Osteoarthritis (OA) of the knee is a chronic condition associated with age-related decline, which affects the health of older adults worldwide. In 2010, OA was ranked as the 11th highest contributor to global disability and the 38th highest burden (Cross et al., 2014).
Knee OA involves gradual changes in the knee cartilage and structures in the joint, such as the synovium, bone, and soft tissue, which lead to pain and dysfunction (Cross et al., 2014; Sofat, Ejindu, & Kiely, 2011). However, risk factors for developing knee OA are multifactorial. Being overweight or obese are predominant contributors to the development and progression of knee OA (Blagojevic, Jinks, Jeffery, & Jordan, 2010; King, March, & Anandacoomarasamy, 2013; World Health Organization [WHO], 2015). Conversely, patients with knee OA who have lost body weight (≥10% over 3 years) have reported significant improvements in pain and functional status (Riddle & Stratford, 2013). According to WHO (2015) global estimates from 2014, more than 1.9 billion adults were overweight and more than 600 million of these individuals were obese. Similar to other countries, data from the Thai National Health Examination Survey I–III during 1991–2004 indicated that one third of Thai adults age 60 and older were obese when using the Asian criteria of body mass index (BMI) (i.e., ≥25 kg/m2) (Aekplakorn & Mo-Suwan, 2009). A pilot study of Thai older adults living in northeastern rural Thailand revealed 55.9% (n = 34) were overweight (Saraboon, Aree-Ue, & Maruo, 2014). An increasing aging population coupled with worldwide obesity is contributing to knee OA becoming a global burden (Cross et al., 2014).
The consequences of knee OA include knee pain; physical function limitations; reduced social participation, work productivity, and quality of life; and increased fatigue and health care resource use (Dibonaventura, Gupta, McDonald, & Sadosky, 2011; Hunter, Schofield, & Callander, 2014). The burden of direct costs is high, with the United Kingdom reporting the annual expenditures charged to insurers were higher in women and men with knee OA compared to those without knee OA (Hunter et al., 2014). Similar to a study reported in the United States, the total direct costs were more than 1.5 times higher in patients with knee OA who reported knee pain compared to those not reporting knee pain from OA (Dibonaventura et al., 2011). Although no study has been published in Thailand regarding health care costs for knee OA treatment, OA is considered a high-cost, high-volume disease due to the direct medical expenses, use of prescription medications for pain, and frequent total knee arthroplasty (Ramathibodi Utilization Management, 2015; Turajane, Chaweevanakorn, Sungkhun, Larbphiboonpong, & Wongbunnak, 2012). This heavy disease burden is a call to action for health care professionals to use strategies that will prevent the onset and reduce the progression of knee OA.
According to the OA Research Society International (OARSI) guideline (McAlindon et al., 2014), weight management and strength training exercises are considered two nonsurgical management strategies for knee OA. Weight loss of 5% over 20 weeks or 0.25% per week is recommended. Strength training exercise, including resistance-based lower limb and quadriceps exercise, along with weight-bearing and nonweight-bearing exercise, are suggested to reduce pain and improve physical function. Being overweight and obese leads to increased loading of the knee and difficulty walking due to greater body mass, which in turn causes knee adduction problems and fear of knee pain. Together these issues lead to physical inactivity and, consequently, patients gain even more weight (King et al., 2013; White et al., 2012). Exercise and weight management interventions have been shown to account for improvement in knee OA symptoms and their progression. Several previous studies conducted with older adults who were overweight or obese showed the benefits of combining exercise, either strength training or walking exercise, and a dietary program on outcome improvement, including pain reduction, decreasing depression and increasing physical function and performance and health-related quality of life (Christensen et al., 2015; Jenkinson et al., 2009; Messier et al., 2013; White et al., 2015). These studies were conducted in Western countries, which may not completely apply to Thai individuals whose lifestyle pattern and dietary consumption differ from Western individuals.
