The Challenges in the Primary Prevention of Osteoarthritis
2022; Elsevier BV; Volume: 38; Issue: 2 Linguagem: Inglês
10.1016/j.cger.2021.11.012
ISSN1879-8853
AutoresJ. Runhaar, Sita Bierma‐Zeinstra,
Tópico(s)Asthma and respiratory diseases
Resumo•Many experts call for a focus on the primary prevention of osteoarthritis.•Preventing the development of osteoarthritis is not as straightforward as it may seem.•Osteoarthritis prevention research should be deemed highly important to oppose the predicted increase in osteoarthritis development and associated costs to health care and society in the near future. •Many experts call for a focus on the primary prevention of osteoarthritis.•Preventing the development of osteoarthritis is not as straightforward as it may seem.•Osteoarthritis prevention research should be deemed highly important to oppose the predicted increase in osteoarthritis development and associated costs to health care and society in the near future. For years, osteoarthritis (OA) has been ranked among the diseases with the largest impact on patients and society.1Diseases G.B.D. Injuries C. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Google Scholar In the absence of disease-modifying drugs and small to moderate efficacy of symptom relieving therapies, the urge for primary prevention increases.2Hunter D.J. Bierma-Zeinstra S. Osteoarthritis.Lancet. 2019; 393: 1745-1759Google Scholar, 3Runhaar J. Zhang Y. Can we prevent OA? Epidemiology and public health insights and implications.Rheumatology (Oxford). 2018; 57: iv3-iv9Google Scholar, 4Roos E.M. Arden N.K. Strategies for the prevention of knee osteoarthritis.Nat Rev Rheumatol. 2016; 12: 92-101Google Scholar The theoretic basis of primary prevention of OA might sound simple, appealing, and feasible: preventing the onset of OA among subjects without but at high risk for OA. Nevertheless, there are many pitfalls in different aspects related to the initiation of preventive measures in both clinical and research settings. To name a few: how and where can we identify the appropriate target groups? What interventions have an acceptable risk-benefit profile in the absence of symptoms in the ones we treat? How do we establish adherence to the intervention when patients cannot experience any benefits of the intervention? How do we evaluate the preventive effectiveness of the intervention in a slowly developing disease such as OA? The current review addresses some of these key challenges in preventing OA, provides insights into our current knowledge, and highlights some essential knowledge gaps in OA prevention. For this, we use a slightly modified version of the well-known PICO approach; in the absence of OA at the initiation of any primary preventive therapy, the P for "patient" in the traditional PICO should be replaced by either "population" or "target group." As trivial as this might seem, this has important implications, mainly for the choice and uptake of a preventive intervention. Given the high prevalence, we will focus on knee, hip, and hand OA. The traditional approach to identify a target population for preventive measures for any condition is through identifying its risk factors. For OA, many risk factors have been identified over the years. Some of the most studied and well-known risk factors for knee OA development include older age, female sex, overweight/obesity, joint trauma, genetic predisposition, and occupational loading.5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar, 6Blagojevic M. Jinks C. Jeffery A. et al.Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2010; 18: 24-33Google Scholar, 7Canetti E.F.D. Schram B. Orr R.M. et al.Risk factors for development of lower limb osteoarthritis in physically demanding occupations: a systematic review and meta-analysis.Appl Ergon. 2020; 86: 103097Google Scholar, 8Spector T.D. MacGregor A.J. Risk factors for osteoarthritis: genetics.Osteoarthritis Cartilage. 2004; 12: S39-S44Google Scholar Although less strong, overweight/obesity has also been established as a risk factor for hip OA development.9Jiang L. Rong J. Wang Y. et al.The relationship between body mass index and hip osteoarthritis: a systematic review and meta-analysis.Joint Bone Spine. 2011; 78: 150-155Google Scholar,10Lievense A.M. Bierma-Zeinstra S.M. Verhagen A.P. et al.Influence of obesity on the development of osteoarthritis of the hip: a systematic review.Rheumatology (Oxford). 2002; 41: 1155-1162Google Scholar Other risk factors for hip OA development include altered joint shape, high-impact sports, occupational loading, and genetic predisposition.7Canetti E.F.D. Schram B. Orr R.M. et al.Risk factors for development of lower limb osteoarthritis in physically demanding occupations: a systematic review and meta-analysis.Appl Ergon. 