ElsevierEditoraLtda.Allrightsreserved.
∗ Correspondingauthor.
E-mail:[email protected](M.Gomes-Neto). http://dx.doi.org/10.1016/j.rbre.2015.08.014
Estudo
comparativo
da
capacidade
funcional
e
qualidade
de
vida
entre
idosos
com
osteoartrite
de
joelho
obesos
e
não
obesos
Palavras-chave: Idosos Osteoartrite Obesidade Qualidadedevida
r
e
s
u
m
o
Introduc¸ão: Aassociac¸ãoentreosteoartrite(OA)eobesidadepodegerarreduc¸ãoda capaci-dadefuncionalecomprometeraqualidadedevida(QV)deidosos.ObjetivoComparara capacidadefuncionaleaQVentreidososcomOAnojoelho,obesosenãoobesos. Métodos: Aamostrafoiconstituídapor35idososcomOAdivididosemdoisgrupos,obesos enãoobesos,deacordocomoíndicedemassacorporal.Paraavaliac¸ãodacapacidade funcionalforamfeitostestesdedesempenho,comoTimedUpandGo(TUG),velocidadeda marchaetestedecaminhadadeseisminutos(TC6).Paraavaliac¸ãodaQVforamaplicados osquestionáriosWOMACeSF-36.Foifeitaestatísticadescritivaeinferencialcomousodo softwareSPSSversão20.0.
Resultados: OsidososcomOAforamdivididosemdoisgrupos(obesos,n=16)e(nãoobesos, n=19).Ascaracterísticassociodemográficasforamsimilaresentreosgrupos(p>0,05).Foi observadareduc¸ãodedesempenhonoTUG,velocidadedamarcharápidaeTC6,commaior intensidadede dor nositens:“executartarefasdomésticas pesadas”,“descerescadas”, “curvar-seemdirec¸ãoaochão”e“levantar-sedacama”nogrupodosobesos(p<0,05).Além disso,ogrupodeobesosapresentoumaiordificuldadeaoexecutartarefasparaositens: “descerescadas”,“levantardacadeira”,“ficardepé”e“sentar/levantardovasosanitaria” (p<0,05).Nãofoiobservadadiferenc¸aestatisticamentesignificativanosdomíniosavaliados doSF-36entreosgrupos(p>0,05).
Conclusão: AOAassociadaàobesidadeimpactounegativamenteacapacidadefunctional. Entretanto,osescoresdeQVforambaixossemdiferenc¸aparaobesosenãoobesos.
©2015ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Duringtheagingprocess,functionallossesoccur,whichare
accentuated due to the lack of activity of the
neuromus-cular system and to reduced muscle strength and fitness.
Inadditiontothedecreaseoffunctionality,theelderlylose
more acutely the ability to retain water and to produce
proteoglycans,causingdegenerative jointdisorders suchas osteoarthritis(OA).1–3
OneoftheriskfactorsforOAisobesity.Inadditiontobeing ariskfactorforOA,theassociationbetweenOAandobesity canincreasetheintensityofpainandfunctionallimitations duetoincreasedweightbearingontheaffectedjoint,with nar-rowingoftheintra-articularspace.Thisscenariomaycausean increaseinpaininthejoint,stiffnessandmuscleatrophy.4,5
Inarecentmeta-analysisthatassessedtheriskforonsetof OA,Blagojevicetal.6reportthatobesepeoplehaveathreefold
riskofdevelopingOAversusnon-overweightindividuals. Excessiveweightincreases bothblood pressure and the stressincidentonthejoint,activatingjointcartilage degra-dation,subchondralbonesclerosisandosteophyteformation mechanisms,andleadingtoOAworsening.7–9 Thesefactors
cannegativelyimpactthequalityoflife(QoL)ofobeseelderly affectedbythedisease.10
OAaloneorinconjunctionwithobesityisassociatedwith increasedriskofmorbidityandmortality,andthismayimpair the QoL of elderly people with this disease. An essential attributeinthehealthoftheelderlyistheirfunctional capac-ity,thisbeingakeycomponentofoverallhealthassessment.11
InadditiontobeingariskfactorforOA,obesitycanworsen
symptoms andexacerbatethe functionaldeclineofelderly patientswithOA.Anunderstandingofthosefactorsthat inter-fere withthe functioningand QoL ofelderly patientswith OA can contribute to the formulation of strategies for its preventionandtreatment.Therefore,thisstudyaimedto com-parethefunctionalcapacityandQoLofobeseandnon-obese elderlypatientswithkneeOA.
