Acessibilidade / Reportar erro

Relationship between pain, functional limitations, dependence, depression and osteoarthritis in older adults

Abstract

Introduction

Knee osteoarthritis (KOA) is a prevalent pathology in older adults, with physical, social and psychological impacts that reduce their quality of life.

Objective

Analyze the correlation between KOA in older individuals and biopsychosocial aspects such as pain, functional limitation, dependence, anxiety and depression.

Methods

A systematic review of English and Portuguese articles published on the Cochrane Library, PUBMED/MEDLINE, SciELO and Web of Science databases between 2016 and 2021, selected according to inclusion and exclusion criteria.

Results

After cross-checking specific to each database, studies were selected by reading the title (2,304), abstract (136) and full article (72), with 30 ultimately included based on the eligibility criteria.

Conclusion

Knee osteoarthritis has a significant negative impact on patients’ lives and is correlated with pain, functional limitation, dependence, anxiety and depression, compromising interpersonal relationships, physical and mental status and causing disability due to chronic pain, making osteoarthritis (OA) a public health issue with a high financial, physical and emotional cost for patients.

Elderly; Knee osteoarthritis; Physical and functional performance; Psychosocial alterations; Quality of life

Resumo

Introdução

A osteoartrite de joelho é uma patologia prevalente em idosos, impactando suas vidas em um contexto físico, social e psicológico, o que ocasiona redução na qualidade de vida desses indivíduos.

Objetivo

Analisar a correlação entre a osteoartrite de joelho em idosos e aspectos biopsicossociais como dor, limitação funcional, dependência, ansiedade e depressão.

Métodos

Revisão sistemática de artigos publicados nas bases de dados Cochrane Library, PUBMED/MEDLINE, SciELO e Web of Science, entre 2016 e 2021, em português e inglês. Após isso, realizou-se a seleção dos artigos de acordo com os critérios de inclusão e exclusão.

Resultados

Após cruzamentos específicos em cada base, selecionaram-se os artigos por meio da leitura do título (2.304), do resumo (136) e do artigo na íntegra (72). Assim, 30 artigos foram selecionados de acordo com os critérios de elegibilidade.

Conclusão

Confirmou-se que a osteoartrite de joelho impacta negativamente a vida dos pacientes e está correlacionada com dor, limitação funcional, dependência, ansiedade e depressão, prejudicando as relações interpessoais, afetando condições físicas e mentais e gerando incapacidade devido à dor crônica, tornando a osteoartrite uma questão de saúde pública de alto custo financeiro, físico e emocional aos pacientes.

Idosos; Osteoartrite de joelho; Desem-penho físico funcional; Alterações psicossociais; Quali-dade de vida

Introduction

Osteoarthritis (OA) is a progressive disease that affects the entire joint.11. Martel-Pelletier J, Barr AJ, Cicuttini FM, Conaghan PG, Cooper C, Goldring MB, et al. Osteoarthritis. Nat Rev Dis Primers. 2016; 2:16072. https://doi.org/10.1038/nrdp.2016.72
https://doi.org/10.1038/nrdp.2016.72...
According to Hawker,22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...
the condition is more prevalent in older adults, affecting an estimated one in three people over the age of 65 years, and is one of the leading causes of disability in this population, with a high social cost. Globally, it affects more than 300 million people.33. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016%2FS0140-6736(18)32279-7
https://doi.org/10.1016%2FS0140-6736(18)...

The main symptoms reported by patients are pain, morning stiffness and crepitus during joint movement.11. Martel-Pelletier J, Barr AJ, Cicuttini FM, Conaghan PG, Cooper C, Goldring MB, et al. Osteoarthritis. Nat Rev Dis Primers. 2016; 2:16072. https://doi.org/10.1038/nrdp.2016.72
https://doi.org/10.1038/nrdp.2016.72...
Risk factors for developing OA are divided into those related to the patient (advanced age, being female, obesity, genetic factors, diet) and the joint (injury, overuse, repetitive use).11. Martel-Pelletier J, Barr AJ, Cicuttini FM, Conaghan PG, Cooper C, Goldring MB, et al. Osteoarthritis. Nat Rev Dis Primers. 2016; 2:16072. https://doi.org/10.1038/nrdp.2016.72
https://doi.org/10.1038/nrdp.2016.72...
,44. Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59(3):134-8. https://doi.org/10.1016/j.rehab.2016.01.006
https://doi.org/10.1016/j.rehab.2016.01....
Given the differences in disease concept definition, the population studied and joints affected, incidence and prevalence estimates vary considerably.44. Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59(3):134-8. https://doi.org/10.1016/j.rehab.2016.01.006
https://doi.org/10.1016/j.rehab.2016.01....

From this perspective, the knee is clinically the most affected joint.55. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019; 393(10182):1745-59. https://doi.org/10.1016/s0140-6736(19)30417-9
https://doi.org/10.1016/s0140-6736(19)30...
The physiopathology of knee osteoarthritis (KOA) is highly complex and multifactorial, making it difficult to accurately establish the factor that triggers pain in these patients. In addition to chronic pain, other impacts of OA on patients include disability and reduced quality of life.66. Lluch E, Nijs J, Courtney CA, Rebbeck T, Wylde V, Baert I, et al. Clinical descriptors for the recognition of central sensitization pain in patients with knee osteoarthritis. Disabil Rehabil. 2018; 40(23):2836-45. https://doi.org/10.1080/09638288.2017.1358770
https://doi.org/10.1080/09638288.2017.13...
As such, the goal of treatment is to mitigate the physical symptoms reported by patients and, at more advanced stages, partial or full joint replacement surgery.77. Hafkamp FJ, Vries J, Gosens T, den Oudsten BL. The relationship between psychological aspects and trajectories of symptoms in total knee arthroplasty and total hip arthroplasty. J Arthroplasty. 2021;36(1):78-87. https://doi.org/10.1016/j.arth.2020.07.071
https://doi.org/10.1016/j.arth.2020.07.0...
,88. Deshpande BR, Katz JN, Solomon DH, Yelin EH, Hunter DJ, Messier SP, et al. Number of persons with symptomatic knee osteoarthritis in the us: impact of race and ethnicity, age, sex, and obesity. Arthritis Care Res (Hoboken). 2016;68(12):1743-50. https://doi.org/10.1002/acr.22897
https://doi.org/10.1002/acr.22897...