To the current authors' knowledge, no published study has assessed participant adherence after termination of an intervention program in overweight Thai older adults with knee OA. The current study aimed to determine whether overweight older adults who participated in the previously reported multifactorial intervention program (MUFIP; Saraboon, Aree-Ue, & Maruo, 2015) (a) adhered to a multicomponent intervention (i.e., quadriceps exercise and weight management program, such as brisk walking exercise and a dietary program) after termination of the intervention; and (b) demonstrated the effectiveness of quadriceps exercise and a weight management program on knee pain, knee function, and weight loss at 6- and 12-month follow up.
The current study is a follow up to the authors' previously reported quasi-experimental study (Saraboon et al., 2015). Participants who met the inclusion criteria were randomly assigned to control (n = 40) or intervention (n = 40) groups. Individuals in the intervention group received the 8-week MUFIP. Data were collected at baseline and 8 weeks. In the current study, data collection was performed at 6 and 12 months after termination of the MUFIP.
Prior to participation in the previous study (Saraboon et al., 2015), participants were screened and recruited from 23 communities in the Nakhon Phanom Municipality District, Thailand. Inclusion criteria were: knee OA classified by the American College of Rheumatology criteria (Brandt, 2010), BMI of 23 kg/m2 to 29.99 kg/m2 (using Asian criteria for BMI classified as overweight and pre-obese [Llido & Mirasol, 2001]), mild to moderate knee OA, and no cognitive impairment. Participants were excluded if they had secondary knee OA (e.g., history of knee injury, rheumatoid arthritis); history of knee surgery; had received any injections in either knee 3 months before participation in the study; had serious medical conditions, such as myocardial infarction; or had progressive symptoms or severe knee OA that required surgery.
After completion of the MUFIP, all participants were contacted by telephone by the research assistant (Y.S.) to ask whether they were willing to participate in the current study for 6- and 12-month follow up. All participants responded affirmatively and agreed to participate in the study. Informed consent (either oral or written) was obtained from all participants after they agreed to participate. The current study was approved by the institutional review board from Faculty of Medicine Ramathibodi Hospital, Mahidol University.
In the previous study (Saraboon et al., 2015), the intervention group (n = 40) received the MUFIP, which included health education, quadriceps muscle exercise, weight reduction/control, and home visit programs. A more detailed description of the MUFIP has been published previously (Saraboon et al., 2015). In the current study, a small (i.e., 8 to 12 individuals) group meeting lasting 1 to 2 hours was arranged for the intervention group. Participants were asked to recall the weight management program protocol and perform the quadriceps exercises as suggested by the previous study to determine whether they performed these correctly. Discussion and responses to participants' questions were provided. Participants followed the multicomponent intervention, which included the quadriceps exercise program and weight management program. The quadriceps exercise program included common exercises, such as sitting and lying straight-leg raises, and a clenching exercise. Participants were asked to perform at least 6 sets of 10 repetitions per day of quadriceps exercise based on the types of exercise they preferred. The weight management program included brisk walking and a dietary program. For brisk walking, participants were encouraged to exercise by walking for 60 minutes per day (inclusive of warm-up and cool-down phases). For the dietary program, participants followed independently designed menus with lower than their required calories, but not less than 1,200 kcal per day. The intervention group completed self-monitoring behavior logs and met with researchers at 6- and 12-month follow up. The control group received the OA knee booklet and a video compact disc, which contained information related to the booklet on the last day of the prior study termination. They had an opportunity to discuss their health problems with the researchers.
Research assistants collected data using the following measures.
Adherence Survey. A 3-item questionnaire was developed by the researchers to ask participants in the intervention group to rate their adherence to the three health behaviors. Each health behavior correlated with one of the components of the intervention program. For example, “How often did you adhere to the walking exercise program?” Responses were recorded using a 3-point Likert scale, where 2 = adherent, 1 = sometimes, and 0 = not adherent/don't remember. Ratings were categorized as adherence (adherent) and non-adherence (sometimes and not adherent/don't remember).
Perspectives on the Health Behavior Intervention Questionnaire. This 9-item questionnaire was used to investigate the appropriateness of the components of the intervention (i.e., quadriceps exercise, brisk walking exercise, and dietary program) for older adults and explore factors promoting or interfering with specific health behaviors. Examples of items included: “Which program is most practical for you?”; “Which program is not practical for you and needs to be modified for your use?”; “What factors help you to adhere to the dietary program?”; and “What are your perceived barriers in adhering to the walking exercise?”
