Effect of diabetes mellitus on physical activity in patients with moderate-to-severe knee osteoarthritis scheduled for total knee arthroplasty: a cross-sectional study

doi:10.21203/rs.3.rs-1626193/v1

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Effect of diabetes mellitus on physical activity in patients with moderate-to-severe knee osteoarthritis scheduled for total knee arthroplasty: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-1626193/v1

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Background: Studies are now emphasizing on the involvement of risk factors like diabetes mellitus (DM) in knee osteoarthritis (OA). Patients with knee OA and those with DM have lower physical activity. However, whether patients with knee OA and DM have more decreased physical activity than do patients with only knee OA and whether DM is associated with physical activity in patients with moderate-to-severe knee OA who are scheduled for total knee arthroplasty (TKA) are unclear. The purpose of this study was to investigate differences in physical activity between patients with and without DM and to determine the association between physical activity and the presence of DM in patients with moderate-to-severe knee OA who are scheduled for TKA.

Methods: We evaluated 183 patients with moderate-to-severe knee OA who were scheduled for TKA. We evaluated knee function (i.e., knee flexion/extension range-of-motion, knee-extension strength, knee pain) and performance-based physical function (e.g., Timed Up-and-Go [TUG] test), and objectively measured physical activity using an accelerometer. Physical activity by intensity was compared between knee OA patients with DM and those without DM. The association between physical activity and DM, including knee function and performance-based physical function, was evaluated.

Results: The average daily step count was significantly fewer (p<0.001), and light-intensity physical activity (LPA) time (p<0.001) and moderate-to-vigorous-intensity physical activity (MVPA) time (p=0.006) were significantly shorter in knee OA patients with DM than in those without DM. After adjusting for age, sex, and body mass index, fewer average daily step count and shorter LPA time were significantly correlated with DM (β = -0.200, p=0.006; β = -0.216, p=0.004) and a longer TUG test time (β = -0.196, p=0.014; β = -0.208, p=0.011). Shorter MVPA time was significantly correlated with lower contralateral knee-extension strength (β = 0.187, p=0.032).

Conclusions: Knee OA patients with DM had lower physical activity than did knee OA patients without DM. The presence of DM was correlated with step count and LPA time in patients with moderate-to-severe knee OA scheduled for TKA. Our results suggested that the progression of decreased physical activity should be a concern for patients with both moderate-to-severe knee OA and DM.

Diabetes mellitus

Knee osteoarthritis

Physical activity

Knee osteoarthritis (OA) is the most common degenerative joint disease worldwide. It is a major cause of pain, disability, and socioeconomic loss, and it contributes to increasing the Global Burden of Disease [1, 2]. The severe pain associated with knee OA impairs activities and movements of daily living. A study of daily activities measured objectively in patients with knee OA demonstrated that most patients were physically inactive, spending two-thirds of their day sitting [3, 4], and approximately only 13% achieved the generally recommended level of activity [3]. Total knee arthroplasty (TKA) is the most effective and efficient treatment for patients with end-stage knee OA [5]. TKA is expected to restore joint function, reduce severe pain and functional disability [6], and consequently improve the quality and quantity of physical activity and shorten the number of years of disabled life. However, a recent systematic review of physical activity, measured with an accelerometer, indicates that physical activity 1 year after TKA remains at the preoperative level [7, 8].

However, in recent years, research on knee OA has led to increased emphasis on the involvement of risk factors of the so-called “metabolic syndrome” such as type 2 diabetes mellitus (DM) and dyslipidemia. A new phenotype, called “metabolic OA” or “diabetes-induced OA” that is specific to DM, has been defined [9, 10]. Approximately 260 million knee OA patients of all ages exist globally, whereas approximately 250 million people have type 2 DM; thus, both of these diseases are extremely common conditions [11]. Research has indicated that 14.4% of knee OA patients have DM [12].