According to the Brazilian Society of Rheumatology,99. Sociedade Brasileira de Reumatologia. Osteoartrite (Artrose) [cited 2022 Feb 7]. Available from: https://www.reumatologia.org.br/doencasreumaticas/osteoartrite-artrose/
https://www.reumatologia.org.br/doencasr...
OA accounts for 30 to 40% of outpatient rheumatology appointments, which causes a considerable economic impact, since KOA is responsible for 7.5% of work absences. This is due to the relationship between the constant increase in pain caused by the disease and the resulting loss of function, which cannot always be mitigated by symptomatic treatment.1010. James RJE, Walsh DA, Ferguson E. Trajectories of pain predict disabilities affecting daily living in arthritis. Br J Health Psychol. 2019;24(3):485-96. https://doi.org/10.1111/bjhp.12364
https://doi.org/10.1111/bjhp.12364...

In addition to its economic effects, OA is associated with cognitive decline and depressive symptoms, which can increase the risk of social isolation 1.47 fold, compromising quality of life and leading to psychological and psychiatric symptoms.1111. Siviero P, Veronese N, Smith T, Stubbs B, Limongi F, Zambon S, et al. Association between osteoarthritis and social isolation: data from the EPOSA study. J Am Geriatr Soc. 2020;68(1):87-95. https://doi.org/10.1093/ageing/afw216
https://doi.org/10.1093/ageing/afw216...
Depression and anxiety are common in this population,1212. Veronese N, Stubbs B, Solmi M, Smith TO, Noale M, Cooper C, et al. Association between lower limb osteoarthritis and incidence of depressive symptoms: data from the osteoarthritis initiative. Age Ageing. 2017;46(3):470-6. https://doi.org/10.1093/ageing/afw216
https://doi.org/10.1093/ageing/afw216...
affecting up to one fifth of patients.1313. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
https://doi.org/10.1093/ageing/afw001...
In this context, OA can increase the chances of institutionalization among older people, thus raising treatment costs. It can also lead to sickness benefits and even retirement, raising the cost of living for patients, who are prevented from working due to disability, and straining public coffers, which fund these benefits.

The physical decline results in greater difficulty with tasks and physical activity, which are therefore per-formed less frequently. This not only affects the quality of life of patients, but predisposes them to psychological symptoms caused by social isolation.1414. Tak ECPM, van Meurs JB, Bierma-Zeinstra SMA, Hofman A, Hopman-Rock M. Changes in disability in older adults with generalized radiographic osteoarthritis: A complex relationship with physical activity. Musculoskeletal Care. 2017;15(4):364-72. https://doi.org/10.1002/msc.1182
https://doi.org/10.1002/msc.1182...
Reduced physical capacity has also been reported as a predictor of depressive symptoms and greater prevalence of anxiety.1515. Sayre EC, Esdaile JM, Kopec JA, Singer J, Wong H, Thorne A, et al. Specific manifestations of knee osteoarthritis predict depression and anxiety years in the future: Vancouver Longitudinal Study of Early Knee Osteoarthritis. BMC Musculoskelet Disord. 2020;21(1):467. https://doi.org/10.1186/s12891-020-03496-8
https://doi.org/10.1186/s12891-020-03496...

Knowledge about the relationship between OA, inactivity, depression and anxiety could promote the development of public policies that better address the complexity of this disease that affects a large part of the population. Understanding that KOA not only compromises individuals physically, but psychologically and socially, is essential in preventing the emergence of associated symptoms and improving quality of life and life expectancy, particularly in the elderly population, which is most affected by this comorbidity.

In light of the above, the aim of this study was to review the existing correlation between the presence of OA and the occurrence of pain, functional limitations, dependence, anxiety and depression in the older population. Assessing these variables to determine whether they are correlated is vital in developing new research and protocols that can help prevent OA in primary care and optimize the available treatments.

Methods

This is a systematic review on the correlation between KOA in older adults and pain, functional limitation, dependence, anxiety and depression, registered on the

PROSPERO database (CRD42021287461).

Searches were conducted on the Cochrane Library, PubMed/MEDLINE, SciELO and Web off Science databases, for articles in English and Portuguese published between 2016 and 2021, based on the descriptors selected and specific cross-checks, using the Boolean operator [AND] to optimize the search:

- "Osteoarthritis" AND "ageing" AND "functional limitation";

- "Osteoarthritis" AND "ageing" AND "independency";

- "Osteoarthritis" AND "ageing" AND "anxiety";

- "Osteoarthritis" AND "ageing" AND "depression".

A manual search of the reference lists of the selected articles and other systematic or integrative reviews on the topic was also carried out.

Inclusion and exclusion criteria

All the articles that demonstrated a correlation between OA and pain, functional limitation, dependence, anxiety and depression in a sample of elderly patients were included in this study.

Excluded were studies that focused on OA treatment protocols during and after surgery or exercises, approaches on disease pathogenesis such as tissue inflammation, chondrocyte degradation or joint dissection, and articles with a generalized view in a nonspecific population, emphasizing pain and not reporting the impact on patients’ lives. These criteria were important in determining whether there is a correlation between osteoarthritis, pain, functional limitation, dependence, anxiety and depression in older adults.