The Self-Monitoring Behavior Log. This instrument was designed by the current authors for self-monitoring health behavior of participants. This tool recorded the number of sets and frequency of the left and right quadriceps exercises performed per day; the frequency and durations of brisk walking exercise performed per week; and the food lists and amount of food consumed each day. Data obtained from these logs were used to validate participants' self-reported adherence by calculating the percentage of agreement between the self-monitoring behavior logs and participants' self-reports.
The Numeric Rating Scale. A 10-cm numeric rating scale (McCaffery & Pasero, 1999) was used to measure knee pain. The straight-line scale ranged from 0 (no pain) to 10 (severe pain), with whole numbers below the line. Participants were asked to circle the number that most closely matched their pain experiences. The tool has been widely used and reported to be valid and reliable.
The Timed Up and Go (TUG) Test. This test was used to measure mobility as a proxy for knee function. To perform the TUG test, participants were instructed to rise from a standard armchair, walk at a smooth and safe pace to a line on the floor 3 m away from the chair, turn and walk back to the same chair, and sit down. Participants could use routine walking aids, but were not permitted to use their arms to stand up. The TUG test has been used with older adults with various health conditions in both non-fallers and fallers. Although the reported values of cutoff time varied from 10 seconds to 32.6 seconds (Beauchet et al., 2011), the original developers (Podsiadro & Richardson, 1991) suggested that older adults who required less than 20 seconds were considered to have good movement. However, the Centers for Disease Control and Prevention (n.d.) recommend older adults who take ≥12 seconds to complete the test are at high risk for falling. For the current study, faster times on the TUG test indicated better mobility.
Goniometer. This plastic tool was used to measure knee range of motion (ROM). The tool consists of a stationary arm and moveable arm. To use the goniometer, participants were asked to sit on a comfortable chair and flex and extend the knee as the researcher/research assistant moved the arms of the goniometer aligned at the knee to be measured. Range of knee extension 0º or knee flexion between 0º and 140º was considered normal ROM (Mulpruek, 2004); however, only knee flexion was calculated in the current study. The accuracy and correct scale of the goniometer was compared with the protractor before use. The interrater reliability validated by the researcher and research assistants revealed a Spearman correlation coefficient (r value) of 0.83 in the authors' previous study (Saraboon et al., 2015).
Weight. Weight was measured using a Camry® BR9807 personal spring digital weight scale. Participants were instructed to remove their shoes and any heavy objects in their pockets before standing on the scale. The scale was calibrated by the manufacturer for accuracy.
Descriptive statistics were used to analyze adherence to the program and responses to the perspectives on the health behavior intervention questionnaire for reasons for adherence/non-adherence to the multicomponent intervention. Compliance with the program was defined as adherence (i.e., performed according to the program protocol) and non-adherence (i.e., performed but not completed according to the program protocol) as determined by the adherence survey, which was confirmed by participants' self-monitoring behavior logs. Descriptive statistics were also used to examine mean and standard deviation and frequencies of outcome variables. A repeated measure analysis of variance (ANOVA) was used to examine whether each outcome variable at 6 and 12 months was significantly different from baseline (data collected included some information from the previous study) when compared between the intervention and control groups and within the intervention group. A p value of 0.05 was set for the significance level. The Bonferroni procedure was used to determine multiple comparisons.
Two (5%) participants from the intervention group and four (10%) participants from the control group withdrew from the study. Reasons for withdrawal were death for four participants (two had died at 6-month follow up) and two participants could not be reached due to moving to another town. Of the remaining participants, most were women (n = 68, 91.9%). Average age of all participants was 67.58 (SD = 6.85 years; range = 60 to 85 years), 67.08 (SD = 6.73 years) in the intervention group and 68.11 (SD = 7.37 years) in the control group. More than 80% of participants had a primary or high school education (n = 33 and n = 32 in the intervention and control groups, respectively). Most participants (>50%) reported at least one chronic condition and bilateral knee OA. At baseline, participants in both groups were similar with respect to demographics, health characteristics, and outcome variables (e.g., age, gender, educational level, job characteristics, affected knee pain, chronic conditions, and BMI), except pain score of the right knee and TUG score.