Materials
and
methods
A quantitative, analytical, cross-sectional study was con-ducted with anon-probabilistic sample. Thirty-five elderly patients,29(82.85%)ofthemfemale,meanageof66.57±7.38 (60–86)years,withkneeOAdiagnosedbyamedical special-istwithinfiveyearsandwithindependentambulationwere includedinthisstudy.
Thesepatientswere referredbyaphysicianforphysical therapy inaphysical therapyteaching clinicin thecity of LaurodeFreitas,Bahia.Patientsonawaitinglistoftheclinic
who had notstarted their physical therapy program were
included.Seniorswhopresentedacognitivedeficit(those sub-jectsshowingdifficultiesinansweringthe questionsinthe questionnaire),anassociateddisease previouslydiagnosed, presenceofarthroplastyinoneorbothknees,patientswith jointinflammationatthetimeofassessment,andpatients whounderwentphysicaltherapeuticcareinthepast6months wereexcluded.
Beforestartingdatacollection,theelderlywereinformed aboutthestudyanditspurposesandsignedaninformed
Committeeofahighereducationinstitutionandapprovedby opinionNo.3,017.
Forabodymassindex(BMI)evaluation,ascaleanda mea-suringtapewereusedformeasurementsofbodyweightand
height. After the measurements, BMI calculation was
per-formed according to the criteria establishedby the World HealthOrganization(WHO),thatis,the productofdividing bodyweightbyheightsquared(kg/m2).12AccordingtoWHO
criteria,individualswithaBMIabove30kg/m2were consid-eredobese.
According to the measured values ofBMI, our patients
were divided into two groups, obese and non-obese
sub-jects.Toassessfunctionalcapacity,threeperformancetests were applied. For the testing,standardized instructions as describedintheliterature13–16 werefollowed.Thetestsused
were:Timed Upand Go(TUG),13 gaitspeed test14 and
six-minutewalktest(6MWT).15,16
ToevaluateQoL,twoquestionnaireswereused:the
West-erm Ontarioand McMasterUniversities (WOMAC) and the
genericSF-36–MedicalOutcomesStudy36-ItemShort-Form HealthSurvey,bothintheBrazilianversion,alreadyadapted andvalidatedinBrazil.10,17,18
TheSF-36 questionnairecontains 36 questions that are groupedintoeightdomains,whosescoresrangefrom0to100, wherezerocorrespondstotheworstgeneralstateofhealth and100tothebeststate,meaningthatthehigherthetotal score,thebettertheperceptionofqualityoflife.17,18
WOMACisathree-dimensional(pain,stiffnessand phys-icalfunction)qualityoflifequestionnairespecificallyforthe evaluationofpatientswithOA.WOMACrecordsthe percep-tionofpain,jointstiffnessandfunctionality,basedonthe48h precedingitsapplication.TheWOMACscoreisassignedina Likert-typescale,rangingfrom0to4;thehigherthescore,the worsethepain,jointstiffnessandfunctionality.19
Descriptivestatisticswere usedintheanalysisof demo-graphicandclinicaldata.Dataofcontinuousvariableswere analyzedwithmeasuresofcentraltendencyanddispersion, expressedasmean,medianandstandarddeviation.Datafrom dichotomousandcategoricalvariableswereanalyzedwith fre-quencymeasuresandexpressedaspercentages.
Fortestingnormality,theShapiro–Wilktestwasperformed for all variables. For normally distributed data, the Stu-dent’sttestforindependentsampleswasusedtocompare meandifferencesofvariablesbetweengroups.Forvariables withnon-parametricdistribution,theMann–Whitneytestwas usedtocomparedifferencesofthemediansbetweengroups. Thesignificancelevelwassetat5%.Statisticalanalysiswas performedusingSPSS(StatisticalPackageforSocialSciences) softwareforWindows(version20.0).
Results
Thirty-five elderly patients with mean age of 66.57±7.38 years,rangingfrom 60–86years,were evaluated.According toBMItheelderlyweredividedintotwogroups:obese(n=16) andnon-obese(n=19).Therewasnostatisticallysignificant differenceinsocio-demographiccharacteristicsandOA dura-tion between groups (p>0.05). Socio-demographic data are presentedinTable1.
