To make this issue be understood better, we carried out the thesis: " Study of knee osteoarthritis and improving capabilities of diagnosis and managements of community health workers in
Trang 1Osteoarthritis (OA) once considered a consequence of aging; OA could
be found in moving joints, especialy affect the large weight-bearing jointssuch as the knee, hip and spine When OA with clinical symptoms, such aspain, physical disability and limiting daily activities, which makes thepatients have to see a doctor regularly and be treated Therefore, this affectsthe quality of their life and causes economically costly
According to a survey conducted in USA, more than 80% of over 55year-old people show signs of OA on X-ray, in which 10 - 20% of peoplehave limited mobility Especially, a few hundred thousands of the peopleare not self-serviced due to hip OA and the cost of treating one patientwith drugs was amounted to USD 141.98 in 30 days In France, OAaccounts for about 28.6% of the musculoskeletal disorder, each yearabout 50,000 people are replacemented artificial hip joints
Along with the increase in average life expectancy of Vietnamese,musculoskeletal disorder, especially knee OA is common, the moreelderly people are the more severe disease are This disease does notdirectly threaten to the patients’ life so patients and the community hasnot paid adequate attention to it, especially manual labors in rural areas
If this disease is detected and treated late, the result of treatment is noteffective as expected, associated with leaving jobs, reducing laborproductivity and limit daily activities, even leading to lifelong disability.Therefore, the role of community health workers is very important in theearly detection, proper treatment and counseling for the people
In Vietnam, there have been research works on the clinicalcharacteristics and treatments on knee OA in a number of hospitals, butepidemiological assessment of knee osteoarthritis and diagnose as well astreatments and counseling for knee OA patients in the community stillreceived little attention To make this issue be understood better, we
carried out the thesis: " Study of knee osteoarthritis and improving capabilities of diagnosis and managements of community health workers in Hai Duong province"
OBJECTIVES OF THE STUDY
1 Describe the real situation of knee osteoarthritis in people aged 40 and older from 02 communes in Gia Loc district, Hai Duong province in 2008.
2 Assess on the effectiveness of intervention model to improve diagnosis and management capabilities of knee OA of community health workers in Hai Duong province
Trang 2NEW CONTRIBUTIONS OTHE THESIS
1 Describe the real situation of knee OA in people aged 40 above from
02 communes in Gia Loc district, Hai Duong province
2 Assess on the effectiveness of intervention models to improvediagnostic and management capabilities of knee OA by communityhealth workers in Hai Duong province
CHAPTER 1 OVERVIEW 1.1 Knee joint anatomy
1.1.1 Scope of the knee:
The knee joint is the connection between the upper and lower legs,which was limited by the upper patellar about 4cm and the lower by thebottom loop under the tibia tuberosity Knee is divided into two areas bythe knee joint: anterior and posterior of the knee
1.1.2 Knee - joint anatomy:
Knee joint is a hinge joint between the bulging of the tibia, femur, andpatella with the face of patella of femur This is a complex joint withvery wide synovial fluid, easily swollen and distended Knee joints inprone areas are easy to be impacted and injurred
Knee joint is a complex joint consisting of two joints:
- Between the femur and tibia (the hinge joints)
- Between the femur and the patella (the flat joints)
1.1.3 The structure and composition of articular cartilage.
Articular cartilage is white, smooth, elastic wrapped around theepicoldyle of femur, tibia, and the back patella Articular cartilage withphysiological functions is to protect the epiphyseal of the bones andspread out the weight bearing on the entire joint surface Normally,articular cartilage is glossy, wet, very hard and strong elastic Thearticular cartilage ensures sliding motion among the articular surfacesoccurring with a very low coefficient of friction, as a buffer layer helps
to reduce compression Articular cartilage has no blood vessels and
Trang 3nerves The basic composition comprises the cartilage cells, collagenfibers and basic chemicals, and arranged and form different layers.