Adherence to the multicomponent intervention (quadriceps exercise and weight management program including brisk walking exercise and a dietary program) was determined by dropout rate (≤15%) and percentage of participants reporting adherence to the program protocol (≥75%). Participants who did not follow the program protocol more than once per week would be excluded from the study; however, no participants were excluded. The current study revealed a dropout rate of 5% (n = 2 due to death at the 6-month assessment). Of 38 remaining participants in the intervention group, the percentages of those reporting adherence to the quadriceps exercise, brisk walking exercise, and dietary program were 78.9%, 68.4%, and 76.3%, respectively, which were slightly decreased compared to the 6-month assessment, except for dietary program, which increased (89.5%, 78.9%, and 63.2%, respectively). The percentage of agreement between participants' self-reports and self-monitoring logs was 100%, except 97% for the dietary program at the 6-month assessment. Most participants in the intervention group (n = 32, 84.2%) perceived that all three of the intervention components were practical and appropriate for older adults. Table 1 provides additional details of participants' reasons for adherence/non-adherence to the multicomponent intervention.
Participant Top 5 Reasons for Adherence or Non-Adherence to Quadriceps Exercise and Weight Management Intervention
The effectiveness of the multi-component intervention is shown in Table 2 and Table 3. There was a significant improvement in knee pain, knee function (TUG and ROM), and body weight compared with baseline (p = <0.01) (Table 2). Table 3 displays the effectiveness of the multicomponent intervention when outcome variables were compared between the intervention and control groups. A repeated measure ANOVA revealed that knee pain and knee function (TUG and ROM) were significantly different between groups (p < 0.01) with a positive effect size (ηp2). As the pain score of the right knee and TUG score were significantly different between groups at baseline, these two variables were treated as covariates to avoid the effect of pre-test outcomes on posttest outcomes. However, the difference of body weight between groups did not reach statistical significance, but additional analysis revealed that the mean body weight in the intervention group decreased 2.58 kg (4.04%) and 2.81 kg (4.73%) at 6- and 12-month follow up, respectively, when compared with baseline. In addition, the percentage of participants who lost weight after program completion was 86.8% (n = 33) in the intervention group compared with 25% (n = 9) in the control group.
Mean Differences (Standard Error) of Study Variables in the Intervention Group (N = 38)
Comparison of Outcome Variables in the Intervention and Control Groups
The current study provided significant information in extending the results from the authors' previous study (Saraboon et al., 2015). The results included a high adherence rate and positive outcomes after the completion of the MUFIP. The percentage of participants who adhered to the multicomponent intervention slightly decreased after 6 months, but the adherence rate remained high compared to previous studies (Picorelli, Pereira, Pereira, Felicio, & Sherrington, 2014; Pisters et al., 2010). There are some possible explanations for these results. In the previous study, the intervention was provided by community nurses and a nutritionist, and participants were also asked to keep self-monitoring behavior logs and have individualized dietary menus based on their preference. In addition, after participation in the 8-week MUFIP, they reported improved knee pain, ROM, and mobility outcomes. These outcomes may have served to motivate participants. Factors associated with adherence in previous studies included when an intervention was delivered by health care professionals, exercise was being performed, pain outcomes were improved, outcome expectations were positive, and physical function and physical performance were improved (Bennell, Dobson, & Hinman, 2014; Pisters et al., 2010). Additional analysis also supported notations described on participants' reasons for adherence to the programs such as “hope to get relief from knee pain” (quadriceps exercise) and “easy and don't need any device” (brisk walking exercise). Consequently, a high rate of participants reporting adherence to the program was found in the current study, which was a vital factor resulting in positive outcomes at 1-year follow up as the participants gained improved knee function (e.g., ROM, mobility) and decreased knee pain after termination of the intervention.