2020; 86: 103097Google Scholar,8Spector T.D. MacGregor A.J. Risk factors for osteoarthritis: genetics.Osteoarthritis Cartilage. 2004; 12: S39-S44Google Scholar,11van Buuren M.M.A. Arden N.K. Bierma-Zeinstra S.M.A. et al.Statistical shape modeling of the hip and the association with hip osteoarthritis: a systematic review.Osteoarthritis Cartilage. 2021; 29: 607-618Google Scholar, 12Lievense A.M. Bierma-Zeinstra S.M. Verhagen A.P. et al.Influence of sporting activities on the development of osteoarthritis of the hip: a systematic review.Arthritis Rheum. 2003; 49: 228-236Google Scholar, 13Lievense A. Bierma-Zeinstra S. Verhagen A. et al.Influence of work on the development of osteoarthritis of the hip: a systematic review.J Rheumatol. 2001; 28: 2520-2528Google Scholar Female sex, older age, overweight/obesity, occupational loading, local muscle weakness, and genetic predisposition are all known to increase the risk for incident hand OA.8Spector T.D. MacGregor A.J. Risk factors for osteoarthritis: genetics.Osteoarthritis Cartilage. 2004; 12: S39-S44Google Scholar,14Kalichman L. Hernandez-Molina G. Hand osteoarthritis: an epidemiological perspective.Semin Arthritis Rheum. 2010; 39: 465-476Google Scholar, 15Jiang L. Xie X. Wang Y. et al.Body mass index and hand osteoarthritis susceptibility: an updated meta-analysis.Int J Rheum Dis. 2016; 19: 1244-1254Google Scholar, 16Leung G.J. Rainsford K.D. Kean W.F. Osteoarthritis of the hand I: aetiology and pathogenesis, risk factors, investigation and diagnosis.J Pharm Pharmacol. 2014; 66: 339-346Google Scholar A very important point to consider here is the fact that most studies on risk factors for OA development have focused on the development of OA disease, that is, pathologic changes in joint tissues. In the available systematic reviews on risk factors for OA development, very little evidence is available for risk factors for OA illness, that is, symptoms and complaints of OA.17Whittaker JL, Runhaar J, Bierma-Zeinstra MA, et al., A lifespan approach to osteoarthritis prevention. Osteoarthritis Cartilage, 2021. (in press).Google Scholar Nevertheless, it is the actual OA illness that drives the large burden for patients and causes major direct and indirect costs for society and health care. Moreover, radiographic OA (OA disease) in the absence of pain was not associated with mortality, whereas OA pain (illness) in the presence and absence of radiographic OA was associated with a 35% to 37% increased risk for mortality in the general population.18Leyland K.M. Gates L.S. Sanchez-Santos M.T. et al.Knee osteoarthritis and time-to all-cause mortality in six community-based cohorts: an international meta-analysis of individual participant-level data.Aging Clin Exp Res. 2021; 33: 529-545Google Scholar Given the general importance of OA illness over OA disease, the focus of OA prevention should be on OA illness, and better insights into risk factors for the onset of OA illness are required. After selecting established risk factors for OA development in the joint of interest, taking the OA illness versus disease concept into account, the identification of a target group for the prevention of OA could focus either on those at risk for a certain risk factor (eg, those at risk for knee joint trauma or at risk for overweight/obesity) or on those with a certain risk factor (eg, those with a recent knee joint trauma or those with overweight/obesity). The list of risk factors described here is far from exhaustive but is rather meant to illustrate that a strong risk factor for OA development does not always easily translate into the identification of a feasible target population. Both modifiable and nonmodifiable risk factors will be addressed; modifiable risk factors (eg, lifestyle, body weight, occupational loading) are amenable to interventions and therefore help to shape the preventive interventions, whereas nonmodifiable risk factors (eg, age, sex, genetic predisposition) are not amenable to interventions but can be used to identify the right target population. For one of the strongest risk factors for knee OA development, joint trauma,5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar,6Blagojevic M. Jinks C. Jeffery A. et al.Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2010; 18: 24-33Google Scholar,19Poulsen E. Goncalves G.H. Bricca A. et al.Knee osteoarthritis risk is increased 4-6 fold after knee injury - a systematic review and meta-analysis.Br J Sports Med. 2019; 53: 1454-1463Google Scholar identification of individuals at risk seems relatively straight forward; sports that put players at increased risk for joint trauma include soccer and rugby for meniscal injuries and American football, soccer, and gymnastics for anterior cruciate ligament (ACL) injuries.20Bram J.T. Magee L.C. Mehta N.N. et al.Anterior cruciate ligament injury incidence in adolescent athletes; A systematic review and meta-analysis.Am J Sports Med. 2021; 49: 1962-1972Google Scholar,21Snoeker B.A. Bakker E.W. Kegel C.A. et al.Risk factors for meniscal tears: a systematic review including meta-analysis.J Orthop Sports Phys Ther. 2013; 43: 352-367Google Scholar Selecting individuals participating in these "high-risk sports" could be a very feasible approach to identify a potential target population for preventive measures. Nevertheless, the incidence of ACL injuries per 1000 hours of athlete exposure ranges between 0.10 and 0.17 only, which leads to very high "numbers needed to treat."20Bram J.T. Magee L.C. Mehta N.N. et al.Anterior cruciate ligament injury incidence in adolescent athletes; A systematic review and meta-analysis.Am J Sports Med. 2021; 49: 1962-1972Google Scholar Also, for other risk factors for OA development in the knee, hip, or hand, for example, overweight/obesity or high occupational loading, different groups of individuals at risk for these risk factors can fairly easily be identified, for instance, low socioeconomic status girls/women who have an increased risk for overweight/obesity22Newton S. Braithwaite D. Akinyemiju T.F. Socio-economic status over the life course and obesity: systematic review and meta-analysis.PLoS One. 2017; 12: e0177151Google Scholar and students in training for occupations with a known risk for OA development.7Canetti E.F.D. Schram B. Orr R.M. et al.Risk factors for development of lower limb osteoarthritis in physically demanding occupations: a systematic review and meta-analysis.Appl Ergon. 2020; 86: 103097Google Scholar,14Kalichman L. Hernandez-Molina G. Hand osteoarthritis: an epidemiological perspective.Semin Arthritis Rheum. 2010; 39: 465-476Google Scholar For other OA risk factors, the identification of the right target group to prevent these risk factors might be more challenging. Local muscle weakness is a known risk factor for both knee and hand OA development.14Kalichman L. Hernandez-Molina G. Hand osteoarthritis: an epidemiological perspective.Semin Arthritis Rheum. 2010; 39: 465-476Google Scholar,23Oiestad B.E. Juhl C.B. Eitzen I. et al.Knee extensor muscle weakness is a risk factor for development of knee osteoarthritis. A systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 171-177Google Scholar Being highly modifiable, local muscle weakness could be seen as a great target for preventive interventions. However, with an average of only 1% decline in muscle mass (a proxy for muscle strength) per year from a peak between the age of 20 and 30 years,24Montero-Fernandez N. Serra-Rexach J.A. Role of exercise on sarcopenia in the elderly.Eur J Phys Rehabil Med. 2013; 49: 131-143Google Scholar identifying those at risk for local muscle weakness is challenging, as there is no threshold to define the presence of muscle weakness. Indications for a stronger decline after the age of 50 years and the strong link to physical inactivity could help to identify those at risk for local muscle weakness. One has to keep in mind that local muscle weakness could also be an early sign of OA disease and therefore not causally related to OA development. If so, targeting local muscle weakness in order to prevent OA development will be ineffective. Focusing on risk factors for OA illness, identifying individuals with overweight/obesity (for knee and hip OA illness), participating in high-impact sports (for hip OA illness), or having physically demanding jobs (for hip OA illness) seems doable.17Whittaker JL, Runhaar J, Bierma-Zeinstra MA, et al., A lifespan approach to osteoarthritis prevention. Osteoarthritis Cartilage, 2021. (in press).Google Scholar Although the presence of other OA illness risk factors such as hip shape morphology, (mild) hip dysplasia, and local muscle strength can be determined accurately and reliably, the feasibility of screening for the presence of these risk factors among subjects free of OA symptoms can be questioned. Besides the low prevalence of these risk factors in the open population, for example, 0% to 13% for cam impingement among nonselective populations,25van Klij P. Heerey J. Waarsing J.H. et al.The prevalence of Cam and Pincer morphology and its association with development of hip osteoarthritis.J Orthop Sports Phys Ther. 2018; 48: 230-238Google Scholar the exposure to radiation required for the determination of the presence of some of these risk factors should be carefully considered. Given the aging population, many studies highlight the importance of older age as a risk factor for OA development.2Hunter D.J. Bierma-Zeinstra S. Osteoarthritis.Lancet. 