1.2 Osteoarthritis
1.2.1 Definition
Osteoarthritis is the dysfunction of articular cartilage, the mainmanifestation of this disease is the phenomenon of wear and tear ofarticular cartilage in relation to minimizing the mechanical operation ofthe joint OA is the result of the mechanical and biological proccess,which causes the imbalance between synthesis and destruction ofcartilage and subchondral bone (the spine and intervertebral discs)
1.2.2 Epidemiology of osteoarthritis
Osteoarthritis is a common musculoskeletal disease Among theelderly, knee OA is a leading cause of chronic disability in the developedcountries Several hundred thousand people in the U.S are unable towalk independently from bed to the bathroom because of knee or hipOA
Under the age of 55, the distribution of this disease in men andwomen is alike For older people, hip OA is often found in men more,while OA in the knee, finger and thumb are more common in women.Similarly, X-ray of knee OA is also discovered more in women
1.2.3 The etiology and pathogenesis of osteoarthritis
Changes of articular cartilage in OA:
When cartilage is degenerated, the most symptoms are the yellowdiscoloration, dull, dry, soft, loss of smoothness, elastic reduction,thinness and cracks Initial cartilage damage is small cracked areas; thecracks can be column form, gray and grainy The damage will spread anddeepen over time This situation progresses down deeply and spreadsvertically and in some cases, some cracks will spread to the subchondralbones There may be ulcers; loss of cartilage exposes the subchondralbone Besides the cracks of the surface cartilage, articular cartilages inolder adults become thinner than articular cartilage in children andadolescents
Pathogenesis: developing process of OA is divided into three main stages:
- Stage I: The PGs were lost gradually and collagen fiber net is degraded,
which hurts the structure and function of the articular cartilage
- Stage II: The surface of cartilage is corroded and fibrous, the
fragments fall into the synovial fluid and is made thinner bymacrophages cells, so it promotes inflammation proccess
Trang 4- Stage III: widespread inflammatory process, because the synovial
membrane cells afected to release protease and cytokines, that promotecatabolism of cartilage degeneration and basic chemicals
1.2.4 Symptoms of knee osteoarthritis.
The main symptom:
- Pain that increases when you are active, relieving when having arest, limitation of mobility, stiffness of the knee, etc
- The majority of joints are not swollen, no heated, may deform due
to the enlargement of spines and fat around the joints, limited the range
of the knee joint, especially, knee folding actions, with the pain in thepatella slots - pulley, - ball pulley; signs of wood shavings; bonyenlargement etc
Diagnostic criteria of knee osteoarthritis basing on clinical symptoms of the American College of Rheumatology (ACR-1991)
1) Pain in the knee
2) Crepitus on action motion
3) Stiffness of the knee less than 30 minutes
4) Age ≥ 38
5) Touching the bony enlargment
Diagnosis identified when having factor 1,2,3,4 or 1,2,5 or 1,4,5
1.2.5 Treatments to OA:
Principle: Slowing the process of joint destruction, especially to
prevent the degradation of articular cartilage, pain relief, mobilitymaintaining, minimizing the disability
- Supplement, including Glucosamine Sulfate, Chondroitin Sulfate, etc
- IL 1 inhibitor, such as artrodar;
- Stem cell therapies
Surgical treatments:
- Treatment under arthroscopy
- Wedge approach to joint, bone chisels
- Joint replacement surgery or arthroplasty
Trang 51.3 Factors related to osteoarthritis
Degradation of articular cartilage and intervertebral discs is due tomany causes, which are mostly aging and mechanical factors to promotethe accelerated degradation, mechanical factors that increase downforce
on a surface area of joints and intervertebral discs are also calledoverloading phenomenon The mechanical factors including congenitalmalformations, deformations, trauma, increasing body weight, increasingpayload by occupation, habits, menopause, etc
1.4 The health care for rural residents
1.4.1 Role of Community health centers (CHCs)
In Vietnam, about 80% of the population lives in rural areas Thenearest and most accessible health care services are CHCs Thestrengthening activities as well as improving the quality of medicalfacilities, especially CHCs are necessary to improve people's access tohealth facilities and ensure equity in health care for all citizens
However, primary medical activities have not currently beencomprehensive, the quality of health care at community health centershave not improved remarkably The attractiveness of the CHCs in healthcare is low; people do not really trust the expertise of clinic staff
1.4.2 Knowledge of the diagnosis and treatments to common diseases
in the community of the medical workers at CHCs.