Table1–Socio-demographicandclinicalcharacteristics oftheobeseandnon-obesegroups.
Variable Obese Non-obese p-Value
Mean±SD Mean±SD
Age(years) 66.12±7.24 66.94±7.67 0.748
BMI 33.29±3.15 23.16±3.18 0.001
DurationofOA 2.87±0.71 2.94±0.70 0.766
Gender
Male 3(18.8%) 3(15.8%)
Female 13(81.2%) 16(84.2%) 0.516
BMI,bodymassindex;OA,Osteoarthritis;SD,standarddeviation.
Table2–Functionalcapacityamongobeseand non-obesepatientswithosteoarthritis.
Variable Obese Non-obese p-Value
Mean±SD Mean±SD
6MWT(m) 298.69±50.10 354.97±67.97 0.010
TUG(s) 8.86±1.83 7.04±0.83 0.002
Customarygait(m/s) 1.10±0.09 1.14±0.12 0.318 Briskgait(m/s) 1.34±0.12 1.56±0.17 0.001
6MWT,six-minutewalktest;TUG,TimedUpandGotest;Gaitspeed (customaryandbrisk);SD,standarddeviation.
Statistically significant difference was found between groups (p<0.05)in tests assessingfunctional capacity. The meansobtainedbythegroupofnon-obeseelderlywerebetter forTUG,fastgaitspeedand6MWT.Ontheotherhand,no sta-tisticallysignificantdifferencebetweengroupswasfoundin thecustomaryspeedtest.MeanvaluesareshowninTable2.
AstothepainseveritydomainofWOMACquestionnaire, amoreintensepainwasidentifiedfortheitems:“walking”, “climbingstairs”,“carryingaheavyweight”and“nightpain”. Theobesegrouphadahigherpainintensityinitems“climbing stairs”and“nightpain”(p<0.05).
Inthe“difficultiesinperformingtasks”domain,agreater difficultywasperceivedbytheelderlyfortheitems: “perform-ingheavyhouseworkchores”,“goingdownstairs”,“bending tothefloor” and“risingfrombed.”Comparedtothegroup of non-obese subjects, the obese elderly found more diffi-culty(p<0.05)intheitems:“goingdownstairs”,“risingfroma chair”,“standing”and“gettingon/offtoilet.”Thepercentages ofpainintensityanddifficultytoperformactivitiesarelisted inTables3and4.
Table3–PainseverityaccordingtoWOMACscore.
Variable Obese Non-obese
Walking 75% 73.68%
Climbingstairs 93.75% 78.94%a
Nightpain 81.25% 36.84%a
Painatrest 50% 36.84%
Whencarryingweight 93.75% 84.21%
Morningstiffness 87.50% 78.94%
Protokineticstiffness 68.75% 57.89%
Table4–PhysicalfunctionaccordingtoWOMACscore.
Variable Obese Non-obese
Stairuse 87.50% 63.15%a
Risingfromsitting 62.50% 36.84%a
Standing 62.50% 36.84%a
Bending 87.50% 94.73%
Walkingonaflatsurface 43.75% 26.31%
Gettingin/outofacar 75% 73.68%
Goingshopping 50% 42.10%
Puttingonsocks/stockings 68.75% 52.63%
Risingfrombed 78.75% 33.15%a
Takingoffsocks/stockings 68.75% 42.10%
Lyinginbed 37.50% 26.31%
Gettingin/outofbath 12.50% 0%
Sitting 37.50% 31.57%
Gettingon/offtoilet 62.50% 37.89%a
Lighthouseholdduties 37.50% 31.57%
Heavyhouseholdduties 100% 100%
a p<0.05.
Table5–Meanandstandarddeviationofdomains assessedbySF-36.
Domain Obese Non-obese
Physicalfunctioning 52.18±24.76 64.21±16.60 Rolelimitationsdue
tophysicalhealth
32.37±31.45 32.89±40.86
Bodilypain 36.87±17.01 44.21±19.23
Generalhealth 52.81±13.90 57.89±17.89
Vitality 55.31±8.26 56.57±11.31
Socialfunctioning 45.31±15.05 47.36±9.84 Rolelimitationsdue
toemotional problems
31.24±37.45 49.12±43.55
Mentalhealth 51.75±9.84 57.47±10.43
Therewasnostatisticallysignificantdifferenceinanyof theSF-36domainsbetweengroups(p>0.05), butareduced scoreinQoLwasnoted.ThescoresarepresentedinTable5.
