Evaluating the effects of pain and disorders of the knee joint on knee extension strength and daily life activities in the female elderly

Hiroki Sugiura, Shinichi Demura, Kenji Takahashi

Faculty of Community Health Care, Teikyo Heisei University, Chiba, Japan.
Graduate School of Natural Science and Technology, Kanazawa University, Ishikawa, Japan;.

DOI: 10.4236/pst.2013.13004                

Abstract

This study aimed at examining the differences in leg strength and activities of daily living (ADL) ability among groups with various knee problems. The subjects consisted of 328 elderly females who were classified into three groups: those without knee pain or a knee disorder, those with knee pain, and those with a knee disorder. The subjects took a knee extension strength test and an ADL survey. Knee extension strength and ADL scores (total score and each domain score of the motions of locomotion, posture change, stability, and manipulation) were selected as the evaluation parameters. The knee extension strength, total ADL score and each domain score of the motions of locomotion, posture change, and stability ranged from low to high in the following order: the group with a knee disorder, the group with knee pain, and the group without pain or a knee disorder. Moreover, manipulation scores were significantly inferior in the group with a knee disorder compared with the other two groups. In conclusion, the female elderly with knee pain or a knee disorder have inferior knee extension strength and ADL with respect to the motions of locomotion, posture change and stability. In addition, with regard toknee extension strength with respect to theabove three motions, the elderly with a knee disorder have inferior scores when compared with the elderly who have only knee pain; thus, they find it difficult to perform activities involving the knee joints.

Keywords

Knee Joint Pain; Knee Joint Disorder; Knee Extension Strength; ADL; Female Elderly

1. INTRODUCTION

At an advanced age, leg strength, balance and leg joint functions have a tendency to decrease. As a result, the ability to perform activities of daily living (ADL) is lowered and a decrease in this ability is also apparent [1,2]. In addition, the decrease greatly affects the occurrence of falls [3,4] and quality of life (QOL) [5]. Therefore, it is necessary for the elderly to prevent a decrease in physical functions in order to achieve and maintain an independent daily life.

Among all the leg joints, knee joints have the greatest load capacity and are important for efficient performance of ADL [6]. Recent observations revealed an increase in the number of elderly suffering from knee disorders [7]; in addition, Tennant et al. [8] reported that 8% of the elderly have knee disorders. According to Ikushima et al. [9], the main cause of decrease in the ability to perform ADL in the elderly is a decrease in leg strength and disorders in the knee joint. In general, leg strength does decrease with age [10-12]; however, in case of the elderly with knee joint disorders, active mass decreases markedly due to the disorder which subsequently causes a rapid decrease in leg strength [13]. In addition, the decrease in leg strength at an advanced age causes a decrease in ability to perform ADL [14-16]. Hence, it is assumed that the elderly suffering from a knee disorder have inferior ability to perform ADL.

On the other hand, despite the absence of a severe knee disorder, many elderly experience subjective knee pain [7,17,18]. They can be considered as an auxiliary group of the elderly with knee disorders. Mc Alindon et al. [19], Reilly et al. [20], and Urwin et al. [21] reported that about 20% of the elderly suffered from knee pain. Sugiura and Demura [22] reported that knee extension strength and the ability to perform ADL were inferior in the group with knee pain when compared with the group without knee pain. Therefore, it is assumed that the elderly with knee pain have inferior ability to perform ADL as compared to the elderly suffering from a knee disorder.

The ADL consists of four domains: locomotion, manipulation, stability, and posture change [23,24]; the ability to perform these motions is important for the elderly to maintain an independent daily life. Manipulation motions mainly use the upper limbs, but the other three motions are significantly affected by movements of the knee joint. Hence, it is assumed that those who suffer from knee pain and/or disorders are less efficient in performing these three motions. In addition, it is assumed that subjects with a specific knee disorder are less efficient in performing the above three motions compared with the elderly who suffer from only knee pain. The latter group is considered to be the reserve group of those with a knee disorder.

It has been reported that the prevalence of knee pain and knee disorders is high in the female elderly [7,25]. This study aimed to examine the differences in knee extension strength and ADL among the female elderly who were divided into the following three groups: those without knee pain or a knee disorder, those with knee pain, and those with a knee disorder.

