Introduction
Osteoarthritis (OA) is one of the widely observed disorders that are asymptomatic, but this disease affects the quality of people’s life significantly (1-2). The purpose of this literature review is to examine how the problem of osteoarthritis was discussed in the scholarly literature during the past ten years (2006-2016) and determine what instruments were used by researchers to measure the quality of life about OA patients. Therefore, this literature review includes sections on the problem of osteoarthritis, epidemiology, risk factors, etiology, pathogenesis, diagnosis, classification of OA, the related physical functioning and quality of life, as well as methods of OA assessments and instruments used to measure the quality of life.
Osteoarthritis
Osteoarthritis is a chronic multi-factor disorder or a group of disorders that are discussed as degenerative ones, and they affect not only joints but also articular cartilage, ligaments, synovial membrane, and the subchondral bone (3). The disorder is characterized by the progress of abnormal processes in joints, as well as by the constant pain that can cause physical disability and limitations in persons’ functioning (4-5). Fists, knees, and hips are most often affected by OA (6-7). The worldwide and national study and survey results (8-9) indicate that OA is one of the most frequent disorders that are typical of elder people.
Thus, the disease is characterized by a high level of prevalence, and the development of this condition depends on the person’s age. Even though OA is observed in persons older than 65 years, today, signs of the disease are observed in individuals aged 40-45 years (1). Researchers (10-12) report that, despite the age, limitations on physical functioning and chronic pain often lead to decreases in the quality of life, as it is stated by those patients who suffer from OA.
Epidemiology
Osteoarthritis is a type of disorder that affects the physical state and functioning of elderly people, and this fact influences the epidemiologic data (11, 13). According to the international data, the adult population usually suffers from different types of OA, and other factors that can influence the development of the disease are gender, age, ethnicity, and occupation (1). As a result, OA of different joints is typical of various groups of patients (14). While referring to the data provided by Garstang and Statik (2), “approximately 30% of adults over 30 have radiographic evidence of hand OA,” and “at least 33% … of persons over 55 have radiographic evidence of knee OA. Clinically, 6% of adults over 30 have symptomatic knee OA, and 10-15% of adults over 60 have symptoms.”
In their studies, researchers refer to the data collected from different sources and nations. According to Alrushud, El-Sobkey, Hafez, and Al-Ahaideb (15), “the rate of aged persons in the world is rapidly rising, and it is estimated that it will reach 27.4% of the total population in 2025.” Therefore, OA will affect more people in different countries. In Europe and the United States, radiographic signs of OA are observed in about 80% of persons who are aged above 75 years (16). Moreover, the data regarding the US population indicate that about 20% of Americans aged 45 years suffer from OA (17).
In the Middle Eastern region, the prevalence of OA is 20% (18). In their turn, Alamri and the group of researchers (17) focused on studying the prevalence and epidemiology of OA in Saudi Arabia. According to the researchers (17), “53.3% men and 60.9% women” in Saudi Arabia suffer from knee OA. However, there are also data that, in the central and eastern regions of Saudi Arabia, knee osteoarthritis is observed only in 3.5% of cases (17). From this point, it is necessary to state what factors are discussed by researchers as associated with the development of the disorder.
Risk Factors
Researchers (8) state that risk factors associated with the development of osteoarthritis belong to two main groups: systemic and local factors. Systemic factors can be defined as systemic qualities, and they cannot be changed. These factors include gender, age, ethnicity, genetics, as well as bone density (19). Local factors are also known as biomechanical because they can develop under the impact of other factors, and they are associated with the pressure on different joints (9). These factors include obesity that is not caused by genetics or systemic diseases, joint injuries, muscle weakness, and ligamentous laxity (9, 20). The impact of the person’s occupation and professional activities is also discussed by researchers and clinicians as a local factor (21). Zhang and Jordan (22) state that, although only several joints can be affected by the disease, the disorder has the multi-factor nature, and the combination of different systemic and local factors can lead to the development of the disease. Thus, Garstang and Statik (2) state that, for example, “genetics may increase the likelihood that joint damage will progress to OA.”
