Correlates of social participation in patients with advanced-stage osteoarthritis

Introduction

Osteoarthritis (OA) is one of the most common degenerative musculoskeletal joint diseases, with a significantly negative impact on quality of life (Courties et al., 2024). In 2019, 528 million people suffered from this chronic disease (70% older than 55 years), representing a 113% increase compared to 1990 (WHO, 2023). OA currently affects up to 7.6% of the world population, and the prevalence of OA is expected to continue rising due to population aging, increasing incidence of obesity, and injuries (WHO, 2023). Hip OA has a lower prevalence compared to knee OA (10% vs 16%) in people older than 45 years and may depend on various factors such as sex and race (Hall et al., 2022).

Among the most severe pathological mechanisms of OA are cartilage degradation, bone changes, and osteophyte formation, causing complex changes in other structures and thus joint mobility (Allen et al., 2022). OA primarily affects the knee and hip joints, which are key parts of the musculoskeletal system responsible for body movement and stability. Typical symptoms of OA include pain, which usually worsens with movement and joint loading, swelling, stiffness that limits range of motion, and progressive mobility deterioration (Wang and Ni, 2022; WHO, 2023). In the end stage, these characteristics can lead to disability and loss of autonomy in daily activities, especially in older patients (Gay et al., 2016). Currently, there is no effective treatment for OA. Approaches to OA management, which focus primarily on symptom relief, improving functional status, or joint stabilization, do not provide satisfactory solutions, as OA symptoms exhibit high variability. This variability cannot be explained solely by disease pathology; psychosocial factors and a holistic approach play a key role in understanding it (Sharma et al., 2016).

Pain in patients with knee and hip OA is perceived in activities of daily living as a dull ache that gradually becomes constant and is interrupted by more intense, unpredictable episodes that are emotionally exhausting (Hall et al., 2022). OA pain in patients has a multifactorial nature and is described not only in terms of intensity but also in terms of its multiple types, which differ in duration, depth (in bones or muscles), type of occurrence, and impact. Pain can be deep, stabbing, similar to an electric shock, contact-related, and patients may feel a sensation of a missing joint, etc. (Cedraschi et al., 2013). Patients with hip OA describe pain as sudden, with rapidly changing intensity, and often compare it to other extremely painful conditions such as childbirth. They also frequently complain of painful side-lying or sexual activity. In contrast, patients with knee OA experience pain when walking stairs, with overweight, and in connection with stiffness (Hall et al., 2022). Results of previous research show that people with OA who experienced severe pain were less likely to engage in (social) activities outside the home — especially those requiring confidence in moving on uneven terrain or visiting shopping centers (Webber et al., 2022).

Fatigue is generally understood as unpleasant, subjective feelings of lack of energy and exhaustion (Fawole et al., 2021). Hackney et al. (2019) add that fatigue means the inability to work effectively and function in family and social roles. Although fatigue is common in patients with OA and 47% of them exhibit a severe level of it, it is still not well researched and defined (Fawole et al., 2021). Stebbings et al. (2010) found that fatigue is significantly related to disability and physical functioning and activity (e.g., walking speed) (Fawole et al., 2020, Hackney et al., 2019). These results lead to the assumption that fatigue may be a significant correlate in the context of social participation.

Physiological disease is often accompanied by psychological symptoms, such as anxiety or depression, which may impact disease prognosis (Yang et al., 2024). Anxiety is a state characterized by the presence of fear or worry about something that may happen, and depression, on the other hand, is a more complex and multifactorial disease characterized by sadness, feelings of emptiness, and irritability (Sharma et al., 2016). Anxiety and depression occur in individuals with OA with high prevalence, significantly reduce quality of life and the effectiveness of pain treatment, and may represent a more accurate predictor of disability than radiographic findings of degenerative joint changes (Yang et al., 2024; Zhang et al., 2024; Sharma et al., 2016; Stubbs et al., 2016). Up to 20% of OA patients have symptoms of anxiety and depression (Stubbs et al., 2016), and compared to patients without depression, they have 38.8% higher direct healthcare costs and experience more intense pain (Wang and Ni, 2022; Fonseca-Rodrigues et al., 2022; Sharma et al., 2016). Research on the significance of relationships between anxiety, depression, and OA symptoms depending on the location of the affected joint has yielded inconclusive results. While the study by Fu et al. (2021) did not demonstrate a relationship between anxiety, depression, and pain in patients with hip OA, research by Yang et al. (2024) confirmed the presence of these relationships in patients with knee OA. A longitudinal study by Zhang et al. (2023) demonstrated significant relationships between anxiety, depression, loneliness, and social isolation in the older population.

