Professional Documents
Culture Documents
discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/51075275
CITATIONS
READS
50
2,016
6 AUTHORS, INCLUDING:
Marlene Fransen
Lisa Bridgett
University of Sydney
University of Sydney
SEE PROFILE
SEE PROFILE
Lyn M March
University of Sydney
SEE PROFILE
SEE PROFILE
REVIEW ARTICLE
Abstract
Worldwide, osteoarthritis (OA) is estimated to be the fourth leading cause of disability. Most of this disability
burden is attributable to the involvement of the hips or the knees. OA is strongly associated with ageing and
the Asian region is ageing rapidly. Further, OA has been associated with heavy physical occupational activity,
a required livelihood for many people living in rural communities in developing countries. Unfortunately,
joint replacement surgery, an effective intervention for people with severe OA involving the hips or knees, is
inaccessible to most people in these regions. On the other hand, obesity, another major risk factor, may be
less prevalent, although it is on the increase. Determining region-specific OA prevalence and risk factor
profiles will provide important information for planning future cost-effective preventive strategies and health
care services. An update of what is currently known about the prevalence of hip and knee OA from population-based studies conducted in the Asian region is presented in this review. Many of the recent studies have
conducted comparisons between urban and rural areas and poor and affluent communities. The results of
Asian-based studies evaluating risk factors from population-based cohorts or casecontrol studies, and the
current evidence on OA morbidity burden in Asia is also outlined.
Key words: Asia, hip, joint pain, knee, osteoarthritis, prevalence.
INTRODUCTION
Osteoarthritis (OA) is the most prevalent of the chronic
rheumatic diseases and is a leading cause of pain and
disability in most countries worldwide.1 The prevalence
of OA increases with age and generally affects women
more frequently than men. Most of the OA disability
burden is attributable to the hips and knees. In fact,
OA is the precipitating diagnosis for more than 90% of
the increasing number of total hip or knee joint
replacement operations being undertaken worldwide.2
M. Fransen et al.
CASE DEFINITION
Internationally, prevalence estimates for OA show
wide variability depending on the age and gender
structure of the studied population and the case definition used. There have only been a few large population-based surveys in Asia that have included
radiographic examination of the hip or knee allowing
a case definition of symptomatic knee or hip OA (if
pain is present in a joint with radiographically evident
disease). However, a case definition requiring attainment of structural changes visible on radiographs is
likely to underestimate the true disease prevalence as
early OA will be undetected. On the other hand, prevalence estimates based only on self-reported joint pain
are likely to include many cases where most of the
pain, aching or stiffness is not directly attributable to
OA. For both symptomatic radiographic disease and
self-reported joint pain, prevalence estimates will vary
114
Osteoarthritis in Asia
Table 1 COPCORD studies. Crude prevalence of knee pain or a diagnosis of knee osteoarthritis (OA)
Asian region
East
South
Country/source (ref.)
China/Shanghai12
Urban
5650
China/Shantou23
China/Taiyuan24
Urban
Urban
2040
2188
North Pakistan14
Rural
Urban
Urban
All
Rural
Urban
Urban
Rural
Urban
Mixed
Urban
Bangladesh16
India/Bhigwan11
India/Pune17
India/Jammu18
Pakistan/Karachi15
South-east
Region/ethnicity
poor
affluent
poor
affluent
poor
683
706
608
1997
2601
1307
1252
4092
8145
1014
2210
Urban affluent
2022
Thailand/Nakornayok10
Philippines/Manila13
Philippines/Luzon19,22
Rural
Urban
Rural
2455
3006
950
Vietnam/Hanoi20
Urban
2119
Malaysia/Banting21
Semi-rural
Malay
Chinese
Indian
1267
474
853
Age (years)
Knee pain
Male/female, %
Knee OA
Male/female, %
3645
4655
5665
6675
> 75
1699
3539
4044
4549
5054
5559
6064
15+
3/9
7/17
14/26
14/24
9/17
8
9/18
(3564 years)