Evidence from previous studies has shown the positive outcomes of quadriceps muscle exercise on knee pain and knee function in patients with knee OA, although a variety of types, duration, and frequency were recommended (Jenkinson et al., 2009; Piyakhachornrot, Aree-Ue, Putwatana, & Kawinwonggowit, 2011). These positive findings were also found in studies that integrated an exercise program with a dietary program for overweight or obese patients with knee OA (Jenkinson et al., 2009; Miller et al., 2006; White et al., 2015). The current study revealed similar findings to the quadriceps exercise program along with the weight management program, which led participants to have improved knee function and decreased knee pain. Knee muscles, particularly the quadriceps and hamstring, help maintain mobility and reallocate and stabilize the knee while performing activities. Quadriceps weakness was commonly found in patients with knee OA (Petterson, Barrance, Buchanan, Binder-Macleod, & Snyder-Mackler, 2008) and led to narrowing of the joint space, progression of knee OA (Segal & Glass, 2011), and knee pain in older women (Glass et al., 2013). Therefore, exercises to promote strength of muscles around the knee, such as quadriceps exercise and walking exercise, revealed better physical function and reduction of pain and disability (Roddy, Zhang, & Doherty, 2005; Sanchez-Ramirez et al., 2015).
The current weight management program did not show a significant difference in weight reduction between groups, although the percentage of participants who lost weight was higher in the intervention group. One possible explanation for this finding is that Thai families are nuclear families. Food preparation was performed by either a grandmother or another family member; therefore, some older participants may not have had a chance to design their meals. This situation was partly supported by respondent data. Two of the top five reasons reported for non-adherence were that participants did not “prepare their meals by themselves” and “eating habits of individual and family.” In addition, problems with calorie counts and food intake record may have led to inaccurate counting of calories consumed as recommended by the dietary program. Moreover, although the dietary program allowed participants to select and plan menus, older adults living in rural areas with low income, per capital income of population (82.5% in the control group and 62.5% in the intervention group) (Saraboon et al., 2015), may have affected their ability to consume according to appropriate food recommendations.
Limitations were noted in the current study. Participants were overweight Thai older adults with knee OA pain and were predominantly women. Thus, the generalizability of the findings to other individuals without these characteristics may be limited. Moreover, adherence to the multicomponent intervention was obtained from participants' self-report and as such it might be overestimated due to recall bias and/or social desirability bias.
Implications for Nursing Practice
Despite the aforementioned limitations, the results from the current study have the potential to impact nursing practice as the multicomponent intervention provides several modalities to achieve behavioral changes. Community health nurses and other health care providers who work with older adults can adopt this intervention as a guide in working with community-dwelling older adults with knee OA. Of note, fear of falling was perceived by one half of participants as a barrier to engage in walking exercise; therefore, screening for fall risk in older adults, particularly those with knee problems, is needed for any further intervention designed to promote walking exercise. Importantly, although the dietary program was one of the beneficial programs for overweight older adults with knee OA, a culturally based approach along with socioeconomic status may raise concerns about adherence. For example, individuals with low socioeconomic status may not be able to afford diets recommended for weight reduction/control. In some cultures, such as Thai culture, children or family members manage the diet of older adult family members. These “diet managers” should consider dietary programs that will help overweight older adults achieve weight control/loss.
Evidence from the current study showed high adherence to and benefits of the multicomponent intervention on knee pain, knee function, and weight loss among community-dwelling overweight Thai older adults with self-reported knee OA. The effect of quadriceps exercise along with weight management programs appeared to last throughout 1-year follow up. A health education and home visit program provided to the intervention group in the previous study was helpful in promoting continued participation and adherence to health behaviors with a low dropout rate.