2019; 393: 1745-1759Google Scholar,5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar From a prevention perspective, the importance of the association between aging and OA incidence is somewhat questionable. Not only is age itself nonmodifiable, the impact on the number of years lived in good health will be less substantial when preventing OA among elderly individuals (eg, 80+ years) than among middle-aged individuals. Next to that, the exposure to/development of many risk factors for OA incidence occurs during adolescence and early adulthood (eg, joint injuries, overweight/obesity, and occupational overload). When using these risk factors to define potential target populations for preventive interventions, the optimal "window of opportunity" likely has passed at an older age. That is why experts in the field call for a lifespan approach to OA prevention (Fig. 1): prevention and treatment of risk factors for OA development at those stages of life where these risk factors are developing or amendable to treatment.17Whittaker JL, Runhaar J, Bierma-Zeinstra MA, et al., A lifespan approach to osteoarthritis prevention. Osteoarthritis Cartilage, 2021. (in press).Google Scholar Despite the fact that there are multiple known strong risk factors for OA development,6Blagojevic M. Jinks C. Jeffery A. et al.Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2010; 18: 24-33Google Scholar,7Canetti E.F.D. Schram B. Orr R.M. et al.Risk factors for development of lower limb osteoarthritis in physically demanding occupations: a systematic review and meta-analysis.Appl Ergon. 2020; 86: 103097Google Scholar,11van Buuren M.M.A. Arden N.K. Bierma-Zeinstra S.M.A. et al.Statistical shape modeling of the hip and the association with hip osteoarthritis: a systematic review.Osteoarthritis Cartilage. 2021; 29: 607-618Google Scholar,14Kalichman L. Hernandez-Molina G. Hand osteoarthritis: an epidemiological perspective.Semin Arthritis Rheum. 2010; 39: 465-476Google Scholar it is the actual combination of the prevalence of the risk factor and the strength of its association to OA development that will determine the importance of that risk factor, in the light of OA prevention. For example, knee joint injuries are one of the strongest risk factors for future knee OA development.6Blagojevic M. Jinks C. Jeffery A. et al.Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2010; 18: 24-33Google Scholar,19Poulsen E. Goncalves G.H. Bricca A. et al.Knee osteoarthritis risk is increased 4-6 fold after knee injury - a systematic review and meta-analysis.Br J Sports Med. 2019; 53: 1454-1463Google Scholar By calculating the population attributable fraction, an estimation of the proportion of new cases in the population that could be avoided if the risk factor was removed, Silverwood and colleagues showed that the number of new cases of knee OA/pain in a 3-year follow-up study of 3907 middle-aged men and women (aged 50 years and older) that could be attributed to knee injuries was only 5.1%.5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar Hence, preventing all knee injuries among these 3907 individuals would only have led to a 5.1% lower incidence of knee OA. Despite the fact that the association between overweight/obesity and knee OA development is less strong than that for knee injuries, the higher prevalence of overweight/obesity resulted in a population attributable fraction of 24.6%.5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar These results might look very promising for a preventive trial on weight loss among overweight/obese subjects free of knee OA/pain. Nevertheless, with a total incidence of knee pain of only 24% in 3 years,26Jinks C. Jordan K.P. Blagojevic M. et al.Predictors of onset and progression of knee pain in adults living in the community. A prospective study.Rheumatology (Oxford). 2008; 47: 368-374Google Scholar the actual effect of preventing all cases of overweight/obesity in the given population would result in a reduction of the total incidence of 24.6% × 24% = 6% in the first 3 years. A quick sample size calculation for a trial with 24.6% incidence in the control group and 18.6% in the intervention group would require 2 groups of 735 individuals followed-up for 3 years (α = 95%, β = 80%).27Tibrewala R. et al.Principal Component analysis of Simultaneous PET-MRI Reveals patterns of Bone-cartilage interactions in osteoarthritis.J Magn Reson Imaging. 