Patients with type 2 DM often lack sufficient exercise [13, 14], and physical activity may be lower in patients with knee OA and DM, especially patients with moderate-to-severe knee OA scheduled for TKA, than in patients with knee OA alone. With regard to research examining the relationship between physical activity and DM in TKA patients, a study of TKA patients with DM revealed that knee function, physical function, and physical activity levels as assessed with a questionnaire, improved after TKA, whereas blood glucose and hemoglobin A1c (HbA1c) levels did not change [15]. Studies of TKA patients have demonstrated a significant increase in the prevalence of DM after TKA or no change of HbA1c level [16, 17]. Frimpong et al. [18] reported that light-intensity physical activity (LPA) improved 6 months after TKA, but moderate-to-vigorous-intensity physical activity (MVPA) did not improve. Boulé et al. [19] reported that, as exercise intensity increased, the HbA1c level decreased. Most previous reports have investigated physical activity by using questionnaires or have not investigated physical activity. As far as we have been able to determine, no reports exist on the association between physical activity by intensity and DM before and after TKA, using accelerometers to measure physical activity.

Therefore, this is a fundamental study carried out to investigate the association between physical activity and DM, before and after TKA. The purpose of this study was to investigate the differences in physical activity between patients with moderate-to-severe knee OA with and without DM, who are scheduled for TKA. We also examined the association between physical activity and the presence of DM and physical function. We hypothesized that patients with knee OA with DM would have lower physical activity than those without DM, and that MVPA in particular would be associated with DM.

Participants

This study was an exploratory cross-sectional study. Participants were radiographically diagnosed with knee OA (i.e., Kellgren‒Lawrence [KL] grade ≥ 2 in one or both knees [20]) and were recruited from the TKA scheduling list at Nagoya Orthopaedic and Joint Replacement Clinic (Kitanagoya, Japan). Patients were included if (1) they had been scheduled to undergo TKA from July 2018 to July 2019 and (2) they were able to walk independently on a flat surface with or without assistive devices. In participants scheduled to undergo bilateral TKA, the side with the highest KL grade (in cases with same grade, the most symptomatic side) was considered the “affected” side. The exclusion criteria were, as follows: (1) cognitive impairment, (2) neurological problems, (3) a history of surgical treatment for a fracture in the lower extremity and/or spine, or (4) patients with severe DM whose HbA1c level was > 8 or who were receiving insulin injections (i.e., the criteria for ineligibility for TKA).

The Ethics Committee of Seijoh University (Tokai, Japan; approval no. 2018A0006) and Nagoya University (Nagoya, Japan; approval no. 20–521) approved the study. All participants provided written informed consent.

Measures

Clinical data were collected before TKA. For all participants, the following outcome measurements were evaluated: knee function (i.e., knee flexion and extension range-of-motion [ROM], knee-extension muscle strength, and knee pain), performance-based physical function (measured with the Timed Up-and-Go [TUG] test), and objectively measured physical activity.

Knee function

Participants underwent knee function assessments 1‒3 weeks before TKA. Knee flexion and extension ROM were assessed as the angle formed by the intersection of the mechanical axes of the femur (i.e., the line from the greater trochanter to the lateral femoral epicondyle) and the lower leg (i.e., the line from the head of the fibula to the lateral malleolus of the fibula). A standard goniometer was used to measure passive knee flexion and extension ROM in the supine position.

Knee-extension muscle strength was measured during isometric contractions by using an isometric dynamometer (Isoforce GT-360; OG Wellness Technologies Co., Ltd., Okayama, Japan). Participants were seated upright on the dynamometer with the knee of the tested limb flexed to 60°. Chair depth, height, placement, and length of the attachment arm were adjusted for each participant. Participants were secured with straps at the distal shank, mid-thigh, pelvis, and trunk. Maximum contractions were attained within 3 s and were maintained for 5 s after the prior orientation. Standardized verbal encouragement was provided to elicit maximal effort from each participant and the maximum knee-extension muscle strength values were recorded. Each participant underwent two trials. Finally, the maximum muscle strength of the two trials was normalized to body weight and was used for data analysis. Knee pain intensity was measured using a 100-mm visual analog scale for pain in the affected and contralateral knee in the preceding week.