CHCs are the first health care facility for people in the community.However, the proportion of people using medical services at CHCS whenthey are ill, is very low despite a large team of health workers Thesituations about the capacity of the health workers is still a matter needed
to be concerned Most medical workers in CHCs are still lack ofknowledge and skills, especially the ability to examine and detectcommon diseases early
1.4.3 The abilities of diagnosis and management of knee OA at the
CHCs.
Currently, together with the increase in average life expectancy ofpeople in Vietnam, musculoskeletal diseases, especially knee OA iscommon, the more elderly people are the more severe the diseases are.After the age of 40-50, manifestation of the disease may appear, andwomen easily get down this disease twice as often as men If beingdetected and treated late, the treating effect is not as expected It isassociated with leaving jobs, reducing labor productivity and limit dailyactivities, even to lifelong disability Therefore, the role of healthworkers at the grassroots levels is vital in the early detection, proper
Trang 6treatment and counseling for people Whether medical workers havesufficient knowledge, detection skills, diagnosis and early treatment forknee OA in the community or not is an issue that needs to be addressed.According to a survey in Malaysia, most primary doctors orderunnecessary tests for the diagnosis of OA X-ray images can help in thediagnosis and severity of illness, but not always parallel with the clinicalmanifestations, in some cases people with X-ray evident of OA but noclinical symptoms In the diagnosis proccess to identify OA, blood testsare not worthy much, however, more than 50% of physicians at CHCsordered to specify blood tests, such as rheumatoid factor, uric acid,ANA, etc to diagnose the OA This can easily lead to misdiagnosis asrheumatoid arthritis or lupus if the RF tests or antinuclear antibodies(ANA) are positive.
Therefore, the authors strongly recommends that training for primarycare physicians focus on the diagnosis and management of OA, andpaying more attention to the musculoskeletal disorder in the trainingprogram at university and guiding OA management for primary carephysicians
CHAPTER 2 MATERIAL AND METHODS
2.1 Subjects of study
2.1.1 Study sites:
- For rural residents from 40 years above including female and male
in 02 communes in Gia Loc district, Hai Duong province
- For communal health workers of Hai Duong province
2.1.2 Subjects:
- For objective 1: People aged 40 and older including male and female
in Lien Hong and Gia Xuyen communes, Gia Loc district, Hai Duongprovince
- For objective 2: Medical doctors and assistant physicians areworking in 263 CHCs in Hai Duong province
2.2 Methods:
2.2.1 Design of study:
- Cross-sectional study: to determine the incidence, clinicalsymptoms, X-ray of the knee osteoarthritis and some related factors in 02communes of Gia Loc district, Hai Duong province Besides, we initial
Trang 7commented on the diagnosis and management of knee osteoarthritis inthe community.
- Intervention study: basing on cross-sectional study results,implementing interventions and evaluating its effectiveness forcommunity health workers is to improve knowledge on diagnosis,treatment and counseling for the knee OA patients, which alsocontributes to good health care for rural residents
2.2.2 Sample size estimation
* The sample size of the cross-sectional study
- Content 1: Determining the incident, clinical characteristic description,
X-ray and a number of related factors to the knee OA in people aged 40 years orolder in 02 communes of Gia Loc district, Hai Duong province, applying theformula of the sample size for cross-sectional descriptive study:
2 2
2 2 /
p
pq Z
n: number of individuals in the study sample
p: estimated propotion of OA (p = 0.3 estimated by the study ofNguyen Thi Nga)
q: the offset to 1 of p (q = 1 - p)
Z1- /2: Critical values of the standard distribution, apply to thesignificance level In this study = 0.05 Z1- /2 = 1.96
p: relative accuracy (: relative accuracy coefficient = 0.1)
Applying the formula above, the sample size for the randomsample, it is calculated: 2n = 1794
In the 23 communes of Gia Loc district, choosing 02 communes:Gia Xuyen and Lien Hong
Enumerating people aged 40 above in 2 communes is 2153 Weinvestigate all 2153 people aged 40 and older in these 02 communes
- Content 2: The capabilities of diagnosis, treatment and counseling for
the knee OA patients at CHCs (the subjects are medical doctors andassistant physicians): selecting all the medical doctors and assistantphysicians are working at 263 CHCs in Hai Duong province
- Content 3: Interventing to improve diagnostic, treating and counseling
capabilities of the knee OA at CHCs:
* The sample size of the intervention study: All medical doctors and
assistant physicians in 263 CHCs of Hai Duong province hadparticipated in cross-sectional study
2.2.3 Intervention
Trang 8Providing the training programme for health workers about knee OA,focusing on the diagnosis, treatment and counseling for the knee OApatients by musculoskeletal specialist doctor of Bach Mai Hospital.
