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The epidemiology of osteoarthritis in Asia


ARTICLE in INTERNATIONAL JOURNAL OF RHEUMATIC DISEASES MAY 2011
Impact Factor: 1.47 DOI: 10.1111/j.1756-185X.2011.01608.x Source: PubMed

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International Journal of Rheumatic Diseases 2011; 14: 113121

REVIEW ARTICLE

The epidemiology of osteoarthritis in Asia


Marlene FRANSEN,1 Lisa BRIDGETT,1 Lyn MARCH,2 Damian HOY,3 Ester PENSERGA4 and
Peter BROOKS5
1
Faculty of Health Sciences and 2School of Medicine, University of Sydney, Sydney, New South Wales, 3School of Population
Health, University of Queensland, Brisbane, Queensland, Australia; 4Department of Medicine, University of the Philippines,
Manilla, Philippines; and 5Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria,
Australia

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

Correspondence: Assoc Prof Marlene Fransen, Faculty of


Health Sciences, University of Sydney, PO Box 170, Lidcombe, NSW 1825, Australia. Email: marlene.fransen@
sydney.edu.au

Many countries in Asia are ageing rapidly.3 It has


been estimated that the percentage of people aged
65 years and over in Asia will more than double in the
next two decades, from 6.8% in 2008 to 16.2% in
2040. In most of the developed world, demographic
change was a gradual process following steady socioeconomic growth over several decades. In many Asian
countries, the change is being compressed into two or
three decades. For example, during the period 2008
2040, it is estimated that Singapore will increase the
proportion of people aged 65 and over by 316%, India
by 274%, Malaysia by 269%, Bangladesh by 261%,
and the Philippines by 256%. In 2008, Japan had the
worlds oldest population (21.6% aged 65 years and
over) and China and India were ranked the top two
countries in the absolute number of people aged 65
and over (106 and 60 million, respectively).3

2011 The Authors


International Journal of Rheumatic Diseases
2011 Asia Pacific League of Associations for Rheumatology and Blackwell Publishing Asia Pty Ltd

M. Fransen et al.

Apart from ageing, there is much evidence from


mostly North American or European cohorts that
obesity or heavy occupational physical activity, such as
carried out by many people in rural communities
within the Asian region, are clear risk factors for symptomatic knee and hip OA.4,5 Joint replacement surgery
is largely inaccessible to most people in rural regions
of developing countries, possibly resulting in a large
and growing number of older people living many
years with severe joint disease. On the other hand,
obesity is less prevalent in these regions, but is on the
increase6 and likely to have a major impact on OA
prevalence in the future.
From an individual viewpoint, symptomatic OA is
associated with chronic pain and increasing difficulty
performing the usual daily activities necessary to
maintain independence. From a societal viewpoint,
OA is costly, having high direct costs in the form of
increased utilization of hospital and medical services,
and also high indirect costs through lost productivity
of individuals and their carers.7,8 Furthermore, significant musculoskeletal disability in an ageing
population will result in a diminished capacity to
successfully extend retirement age, a strategy often
proposed to successfully deal with the anticipated
resource burden of the ageing population. Evaluating
OA prevalence data collected in Asian communities is
therefore of great importance for identifying regionspecific modifiable risk factors, developing cost-effective preventive strategies and planning future healthcare services.

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

according to the temporal criterion. Case definitions


requiring only ever pain are likely to yield higher
prevalence estimates compared with those requiring
current pain or pain for most days in the past
month.
Much of the data on musculoskeletal pain and OA
prevalence in Asia has come from the Community-Oriented Program for the Control of Rheumatic Diseases
(COPCORD) studies. The planned focus of the COPCORD program is to evaluate the rheumatic diseases
burden particularly in rural communities in developing
countries.9 The methodology for the COPCORD studies is well described by S Haq and Davatchi in this
issue. One comment that should be made is that, as
the focus of COPCORD is on inflammatory and systemic rheumatic diseases, not all COPCORD studies
report knee or hip pain or joint-specific OA prevalence.