Performance-based physical function measure

We objectively assessed performance-based physical function, using one activity recommended by the Osteoarthritis Research Society International: time taken to perform the TUG test (i.e., ambulatory transitions). The TUG test [21] is a simple, commonly used, and reliable test for clinical use in individuals with or at risk of developing knee OA [22, 23]. Participants were instructed to rise from a chair (seat height of 40 cm), walk 3 m, turn around, return to the seat, and sit down at a normal speed without physical assistance (although assistive devices could be used, if necessary). The time to perform this test was measured once by using a stopwatch.

Physical activity

Three to 4 weeks before TKA, physical activity was measured for 14 consecutive days by using a uniaxial accelerometer (Lifecorder; Suzuken Co., Ltd., Nagoya, Japan), which is widely used by children to older individuals in Japan and worldwide [24–28]. We distributed explanatory leaflets and provided oral explanations to each participant as to the manner of wearing the accelerometer. Participants were instructed to wear the accelerometer at their waist level, above either leg, constantly throughout the day, except during sleep and water-related activities (e.g., bathing, showering, swimming). To be included in the study, participants needed to wear the accelerometer for ≥ 4 days (including 1 weekend day) with at least 10 hours of wear time per day [29]. “Nonwear time” was defined as a period of at least 60 consecutive minutes when body movement data were not recorded with allowance for up to 2 minutes of some limited movement [29]. The accelerometer data were edited and aggregated using physical activity analysis software (LifeLyzer05 Coach; Suzuken Co., Ltd., Nagoya, Japan). Based on the eleven exercise intensity levels from the accelerometer data (the device records a signal at intensity level 0, 0.5, or 1–9 every 4 seconds while being worn), physical activity intensities were classified as light (i.e., intensity level 1–3; ≥1.5 to < 3 metabolic equivalents [METs]), moderate (i.e., intensity level 4–6; ≥3 to < 6 METs), or vigorous (i.e., intensity level 7–9; ≥6 METs) [24]. The average daily step count (in steps/day) and time spent in physical activity at the respective intensity were calculated. Nearly 70% of the participants did not accumulate any time spent in vigorous intensity physical activity; therefore, a single variable was constructed that combined accumulated time spent in moderate and vigorous intensity physical activity [30].

Demographic characteristics and laboratory data

Data on age, sex, height, weight, radiographic OA severity, and laboratory data (e.g., HbA1c, fasting plasma glucose, triglycerides, total cholesterol, high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein cholesterol) were collected from the clinical records. Body mass index (BMI) was calculated by dividing the weight by the square of the height. Radiographic OA severity of the tibiofemoral joint, based on KL grades [20], was assessed for each patient in the anteroposterior and weight-bearing position by a trained examiner (orthopedist). DM was defined as an elevated fasting plasma glucose level (≥ 126 mg/dL) or HbA1c level (≥ 6.5%), a history of a physician’s diagnosis of DM, or the use of antidiabetic medications [31].

Data analyses

The sample size was determined as the number of all eligible patients attending the clinic during the study period. All statistical analyses were conducted using SPSS v25 (IBM Japan, Tokyo, Japan). Participants were categorized into two groups: individuals with DM and individuals without DM. Each outcome variable was statistically compared between participants with and without DM. In these comparisons, univariate analyses were conducted using Student’s t-test for parametric continuous variables, the Mann‒Whitney U test for nonparametric continuous variables, and the chi-square/Fisher’s exact test for dichotomous/categorical variables. The normality of continuous variables was assessed with the Shapiro‒Wilk test. The homogeneity of the variances between groups was confirmed for all parametric continuous variables by using Levene’s test. Descriptive statistics were calculated as the mean and standard deviation for continuous variables and as the proportion for dichotomous/categorical variables.