NA
15+
14
14
16
10/16
8
NA
3/8
1/3
3/7
2/11
5/9
4/9
0/6
0/10
6/18
12/17
NA
1
2/3
11/12
24/8
15+
15+
15+
15+
3544
4554
4464
65+
15+
3544
4554
4464
65+
15+
15+
1544
4564
65+
16+
1634
3554
5564
65+
15+
NA
4
3/4
3/9
7/16
10/27
14/27
13/34
4
3
5
4/5
6/9
10/8
6/16
4
6
4
NA
NA
6
NA
3/3
3
< 1/1
5/4
22/22
41/36
9/11
3/6
8/13
2/3
1/1
3/6
115
M. Fransen et al.
Table 2 Non-COPCORD population-based surveys. Crude prevalence of symptomatic radiographic knee OA and knee pain
Country/source (ref.)
Knee OA and knee pain
China/Beijing25
China/Wuchuan27
China/Shanghai26
Japan/Miyagawa30
Japan/ROAD study29
Korea/Chuncheon28
Region
Age (years)
Urban
1781
Rural
Urban
Rural
Urban
Rural (M)
Rural (S)
Urban
1027
2093
598
1135
699
447
573
6064
6569
7074
7579
80+
50+
40+
65+
60+
50+
Symptomatic OA
Male/female, %
3/14
4/14
10/15
9/22
11/16
7/14
4/10
11/27
14/32
23/38
10/14
7/38
Pain
Male/female, %
17/30 (60+ years)
44/56
6/13
25/40
29/41
14/26
116
Osteoarthritis in Asia
South
South East
Source (ref.)
Region
Age (years)
Hip pain
Male/female, %
Hip OA
Male/female, %
China/Shanghai12
China/Shantou23
Beijing (non-COPCORD)33
Bangladesh16
Urban
Urban
Urban
Rural
Urban poor
Urban affluent
Rural
Urban
Rural
Rural
6584
2040
1506
2601
1307
1252
4092
8145
2455
950
1599
1699
60+
15+
< 1/2
2
6/11
13
6
7
1
<1
NA
3 cases only
5 cases only
NA
India/Bhigwan11
India/Pune17
Thailand/Nakornayok10
Philippines/Luzon19,22
Vietnam/Hanoi20
Malaysia/Banting21
Urban
Malay
Chinese
Indian
2119
1267
474
853
15+
15+
15+
15+
1544
4564
65+
16+
1634
3554
5564
65+
15+
NA
<1
1
2 cases only
1/1
5/2
3/3
3 cases only
< 1/< 1
2/1
13/15
15/12
2/3
1/1
1/4
NA
Squatting or Kneeling
An analysis of the ROAD study, conducted in Japan,40
demonstrated that occupations involving squatting or
kneeling more than 2 h per day were associated with
an approximately two-fold significantly increased risk
of moderate to severe radiographic knee OA (Kellgren
Lawrence grade 3). From the cohort study conducted
among people aged 60 years or older in Beijing,25 prolonged squatting at 25 years of age (> 1 h per day)
was a common activity and was found to be a strong
risk factor for OA of the tibio-femoral joint of the
knee.40 In this analysis, people who reported squatting
more than 3 h per day, compared to those who
reported squatting < 30 min a day, had twice the
117
M. Fransen et al.
Stair-Climbing
A casecontrol study of hospitalized hip or knee OA
patients conducted in Hong Kong demonstrated that a
history of joint injury, frequent stair-climbing (15 or
more flights per day) or frequent lifting of heavy
weights (10 kg or more) were all associated with knee
OA.44 Somewhat in contrast, another study in China24
reported that people aged 3564 years living in multistorey buildings without elevators had a significantly
higher prevalence of knee pain compared with those
living in single-storey homes (10.1% and 6.5%,
respectively); however no correlation between knee
118
OA and climbing stairs could be demonstrated. Interestingly, data from the ROAD study suggest that living
in a rural mountainous area doubled the likelihood of
symptomatic knee OA (confirmed by radiographs)
compared with living in a seaside or urban region.29
Osteoarthritis in Asia
knee pain were 25 times more likely to report difficulty with walking, stair-climbing, mobility and every
day housekeeping duties compared to people without
knee pain.47 Furthermore, among those reporting
knee pain in the past year, the concomitant presence
of radiographic disease (Kellgren Lawrence grade 2)
was associated with significantly increased odds of
reporting episodes of unbearable pain (59% vs.