PREVALENCE OF KNEE PAIN AND


SYMPTOMATIC KNEE OA
From the COPCORD studies conducted to-date in the
Asian region and providing estimates of knee pain
(phase 1) or knee OA (phase 3), it is evident that the
prevalence of either knee pain or knee OA is high,
particularly given that the cohorts are quite young,
usually 15 years or over, with a mean age mostly
between 30 and 39 years (Tables 1 and 2).1024 The
COPCORD studies providing age and gender-stratified
prevalence estimates generally demonstrate that prevalence increases with age and is higher among women.
It is difficult to compare prevalence estimates between
the COPCORD studies due to some differences in the
screening pain questionnaire terminology and survey
methodology, as well as the often incomparable age
stratifications reported.
The COPCORD studies conducted in India, Bangladesh and Pakistan each collected data from several
communities, aiming to detect ruralurban or affluent
poor differences. The two large surveys conducted in
India by one group of researchers11,17 presented data
from these two communities adjusted to the Indian
population census of 2001. This adjusted comparison
revealed a significantly higher prevalence of knee pain
in the rural (13.7%) compared with the urban (6.0%)
community.17 The two surveys conducted in Pakistan
demonstrated a higher prevalence of knee pain among
the urban affluent compared with the urban poor
cohorts within each study.14,15 Both attributed this
finding to the increasing prevalence of obesity with
rising affluence in Pakistan. The finding of a higher

International Journal of Rheumatic Diseases 2011; 14: 113121

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

NA, not available.

prevalence of knee pain in affluent urban compared


with poor urban or rural communities was again demonstrated in a large survey conducted in Bangladesh.16

International Journal of Rheumatic Diseases 2011; 14: 113121

Apart from the COPCORD studies, there have only


been a few population-based surveys conducted in the
Asian region able to provide prevalence estimates of

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

M, mountainous region; S, seaside region.

knee pain or symptomatic knee OA (Table 2).2530


These non-COPCORD surveys have used knee radiographs on all participants to define symptomatic knee
OA. The population-based surveys conducted in urban
Beijing25 and rural Wuchuan County27 in China both
used the same symptomatic and radiographic knee
OA and knee pain case definitions as used by the
Framingham study in North America,31 providing an
opportunity for meaningful ruralurban and Chinese
Caucasian comparisons. When analysis was restricted
to participants aged 60 years and over (as per the Beijing study cohort restrictions), men in Wuchuan demonstrated about double the prevalence (prevalence
ratio [PR] 1.9, 95% confidence interval [CI] 1.32.9)
of symptomatic knee OA compared with their Beijing
counterparts. A similar significantly higher prevalence
was also evident among women in Wuchuan (PR 1.6,
95% CI 1.22.1) compared with their urban counterparts. The prevalence of knee pain (most days of
1 month in the past year) was markedly higher in the
rural Chinese cohort (around 50% of participants),
compared with the urban Chinese cohort. Interestingly, the prevalence of bilateral knee OA and lateral
compartment disease were two to three times higher
in both Chinese cohorts compared with estimates
from the Framingham OA Study.27 The large population-based survey conducted in Japan29 also provided
an opportunity to compare urban and rural cohorts
for symptomatic knee OA, confirmed by radiographs.
However, the difference in prevalence was more evident between the two rural regions (mountainous and
seaside) than between rural and urban regions.
Another study among 500 people 15 years or older in

116

19 villages in rural Tibet found a prevalence of current


knee pain of 25% (95% CI 1930), and compared
with the younger age category, being 50 years or older
was significantly associated with reporting knee pain
(odds ratio [OR] 3.4, 95% CI 2.25.2).32

PREVALENCE OF HIP PAIN AND


SYMPTOMATIC HIP OA
It is clear that hip OA as diagnosed by a clinician is rare
in all of the Asian regions (Table 3).1012,16,17,1923,33
The prevalence of hip pain is also mostly low in these
young adult populations. Only one study made
urbanrural comparisons (Bangladesh), which found
a much higher prevalence of hip pain in the rural
community compared to urban communities. Interestingly, while a survey in Vietnam demonstrated a
much higher prevalence of hip pain in older age
groups,20 this trend was not observed in a survey conducted in the Philippines.19 Given the relative rarity
of radiographic hip OA in the Asian region,34 unless
anterior groin pain was specified in the screening
questionnaire, some of the reported hip pain may
have been attributable to referred pain from the lumbar spine. The one non-COPCORD study evaluating
hip OA and hip pain provides low prevalence estimates in China,33 similar to those reported in the
COPCORD studies.

RISK FACTORS FOR KNEE OA


Risk factors for knee OA have been studied mostly
in Caucasian populations residing in high-income

International Journal of Rheumatic Diseases 2011; 14: 113121

Osteoarthritis in Asia

Table 3 COPCORD studies. Crude prevalence of hip pain or a diagnosis of hip OA


Asian region
East

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

NA, not available.