To evaluate the effect of DM on physical activity, we conducted hierarchical multiple linear regression analysis with physical activity parameters (e.g., average daily step count, time spent in LPA and in MVPA) as the dependent variables, while adjusting for age, sex, and BMI. These adjustment variables were chosen a priori, based on clinical judgment, because they may be associated with physical activity [32]. The independent variable was DM (0 is without DM, 1 is with DM), whereas knee pain, knee flexion/extension ROM, and knee-extension muscle strength were simultaneously included in the model. These independent variables were chosen a priori, based on clinical judgment for possibly being associated with physical activity and knee OA [33, 34]. Each model had two steps. In step 1, the adjustment variables were included by using the forced-entry method. In step 2, DM, knee pain, knee flexion/extension ROM, and knee-extension muscle strength were further included by using the stepwise method. All independent variables were screened for multicollinearity by calculating the variance inflation factor. For residual analysis, independence of residual errors was assessed using the Durbin‒Watson statistic. The Durbin‒Watson statistic in the range of 1.5‒2.5 indicated independence. The standardized partial regression coefficient (β) was used to interpret the significance of correlations. A p-value < 0.05 was considered statistically significant.

In total, 227 patients with moderate-to-severe knee OA were scheduled to undergo TKA between July 2018 and July 2019. Fig. 1 is the flow diagram showing the process for inclusion in the analysis. One hundred eighty-three patients (28 men, 155 women) were included in the analysis. Forty-four patients were excluded: one patient had a neurological problem, three patients had a history of surgical treatment for a fracture in the lower extremities, and 40 patients could not give consent.

Among the 183 participants, 46 (25.1%) patients had DM with an HbA1c level of ≤8.0%. Furthermore, 43 (23.5%) patients had an operated knee on the contralateral side. Table 1 summarizes the characteristics of participants with and without DM. Participants with DM were significantly heavier (p=0.001); had a higher BMI (p<0.001) and higher levels of HbA1c (p<0.001), fasting plasma glucose (p<0.001), and triglycerides (p=0.024); and had lower levels of total cholesterol (p=0.032) and HDL cholesterol (p=0.001). No significant differences existed between the two groups in severity of knee OA (i.e., KL grade) and age. Participants with DM had lower knee flexion ROM on the affected and contralateral side (p=0.028 and p=0.039, respectively) and lower knee-extension ROM on the contralateral side (p=0.006). An important finding was that participants with DM had fewer average daily step count (p<0.001) and less time spent in LPA and MVPA (p<0.001, p=0.006, respectively).

Table 1 Summary of the characteristics of knee osteoarthritis participants with and without diabetes mellitus