36%), restricted activity due to knee pain (64% vs.
39%) and a higher use of non-steroidal anti-inflammatory drugs (NSAIDS: 88% vs. 78%) or visiting a
general practitioner (59% vs. 33%) for knee pain in
the past year.47 Radiographic disease severity was
positively linked to increased pain, disability and
use of healthcare services. In addition, the very high
utilisation of NSAIDs compared with paracetamol
(< 5%) for knee pain in this older cohort should be
of concern given the known association with adverse
medical events.
Another recent study conducted among older people
in Korea (Hallym Aging Study) demonstrated that
cohort participants with radiographic knee OA were
twice as likely to belong to the worst quartile pain
score (OR 2.1; 95% CI 1.33.4) and three times as
likely to belong to the worst quartile physical function
score (OR 3.0; 95% CI 1.84.8) using the WOMAC
questionnaire.48 Further participants with OA had significantly lower quality of life scores, measured using
the Short Form (SF)-12 questionnaire.
In Global Burden of Disease studies, morbidity
and mortality are combined and expressed as disability-adjusted life years (DALYs) to account for years
lived with disability or years of healthy life lost due to
disability. A disability weight is a weight factor that
reflects the severity of the disease on a scale from 0
(perfect health) to 1 (death). The disability weight
assigned to hip or knee osteoarthritis in Global Burden of Disease studies typically range from 0.10 to
0.15. In Singapore, musculoskeletal conditions are
listed as the fifth leading cause of morbidity in 2004,
accounting for 4.9% of years lost to disability
(YLD).49 This approximates the comparable YLD in
Australia, where musculoskeletal conditions ranks as
the third most common cause of YLD (4.8%).50
CONCLUSION
The prevalence of knee pain or symptomatic knee
osteoarthritis is high among older people in the Asian
region in rural and urban areas. The prevalence is comparable to that found in other regions of the world,
and should be of concern given the current rapid ageing and increasing obesity evident in most Asian countries. Apart from targeting obesity, investigating simple
methods or workplace practices to reduce exposure to
continual heavy manual occupational activity or longterm kneeling or squatting would appear to be useful
strategies to reduce the prevalence of chronic knee pain
and disability in the Asian region. The prevalence of
hip pain or symptomatic hip OA is low.
ACKNOWLEDGMENT
Associate Professor Fransen was supported by a
NHMRC (Australia) Career Development Award.
REFERENCES
1 World Health Organization (2002) World Health Report
2002. Reducing Risks, Promoting Healthy Life. Geneva,
WHO.
2 Australian Orthopaedic Association (2009) Hip and Knee
Arthoplasty. National Joint Replacement Registry Annual
Report 2009.
3 Kinsella K, He W (2009) An Ageing World: 2008. U.S.
Census Bureau, Washington, DC.
4 Jensen LK (2008) Knee osteoarthritis: influence of work
involving heavy lifting, kneeling, climbing stairs or ladders, or kneeling/squatting combined with heavy lifting.
Occup Environ Med 65, 7289.
5 Jensen LK (2008) Hip osteoarthritis: influence of work
with heavy lifting, climbing stirs or ladders, or combining
kneeling/squatting with heavy lifting. Occup Environ Med
65, 619.
6 Yoon KH, Lee JH, Kim JW, et al. (2006) Epidemic obesity
and type 2 diabetes in Asia. Lancet 368, 16818.
7 Woo J, Lau E, Lau CS, et al. (2003) Socioeconomic
impact of osteoarthritis in Hong Kong: utilization of
health and social services, and direct and indirect costs.
Arthritis Rheum 49, 52634.
8 Pincus T, Mitchell JM, Burkhauser RV (1989) Substantial
work disability and earnings losses in individuals less
than age 65 with osteoarthritis: comparisons with rheumatoid arthritis. J Clin Epidemiol 42, 44957.
9 Haq SA, Rasker JJ, Daremawan J, Chopra A (2008)
WHO-ILAR-COPCORD in the Asia-Pacific: the past, present and future. Int J Rheum Dis 11, 410.