Study selection and data extraction

Studies were selected by three independent authors. Articles were initially chosen based on their titles, after which the abstracts were analyzed and those not related to the specific topic were discarded, while those that met the inclusion criteria were read in full. The articles chosen were evaluated maintaining their authors’ chosen terminology.

Data extraction was performed by all three authors working together, compiling the information, mechanisms and results of all the included articles, followed by a detailed analysis to rule out any discrepancies.

The search strategies applied in January 2022 to all four electronic databases and the refined search for articles published in the last five years yielded 2,304 articles. After analyzing the titles according to the eligibility criteria, 184 articles were selected and 48 discarded as duplicates, leaving 136 to be evaluated based on their abstracts. After reading the abstracts, 72 articles were chosen to be read in full, yielding 30 studies that met the eligibility criteria for inclusion in this systematic review (Figure 1).

Figure 1
- Flowchart of study selection for the systematic review.

Results

Based on the eligibility criteria, 30 articles were chosen for the systematic review and are presented in Table 1.

Table 1
Studies selected to integrate the systematic review

In regard to pain, Santos et al.1616. Santos MG, Damiani P, Marcon ACZ, Haupenthal A, Avelar NPC. Influence of knee osteoarthritis on functional performance, quality of life and pain in older women. Fisioter Mov. 2020;33:e003306. https://doi.org/10.1590/1980-5918.033.AO06
https://doi.org/10.1590/1980-5918.033.AO...
and Lee and Oh1717. Lee MK, Oh JH. The relationship between pain and physical function: mediating role of sleep quality, depression, and fatigue. J Gerontol Nurs. 2019;45(7):46-54. https://doi.org/10.3928/00989134-20190612-05
https://doi.org/10.3928/00989134-2019061...
reported increased pain in patients with OA, and Koning et al.1818. Koning EJ, Timmermans EJ, van Schoor NM, Stubbs B, van den Kommer TN, Dennison EM, et al. Within-person pain vari-ability and mental health in older adults with osteoarthritis: An analysis across 6 european cohorts. J Pain. 2018;19(6):690-8. https://doi.org/10.1016/j.jpain.2018.02.006
https://doi.org/10.1016/j.jpain.2018.02....
correlated the disease with functional limitation issues and reduced independence in older adults. Signs and symptoms of anxiety and depression are also prevalent in older individuals diagnosed with OA, as confirmed by Stubbs et al.1313. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
https://doi.org/10.1093/ageing/afw001...
and Alabajos-Cea et al.1919. Alabajos-Cea A, Herrero-Manley L, Suso-Martí L, Alonso-Pérez-Barquero J, Viosca-Herrero E. Are psychosocial factors determinant in the pain and social participation of patients with early knee osteoarthritis? A cross-sectional study. Int J Environ Res Public Health. 2021;18(9):4575. https://doi.org/10.3390/ijerph18094575
https://doi.org/10.3390/ijerph18094575...

In this scenario, the studies confirm the negative impact of KOA on the everyday lives of patients, affecting their family and social relationships, as well as their mental and physical condition. Osteoarthritis is also responsible for causing pain, functional limitations, dependence, anxiety and depression.

Discussion

Osteoarthritis is characterized by joint pain, stiffness and functional limitations, compromising patient participation in everyday and work-related activities. The disease is most prevalent among older adults, affecting an estimated one in three people aged over 65 years.22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...

KOA pain presents heterogeneously, since the relationship that patients have with pain changes over times.1010. James RJE, Walsh DA, Ferguson E. Trajectories of pain predict disabilities affecting daily living in arthritis. Br J Health Psychol. 2019;24(3):485-96. https://doi.org/10.1111/bjhp.12364
https://doi.org/10.1111/bjhp.12364...
KOA-related joint pain leads to functional limitations, poor sleep quality, fatigue, depression and loss of independence. It is also the main indicator for joint replacement surgery.22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...

AKOA is currently underdiagnosed and a barrier to physical activity in patients, who begin to avoid activities that exacerbate their pain, further limiting their mobility and functional capacity.22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...
This compromises functionality in activities such as sitting, crouching, climbing stairs and standing for extended periods.1616. Santos MG, Damiani P, Marcon ACZ, Haupenthal A, Avelar NPC. Influence of knee osteoarthritis on functional performance, quality of life and pain in older women. Fisioter Mov. 2020;33:e003306. https://doi.org/10.1590/1980-5918.033.AO06
https://doi.org/10.1590/1980-5918.033.AO...
Additionally, the greater the intensity of OA-induced pain, the more restricted patients are in their basic activities of daily living,2020. García-López S, Llopart-Carles N, Castro-Domínguez F, Rejas-Gutierrez J. Patient self-reported functioning by pain severity and usual analgesic treatment among older adults with osteoarthritis: analysis of the 2017 Spanish National Health Survey. Eur Geriatr Med. 2021;12(5):989-1001. https://doi.org/10.1007/s41999-021-00488-2
https://doi.org/10.1007/s41999-021-00488...
which is problematic because physical activity is the most effective nonsurgical treatment for KOA.22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...
Physical exercise and daily activities contribute to independence and are effective at reducing pain and disability in people with OA.1313. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
https://doi.org/10.1093/ageing/afw001...