countries and include age, female gender, obesity, a


history of knee surgery or significant trauma, or having
an occupation requiring heavy lifting, kneeling or
squatting.4,35 Less epidemiological research in chronic
musculoskeletal conditions has been conducted in low
and middle-income countries in the Asian region.
While it is reasonable to extrapolate some of the risk
factor findings from high-income countries to lowand middle-income countries, there are also likely to
be significant demographic and environmental differences influencing the onset and progression of OA in
these regions. Cultural differences of specific importance are the probable lower, though increasing, prevalence of obesity, higher proportion of the population
in occupations requiring heavy physical labour, squatting, kneeling and climbing, less access to healthcare
and social welfare services, variation between cultures
in the way pain is perceived and linguistic variation in
the way pain is defined and classified.36,37 Recognition
of probable demographic and environmental differences has driven the recent development of a questionnaire identifying risk factor profiles specific for
the Asia-Pacific region.38 The proposed questionnaire
includes unique items such as exposures to: religious
activities (praying and other sitting religious wor-

International Journal of Rheumatic Diseases 2011; 14: 113121

ships); squatting; duration of heavy physical activity;


type of toilet; and sitting on the floor (criss-cross, lotus
or applesauce, for home activities).

Age, Gender, Obesity


Several recent large population-based cohort studies
conducted in China, Japan, Korea and Pakistan have
confirmed an increased risk of symptomatic knee
OA associated with older age, female gender and
obesity.15,24,26,2830,39

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.

likelihood of tibio-femoral OA. The study concluded


that prolonged squatting accounted for a substantial
proportion of the difference in knee OA prevalence
between Chinese subjects in Beijing and White subjects participating in the Framingham OA study.41

Heavy Occupational Physical Activity


In the ROAD study, among Japanese people aged
60 years or above, having an occupation involving
climbing more than 1 h a day (OR 2.2, 95% CI: 1.6
3.0), standing more than 2 h a day, (OR 2.0, 95% CI:
1.42.7), lifting weights of 10 kg or more at least once
a week (OR 1.9, 95% CI: 1.52.4), and walking more
than 3 km a day were each associated with a 1.42.0
increased odds of radiographic knee OA (Kellgren
Lawrence grade 2), after adjustment for age, sex and
body mass index (BMI).40 The Hallym Ageing Study,28
conducted in Korea among people aged 50 years or
over, demonstrated an increased likelihood of radiographic knee OA with reporting a manual occupation
(OR 2.1, 95% CI: 1.23.8) in multivariate analysis. It
was demonstrated that the prevalence of symptomatic
knee OA and knee pain was significantly higher in
rural Wuchuan county, compared with urban Beijing
among people aged 60 years or over and using identical disease case definitions.27 The majority of participants in the Wuchuan study (91%) reported that the
job they held the longest involved heavy physical
work, compared with 35% of Beijing study participants.27 In a casecontrol study among Japanese men
aged 45 years or above, it was found that apart from
heavy previous body weight, a history of knee injury
and manual occupations were associated with knee
OA.42 Similarly, among women aged 45 years or
older, heavy previous body weight and previous knee
injuries were significant risk factors for knee OA, while
sedentary work during initial employment was a
protective factor.43

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

RISK FACTORS FOR HIP OA


As the prevalence of hip OA appears to be rare in the
Asian region, casecontrol studies are required to feasibly provide risk factor estimates. In a large case
control study (n = 550) of hospitalized hip OA
patients conducted in Hong Kong, in a similar fashion
to knee OA, a history of joint injury, frequent stairclimbing (15 or more flights per day) or frequent lifting of heavy weights (10 or 50 kg or more) were each
significantly associated with hip OA for men and
women, respectively.44 The strongest association was
for the history of joint injury. The upper quartiles of
body weight were only weakly associated with hip OA,
and then only among women.44 Another casecontrol
study (n = 228) conducted in Japan among mostly
women aged 45 years or older on the waiting list for
hip replacement surgery for OA, a significant association between occupational lifting of 25 kg (OR 3.6,
95% CI: 1.39.7) and hip OA was demonstrated.45
The authors found no association between obesity and
hip OA.45

MORBIDITY ASSOCIATED WITH KNEE


OR HIP OA
Initial studies suggest domains considered most
important for health-related quality of life by Asian
patients with OA are broadly similar to those reported
in Western societies, that is, pain, physical disability
and other physical symptoms of OA such as limping,
swelling, stiffness.46 However, very few studies conducted in Asia have evaluated the effect of knee or hip
pain or joint-specific OA on physical disability or
health-related quality of life. Some of the COPCORD
studies reported evaluations of physical disability;
however, the results presented were undifferentiated
for pain location or rheumatic disease diagnosis; the
study presented mostly a simple comparison between
positive responders in phase 1 (recent joint pain,
stiffness or aching) and those reporting no joint
symptoms.
The population-based survey conducted in rural
China (Wuchuan) specifically evaluating the presence
of knee symptoms, demonstrated that people with

International Journal of Rheumatic Diseases 2011; 14: 113121

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,

International Journal of Rheumatic Diseases 2011; 14: 113121

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.

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