Variable	All (n = 183) Mean ± SD or n (%)	Without DM (n = 137) Mean ± SD or n (%)	With DM (n = 46) Mean ± SD or n (%)	p-value*
Demographic characteristic
Age (y)	74.9 ± 6.4	74.7 ± 6.6	75.4 ± 6.1	0.735
Sex
Men	28 (15.3)	19 (13.9)	9 (19.6)	0.353
Women	155 (84.7)	118 (86.1)	37 (80.4)
Height (cm)	153.2 ± 7.4	153.2 ± 7.3	153.5 ± 7.9	0.999
Weight (kg)	59.6 ± 10.4	58.1 ± 9.8	64.1 ± 10.9	0.001
BMI (kg/m²)	25.3 ± 3.5	24.7 ± 3.2	27.1 ± 3.8	<0.001
Severity of knee OA
Kellgren‒Lawrence grade on affected side (3/4)	25/ 158 (13.7/86.3)	18/ 119 (13.1/86.9)	7/ 39 (15.2/84.8)	0.722
Kellgren‒Lawrence grade on contralateral side (2/3/4/operated/unknown)	17/35/86/43/2 (9.3/9.1/47.0/23.5/1.1)	14/27/64/31/1 (10.2/19.7/46.7/22.6/0.7)	3/8/22/12/1 (6.5/17.4/47.8/26.1/2.2)	0.836
Laboratory data
HbA1c (%)	5.8 ± 0.5	5.6 ± 0.3	6.4 ± 0.5	<0.001
Fasting plasma glucose (mg/dl)	99.7 ± 25.1	94.7 ± 11.9	114.6 ± 42.7	<0.001
Triglycerides (mg/dl)	145.8 ± 76.2	137.7 ± 68.5	169.8 ± 92.4	0.024
Total cholesterol (mg/dl)	197.5 ± 36.5	200.7 ± 37.3	188.0 ± 32.4	0.032
HDL cholesterol (mg/dl)	59.9 ± 13.4	61.5 ± 13.6	54.9 ± 11.5	0.001
LDL cholesterol (mg/dl)	111.7 ± 29.4	113.2 ± 29.0	107.2 ± 30.3	0.081
Knee function
Knee flexion ROM (°)
Affected side	130.1 ± 14.0	131.3 ± 13.9	126.6 ± 13.7	0.028
Contralateral side	129.2 ± 13.6	130.4 ± 13.4	125.8 ± 13.8	0.039
Knee-extension ROM (°)
Affected side	-6.4 ± 5.8	-6.2 ± 5.7	-7.2 ± 5.8	0.314
Contralateral side	-5.1 ± 6.0	-4.5 ± 5.9	-6.8 ± 6.0	0.006
Knee-extension muscle strength (Nm/kg)
Affected side	1.03 ± 0.36	1.02 ± 0.38	1.05 ± 0.32	0.619
Contralateral side	1.16 ± 0.38	1.18 ± 0.40	1.12 ± 0.33	0.356
Knee pain, VAS (mm)
Affected side	53.0 ± 25.6	53.9 ± 25.3	50.2 ± 26.7	0.380
Contralateral side	27.8 ± 25.3	28.0 ± 24.8	27.3 ± 27.2	0.737
Performance-based physical function measure
TUG test time (s)	12.8 ± 5.2	12.7 ± 4.6	13.0 ± 6.5	0.964
Physical activity
Average daily step count (steps/day)	4275.4 ± 2420.7	4656.7 ± 2472.9	3122.1 ± 1845.5	<0.001
Time spent in LPA (min)	45.0 ± 24.2	49.0 ± 24.6	32.9 ± 18.2	<0.001
Time spent in MVPA (min)	4.0 ± 5.1	4.5 ± 5.5	2.5 ± 3.4	0.006

BMI Body mass index, OA Osteoarthritis, DM Diabetes mellitus, HbA1c Hemoglobin A1c, HDL High-density lipoprotein, LDL Low-density lipoprotein, ROM Range-of-motion, VAS Visual analog scale, TUG Timed Up-and-Go, LPA Light-intensity physical activity, MVPA Moderate-to-vigorous-intensity physical activity, SD Standard deviation

* Based on unadjusted analysis (Student’s t-test [weight, BMI, HbA1c, and knee-extension muscle strength on both side] or Mann‒Whitney U test [age, height, fasting plasma glucose, triglycerides, total, HDL and LDL cholesterol, knee flexion and extension ROM on both side, knee pain on both side, TUG test time, average daily step count, time spent in LPA, and time spent in MVPA] or the chi-square test [sex]) between OA patients with and without DM. Non-normality of continuous variables was assessed using the Shapiro‒Wilks test (p<0.05); these variables were analyzed using the Mann‒Whitney U test.

Note: The values in bold font indicate statistically significant effects.