10 Chaiamnuay P, Darmawan J, Muirden KD, Assawatanabodee P (1998) Epidemiology of rheumatic disease in
rural Thailand: a WHO-ILAR COPCORD study. J Rheumatol 25, 13827.
11 Chopra A, Patil J, Billempelly V, Relwani J, Tandle HS
(2001) Prevalence of rheumatic diseases in a rural population in western India: a WHO-ILAR COPCORD Study.
J Assoc Physicians India 49, 2406.
119
M. Fransen et al.
12 Dai SM, Han XH, Zhao DB, Shi YQ, Liu Y, Meng JM
(2003) Prevalence of rheumatic symptoms, rheumatoid
arthritis, ankylosing spondylitis, and gout in Shanghai,
China: a COPCORD study. J Rheumatol 30, 224551.
13 Dans LF, TankehTorres S, Amante CM, Penserga EG
(1997) The prevalence of rheumatic diseases in a Filipino
urban population: a WHO-ILAR COPCORD study.
J Rheumatol 24, 18149.
14 Farooqi A, Gibson T (1998) Prevalence of the major
rheumatic disorders in the adult population of north
Pakistan. Br J Rheumatol 37, 4915.
15 Gibson T, Hameed K, Kadir M, Sultana S, Fatima Z, Syed
A (1996) Knee pain amongst the poor and affluent in
Pakistan. Br J Rheumatol 35, 1469.
16 Haq SA, Darmawan J, Islam MN, et al. (2005) Prevalence
of rheumatic diseases and associated outcomes in rural
and urban communities in Bangladesh: a COPCORD
study. J Rheumatol 32, 34853.
17 Joshi VL, Chopra A (2009) Is there an urban-rural divide?
Population surveys of rheumatic musculoskeletal disorders in the pune region of india using the COPCORD
Bhigwan Model. J Rheumatol 36, 61422.
18 Mahajan A, Jasrotia DS, Manhas AS, Jamwal SS (2003)
Prevalence of major rheumatic disorders in Jammu. JK
Science 5, 636.
19 Manahan L, Caragay R, Muirden KD, Allander E, Valkenburg HA, Wigley RD (1985) Rheumatic pain in a Philippine village. A WHO-ILAR COPCORD study. Rheumatol
Int 5, 14953.
20 Minh Hoa TT, Damarwan J, Chen SL, Van Hung N, Thi
Nhi C, Ngoc An T (2003) Prevalence of the rheumatic
diseases in urban Vietnam: a WHO-ILAR COPCORD
study. J Rheumatol 30, 22526.
21 Veerapen K, Wigley RD, Valkenburg H (2007) Musculoskeletal pain in Malaysia: a COPCORD survey. J Rheumatol 34, 20713.
22 Wigley RD, Manahan L, Muirden KD, et al. (1991) Rheumatic disease in a Philippine village II: a WHO-ILARAPLAR COPCORD study, phases II and III. Rheumatol Int
11, 15761.
23 Zeng QY, Chen R, Xiao ZY, et al. (2004) Low prevalence
of knee and back pain in southeast China; the Shantou
COPCORD study. J Rheumatol 31, 243943.
24 Zeng QY, Zang CH, Li XF, Dong HY, Zhang AL, Lin L
(2006) Associated risk factors of knee osteoarthritis: a
population survey in Taiyuan, China. Chin Med J 119,
15227.
25 Zhang Y, Zu L, Nevitt MC, et al. (2001) Comparison of
the prevalence of knee osteoarthritis between the elderly
chinese population in Beijing and Whites in the United
States. The Beijing Osteoarthritis Study. Arthritis Rheum
44, 206571.
26 Du H, Chen SL, Bao CD, et al. (2005) Prevalence and
risk factors for knee osteoarthritis in Huang-Pu District,
Shanghai, China. Rheumatol Int 25, 58590.
120
27 Kang X, Fransen M, Zhang Y, et al. (2009) The high prevalence of knee osteoarthritis in a rural Chinese population: the Wuchuan OA Study. Arthritis Rheum 61, 6417.