In the Gulf Cooperation Council (GCC) countries, the most prevalent local factor is obesity. Asokan and the group of researchers (23) conducted the study in Bahrain, and they have found that obesity associated with the sedentary lifestyle is a cause of OA in most reported cases. Benjamin and Donnelly (24) also concentrated on studying the Arab population, and they have found that the problem is in the limited physical activity, the lack of time to pay attention to exercises, and the geographical factors among others. Ismail, Al-Abdulwahab, and Al-Mulhim (25) and Alamri et al. (17) have accentuated obesity as a risk factor for the population of Saudi Arabia. Furthermore, Mohamed, Al-Harizi, Bedewi, and Gafar (26) added vitamin D deficiency to the list of OA risk factors in Saudi Arabia.
Etiology and Pathogenesis
The multi-factor nature of OA does not allow for focusing on the concrete causes that can lead to the development of the disease in different categories of persons. When OA is caused by mainly systemic factors, including hormonal and metabolic changes, age, gender, and genetics, it is regarded as primary, and the actual cause of the problem is difficult to be determined (27). If OA is caused by traumas and mechanical factors or associated with the style of the patient’s life and occupation, it is discussed as secondary (28-29). In many cases, OA is a result of immunologic processes, traumas of a joint, and inflammatory processes in the synovial membrane. Michael, Schlüter-Brust, and Eysel (30) note that, in this case, the role of genetics and gender should also be taken into account. OA is characterized by the degeneration of articular cartilage and the development of osteophytes among other pathological processes (31). Articular cartilage is defined as a connective smooth tissue that covers bones to guarantee the movement of joints (30).
Structural changes in the subchondral trabeculae and bone are also associated with the degeneration of articular cartilage and inflammatory processes that lead to secreting specific proteolytic enzymes (28). If articular cartilage and other parts of joints are affected, their function becomes limited, causing pain and stiffness (30). The study by Hodge, Harman, and Banks (32) have demonstrated that the pathogenesis of OA depends on the ethnicity factor significantly. The authors (32) have compared the development of the disease in North American and Saudi Arabian patients and found that differences are in the degeneration of articular cartilage. These aspects influence the procedure of diagnosing the disorder.
Diagnosis
Researchers (22) state that the diagnosis of OA is a complex process that involves both clinical and radiological testing. In Kuwait, Qatar, and other GCC and Arab countries, including Saudi Arabia, clinicians continue to use conventional methods of diagnosing OA, and the popular approach to managing the severe form of this disorder is Total Knee Arthroplasty (33-39). The localization of changes in joints determines symptoms and specific signs of the disease. Therefore, Homoud (3) has stated that the diagnosis is mainly clinical since “radiographic findings do not always correlate with symptoms.”
Clinicians examine specifics of joint movements and the muscle structure to conclude regarding the problem. To diagnose OA, clinicians also refer to the rheumatic factor and measuring C‑reactive protein (3, 28). They also examine roentgen to determine the disease stage (27). Much attention is also paid to types of pain experienced by patients. To treat and manage the disorder, clinicians prescribe symptomatic drugs and corticosteroids depending on the intensity of inflammation and associated pain (1). In Saudi Arabia, the challenges in managing OA were studied by Homoud (3) who focused on assessing the competency of Saudi physicians in coping with OA to improve the patients’ quality of life. The researcher (3) has found that many physicians in Saudi Arabia are unaware of changes in the patients’ quality of life and good approaches to managing the disease.
Classification of Osteoarthritis
The absence of widely accepted OA diagnostic criteria led to problems related to classifying osteoarthritis. Clinicians are inclined to discuss OA as having two forms, such as primary and secondary types, that are associated with specific factors that provoke the development of the disease (40). However, the variety of OA forms that depend on the localization of the disease also allows for speaking about another classification of the disorder. Thus, researchers and clinicians distinguish between knee, hip, hand, and ankle OA (41). These types of OA are usually caused by different factors, and they are typical of different genders and ages. For instance, hip OA is more common for women than for men (42). To classify OA and select the appropriate treatment, clinicians apply radiological and clinical criteria.