2. METHOD

2.1. Subjects

The subjects consisted of 328 elderly female subjects (60 - 94 years old; mean age 76.1 years; SD = 6.2) participating in health classes or social educational activities hosted by municipal governments. These women were classified into the following three groups: 168 females without knee pain or disorder (G1, knee no-pain and disorder group), 116 females with subjective knee pain (G2, one knee pain group, n = 75; G3, both knees pain group, n = 41), and 44 females with a knee disorder (G4, one knee disorder group, n = 21; G5, both knees disorder group, n = 23). Forty females in the knee pain group and 11 females in the knee disorder group had right knee pain. The knee pain and disorders were judged by the Japanese edition of knee function scale based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) [26] prepared by Hashimoto et al. [27]; the cut-off point was set at 210 points [25]. The elderly with a knee disorder could perform limited activities and regularly visited a hospital for treatment of their knee disorders; however, they could independently perform ADL. In general, we observed that the elderly with a knee disorder could not perform ADL efficiently. If the ADL levels achieved by the subjects with knee disorders in this study were lower than those achieved by the general elderly population, the levels achieved by elderly subjects with knee disorders should be even lower. Table 1 lists the basic statistics of age, height, and body weight for each group. Before the study was conducted, the purpose and procedure of this study were explained to all of the subjects in detail and informed consent was obtained. The present experimental protocol was approved by the Ethics Committee on Human Experimentation of Faculty of Human Science, Kanazawa University (Ref. No. 2012-12).

2.2. Leg Strength

To evaluate the leg strength, we selected the measurements of knee extension strength as it is severely affected by knee pain or knee disorder [22,28,29]. During the measurement of isometric knee extension strength, the subjects were seated upright in a rigid chair with knees flexed at a 90˚ angle. Their lower legs were strapped by a pad just above the ankle and attached with a backward rigid bar to a tension meter (T.K.K.1269f; Takei Scientific Instruments Co. Ltd., Japan). In addition, the subjects folded their arms across their chest. An examiner held the pad fixed in its place and asked the subjects to extend their knee as far as possible and to hold the position for 3 s. Leg strength was measured twice for each of the legs and a mean of two trials was used as a parameter for each leg. Furthermore, for knee no-pain and disorder group, both knees pain group, and both knees disorder group, a mean of the above values (for right and left legs) was used as a parameter.

2.3. ADL

The ADL survey developed by the Ministry of Education, Culture, Sports, Science and Technology of Japan was used to evaluate activities of daily living (Table 2). This survey was created to assess the physical function level at which the elderly would be able to safely participate in a physical fitness test. This survey method consists of four domains: locomotion (walking, running, jumping across a ditch, ascending and descending stairs, convey), posture change (sitting up, standing up from the floor), stability (standing on one foot with eyes open, standing in a bus or train, dressing while standing) and manipulation (buttoning a shirt, taking a Japanese mattress in and out of the closet), thereby assessing the degree of achievement of ADL based on these 12 activities, which are essential for an independent living [23,24]. Each item had 3 different levels of difficulty. The subjects answered any one of three responses for each question. The total score in each domain and the total score with respect to these 12 activities were calculated. In addition, the

Table 1. The basic statistics and test results of age, height and body weight among groups.

Table 2. ADL test.

elderly with higher ADL scores were judged to have superior ability to perform ADL.

2.4. Statistical Analysis

Mean differences of knee extension strength and each ADL score were examined using the analysis of covariance (ANCOVA) with body weight as a covariate. A Scheffe’s test was used as a linear comparison test if a significant difference was observed among the means. The laterality of knee extension strength in G2 and G4 was examined by paired t-test. A significance level in this study was set at p < 0.05.

3. RESULTS

Table 1 lists the basic statistics of age, height and body weight in the knee no-pain and disorder (G1), one knee pain (G2), both knees pain (G3), one knee disorder (G4), and both knees disorder (G5) groups, and the test results when their mean values were compared. The results of the one-way analysis of variance (ANOVA) showed a significant difference with respect to body weight only. Subjects in knee disorder group (G4 + G5) were significantly heavier than the no knee pain or disorder group (G1). Additionally, the body weight between G2 and G3, as well as between G4 and G5 showed an insignificant difference.