28 Kim I, Kim HA, Se Y-I, Song YW, Jeong J-Y, Kim DH
(2010) The prevalence of knee osteoarthritis in elderly
community residents in Korea. J Korean Med Sci 25, 293
8.
29 Muraki S, Oak H, Akune T, et al. (2009) Prevalence of
radiographic knee osteoarthritis and its association with
knee paion in the elderly of Japanese population-based
cohorts: the ROAD Study. Osteoarthr Cartil 17, 113743.
30 Sudo A, Miyamoto N, Horikawa K, et al. (2008) Prevalence and risk factors for knee osteoarthritis in elderly
Japanese men and women. J Orthop Sci 13, 4138.
31 Felson DT, Naimark A, Anderson J, Kazis L, Castelli W,
Meenan RF (1987) The prevalence of knee osteoarthritis
in the elderly. The Framingham Osteoarthritis Study.
Arthritis Rheum 30, 9148.
32 Hoy D, Fransen M, March L, Brooks P, Durham J, Toole
MJ (2010) In rural Tibet, the prevalence of lower limb
pain, especially knee pain, is high: an observational
study. J Physiother 56, 4954.
33 Nevitt MC, Xu L, Zhang Y, et al. (2002) Very low prevalence of hip osteoarthritis among Chinese elderly in Beijing, China, compared with whites in the United States: the
Beijing osteoarthritis study. Arthritis Rheum 46, 17739.
34 Dagenais S, Garbedian S, Wai EK (2009) Systematic
review of the prevalence of radiographic primary hip
osteoarthritis. Clin Orthop Relat Res 467, 62337.
35 Felson DT (2004) An update on the pathogenesis and
epidemiology of osteoarthritis. Radiol Clin North Am
42:19, v.
36 Diller A (1980) Cross-cultural pain semantics. Pain 9, 9
26.
37 Gureje O, Von Korff M, Simon GE, Gater R (1998) Persistent pain and well-being: a World Health Organization
Study in Primary Care. JAMA 280, 14751.
38 Haq SA, Davatchi F, Dahaghin S, et al. (2010) Development of a questionnaire for identification of the risk factors for osteoarthritis of the knees in developing
countries. A pilot study in Iran and Bangladesh. An ILARCOPCORD phase III study. Int J Rheum Dis 13, 20314.
39 Zeng QY, Darmawan J, Xiao ZY, et al. (2005) Risk factors
associated with rheumatic complaints: a WHO-ILAR
COPCORD study in Shantou, Southeast China. J Rheumatol 32, 9207.
40 Muraki S, Akune T, Oka H, et al. (2009) Association of
occupational activity with radiographic knee osteoarthritis and lumbar spondylosis in elderly patients of population-based cohorts: a large-scale population-based study.
Arthritis Rheum 61, 77986.
41 Zhang Y, Hunter DJ, Nevitt MC, et al. (2004) Association
of squatting with increased prevalence of radiographic
tibiofemoral knee osteoarthritis: the Beijing Osteoarthritis
Study. Arthritis Rheum 50, 118792.
Osteoarthritis in Asia
42 Yoshimura N, Kinoshita H, Hori N, et al. (2006) Risk factors for knee osteoarthritis in Japanese men: a casecontrol study. Mod Rheumatol 16, 249.
43 Yoshimura N, Nishioka S, Kinoshita H, et al. (2004) Risk
factors for knee osteoarthritis in Japanese women: heavy
weight, previous joint injuries, and occupational activities. J Rheumatol 31, 15762.
44 Lau EC, Cooper C, Lam D, Chan VN, Tsang KK, Sham A
(2000) Factors associated with osteoarthritis of the hip
and knee in Hong Kong Chinese: obesity, joint injury,
and occupational activities. Am J Epidemiol 152, 85562.
45 Yoshimura N, Sasaki S, Iwasaki K, et al. (2000) Occupational lifting is associated with hip osteoarthritis: a Japanese casecontrol study. J Rheumatol 27, 43440.
46 Xie F, Li S-C, Fong K-Y, et al. (2006) What health
domains and items are important to patients with knee
47
48
49
50
121