Social participation is a relevant aspect not only of healthy and successful aging, but especially for older people suffering from chronic diseases such as OA, it is also an important element of rehabilitation (Perruccio et al., 2021; Piškur et al., 2014). Social participation focuses on complex activities that are based on contact with other people (Turcotte et al., 2015; Cosco, Prina, Perales, 2013), denotes the inclusion of an individual in social life, and presupposes their active participation in the social environment (van Brakel, 2010). Aging limits the opportunities to fulfill participation needs, not only in the areas of personal care, housing, and mobility, but also in community life and leisure activities (Turcotte et al., 2015). These are activities performed mainly outside the home environment (walking) that require complex activities, e.g., overcoming environmental barriers (stairs) (Turcotte et al., 2015). Mobility and activity limitations resulting from OA increase the risk of reduced diversity and intensity of social participation (Pasin, Karatekin, 2024; Perruccio et al., 2021). Moreover, patients who are socially isolated have been found to have a higher prevalence of anxiety, depression, inflammation, pain, and associated pain medication use, as well as worse physical functioning (Siviero et al., 2019). Although the relationship between depression and social participation is significant, it is not sufficiently investigated in OA patients, as social participation is often an overlooked concept (Alabajos-Cea et al., 2021). The aim of this study is therefore to examine the relationship between functional status, pain, fatigue, anxiety, depression, and social participation in patients with end-stage OA.

Methods

Sample and procedure

The research sample consisted of 423 patients with end-stage OA undergoing total knee or hip arthroplasty at the Clinic of Musculoskeletal and Sports Medicine, AGEL Hospital Košice-Šaca. Clinical examination was followed by a structured interview conducted by trained staff, during which information on sociodemographic characteristics was collected, and subsequently patients completed self-report questionnaires on functional status, pain, fatigue, anxiety, depression, and social participation. Other examinations included radiographic examination of hip/knee OA, severe pain, and functional impairment. Inclusion criteria were as follows: admission for surgery (grade 3–4 according to the Kellgren-Lawrence classification of osteoarthritis, severe pain, functional limitation), ability to read, write, and understand the Slovak language. Exclusion criteria were the presence of rheumatoid arthritis and hospitalization due to trauma, e.g., femoral neck fracture, distal femur fracture. Data collection took place from March 2019 to September 2020. Patients participating in the study signed informed consent. The study was approved by the Ethics Committee of AGEL Hospital Košice-Šaca (Registration No. 03-2019).

Measures

Sociodemographic data such as age, sex, education, and socioeconomic status were collected using a structured interview. Socioeconomic status was divided into three categories: 1. income equal to or below the subsistence minimum, 2. income above the subsistence minimum, 3. income at least twice the subsistence minimum, based on the criteria of the Ministry of Labor, Social Affairs and Family of the Slovak Republic (2022).

Functional status was measured using the self-report Oxford Knee Score (OKS) and Harris Hip Score (HHS). The OKS contains 12 items scored from 0 (extreme difficulty) to 4 (no difficulty), with a total score ranging from 0–48. To compare functional status in patients with knee and hip OA, a simple linear transformation was used to recode the OKS score from 0 to 100, where a higher score indicates better functional status (Jenny and Deisinger, 2012). Cronbach's alpha was 0.86. The HHS consists of 10 items, with scores ranging from 0–100, where higher values represent better functional status (Weick et al., 2020; Nilsdotter and Bremander, 2011).

