Understanding the physical and psychological impairments and associated disability characterising individuals with ankle symptoms and osteoarthritis

Abstract

Musculoskeletal conditions are associated with pain, disability and impaired quality of life (QoL). Osteoarthritis (OA) is a common, costly and disabling musculoskeletal condition. Lower limb OA research has focussed on the hip and knee and, as a consequence, impairments characterising ankle OA are not well understood. This thesis aims to advance our understanding of the physical, functional and psychological impairments and associated disability in individuals with persistent ankle symptoms and in those with radiographic evidence of ankle OA.Study 1A systematic literature review and meta-analysis was conducted to synthesise and appraise the quality of studies investigating physical impairments in ankle OA. The review identified eight studies, three of which were included in the meta-analyses. Meta-analyses revealed large impairments of ankle sagittal plane range of motion (ROM) on the affected compared to the unaffected side and less sagittal plane torque in ankle OA compared to controls. Evidence from single studies indicated deficits in frontal plane ROM and strength, talar translation and rotation, balance, electromyography of ankle muscles, abnormal bony alignments and greater fatty infiltrate in all calf muscle compartments in individuals with ankle OA. Critical appraisal of the literature revealed limitations surrounding assessor blinding, measurement validity, and lack of generalization.:Study 2:A cross-sectional laboratory study of 96 participants compared physical measures of function, strength, ROM and posture and patient-reported outcomes in 1) individuals with symptoms and radiographic evidence of ankle OA to asymptomatic individuals; and 2) asymptomatic individuals with and without radiographic evidence of ankle OA. Those with symptomatic OA reported greater pain, disability, instability, kinesiophobia, lower function and QoL, and exhibited significant deficits in muscle strength, ROM and ambulatory function compared to asymptomatic individuals. Most patient-reported and physical outcomes were similar between asymptomatic individuals with and without radiographic OA. Stair function times were significantly associated with QoL and self-reported function.Study 3:A cross-sectional exploratory survey (n=394) was conducted to compare self-reported daily living and sports function, ankle pain and disability, physical activity, ankle instability, and QoL between individuals with and without persistent ankle pain and stiffness, and to explore factors associated with QoL. Individuals with ankle symptoms reported worse scores for all measures, except self-reported physical activity. Daily living function and age explained 66% of the variance in QoL.Study 4:Individuals with and without persistent ankle pain and stiffness (n= 231) participated in an online survey to obtain data about pain severity, pain self-efficacy, anxiety, depression, kinesiophobia, pain catastrophizing, and function. Individuals with persistent ankle pain reported higher pain and depressive symptoms, and lower function than controls. Higher pain self-efficacy and lower levels of ankle pain and kinesiophobia were associated with a better function in the symptomatic group.Study 5:Work limitation, function, and psychological features were compared between working individuals with and without persistent ankle symptoms and between working and non-working individuals with persistent ankle symptoms. Working individuals with ankle symptoms reported higher pain levels, work limitation, and lower function than working controls. Among the symptomatic group, individuals who remained in the workplace were significantly younger with less pain in the ankle and in other body sites, and at a lower risk of clinical catastrophising than individuals who were not working. Working individuals also reported higher function and pain self-efficacy compared to non-working symptomatic individuals. Total psychological stress, depression and catastrophizing were significantly lower among the working than non-working symptomatic individuals. Higher levels of depression and kinesiophobia and lower pain self-efficacy were associated with greater work limitation. Study 6:Data on the number of falls and associated injuries/hospitalization in the past 12 months, balance confidence, falls efficacy, function, and comorbidities associated with risk of falling were collected in individuals with and without persistent ankle pain and stiffness using an online survey (n=226). Individuals with persistent ankle pain and stiffness reported more falls, greater fear of falling, more fall-related injuries, lower function and balance confidence when compared to controls. The number of falls was associated with fear of falling and severity of ankle pain.This thesis has demonstrated that individuals with symptomatic ankle OA present with impairments in ambulation, ROM, muscle strength and endurance compared to asymptomatic individuals. Interestingly, there were minimal differences in these outcomes between individuals with and without radiographic OA who did not have ankle symptoms. This suggests the presence of ankle pain and stiffness has a greater influence on function and impairments than radiographic OA at the ankle. Further, our data indicate that persistent ankle pain and stiffness negatively impacts QoL and function and is associated with limitations at work, increased falls and psychological impairment. Further research is needed to better understand the mediators of the poorer physical impairments in ankle OA, psychological distress, and QoL in those with persistent ankle pain and stiffness. This would plausibly lead to more directed investigations of the effect of interventions for ankle OA.