2.2.4 Data collecting techniques
2.3 Research Ethics:
The proposal must be approved and decided by the commitee of HanoiMedical University and Ministry of Education and Training
CHAPTER 3 RESULTS 3.1 Describing the characterisstics of knee OA in people aged 40 and older from 02 communes in Gia Loc district, Hai Duong province in 2008.
Figuge 3.1:
Percentage
of knee OA (ACR
criteria in
1991 basing
on history and physical examination)
Comments: According to the investigated 2153 people aged 40 and
over, we found 584 of those with knee OA (27.1%)
21,1%
78,9%
pain in a joint pain in both joints
Figure 3.2: Site of knee OA
27,1%
72,9%
Knee OA Non Knee OA
Trang 9Comments: Of the 584 participants with knee OA, there were 78.9%
painful in both knee joints, while the number of patients suffering pain inone knee joint accounted for 21.1% 1
Table 3.1: Relationship between knee OA and age groups
Age group
Knee OA based
on physicalexaminationfindings
Not enoughsymptoms of knee
OA on physicalexamination
Comments: The prevalence of knee OA in groups of 50 upper is higher
than the group of 40-49 and gradually increases according to age groups
Table 3.2: Relationship between knee OA and gender
Gender
Knee OA based on
physicalexaminationfindings
Not enoughsymptoms of knee
OA on physicalexamination
Comments: The prevalence of knee OA in female is higher than
male (29.8% compared with 18.4%)
Table 3.3: Relation between knee osteoarthritis and BMI
Not enoughsymptoms of knee
OA on physicalexamination
Total
BMI < 23 456 25,8 1310 74,2 176 6 100
Trang 10p OR = 1,40 (1,12 – 1,80), p <0,05 Comments: Knee OA prevalence of people with BMI ≥ 23 were
considerably higher than the group with BMI <23 (33.1% compared with 25.8%)
Table 3.4: Knee osteoarthritis with a history of knee joint trauma
Not enoughsymptoms of knee
OA on physicalexamination
Comments: Patients with a trauma history having incidence of knee
OA is 2.44 times higher than those without history of trauma
Table 3.5: Knee OA with menstrual status of women
Knee OA
menstrual status
of women by age groups
Knee OAbased onphysicalexaminationfindings
Not enoughsymptoms ofknee OA onphysicalexamination
Comments: The results showed that the prevalence of knee OA in
menopause women increases comparing with menstrual women at all age groups
Table 3.6: Knee osteoarthritis with a history of childbearing
Knee OA
History of childbearing
By age groups
Knee OAbased onphysicalexaminationfindings
Not enoughsymptoms ofknee OA onphysicalexamination
Trang 11Comments: The results indicated that in the group aged 50 above,
women with 3 or more children manifesting clinical knee osteoarthritisare higher than women with 2 children or less
Table 3.7: Knee osteoarthritis with the nature of work
Index
Knee OA based
on physicalexaminationfindings
Not enoughsymptoms of knee
OA on physicalexamination
Comments: The prevalence of knee OA in the people carrying heavy
weight is remarkably higher than those carrying lightweight (31.6%compared with 10.1%) Similarly, for the people walking to workprimarily, this rate is also higher than those with less walking to work(32.6% compared with 15, 1%) p <0.001
Table 3.8: Knee osteoarthritis with carrying normal weight per once
Knee OA Knee OA based Not enough Total