Hierarchical multiple linear regression analysis, after adjusting for age, sex, and BMI, revealed that fewer average daily step count was significantly correlated with DM (β = -0.200; p=0.006) and a longer TUG test time (β = -0.196; p=0.014) (Table 2). Furthermore, less time spent in LPA was significantly correlated with DM (β = -0.216; p=0.004) and a longer TUG test time (β = -0.208; p=0.011) (Table 3). Less time spent in MVPA was significantly correlated only with more decreased knee-extension muscle strength on the contralateral side (β = 0.187; p=0.032) (Table 4).

Table 2 Effect of diabetes mellitus on the average daily step count

	Step 1			Step 2
	B	β	p-value	B	β	p-value
Intercept	21988.0		<0.001	19108.4		<0.001
Age	-187.1	-0.486	<0.001	-145.3	-0.378	<0.001
Sex (0: men; 1: women)	445.8	0.066	0.361	406.0	0.060	0.390
BMI	-161.8	-0.246	0.001	-114.0	-0.173	0.020
DM (0: without DM; 1: with DM)				-1102.1	-0.200	0.006
TUG test time				-89.8	-0.196	0.014
Adjusted R²	0.237			0.297

BMI Body mass index, DM Diabetes mellitus, TUG Timed Up-and-Go

Note: B is the partial regression coefficient and β is the standardized partial regression coefficient. Bold values indicate a statistically significant effect.

Table 3 Effect of diabetes mellitus on time spent in light-intensity physical activity

	Step 1			Step 2
	B	β	p-value	B	β	p-value
Intercept	12140.3		<0.001	10308.9		<0.001
Age	-97.2	-0.424	<0.001	-70.8	-0.308	<0.001
Sex (0: men; 1: women)	333.6	0.083	0.268	306.7	0.076	0.291
BMI	-96.6	-0.246	0.001	-65.9	-0.168	0.028
DM (0: without DM; 1: with DM)				-710.8	-0.216	0.004
TUG test time				-56.7	-0.208	0.011
Adjusted R²	0.187			0.257

BMI Body mass index, DM Diabetes mellitus, TUG Timed Up-and-Go

Note: B is the partial regression coefficient and β is the standardized partial regression coefficient. Bold values indicate a statistically significant effect.

Table 4 Effect of diabetes mellitus on time spent in moderate-to-vigorous-intensity physical activity

	Step 1			Step 2
	B	β	p-value	B	β	p-value
Intercept	2385.9		<0.001	1809.2		<0.001
Age	-24.3	-0.501	<0.001	-21.2	-0.437	<0.001
Sex (0: men; 1: women)	12.5	0.015	0.840	71.8	0.084	0.284
BMI	-13.5	-0.162	0.028	-8.7	-0.105	0.176
Knee-extension muscle strength on the contralateral side				149.8	0.187	0.032
Adjusted R²	0.230			0.249

BMI Body mass index

Note: B is the partial regression coefficient and β is the standardized partial regression coefficient. Bold values indicate a statistically significant effect.

The VIF was below 10, which indicated that no collinearity existed among the variables and that any significant relationships were not inflated by correlations between the independent variables [35]. Residual plots revealed a random distribution pattern. Independence was observed among the residual errors of average daily step count, time spent in LPA, and time spent in MVPA (the Durbin–Watson statistic was 1.937, 1.912 and 1.936, respectively). These findings indicated that the multivariate regression analysis results in this study were valid.

In this study, the physical activity of patients with DM and without DM who were scheduled for TKA for moderate-to-severe knee OA was compared to determine whether physical activity and the presence of DM were associated. We found that physical activity was lower among knee OA patients with DM than among those without DM. Adjusted age, sex, and BMI, average daily step count, and LPA time were correlated with the presence of DM and the TUG test time, whereas MVPA time was correlated with knee-extension muscle strength on the contralateral side.

The prevalence of DM in patients with knee OA was 14.4% in a meta-analysis by Louati et al. [12], although the prevalence in individual studies since 2010 that were used in this meta-analysis ranged from 5.2–38.0%. The prevalence in the present study was 25.1%. This value was higher than the reported value of 14.4%, but it was within the range of prevalence in studies reported since 2010, which indicated that the participants in our study were similar to those in previous studies.