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Hurley, M.V., Rees, J. and Newham, D.J. (1998) Quadriceps function, proprioceptive acuity and functional performance in healthy young, middle-aged and elderly subjects. Age and Ageing, 27, 55-62. http://dx.doi.org/10.1093/ageing/27.1.55
[2]	Jochanan, S., Robert, H.R., Aaron, C., Eliana, E.M. and Jeremy, M.J. (2009) Physical activity, function, and longevity among the very old. Archives of Internal Medicine, 169, 1476-1483. http://dx.doi.org/10.1001/archinternmed.2009.248
[3]	Tinetti, M.E. and Williams, C.S. (1998) The effect of falls and fall injuries on functioning in community-dwelling older persons. Journal of Gerontology: Medical Sciences, 53, 112-119. http://dx.doi.org/10.1093/gerona/53A.2.M112
[4]	Mary, E. and Tinetti, M.D. (2003) Preventing falls in elderly persons. New England Journal of Medicine, 348, 42-49. http://dx.doi.org/10.1056/NEJMcp020719
[5]	Aoki, K. (2008) Relationships among QOL, ADL, physical activity and self-rated health in the elderly living at home. Journal of Social Welfare, 49, 71-84.
[6]	Okanishi, T. and Tsurumi, T. (2001) Physiotherapy of leg joint disorders. 1st Edition, Mitsuwa Shoten, Tokyo.
[7]	Peat, G., McCarney, R. and Croft, P. (2001) Knee pain and osteoarthritis in older adults: A review of community burden and current use of primary health care. Annals of the Rheumatic Diseases, 60, 91-97. http://dx.doi.org/10.1136/ard.60.2.91
[8]	Tennant, A., Fear, J., Pickering, A., Hillman, M., Cutts, A. and Chamberlain, M.A. (1995) Prevalence of knee problems in the population aged 55 years and over: Identifying the need for arthroplasty. British Medical Journal, 310, 1291-1293. http://dx.doi.org/10.1136/bmj.310.6990.1291
[9]	Ikushima, H., Hidaka, M. and Ikeda, K. (1994) The relationship between activities of daily living and pain and/or muscle strength in patients with osteoarthritis of the knee. Physiotherapy, 21, 347-350.
[10]	Murray, M.P., Duthie, E.H., Gambert, S.R., Sepic, S.B. and Mollinger, L.A. (1985) Age-related differences in knee muscle strength in normal women. Journal of Gerontology, 40, 275-280. http://dx.doi.org/10.1093/geronj/40.3.275
[11]	Borges, O. (1989) Isometric and isokinetic knee extension and flexion torque in men and women aged 20 - 70. Scandinavian Journal of Rehabilitation Medicine, 21, 45- 53.
[12]	Frontera, W.R., Hughes, V.A., Lutz, K.J. and Evans, W.J. (1991) A cross-sectional study of muscle strength and mass in 45- to 78-yr-old men and women. Journal of Applied Physiology, 71, 644-650.
[13]	Kirsten, G.N. (2009) Gait analysis by observation. 1st Edition, Igaku-Shoin, Tokyo.
[14]	Hunter, G.R., Treuth, M.S., Weinsier, R.L., Kekes-Szabo, T., Kell, S.H., Roth, D.R. and Nicholson, C. (1995) The effects of strength conditioning on older women’s ability to perform daily tasks. Journal of the American Geriatrics Society, 43, 756-760.
[15]	Corrigan, D. and Bohannon, R.W. (2001) Relationship between knee extension force and stand-up performance in community-dwelling elderly women. Archives of Physical Medicine and Rehabilitation, 82, 1666-1672. http://dx.doi.org/10.1053/apmr.2001.26811
[16]	Oya, Y., Nakamura, M., Tabata, E., Morizono, R., Mori, S., Komuro, Y. and Horikawa, E. (2008) Fall risk assessment and knee extensor muscle activity in elderly people. Journal of Geriatrics, 45, 308-314.
[17]	Zaharni, K.S. and Bakheit, A.M. (2002) A study of the gait characteristics of patients with chronic osteoarthritis of the knee. Disability and Rehabilitation, 24, 275-280. http://dx.doi.org/10.1080/09638280110087098
[18]	Zoltan, B., Robert, P., Arpad, I., Rita, M.K. (2006) The influence of walking speed on gait parameters in healthy people and in patients with osteoarthritis. Knee Surgery, Sports Traumatology, Arthroscopy, 14, 612-622. http://dx.doi.org/10.1007/s00167-005-0005-6