Discussion
Obese seniors with OA have reduced functional capacity,
higher level ofpain and difficulty in performing everyday tasksthat require effort;these changesmay be associated withtheincreasedbodymassandconsequentjointoverload. Thejointoverloadlimitsthemovementsandincreasesjoint stress,whichcangeneratehigherlevelsofdisabilityinobese seniors.2Thus,thispopulationareatincreasedriskforthe
developmentofpainandfunctionaldifficulty,whencompared tonon-obesesubjects.
Inthisstudy,obeseolderadultswithOAshowedahigher levelofpainanddifficultyinsomefunctionalactivities,such asclimbing and descendingstairs, gettingout ofbed,and bendingtowardthefloor.InthestudybyHeoetal.20itbecame
apparenttheassociationofincreasedBMIwithincreasedjoint pain;thisfindingisinlinewithresultsofVasconcelosetal.21
study;theseauthorsreportthatdifficultieswithphysical func-tionisrelatedtomobilityactivitiesthatrequiremovementand weight-bearingintheirjoints.
Regarding functional capacity, non-obese subjects
achieved better outcomes in mobility, brisk walking and
conditioning.Greaterspeedandlesstimerequiredforthese testsmaycauseexcessivestresstothekneejoint, overload-ingthejointandcontributingtopoorperformanceofobese individuals,sincethesepeopleuseastrategyofalowergait speedtoreducepainandjointimpact.22
Rosemann et al.23 evaluated the impact of OA on 978
patients; functionalcapacitywasreduced inthose patients withweightgain,however,therewasnodifferenceinthe
eval-uateddomainsofQoLamongoverweightandnon-overweight
subjects,corroborating theresultsofthisstudy.Ourresults alsoindicateareductionforscoresofalldomainsassessed, revealingadecreaseinQoLinbothgroups,butwithno
dif-ference between obese and non-obese subjects. In astudy
comparingQoLof264patients,Salaffietal.24identifiedlow
scoresinall domainsoftheSF-36questionnaireinthe OA group,aresultsimilartothepresentstudy.
In the study ofSutbeyaz et al.,25 28 patients with knee
osteoarthritis and 28 healthysubjects were compared.The groupwithkneeOAshowedasignificantdecreaseofQoLin alldomainsoftheSF-36.Inthepresentstudy,itwasfound
thatevennon-obesesubjectswithOA alsoshowedreduced
scoresintheSF-36anddifficultyinexecutingtheactivities evaluatedintheWOMACquestionnaire.ThisdecreaseinQoL maybeaconsequenceoftheagingprocessperseandofjoint
andmusclechangesduetoOA,mostoftenassociatedwith
localpainwhich,inturn,maycompromisetheabilityto per-formdynamictasksandimpactingnegativelytheQoLofthis population.26
ThecontroloffactorsassociatedwithOAcausingnegative functionalconsequences,besidescompromisingQoLofthis population,mustbeinvestigated.Obesityisoneofthemain riskfactorsandhasbeenassociatedwithfunctionaldecline, sedentarylifestyle,increaseinsecondarycomplicationsand cardiovascularrisk.Coggonetal.27claimthatprevention
ini-tiativesthataredevelopedinpublichealthprogramsforrisk factors ofobesity and its controlmay contribute to reduc-ingthenegativeimpactofosteo-articulardiseases,especially kneeOA.
Importantly,thisstudyanalyzedobesityusingBMI,a mea-sure ofweight excess foragiven height.BMIvalue isjust achange inthe energybalance ofthe individual;however, it doesnotallowthatother factors,suchasmetabolicand inflammatorydisordersandoflean/fatbodymass composi-tion,aretakenintoaccount.21,22Itispossiblethatthesenot
evaluatedfactorshaveagreaterimpactonfunctionalcapacity ofobeseseniors.
understanding of the factors that influence the functional capacityandQOLofobeseandnon-obeseelderly.
Conclusion
OAassociatedwithobesityhadanegativeimpactonthe func-tionalcapacityofolderpeople,whohadamoreintensepain and difficulty inperforming everyday tasks. Theelderly in bothgroupsshowedreducedQoLscores,withnodifference inobeseandnon-obese.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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