In this scenario, as individuals experience greater difficulty in executing basic tasks, their dependence makes them less motivated to interact in society and even with their own family, resulting in social isolation.2020. García-López S, Llopart-Carles N, Castro-Domínguez F, Rejas-Gutierrez J. Patient self-reported functioning by pain severity and usual analgesic treatment among older adults with osteoarthritis: analysis of the 2017 Spanish National Health Survey. Eur Geriatr Med. 2021;12(5):989-1001. https://doi.org/10.1007/s41999-021-00488-2
https://doi.org/10.1007/s41999-021-00488...
Older adults who are completely dependent require care that their families are often unable to provide due to work commitments. This leads to institutionalization, which further deprives these individuals of social contact and overburdens social and family welfare services. García-López et al.2020. García-López S, Llopart-Carles N, Castro-Domínguez F, Rejas-Gutierrez J. Patient self-reported functioning by pain severity and usual analgesic treatment among older adults with osteoarthritis: analysis of the 2017 Spanish National Health Survey. Eur Geriatr Med. 2021;12(5):989-1001. https://doi.org/10.1007/s41999-021-00488-2
https://doi.org/10.1007/s41999-021-00488...
studied patients with intense OA-related pain and found that about half required assistance from a caregiver to perform everyday activities. In this respect, pain severity is the main determining factor of disability in patients predisposed to dependence.

Hawker,22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...
Duica et al.2121. Duica L, Szakács J, Silișteanu SC. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. Balneo Res J. 2020;11(1):95-104. http://dx.doi.org/10.12680/balneo.2020.323
http://dx.doi.org/10.12680/balneo.2020.3...
and Fielding et al.2222. Fielding RA, Guralnik JM, King AC, Pahor M, McDermott MM, Tudor-Locke C, et al. Dose of physical activity, physical functioning and disability risk in mobility limited older adults: Results from the LIFE study randomized trial. PLoS One. 2017;12(8):e0182155. https://doi.org/10.1371/journal.pone.0182155
https://doi.org/10.1371/journal.pone.018...
also reported dependence and functional limitations caused by KOA pain. Depression and anxiety exacerbate symptoms such as pain and disability, in addition to reducing the quality of life and social participation of older adults with OA.22. Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
https://www.clinexprheumatol.org/abstrac...
,1313. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
https://doi.org/10.1093/ageing/afw001...
,2121. Duica L, Szakács J, Silișteanu SC. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. Balneo Res J. 2020;11(1):95-104. http://dx.doi.org/10.12680/balneo.2020.323
http://dx.doi.org/10.12680/balneo.2020.3...
Helminem et al.2323. Helminen EE, Sinikallio SH, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study. Clin Rehabil. 2016; 30(9):890-900. https://doi.org/10.1177/0269215515619660
https://doi.org/10.1177/0269215515619660...
used the WOMAC and RAND-36 questionnaires and identified important psychosocial and behavioral impacts in the individuals analyzed, especially fear of movement (kinesiophobia), worsening of pain and disability.

Although some authors have demonstrated that pain is a determining factor and/or predictor of reduced physical function,1010. James RJE, Walsh DA, Ferguson E. Trajectories of pain predict disabilities affecting daily living in arthritis. Br J Health Psychol. 2019;24(3):485-96. https://doi.org/10.1111/bjhp.12364
https://doi.org/10.1111/bjhp.12364...
,2424. Carlesso LC, Hawker GA, Waugh EJ, Davis AM. Disease-specific pain and function predict future pain impact in hip and knee osteoarthritis. Clin Rheumatol. 2016;35(12):2999-3005. https://doi.org/10.1007/s10067-016-3401-z
https://doi.org/10.1007/s10067-016-3401-...
,2525. Helminen EE, Arokoski JP, Selander TA, Sinikallio SH. Multiple psychological factors predict pain and disability among community-dwelling knee osteoarthritis patients: a five-year prospective study. Clin Rehabil. 2020;34(3):404-15. https://doi.org/10.1177/0269215519900533
https://doi.org/10.1177/0269215519900533...
others, such as Zambon et al.,2626. Zambon S, Siviero P, Denkinger M, Limongi F, Castell MV, van der Pas S, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European Project on Osteoarthritis. Arthritis Care Res (Hoboken). 2016;68(6):801-10. https://doi.org/10.1002/acr.22755
https://doi.org/10.1002/acr.22755...
found that the psychological aspect is as important as the musculoskeletal decline. These authors revealed that, despite symptomatic pain control, patients with OA were still limited in activities of daily living.2626. Zambon S, Siviero P, Denkinger M, Limongi F, Castell MV, van der Pas S, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European Project on Osteoarthritis. Arthritis Care Res (Hoboken). 2016;68(6):801-10. https://doi.org/10.1002/acr.22755
https://doi.org/10.1002/acr.22755...
This clearly demonstrates the psychosocial bias of this disease, prevalent in older people, which involves everything from kinesiophobia,2727. Uritani D, Kasza J, Campbell PK, Metcalf B, Egerton T. The association between psychological characteristics and physical activity levels in people with knee osteoarthritis: a cross-sectional analysis. BMC Musculoskelet Disord. 2020;21(1):269. https://doi.org/10.1186/s12891-020-03305-2
https://doi.org/10.1186/s12891-020-03305...
to sleep disturbances, fatigue, anxiety and depression1212. Veronese N, Stubbs B, Solmi M, Smith TO, Noale M, Cooper C, et al. Association between lower limb osteoarthritis and incidence of depressive symptoms: data from the osteoarthritis initiative. Age Ageing. 2017;46(3):470-6. https://doi.org/10.1093/ageing/afw216
https://doi.org/10.1093/ageing/afw216...
,2828. Li M, Nie Y, Zeng Y, Wu Y, Liu Y, Wu L, et al. The trajectories of depression symptoms and comorbidity in knee osteoarthri-tis subjects. Clin Rheumatol. 2022;41(1):235-43. https://doi.org/10.1007/s10067-021-05847-9
https://doi.org/10.1007/s10067-021-05847...
in a cyclic process.