Radiological Criteria
Radiographs are actively used to diagnose and classify OA. Different stages of OA are marked according to the radiographic findings while using certain indices. In this case, classification depends on the observation of osteophytes, sclerosis of the subchondral bone, periarticular ossicles, and alterations in the bone (22). To determine the stage, observed signs are rated from 0 to 4 to conclude regarding the severity of pathology (43). Zhang and Jordan (22) have accentuated that the use of magnetic resonance imaging (MRI) to determine alterations and structures in joints is the more appropriate radiological method than the use of standard radiographs.
Different Methods of OA Assessment
In addition to radiological criteria, clinicians also apply different assessment instruments that are useful to evaluate the state of patients’ joints. Bauer et al. (44) have shown that OA biomarkers are important to determine the stage and severity of the disease in the concrete case. In their study, Felson et al. (45) proposed to use Whole Organ Magnetic Resonance Imaging Score (WORMS) and Boston Leeds Osteoarthritis Knee Score (BLOKS) that are based on the radiological data to receive the most complex information regarding the OA patient’s state.
Hawker, Mian, Kendzerska, and French (46) and Sanghi, Avasthi, Mishra, Singh, Agarwal, and Srivastava (43) proposed measuring pain related to OA with the help of the Visual Analog Scale (VAS) for pain. Also, the researchers (46) also promoted the focus on measuring intermittent and constant osteoarthritis pain (ICOAP) to classify OA and the use of the McGill Pain Questionnaire (MPQ) and the Numeric Rating Scale (NRS) for pain. Still, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) remains to be one of the most actively used disease-specific OA tools, and it is developed to measure the functional or physical capacity, the level of the experienced pain, and the kind of stiffness (30, 47). In the context of Saudi Arabia, Alghadir, Anwer, Iqbal, and Alsanawi (48) have found that the ArWOMAC index as the Arabic version of the tool is “a reliable and valid instrument for evaluating the severity of knee OA.”
Physical Functioning
While assessing and classifying OA, clinicians pay much attention to examining the physical function of a joint to conclude regarding the patient’s state (49).
Terminology Related to Physical Functioning
In recent articles (50-51), physical functioning associated with OA is defined as an ability to perform certain physical activities. Researchers (51) state that, while discussing the physical function in the context of OA, it is important to pay attention to the notions of ‘limitation’ and ‘disability’ to understand how the factor of physical functioning can influence OA patients’ life. The limitation in physical functioning is associated with the reduced mobility of patients and the reduced range of motion about knees, hips, or hands (50). In this case, the disability is reported as the overall restriction of joints’ functionality associated with significant pain and muscle weakness (51).
Schmitt, Fitzgerald, Reisman, and Rudolph (52) have reported that the physical functioning of OA patients is directly affected by pain and joints’ instability. As a result, patients cannot perform their daily activities. These results were supported by Kwok, Vlieland, Rosendaal, Huizinga, and Kloppenburg (53) and Montero, Mulero, Tornero, Guitart, and Serrano (54) in their studies. In their recent study, Araujo and the group of researchers (49) have also examined how restrictions in the functional independence of patients caused by OA can negatively influence the quality of life. Gomes-Neto, Araujo, Junqueira, Oliveira, Brasileiro, and Arcanjo (55) conducted the study in Brazil, and they concluded that the functional capacity of patients should be assessed to discuss persons’ quality of life and propose effective interventions.
Methods of Assessment
To assess the physical functioning of OA patients and determine how the limited physical activity is correlated with the quality of life, researchers (56) propose to use not only the WOMAC but also other instruments designed to evaluate patients’ performance. Stratford, Kennedy, and Woodhouse (57) proposed to refer to physical function items in the WOMAC to measure changes in activities. Still, Dobson and the group of researchers (50) reported the use of specific performance measures and multidimensional pain questionnaires in addition to the WOMAC to determine how the pain could lead to decreasing the physical function in OA patients. In their turn, referring to the results of the study conducted in Germany, Brandes, Schomaker, Möllenhoff, and Rosenbaum (58) have proposed using the gait analysis as an appropriate tool to measure Spatio-temporal parameters and associated physical functioning. From this perspective, the measurement of physical functioning is important to conclude regarding OA patients’ quality of life.