Pain was measured using the pain subscale of the self-report Knee Injury/Hip Disability and Osteoarthritis Outcome Score (KOOS/HOOS). This subscale measures the frequency and intensity of pain in activities of daily living using ten items (Roos et al., 2003). Each item is scored from 0 to 4, with a total score of 0–100 and a higher score indicating a lower level of pain. Cronbach's alpha values were 0.83 and 0.88 for patients with knee and hip OA, respectively.

Fatigue was measured using the Multidimensional Fatigue Inventory (MFI-20). The general fatigue subscale was selected for statistical analyses because it is considered the most representative and can be used as a general indicator of fatigue (Kieffer et al., 2021). Each item is scored from 1 to 5. A higher score indicates a higher level of fatigue (Hinz et al., 2020; Smets et al., 1995). Cronbach's alpha was 0.70 for both types of OA.

Anxiety and depression were measured using the Anxiety and Insomnia and Severe Depression subscales of the 28-item self-report General Health Questionnaire (GHQ-28). Each subscale consists of seven screening items rated on a four-point Likert scale (1–4), with a higher score indicating greater symptom severity (Goldberg and Hillier, 1979). Cronbach's alpha in our sample reached 0.87 for anxiety and 0.81 for depression.

Social participation was measured using the 18-item Participation Scale (P-scale). This scale assesses perceived problems in major life domains and the severity of limitations they cause in social participation. Respondents rate their social participation compared to their peers. Each item is rated on a five-point scale, with a total score ranging from 0 to 90. Patients who score more than 12 points are classified as having reduced social participation (Van Brakel et al., 2010, 2006). Cronbach's alpha in our sample reached 0.89.

Statistical analyses

Data were analyzed using descriptive and inferential statistics (frequencies and percentages for categorical variables, mean and standard deviation for continuous variables). Differences between patients with knee and hip OA were analyzed using t-tests and chi-square tests. Correlation analyses and regression analysis were used to analyze associations between anxiety, depression, functional status, and social participation. Statistical significance was set at p≤0.05, and statistical analyses were performed using IBM SPSS 26 statistical software.

Results

The research sample consisted of 423 patients with end-stage OA. Of these, 241 (57%) were patients with knee OA and 182 (43%) were patients with hip OA (Table 1). The mean age of patients with knee OA was 65.1±8.4 years and of patients with hip OA was 63.5±9.7 years. There were significantly more women among patients with knee OA than among patients with hip OA (59.8% knee OA and 39.1% hip OA). The vast majority of patients had completed secondary education (70.5% knee OA and 59.1% hip OA), lived with a partner (79.6% knee OA and 72.4% hip OA), and were retirees or disability pensioners (67.9% knee OA and 59.1% hip OA). Patients with knee OA had a higher income (48.9%), and patients with hip OA had equally higher and twice as high income (45.5%) compared to the subsistence minimum. Patients with knee OA had longer disease duration, worse functional status, were less depressed, and had a higher level of social participation compared to patients with hip OA.

Table 1. Descriptive characteristics of the research sample (n=423)

Correlations were used to analyze the relationships between functional status, pain, fatigue, anxiety, depression, and social participation (Table 2). Worse functional status (-0.42, p=0.000/-0.25, p=0.014), higher pain (-0.24, p=0.003/-0.20, p=0.022), higher fatigue (0.31, p=0.000/0.29, p=0.001), and higher anxiety (0.18, p=0.023/0.29, p=0.000) were statistically significantly associated with lower social participation in patients with knee and hip OA. In patients with knee OA, female sex (0.21, p=0.007) and lower education (0.21, p=0.007) were additionally significantly associated with lower social participation. On the other hand, in patients with hip OA, lower income (-0.17, p=0.048) and depression (0.35, p=0.000) were significantly associated with lower social participation.

Table 2. Bivariate correlation coefficients of the examined variables

The results of linear regression analysis showed that, after controlling for sociodemographic variables, social participation was associated with functional status in patients with knee OA (β=0.40, p=0.001) and with depression (β=0.33, p=0.009) in patients with hip OA (β=0.33, p=0.009). The total explained variance of social participation was 17% for knee OA and 18% for hip OA (Table 3).