The LPA time was 32.9% lower and the MVPA time was 44.4% lower in participants with DM than in those without DM. When a person’s activity is limited to inside the home, they engage in approximately 4000 steps/day and less than 5 minutes/day of MVPA [36–38]. In the present study, the average daily step count was 4656 steps among participants without DM and 3122 steps among those with DM, and the MVPA time was 4.5 minutes/day among participants without DM and 2.5 minutes/day among those with DM. Both groups demonstrated < 5 minutes/day of MVPA, and it was particularly low for participants with DM. The finding that the group with DM also took fewer than 4000 steps/day suggested that knee OA patients with DM, in particular, are active only at home and highlights their high level of inactivity.

Our results showed that, in addition to the presence of DM, the TUG test time was correlated with step count and LPA time. The TUG test time is an appropriate clinical measure of functional mobility and balance [39]. Patients with balance-related disabilities most often exhibit impairments in standing balance, have slow walking speeds, and/or are unable to perform the chair–stand test [40]. In patients with arthritis, which includes most OA patients, mobility and gait limitations are factors that can lead to insufficient activity [41]. The aforementioned findings suggested that patients with moderate-to-severe knee OA who are scheduled for TKA tend to decrease their step count and LPA time as their mobility and balance decrease, as assessed by the TUG test.

The MVPA time was correlated with knee-extension muscle strength on the contralateral side, and was not correlated with the presence of DM, which was contrary to our hypothesis. In previous research on the effect of knee-extension muscle strength on MVPA time, increased MVPA time was correlated with higher knee-extension muscle strength in middle-aged women, but LPA time was not correlated with knee-extension muscle strength [42]. Aoyagi et al. [27] report that knee-extension muscle strength exhibits significant positive correlations with daily step count and with MVPA time in older people. Later research demonstrated that lower-limb muscle mass was more closely associated with MVPA time than with the daily step count [43]. Furthermore, the participants in the present study had lower knee-extension muscle strength on the affected side than on the contralateral side (Table 1), which suggested that activities focused on the contralateral side could help the activity of these patients. These findings suggested that, in patients with moderate-to-severe knee OA scheduled for TKA, MVPA cannot be maintained because of reduced knee-extension muscle strength on the contralateral side rather than because of DM.

On comparing the groups with and without DM, only ROM among the knee functions was significantly more limited in the group with DM than in the group without DM, despite no significant differences in severity (i.e., KL grade) or age. The main factors affecting joint mobility in DM are increased stiffness of the joint capsules, ligaments, and tendons for which the underlying mechanism involves nonenzymatic glycosylation of collagen, accompanied by the formation of advanced glycated endproducts. Muscles are also involved with increased collagen content in the muscles and reduced contractility of the muscle fibers [44], which suggests that knee ROM is limited. However, Miner et al. [45] report that the satisfaction and quality of life of patients who underwent TKA were not correlated with knee ROM. Robertson et al. [46] report that knee ROM at 1‒10 years after TKA was worse in patients with DM, even though the Knee Society Scores did not change. This finding may explain why knee ROM was not correlated with physical activity in the hierarchical multiple regression analysis in the present study.

The recommended nonsurgical treatments for knee OA are exercise therapy such as muscle strengthening, aerobic exercise, and balance training; the use of walking aids; and patient education that includes advice on achieving a healthy lifestyle such as maintaining regular physical activity [47, 48]. In TKA patients, physical activity at 1 year after TKA reportedly remains at preoperative levels [7, 8]. In particular, knee OA patients with DM have significantly lower physical activity, which raises concerns about postoperative physical inactivity. Rehabilitation to increase physical activity in knee OA patients with DM is necessary, even before TKA.