Health-Related Quality of Life
Osteoarthritis has a significant negative impact on the patients’ health-related quality of life because of the constant pain, limitations regarding physical and social functioning, and the decreased emotional state (10). According to Fernandez-Cuadros, Pérez-Moro, and Miron-Canelo (59), the quality of life is “expressed as the degree of perception to which the disease or its treatment affects the physical, psychic, emotional and social abilities of an individual.” Chan and Wu (60) have noted that the quality of life is also associated with a specific perception of the individual’s health and life satisfaction. Thus, according to Alkan, Fidan, Tosun, and Ardıçoğlu (61), patients with OA report the poorer quality of life in comparison with other patients and healthy people.
The researchers (62-63) agree that the reduced quality of life caused by OA is associated with limited physical functioning, the inability to participate in physical activities, the inability to perform usual occupational and daily tasks, and depression. Araujo, Castro, Daltro, and Matos (49) and Kiadaliri et al. (64) also note that the progress of OA leads to worsening the patient’s state and quality of life because of impossibility to perform effectively at work, conduct everyday tasks, and develop social relationships. Furthermore, the perception of health and quality of life can be different depending on gender (65-66). According to the results of Rosemann, Laux, and Szecsenyi’s (42) study, women and men have different perceptions of OA and the associated quality of life because of biological and emotional differences. Thus, OA influences women more significantly in terms of such aspects of the quality of life as pain, mood, and well-being, but the researchers have not discussed the causes of such differences (42).
In recent studies (67, 12), there are also many discussions of approaches to reducing OA patients’ suffering and improving the quality of life. Xie et al. (12) have found that the patients’ life can improve in terms of physical and social functioning after the total knee replacement, but the patients’ emotional or mental health can remain to be unaffected. Rat et al. (68) also conducted a similar study. The researchers (68) showed that total knee replacement could have only a partial effect regarding the improvement of the patients’ quality of life.
While referring to the situation in the GCC countries, it is important to concentrate on the study by Hassanein, Shamssain, and Hassan (18). In their study, the researchers (18) have focused on measuring the quality of life-related to those OA patients who live in the United Arab Emirates. They have discussed such approaches to improving the quality of life as pain reduction by using certain types of medications (18). These methods have positive outcomes, and they lead to improving physical functioning. The situation in Qatar is reported in the study by Gerber, Chiu, Verjee, and Ghomrawi (69). The researchers (69) have found that patients with OA in Qatar report the physical disability and the poor quality of life extremely often, and there are no adequate methods to address the problem.
Crushed, El-Sobkey, Hafez, and Al-Ahaideb (15) have examined how OA can affect the quality of life of elderly people in Saudi Arabia. The researchers (15) have shown that their findings are similar to the results demonstrated by authors from other countries in terms of accentuating the decreased levels of quality of life because of the constant joint pain and limited movements. Still, the researchers (15) have found that, for Saudi OA patients, the decreased quality of life is more associated with the affected mental and emotional health rather than with physical health. In their recent study, Alamri and the group of researchers (17) have also concentrated on the context of Saudi Arabia. The researchers (17) focused on discussing the quality of patients’ life in terms of life expectancy associated with OA and chronic pain, as well as the intensity of the experienced pain. The researchers (17) have stated that such conditions can lead not only to decreasing the quality of life but also to increased mortality among OA patients in Saudi Arabia. From this point, it is important to discuss what measures of the quality of life for OA patients are accepted to conclude regarding outcomes.
Measures of Health-Related Quality of Life
Researchers (51, 70) determine such measures related to the quality of life as the experienced pain, physical functioning, physical mobility, social functioning, social isolation, sleep, mood, levels of energy, emotional state, and mental health. It is possible to measure the quality of life with the help of generic survey instruments and questionnaires, as well as with the help of specific health and disease questionnaires. Generic instruments aim to measure the effects of any disease on the patients’ general health and activities.