Given the relationship between mental health and rheumatic diseases, patients with poor mental health tend to exhibit worse evolution for chronic physical diseases in a feedback-type process.2929. Aqeel M, Rehna T, Sarfraz R. The association among perception of osteoarthritis with adverse pain anxiety, symptoms of depression, positive and negative affects in patients with knee osteoarthritis: A cross sectional study. J Pak Med Assoc. 2021;71(2(B)):645-50. https://doi.org/10.47391/jpma.862
https://doi.org/10.47391/jpma.862...
,3030. Rathbun AM, Shardell MD, Stuart EA, Yau MS, Gallo JJ, Schuler MS, et al. Pain severity as a mediator of the association between depressive symptoms and physical performance in knee osteoarthritis. Osteoarthritis Cartilage. 2018;26(11):1453-60. https://doi.org/10.1016/j.joca.2018.07.016
https://doi.org/10.1016/j.joca.2018.07.0...
Thus, depression may be an aggravating factor for pain and disability, drastically reducing patient quality of life.1313. Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
https://doi.org/10.1093/ageing/afw001...
,3131. Ahn H, Weaver M, Lyon D, Choi E, Fillingim RB. Depression and pain in Asian and white Americans with knee osteoarthritis. J Pain. 2017;18(10):1229-36. https://doi.org/10.1016/j.jpain.2017.05.007
https://doi.org/10.1016/j.jpain.2017.05....
,3232. White DK, Neogi T, Nguyen USDT, Niu J, Zhang Y. Trajectories of functional decline in knee osteoarthritis: the Osteoarthritis Initiative. Rheumatology (Oxford). 2016;55(5):801-8. https://doi.org/10.1093/rheumatology/kev419
https://doi.org/10.1093/rheumatology/kev...

Anxiety is another psychological disorder that permeates the everyday lives of patients with OA. Studies based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) reported positive relationships for the emergence of anxiety in individuals with OA.2121. Duica L, Szakács J, Silișteanu SC. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. Balneo Res J. 2020;11(1):95-104. http://dx.doi.org/10.12680/balneo.2020.323
http://dx.doi.org/10.12680/balneo.2020.3...
,2626. Zambon S, Siviero P, Denkinger M, Limongi F, Castell MV, van der Pas S, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European Project on Osteoarthritis. Arthritis Care Res (Hoboken). 2016;68(6):801-10. https://doi.org/10.1002/acr.22755
https://doi.org/10.1002/acr.22755...
,3333. Zheng S, Tu L, Cicuttini F, Zhu Z, Han W, Antony B, et al. Depression in patients with knee osteoarthritis: risk factors and associations with joint symptoms. BMC Musculoskelet Disord. 2021;22(1):40. https://doi.org/10.1186/s12891-020-03875-1
https://doi.org/10.1186/s12891-020-03875...
In this respect, anxiety may also be a predictor of worse prognosis and pain evolution in individuals with OA, heavily impacting their daily lives.1919. Alabajos-Cea A, Herrero-Manley L, Suso-Martí L, Alonso-Pérez-Barquero J, Viosca-Herrero E. Are psychosocial factors determinant in the pain and social participation of patients with early knee osteoarthritis? A cross-sectional study. Int J Environ Res Public Health. 2021;18(9):4575. https://doi.org/10.3390/ijerph18094575
https://doi.org/10.3390/ijerph18094575...
,2525. Helminen EE, Arokoski JP, Selander TA, Sinikallio SH. Multiple psychological factors predict pain and disability among community-dwelling knee osteoarthritis patients: a five-year prospective study. Clin Rehabil. 2020;34(3):404-15. https://doi.org/10.1177/0269215519900533
https://doi.org/10.1177/0269215519900533...
Much like depression, anxiety symptoms can be caused by OA itself, with factors such as knee swelling reported by patients deemed predictors of anxiety.1515. Sayre EC, Esdaile JM, Kopec JA, Singer J, Wong H, Thorne A, et al. Specific manifestations of knee osteoarthritis predict depression and anxiety years in the future: Vancouver Longitudinal Study of Early Knee Osteoarthritis. BMC Musculoskelet Disord. 2020;21(1):467. https://doi.org/10.1186/s12891-020-03496-8
https://doi.org/10.1186/s12891-020-03496...

This results in a vicious cycle, where OA causes considerable pain that leads to disability and dependence, resulting in social isolation or institutionalization, a precipitating factor for the emergence of psychological disorders, especially anxiety and depression. Furthermore, it clearly demonstrates the relationship between OA, poor mental health, reduced social interaction and a subsequent decline in quality of life, particularly in middle-aged and older adults.3434. Park HM, Kim HS, Lee YJ. Knee osteoarthritis and its association with mental health and health-related quality of life: A nationwide cross-sectional study. Geriatr Gerontol Int. 2020;20(4):379-83. https://doi.org/10.1111/ggi.13879
https://doi.org/10.1111/ggi.13879...