Table 3. Linear regression analysis: social participation in relation to sociodemographic, clinical, and psychological variables

Discussion

The aim of this study was to examine the relationship between functional status, pain, fatigue, anxiety, depression, and social participation in patients with end-stage OA. The results of bivariate analyses showed that worse functional status, higher pain, higher fatigue, and higher anxiety were statistically significantly associated with lower social participation in patients with knee and hip OA. The results of regression analyses showed that, after controlling for the influence of sociodemographic factors, reduced social participation in patients with knee OA was primarily associated with worse functional status, while in patients with hip OA it was associated with higher depression.

Our results are consistent with the conclusions of several studies demonstrating that in patients with knee OA, not only pain but also the entire complex of limitations, including problems with mobility and physical performance, are risk factors for social isolation (Wang and Ni, 2022; Siviero et al., 2019). This may also be due to worse functional status in patients with knee OA compared to the hip OA group. The results are also consistent with research by Perruccio et al. (2021), which found an association of activity limitation in patients with OA with reduced social participation. Social participation was divided into two constructs (diversity and intensity), which were differently associated with age, sex, income, and education (Perruccio et al., 2021). Similarly, our bivariate analysis results showed statistically significant relationships, particularly between sex, education, income, and social participation.

The results of this study also highlighted a significant relationship between higher levels of depression and lower social participation in patients with hip OA, but not in patients with knee OA. Depression, as a complex phenomenon, can weaken an individual's functional capacity (Sharma et al., 2016), which subsequently manifests in reduced participation in social activities (Choi et al., 2021). Research by Alabajos-Cea et al. (2021) points to depression as a significant factor influencing social participation in patients with knee OA already at stages 1–2 according to the Kellgren-Lawrence scale. Our patients with knee OA had a more advanced disease stage compared to patients in the study by Alabajos-Cea et al. (2021). In their case, functional status played a key role, which was significantly worse than in patients with hip OA. At the same time, patients with hip involvement had significantly higher depression scores and greater limitations in social participation. These factors may explain our results and are consistent with previous research (Choi et al., 2021).

Conclusion

The results of our study showed that in patients with knee OA, a significant relationship was demonstrated between functional status and social participation. Conversely, in patients with hip OA, a significant relationship was found between depression and social participation. These differences may be key to a better understanding of the mechanisms of management in OA patients, which can help tailor non-pharmacological psychosocial interventions that contribute to increased social participation and better integration of OA patients. Our results can also serve as a basis for the development and optimization of educational seminars intended for patients with OA, as well as for improving physicians' approach to these patients in clinical practice. At the same time, they highlight the need for healthcare providers to distinguish between patients with knee and hip OA not only in terms of physical manifestations of the disease, but also with regard to differences in psychosocial factors and their influence on the level of social participation.

This work was supported by the Slovak Research and Development Agency under contract No. APVV-22-0587.

Authors Mgr. Július Evelley Institute of Social and Behavioral Medicine, Faculty of Medicine, UPJŠ, Košice MUDr. Peter Polan, PhD., MPH Clinic of Musculoskeletal and Sports Medicine, Faculty of Medicine, UPJŠ, Košice Mgr. Alexandra Husivargová Theofanidis, PhD. Institute of Social and Behavioral Medicine, Faculty of Medicine, UPJŠ, Košice Mgr. Laura Hammer Institute of Social and Behavioral Medicine, Faculty of Medicine, UPJŠ, Košice MUDr. Martin Vicen Clinic of Musculoskeletal and Sports Medicine, Faculty of Medicine, UPJŠ, Košice Mgr. Iveta Nagyová, PhD., FABMR Institute of Social and Behavioral Medicine, Faculty of Medicine, UPJŠ, Košice

Corresponding address: Mgr. Iveta Nagyová, PhD., FABMR Institute of Social and Behavioral Medicine Faculty of Medicine, UPJŠ Trieda SNP 1, 040 11 Košice iveta.nagyova@upjs.sk

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