[19]	Mc Alindon, T.E., Snow, S., Cooper, C. and Dieppe, P.A. (1992) Patterns of osteoarthritis of the knee joint in the community: The importance of the patellofemoral joint. Annals of the Rheumatic Diseases, 51, 844-849. http://dx.doi.org/10.1136/ard.51.7.844
[20]	Reilly, S.C., Muir, K.R. and Doherty, M. (1996) Screening for pain in knee osteoarthritis: Which question? Annals of the Rheumatic Diseases, 55, 931-933. http://dx.doi.org/10.1136/ard.55.12.931
[21]	Urwin, M., Symmons, D., Allison, T., Brammah, T., Bus- by, H. and Roxby, M. (1998) Estimating the burden of musculoskeletal disorders in the community: The comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Annals of the Rheumatic Diseases, 57, 649-655. http://dx.doi.org/10.1136/ard.57.11.649
[22]	Sugiura, H. and Demura, S. (2012) Effect of subjective knee joint pain on knee extension strength, gait and ADL score in the female elderly. Gazzetta Medica Italiana, 171, 533-540.
[23]	Demura, S., Sato, S., Minami, M., Kobayashi, H., Noda, Y., Matsuzawa, J., Kobayashi, K. and Aoki, J. (2000) Development of ADL index for older community people. Japanese Journal of Physical Fitness and Sports Medi- cine, 49, 375-384.
[24]	Sato, S., Demura, S., Matsuzawa, J., Noda, Y., Miyaguchi, H., Tada, N., Kobayashi, H., Goshi, F., Minami, M. and Sugano, N. (2000) Development of ADL index for heal- thy older persons: Proposal of useful ADL items and their scales. Journal of Physical Education Health and Sport Sciences, 45, 472-488.
[25]	Oida, Y. and Nakamura, N. (2008) Exercise learning support manual for the knee joint ache prevention and reduction. 1st Edition, Sunlife Plan, Tokyo.
[26]	Bellamy, N., Buchanan, W.W., Goldsmith, C.H., Campbell, J. and Stitt, L.W. (1988) Validation study of WO- MAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Journal of Rheumatology, 15, 1833-1840.
[27]	Hashimoto, H., Hanyu, T., Sledge, C.B. and Lingard, E.A. (2003) Validation of a Japanese patient-derived outcome scale for assessing total knee arthroplasty: Comparison with Western Ontario and McMaster Universities osteoarthritis index (WOMAC). Journal of Orthopaedic Science, 8, 288-293. http://dx.doi.org/10.1007/s10776-002-0629-0
[28]	Astephen, J.L., Deluzio, K.J., Caldwell, G.E. and Dunbar, M.J. (2008) Biomechanical changes at the hip, knee, and ankle joints during gait are associated with knee osteoarthritis severity. Journal of Orthopaedic Research, 26, 332-341. http://dx.doi.org/10.1002/jor.20496
[29]	Sugiura, H. and Demura, S. (2012) Effect of subjective knee-joint pain on the laterality of knee extension strength and gait in elderly women. Archives of Gerontology and Geriatrics, 54, 366-369. http://dx.doi.org/10.1016/j.archger.2011.04.024
[30]	Morrison, J.B. (1970) The mechanics of the knee joint in relation to normal walking. Journal of Biomechanics, 3, 51-61. http://dx.doi.org/10.1016/0021-9290(70)90050-3
[31]	Oliveria, S.A., Felson, D.T., Cirillo, P.A., Reed, J.I. and Walker, A.M. (1999) Body weight, body mass index, and incident symptomatic osteoarthritis of the hand, hip and knee. Epidemiology, 10, 161-166. http://dx.doi.org/10.1097/00001648-199903000-00013
[32]	Yoshimura, N., Nishioka, S., Kinoshita, H., Hori, N., Ni- shioka, T., Ryujin, M., Mantani, Y., Miyake, M., David, C. and Cyrus, C. (2004) Risk factors for knee osteoarthritis in Japanese women: Heavy weight, previous joint injuries, and occupational activities. Journal of Rheumatology, 31, 157-162.
[33]	Spector, W.D., Katz, S., Murphy, J.B. and Fulton, J.P. (1987) The hierarchical relationship between activities of daily living and instrumental activities of daily living. Journal of Chronic Diseases, 40, 481-489. http://dx.doi.org/10.1016/0021-9681(87)90004-X
[34]	Kim, H.S., Matsuura, Y., Tanaka, K. and Inagaki, A. (1993) Facyorial structure and establishment of a test battery to evaluate ability of daily living activity in the elderly. Journal of Physical Education Health and Sport Sciences, 38, 187-200.