Han et al.3535. Han A, Gellhorn AC. Trajectories of quality of life and associated risk factors in patients with knee osteoarthritis: findings from the osteoarthritis initiative. Am J Phys Med Rehabil. 2018;97(9):620-7. https://doi.org/10.1097/phm.0000000000000926
https://doi.org/10.1097/phm.000000000000...
concluded that a patient’s quality of life can be improved over time by determining the factors that influence it. Thus, for rheumatic patients, treatment should be individualized and tailored according to age as opposed to adopting a generalist approach, in order to mitigate symptoms and delay disease progression.2121. Duica L, Szakács J, Silișteanu SC. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. Balneo Res J. 2020;11(1):95-104. http://dx.doi.org/10.12680/balneo.2020.323
http://dx.doi.org/10.12680/balneo.2020.3...
,2424. Carlesso LC, Hawker GA, Waugh EJ, Davis AM. Disease-specific pain and function predict future pain impact in hip and knee osteoarthritis. Clin Rheumatol. 2016;35(12):2999-3005. https://doi.org/10.1007/s10067-016-3401-z
https://doi.org/10.1007/s10067-016-3401-...
The most feasible alternative is to stimulate physical activity and social interaction, since healthy active people have a better prognosis than inactive individuals with OA.2828. Li M, Nie Y, Zeng Y, Wu Y, Liu Y, Wu L, et al. The trajectories of depression symptoms and comorbidity in knee osteoarthri-tis subjects. Clin Rheumatol. 2022;41(1):235-43. https://doi.org/10.1007/s10067-021-05847-9
https://doi.org/10.1007/s10067-021-05847...

Finally, this study is limited by the small number of articles that address all the biopsychosocial aspects analyzed in our investigation and their correlation with KOA, in addition to their subjectivity. Another limitation was the different methodologies used in the literature to obtain the results reported. On the other hand, this study is innovative in that it jointly correlates the main biopsychosocial factors that affect older adults with this pathology. As such, this systematic review can contribute to future research on the connection between OA and biopsychosocial aspects with a view to finding alternatives to mitigate symptoms, develop new lines of research and delay disease progression, thus improving the quality of life of older adults and providing healthcare professionals with a new way of managing the disease that focuses on biopsychosocial aspects.

Multi and interprofessional management that considers the individualities and particularities of each case can help manage pain, improve inactivity and socialization and encourage independence, in addition to delaying disease progression and the emergence of other associated symptoms. It can therefore also reduce the socioeconomic impact of the disease, particularly in relation to medication, institutionalization and social isolation among older adults, lowering health system costs by decreasing hospitalizations, consultations and early retirement due to illness.

Conclusion

Knee osteoarthritis is a chronic disease that causes pain and disability, as well as being responsible for considerable social and health costs. The present study confirms the correlation between knee osteoarthritis and biopsychosocial aspects such as functional limitations, anxiety and depression. However, further research is needed to elucidate knee osteoarthritis as the sole cause of these symptoms. Thus, it was concluded that the disease negatively impacts the mental and physical well-being of older adults, causing dependence, reduced quality of life and physical and psychological symptoms. There is therefore a need for a preventive multi and interprofessional approach to mitigate the symptoms and improve the quality of life of patients.