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Participant Top 5 Reasons for Adherence or Non-Adherence to Quadriceps Exercise and Weight Management Intervention
|Reason||n (%)||Reason||n (%)|
|Quadriceps exercise||Hope to get relief from knee pain||35 (92.1)||Forget to practice||6 (75)|
|Easy and convenient to practice||32 (84.2)||Lack of time||5 (62.5)|
|Practical strategy for older adults||32 (84.2)||Tired from working||3 (37.5)|
|Knee pain relief after exercise||31 (81.5)||Having leg pain and knee pain||2 (25)|
|Flex knee easily and improve walking||30 (78.9)|
|Brisk walking exercise||Easy and no device needed||23 (88.5)||Lack of time because of working||10 (83.3)|
|Appropriate strategy for older adults||18 (69.2)||Fear of falling||6 (50)|
|Habitual behavior||16 (61.5)||Knee pain||5 (41.7)|
|Weight loss after practice||16 (61.5)||Difficulty walking||4 (33.3)|
|Improve health||14 (53.8)||Lack of walking friends or leaders||3 (25)|
|Diet program||Reduce the amount of food||28 (73.7)||Eating habits of individual and family||16 (80)|
|Avoid eating sweet and fatty foods||26 (68.4)||Problem with calorie counts and food intake record||13 (65)|
|Increase intake of water||18 (47.4)||Did not prepare meals by oneself||13 (65)|
|Strictly adhere to the weight control program||16 (42.1)||Lack of time for eating||12 (60)|
|No snacking between meals||15 (39.5)||Problem with diet-related health problems||10 (50)|
Mean Differences (Standard Error) of Study Variables in the Intervention Group (N = 38)
|Variables||Baseline to 6 Months||95% CIa||p Value||Baseline to 12 Months||95% CIa||p Value||6 to 12 Months||95% CIa||p Value|
|Pain (Visual Analog Scale)|
| Left knee pain||4.30 (0.58)||[2.5, 5.0]||<0.01||4.80 (0.53)||[2.7, 5.3]||<0.01||0.5 (0.26)||[−0.1, 0.5]||>0.05|
| Right knee pain||4.42 (0.75)||[2.2, 4.8]||<0.01||5.52 (0.61)||[2.1, 4.8]||<0.01||1.10 (0.53)||[−0.7, 0.6]||>0.05|
|TUG (score)||2.77 (0.30)||[1.7, 3.2]||<0.01||3.74 (0.32)||[2.5, 4.2]||<0.01||0.86 (0.16)||[0.5, 1.2]||<0.01|
|Range of motion (°)|
| Left knee flexion||−11.78 (0.85)||[−13.9, −9.6]||<0.01||−14.52 (0.96)||[−16.9, −12.1]||<0.01||−2.73 (0.42)||[−3.7, −1.7]||<0.01|
| Right knee flexion||−11.57 (0.83)||[−13.6, −9.5]||<0.01||−14.21 (0.85)||[−16.3, −12.1]||<0.01||−2.63 (0.36)||[−3.5, −1.7]||<0.01|
|Body weight (kg)||2.48 (0.35)||[1.6, 3.4]||<0.01||2.88 (0.40)||[1.9, 3.9]||<0.01||0.39 (0.28)||[−0.3, 1.1]||>0.05|
Comparison of Outcome Variables in the Intervention and Control Groups
|Intervention (n = 38)||Control (n =36)|
|Variable||Baseline||6 Months||12 Months||Baseline||6 Months||12 Months||Fa||ES (ηp2)|
| Left knee||5.9(2.1)||1.6 (1.2)||1.1 (1.0)||6.1 (2.2)||3.9 (2.8)||4.2 (2.7)||23.45*||0.24|
| Right knee||6.3 (0.9)||1.9 (1.8)||0.8 (0.9)||4.9 (0.9)||4.1 (2.9)||4.5 (3.2)||29.75*||0.29|
|TUG (score)||12.7 (1.9)||9.9 (1.7)||9.0 (1.7)||11.2 (2.1)||12.6 (2.9)||13.3 (2.9)||19.56*||0.21|
|Range of motion (°)|
| Left knee flexion||130.6 (4.8)||142.5 (5.2)||145.2 (5.8)||131.5 (4.1)||127.8 (5.1)||127.9 (7.5)||55.02*||0.43|
| Right knee flexion||131.7 (4.3)||143.3 (5.7)||145.9 (6.1)||131.3 (6.3)||125.9 (5.9)||126.0 (8.4)||83.05*||0.53|
|Body weight (kg)||63.9 (8.4)||61.5 (9.2)||61.1 (9.6)||61.8 (8.8)||63.8 (9.8)||64.3 (9.5)||1.54||N/A|