A strength of this study is that the physical activity of patients with moderate-to-severe knee OA with and without DM was objectively measured using an accelerometer. Most previous studies have investigated physical activity by using questionnaires. We believe that our study is the first to investigate the physical activity of patients with moderate-to-severe knee OA with DM. This study had several limitations that should be considered when interpreting the findings. First, accelerometers cannot track certain types of physical activity (e.g., water-related activities and cycling) and cannot distinguish posture. Second, some participants had undergone TKA on the contralateral side. Third, the control of DM is a criterion for TKA; therefore, patients with severe DM such as an HbA1c level > 8% and patients being treated with insulin injections were not included. Fourth, physical activity has been correlated with psychological factors, psychosocial factors, and environmental factors as well as age, sex, and physical factors [32, 37, 49]. However, psychological factors, psychosocial factors, and environmental factors were not investigated in this study. Fifth, this study was a cross-sectional study and thus could not identify causation.

In this study, we found that patients with moderate-to-severe knee OA scheduled for TKA, even patients with mild DM, had lower physical activity than did those without DM. In the future, longitudinal determinant studies will be needed to better understand the factors that affect physical activity in patients with moderate-to-severe knee OA.

Among patients with moderate-to-severe knee OA scheduled for TKA, knee OA patients with DM had lower physical activity than did those without DM. The presence of DM, mobility, and balance ability were correlated with step count and LPA time. Knee-extension muscle strength on the contralateral side was correlated with MVPA time.

This study was a fundamental study to investigate the relationship between physical activity before and after TKA and DM. The results of this study demonstrated that DM is correlated with physical activity in knee OA patients before TKA. Therefore, future studies should consider interventions to increase physical activity in patients with knee OA and DM, before TKA. Furthermore, we would like to investigate physical activity in knee OA patients before and after TKA, focusing on the relationship between physical activity and DM, to use the results to develop interventions to increase physical activity.

BMI: Body mass index; DM: Diabetes mellitus; HbA1c: Hemoglobin A1c; HDL: High-density lipoprotein; KL: Kellgren‒Lawrence; LPA: Light-intensity physical activity; MET: Metabolic equivalent; MVPA: Moderate-to-vigorous-intensity physical activity; OA: Osteoarthritis; ROM: Range-of-motion; TKA: Total knee arthroplasty; TUG: Timed Up-and-Go; VIF: Variance inflation factor

Ethics approval and consent to participate

The study was conducted in line with the principles of the Declaration of Helsinki and approved by the Ethics Committee of Seijoh University (Tokai, Japan; approval no. 2018A0006) and Nagoya University (Nagoya, Japan; approval no. 20-521). All methods were conducted in accordance with the relevant guidelines and regulations. All participants provided written informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by Grants-in-Aid for Scientific Research (JSPS KAKENHI; grant no. JP19K19749).

Authors’ contributions

RF contributed to the study design, data collection, data analysis, interpretation, and writing and revising the manuscript. S. Ota and HS contributed to the study conception and design, data analysis and interpretation, and revising the manuscript. YY, AK, and HW contributed to recruiting participants and data collection and interpretation. TI and S. Ozeki contributed to data collection and interpretation. All authors have read and approved the final manuscript.

Acknowledgements

We would like to thank the participants in this study. We also acknowledge Naomichi Matsunaga, PT, MS; Jun Mizusawa, PT, MS; Nao Masaoka, PT; and the staff members of the Nagoya Orthopaedic and Joint Replacement Clinic (Kitanagoya, Japan) for assistance with data collection.

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No competing interests reported.

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Effect of diabetes mellitus on physical activity in patients with moderate-to-severe knee osteoarthritis scheduled for total knee arthroplasty: a cross-sectional study

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Abstract

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Background

Methods

Participants

Measures

Knee function

Performance-based physical function measure

Physical activity

Demographic characteristics and laboratory data

Data analyses

Results

Discussion

Conclusion

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References

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