References

  • 1
    Martel-Pelletier J, Barr AJ, Cicuttini FM, Conaghan PG, Cooper C, Goldring MB, et al. Osteoarthritis. Nat Rev Dis Primers. 2016; 2:16072. https://doi.org/10.1038/nrdp.2016.72
    » https://doi.org/10.1038/nrdp.2016.72
  • 2
    Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019;37(Suppl. 120):S3-6. https://www.clinexprheumatol.org/abstract.asp?a=14780
    » https://www.clinexprheumatol.org/abstract.asp?a=14780
  • 3
    GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1789-858. https://doi.org/10.1016%2FS0140-6736(18)32279-7
    » https://doi.org/10.1016%2FS0140-6736(18)32279-7
  • 4
    Palazzo C, Nguyen C, Lefevre-Colau MM, Rannou F, Poiraudeau S. Risk factors and burden of osteoarthritis. Ann Phys Rehabil Med. 2016;59(3):134-8. https://doi.org/10.1016/j.rehab.2016.01.006
    » https://doi.org/10.1016/j.rehab.2016.01.006
  • 5
    Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019; 393(10182):1745-59. https://doi.org/10.1016/s0140-6736(19)30417-9
    » https://doi.org/10.1016/s0140-6736(19)30417-9
  • 6
    Lluch E, Nijs J, Courtney CA, Rebbeck T, Wylde V, Baert I, et al. Clinical descriptors for the recognition of central sensitization pain in patients with knee osteoarthritis. Disabil Rehabil. 2018; 40(23):2836-45. https://doi.org/10.1080/09638288.2017.1358770
    » https://doi.org/10.1080/09638288.2017.1358770
  • 7
    Hafkamp FJ, Vries J, Gosens T, den Oudsten BL. The relationship between psychological aspects and trajectories of symptoms in total knee arthroplasty and total hip arthroplasty. J Arthroplasty. 2021;36(1):78-87. https://doi.org/10.1016/j.arth.2020.07.071
    » https://doi.org/10.1016/j.arth.2020.07.071
  • 8
    Deshpande BR, Katz JN, Solomon DH, Yelin EH, Hunter DJ, Messier SP, et al. Number of persons with symptomatic knee osteoarthritis in the us: impact of race and ethnicity, age, sex, and obesity. Arthritis Care Res (Hoboken). 2016;68(12):1743-50. https://doi.org/10.1002/acr.22897
    » https://doi.org/10.1002/acr.22897
  • 9
    Sociedade Brasileira de Reumatologia. Osteoartrite (Artrose) [cited 2022 Feb 7]. Available from: https://www.reumatologia.org.br/doencasreumaticas/osteoartrite-artrose/
    » https://www.reumatologia.org.br/doencasreumaticas/osteoartrite-artrose/
  • 10
    James RJE, Walsh DA, Ferguson E. Trajectories of pain predict disabilities affecting daily living in arthritis. Br J Health Psychol. 2019;24(3):485-96. https://doi.org/10.1111/bjhp.12364
    » https://doi.org/10.1111/bjhp.12364
  • 11
    Siviero P, Veronese N, Smith T, Stubbs B, Limongi F, Zambon S, et al. Association between osteoarthritis and social isolation: data from the EPOSA study. J Am Geriatr Soc. 2020;68(1):87-95. https://doi.org/10.1093/ageing/afw216
    » https://doi.org/10.1093/ageing/afw216
  • 12
    Veronese N, Stubbs B, Solmi M, Smith TO, Noale M, Cooper C, et al. Association between lower limb osteoarthritis and incidence of depressive symptoms: data from the osteoarthritis initiative. Age Ageing. 2017;46(3):470-6. https://doi.org/10.1093/ageing/afw216
    » https://doi.org/10.1093/ageing/afw216
  • 13
    Stubbs B, Aluko Y, Myint PK, Smith TO. Prevalence of depressive symptoms and anxiety in osteoarthritis: a systematic review and meta-analysis. Age Ageing. 2016;45(2):228-35. https://doi.org/10.1093/ageing/afw001
    » https://doi.org/10.1093/ageing/afw001
  • 14
    Tak ECPM, van Meurs JB, Bierma-Zeinstra SMA, Hofman A, Hopman-Rock M. Changes in disability in older adults with generalized radiographic osteoarthritis: A complex relationship with physical activity. Musculoskeletal Care. 2017;15(4):364-72. https://doi.org/10.1002/msc.1182
    » https://doi.org/10.1002/msc.1182
  • 15
    Sayre EC, Esdaile JM, Kopec JA, Singer J, Wong H, Thorne A, et al. Specific manifestations of knee osteoarthritis predict depression and anxiety years in the future: Vancouver Longitudinal Study of Early Knee Osteoarthritis. BMC Musculoskelet Disord. 2020;21(1):467. https://doi.org/10.1186/s12891-020-03496-8
    » https://doi.org/10.1186/s12891-020-03496-8
  • 16
    Santos MG, Damiani P, Marcon ACZ, Haupenthal A, Avelar NPC. Influence of knee osteoarthritis on functional performance, quality of life and pain in older women. Fisioter Mov. 2020;33:e003306. https://doi.org/10.1590/1980-5918.033.AO06
    » https://doi.org/10.1590/1980-5918.033.AO06
  • 17
    Lee MK, Oh JH. The relationship between pain and physical function: mediating role of sleep quality, depression, and fatigue. J Gerontol Nurs. 2019;45(7):46-54. https://doi.org/10.3928/00989134-20190612-05
    » https://doi.org/10.3928/00989134-20190612-05
  • 18
    Koning EJ, Timmermans EJ, van Schoor NM, Stubbs B, van den Kommer TN, Dennison EM, et al. Within-person pain vari-ability and mental health in older adults with osteoarthritis: An analysis across 6 european cohorts. J Pain. 2018;19(6):690-8. https://doi.org/10.1016/j.jpain.2018.02.006
    » https://doi.org/10.1016/j.jpain.2018.02.006
  • 19
    Alabajos-Cea A, Herrero-Manley L, Suso-Martí L, Alonso-Pérez-Barquero J, Viosca-Herrero E. Are psychosocial factors determinant in the pain and social participation of patients with early knee osteoarthritis? A cross-sectional study. Int J Environ Res Public Health. 2021;18(9):4575. https://doi.org/10.3390/ijerph18094575
    » https://doi.org/10.3390/ijerph18094575
  • 20
    García-López S, Llopart-Carles N, Castro-Domínguez F, Rejas-Gutierrez J. Patient self-reported functioning by pain severity and usual analgesic treatment among older adults with osteoarthritis: analysis of the 2017 Spanish National Health Survey. Eur Geriatr Med. 2021;12(5):989-1001. https://doi.org/10.1007/s41999-021-00488-2
    » https://doi.org/10.1007/s41999-021-00488-2
  • 21
    Duica L, Szakács J, Silișteanu SC. Study on the correlation between knee osteoarthritis and anxiety in patients aged over 55. Balneo Res J. 2020;11(1):95-104. http://dx.doi.org/10.12680/balneo.2020.323
    » http://dx.doi.org/10.12680/balneo.2020.323
  • 22