Disease-specific questionnaires measure the impact of OA on specific domains of the patient’s health. The 36-Item Short-Form Health Survey (SF-36) is one of the most popular generic tools, and the WOMAC is the most widely used disease-specific tools for assessing OA patients and their experiences (11). Different translated versions of the WOMAC are available to researchers and clinicians from different countries (71). Disease-specific questionnaires can also be different depending on the type of OA. Therefore, for assessing knee OA, researchers and clinicians use the Oxford Knee Score (OKS), the Knee Society Clinical Rating Scale (KSS), and the Osteoarthritis Knee and Hip Quality of Life (OAKHQOL) questionnaire (63). Knee Injury and Osteoarthritis Outcome Score (KOOS) is another popular disease-specific tool that is appropriate to measure pain and activities related to knee joints (72-73).
In their study, Rosemann, Laux, and Szecsenyi (42) used the Patient Health Questionnaire (PHQ-9) to measure the level of depression in OA patients and conclude regarding the quality of life. Saffari and the group of researchers (63) chose to focus on the Lequesne index applied in combination with the Arthritis Impact Measurement Scale 2 (AIMS2) to analyze the quality of the patients’ life. The Nottingham Health Profile (NHP) was successfully used by Aksekili, Fidan, Alkan, Alemdar, Aksekili, and Ardıçoğlu (74). To conduct the study in Turkey, Esenyel, İçağasıoğlu, and Esenyel (75) selected the Quality of life questionnaire of the European Foundation for Osteoporosis (QALEFFO-41).
Different tools are also popular in the GCC region, and while conducting the OA study in the United Arab Emirates, Al-Jaziri and Mahmoodi (76) selected the simple pain scale. On the contrary, for the study in Saudi Arabia, Vennu and Bindawas (77) chose the KOOS and focused on measuring lifestyle characteristics using this instrument. However, disease-specific questionnaires often include only one section related to the quality of life, and many clinicians prefer to use generic instruments.
Short Form-36 Questionnaire
The 36-Item Short-Form Health Survey (SF-36) is one of the most actively used generic instruments proposed in the form of a questionnaire to measure how persons perceive their health state with the focus on eight domains, such as physical functioning, social functioning, physical role, pain, vitality, general health, mental health, and emotional health (78). Respondents are expected to rate their answers from 0 to 100, and the higher score means better health (79-81). The questionnaire is effective to be used in musculoskeletal studies, as well as the orthopedic research (82). While applying the questionnaire, it is possible to receive a detailed description of the health condition with the focus on the aspect of the quality of life (61, 83). SooHoo, Vyas, Samimi, Molina, and Lieberman (84) compared the use of the WOMAC and the SF-36 to conclude regarding the appropriateness of disease-specific and generic instruments to evaluate the quality of life in OA patients. They have found that the SF-36 can demonstrate results that are close to the WOMAC findings. Thus, researchers (59, 85) view the SF-36 questionnaire as a reliable and valid instrument because it is typically used to measure the impact of different chronic conditions with the focus on diverse population groups.
In their study, Xie et al. (12) used the SF-36 questionnaire to measure how the total knee replacement could improve the quality of life in Asian patients. Coleman, Briffa, Carroll, Inderjeeth, Cook, and McQuade (86) used the SF-36 questionnaire to test the Osteoarthritis of the Knee Self-Management Program proposed for Australian patients to improve their experience, physical functioning, and the quality of life. Fernandez-Cuadros, Pérez-Moro, and Miron-Canelo (59) applied the questionnaire for assessing the impact of knee arthroplasty on the patients’ quality of life in the context of Spain. Hassanein, Shamssain, and Hassan (18) conducted the study in the context of the United Arab Emirates, and they selected to use the SF-36 instead of the WOMAC because of the necessity to assess the variety of aspects related to the patients’ quality of life.
Summary
The review of the recent literature in the field of osteoarthritis studies conducted globally and in the GCC countries demonstrates that researchers are inclined to determine a direct relationship between OA and decreases in quality of life. Therefore, clinicians and researchers choose the variety of assessment methods to measure OA symptoms and the quality of patients’ life. Much attention is paid to assessing the health-related quality of life with the help of an SF-36 questionnaire.
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