    Fielding RA, Guralnik JM, King AC, Pahor M, McDermott MM, Tudor-Locke C, et al. Dose of physical activity, physical functioning and disability risk in mobility limited older adults: Results from the LIFE study randomized trial. PLoS One. 2017;12(8):e0182155. https://doi.org/10.1371/journal.pone.0182155
    » https://doi.org/10.1371/journal.pone.0182155
  • 23
    Helminen EE, Sinikallio SH, Valjakka AL, Väisänen-Rouvali RH, Arokoski JP. Determinants of pain and functioning in knee osteoarthritis: a one-year prospective study. Clin Rehabil. 2016; 30(9):890-900. https://doi.org/10.1177/0269215515619660
    » https://doi.org/10.1177/0269215515619660
  • 24
    Carlesso LC, Hawker GA, Waugh EJ, Davis AM. Disease-specific pain and function predict future pain impact in hip and knee osteoarthritis. Clin Rheumatol. 2016;35(12):2999-3005. https://doi.org/10.1007/s10067-016-3401-z
    » https://doi.org/10.1007/s10067-016-3401-z
  • 25
    Helminen EE, Arokoski JP, Selander TA, Sinikallio SH. Multiple psychological factors predict pain and disability among community-dwelling knee osteoarthritis patients: a five-year prospective study. Clin Rehabil. 2020;34(3):404-15. https://doi.org/10.1177/0269215519900533
    » https://doi.org/10.1177/0269215519900533
  • 26
    Zambon S, Siviero P, Denkinger M, Limongi F, Castell MV, van der Pas S, et al. Role of osteoarthritis, comorbidity, and pain in determining functional limitations in older populations: European Project on Osteoarthritis. Arthritis Care Res (Hoboken). 2016;68(6):801-10. https://doi.org/10.1002/acr.22755
    » https://doi.org/10.1002/acr.22755
  • 27
    Uritani D, Kasza J, Campbell PK, Metcalf B, Egerton T. The association between psychological characteristics and physical activity levels in people with knee osteoarthritis: a cross-sectional analysis. BMC Musculoskelet Disord. 2020;21(1):269. https://doi.org/10.1186/s12891-020-03305-2
    » https://doi.org/10.1186/s12891-020-03305-2
  • 28
    Li M, Nie Y, Zeng Y, Wu Y, Liu Y, Wu L, et al. The trajectories of depression symptoms and comorbidity in knee osteoarthri-tis subjects. Clin Rheumatol. 2022;41(1):235-43. https://doi.org/10.1007/s10067-021-05847-9
    » https://doi.org/10.1007/s10067-021-05847-9
  • 29
    Aqeel M, Rehna T, Sarfraz R. The association among perception of osteoarthritis with adverse pain anxiety, symptoms of depression, positive and negative affects in patients with knee osteoarthritis: A cross sectional study. J Pak Med Assoc. 2021;71(2(B)):645-50. https://doi.org/10.47391/jpma.862
    » https://doi.org/10.47391/jpma.862
  • 30
    Rathbun AM, Shardell MD, Stuart EA, Yau MS, Gallo JJ, Schuler MS, et al. Pain severity as a mediator of the association between depressive symptoms and physical performance in knee osteoarthritis. Osteoarthritis Cartilage. 2018;26(11):1453-60. https://doi.org/10.1016/j.joca.2018.07.016
    » https://doi.org/10.1016/j.joca.2018.07.016
  • 31
    Ahn H, Weaver M, Lyon D, Choi E, Fillingim RB. Depression and pain in Asian and white Americans with knee osteoarthritis. J Pain. 2017;18(10):1229-36. https://doi.org/10.1016/j.jpain.2017.05.007
    » https://doi.org/10.1016/j.jpain.2017.05.007
  • 32
    White DK, Neogi T, Nguyen USDT, Niu J, Zhang Y. Trajectories of functional decline in knee osteoarthritis: the Osteoarthritis Initiative. Rheumatology (Oxford). 2016;55(5):801-8. https://doi.org/10.1093/rheumatology/kev419
    » https://doi.org/10.1093/rheumatology/kev419
  • 33
    Zheng S, Tu L, Cicuttini F, Zhu Z, Han W, Antony B, et al. Depression in patients with knee osteoarthritis: risk factors and associations with joint symptoms. BMC Musculoskelet Disord. 2021;22(1):40. https://doi.org/10.1186/s12891-020-03875-1
    » https://doi.org/10.1186/s12891-020-03875-1
  • 34
    Park HM, Kim HS, Lee YJ. Knee osteoarthritis and its association with mental health and health-related quality of life: A nationwide cross-sectional study. Geriatr Gerontol Int. 2020;20(4):379-83. https://doi.org/10.1111/ggi.13879
    » https://doi.org/10.1111/ggi.13879
  • 35
    Han A, Gellhorn AC. Trajectories of quality of life and associated risk factors in patients with knee osteoarthritis: findings from the osteoarthritis initiative. Am J Phys Med Rehabil. 2018;97(9):620-7. https://doi.org/10.1097/phm.0000000000000926
    » https://doi.org/10.1097/phm.0000000000000926
  • 36
    Husnain A, Khan A, Aziz T, Hussain FN. Anxiety and depression in osteoarthritis using HADS questionnaire. Rawal Medical J. 2021;46(1):56-61. https://www.bibliomed.org/?mno=120596
    » https://www.bibliomed.org/?mno=120596
  • 37
    Milano JV, Barbero MH, Basallote SG, Martín JV, Lladó EV, Serrano HM, et al. Anxiety and depression in knee osteoarthritic patients: Results from EMARTRO study. Osteoarthr Cartil. 2016;24:S218-9. https://www.oarsijournal.com/action/showPdf?pii=S1063-4584%2816%2900441-6
    » https://www.oarsijournal.com/action/showPdf?pii=S1063-4584%2816%2900441-6
  • 38
    Shams A, Hadi SP, Sahaf R. Comparing levels of depression in healthy active and inactive elders versus those with knee osteoarthritis disease. Ann Appl Sport Sci. 2016;4(1):49-56. https://doi.org/10.7508/aass.2016.01.008
    » https://doi.org/10.7508/aass.2016.01.008
  • 39
    El Monaem SMA, Hashaad NI, Ibrahim NH. Correlations between ultrasonographic findings, clinical scores, and depres-sion in patients with knee osteoarthritis. Eur J Rheumatol. 2017;4(3):205-9. https://doi.org/10.5152/eurjrheum.2017.160097
    » https://doi.org/10.5152/eurjrheum.2017.160097
  • 40
    Duarte N, Rodrigues AM, Branco JC, Canhão H, Hughes SL, Paúl C. Health and lifestyles factors associated with osteoarthritis among older adults in Portugal. Front Med (Lausanne). 2017; 4:192. https://doi.org/10.3389/fmed.2017.00192
    » https://doi.org/10.3389/fmed.2017.00192

Publication Dates

  • Publication in this collection
    24 Mar 2023
  • Date of issue
    2023

History

  • Received
    29 June 2022
  • Reviewed
    27 Nov 2022
  • Accepted
    2 Feb 2023
Pontifícia Universidade Católica do Paraná Rua Imaculada Conceição, 1155 - Prado-Velho -, Curitiba - PR - CEP 80215-901, Telefone: (41) 3271-1608 - Curitiba - PR - Brazil
E-mail: revista.fisioterapia@pucpr.br