2020; 52: 1462-1474Google Scholar The aforementioned examples illustrate the importance of the selection of target populations based on the interaction of multiple risk factors for future preventive interventions. Risk factors such as female sex/gender or genetic predisposition might not be relevant on their own for the selection of a target population for OA prevention, as these factors are nonmodifiable. However, given the known interaction between female sex/gender, knee joint injuries, and adiposity on knee OA development,28Toomey C.M. Whittaker J.L. Nettel-Aguirre A. et al.Higher Fat mass is associated with a history of knee injury in Youth sport.J Orthop Sports Phys Ther. 2017; 47: 80-87Google Scholar focusing on the prevention of weight gain among female athletes who suffered from a knee injury might provide a more feasible treatment target. Unfortunately, little is known about the interaction of risk factors for OA development and should therefore be a focus of future research initiatives.17Whittaker JL, Runhaar J, Bierma-Zeinstra MA, et al., A lifespan approach to osteoarthritis prevention. Osteoarthritis Cartilage, 2021. (in press).Google Scholar To better communicate individuals' risk for OA development and to visualize the potential of certain interventions, risk stratification tools, such as those for cardiovascular events in which multiple risk factors are incorporated, might improve the understanding among high-risk individuals and could also help to motivate them to adhere to any preventive intervention. So, for the selection of OA risk factors, either to prevent the occurrence of the risk factor or to intervene once the risk factor is present, both the prevalence of the risk factor and the strength of its association with OA development are of great importance for the relevance of the selected target population. Obviously, the next step to consider is if and when the selected risk factor is modifiable (ie, amenable to any intervention). As indicated earlier, overweight/obesity is one of the major drivers for the development of OA.5Silverwood V. Blagojevic-Bucknall M. Jinks C. et al.Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2015; 23: 507-515Google Scholar,6Blagojevic M. Jinks C. Jeffery A. et al.Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.Osteoarthritis Cartilage. 2010; 18: 24-33Google Scholar The main cause for the high prevalence of overweight/obesity worldwide is the overconsumption of processed, energy-dense food.29Swinburn B.A. Sacks G. Hall K.D. et al.The global obesity pandemic: shaped by global drivers and local environments.Lancet. 2011; 378: 804-814Google Scholar The purchase and consumption of food are influenced by the interaction of pricing, palatability, and cultural and ethnic habits.30Seidell J.C. Halberstadt J. The global burden of obesity and the challenges of prevention.Ann Nutr Metab. 2015; 66: 7-12Google Scholar Given these complex interactions, designing interventions that prevent overweight/obesity is very challenging. Despite the multidisciplinary nature of primary care, which is generally seen as the optimal setting for targeting the prevention of overweight/obesity, there is little to no evidence for effective interventions.31Peirson L. Douketis J. Ciliska D. et al.Prevention of overweight and obesity in adult populations: a systematic review.CMAJ Open. 2014; 2: E268-E272Google Scholar Given the potential of population-based approaches and effective examples from these kinds of approaches on, for example, smoking and alcohol usage,32Capewell S. Dowrick C. Healthful Diet and physical activity for cardiovascular disease prevention in adults without known risk factors: is behavioral Counselling Necessary?.JAMA Intern Med. 2017; 177: 1254-1255Google Scholar already in 2007, there was a call from the World Health Organization for more upstream interventions by countries to "develop its own needs-driven portfolio of appropriate and realistic interventions, and involve many stakeholders from all relevant sectors in a transparent and explicit process."33Organisation, W.H., The challenge of obesity in the WHO European Region and the strategies for response, F. Branca, H. Nikogosian, and T. Lobstein, Editors. 2007.Google Scholar Unfortunately, nowadays implementation of such strategies is limited.34Seidell J.C. Halberstadt J. Noordam H. et al.An integrated health care standard for the management and prevention of obesity in The Netherlands.Fam Pract. 2012; 29: i153-i156Google Scholar The initiatives for the prevention of joint injuries illustrate another major challenge when designing a preventive intervention, namely adherence/uptake. There is sufficient high-quality evidence available showing that injury prevention programs (ie, plyometrics, strengthening, and agility exercises) are effective in the prevention of anterior cruciate ligament injuries.35Huang Y.L. Jung J. Mulligan C.M.S. et al.A Majority of anterior cruciate ligament injuries can Be prevented by injury prevention programs: a systematic review of randomized controlled trials and Cluster-randomized controlled trials with meta-analysis.Am J Sports Med. 2020; 48: 1505-1515Google Scholar Nevertheless, implementation of these programs into real-world settings is a major challenge, as adherence to these programs in the real world is generally very low.36Owoeye O.B.A. McKay C.D. Verhagen E. et al.Advancing adherence research in sport injury prevention.Br J Sports Med. 2018; 52: 1078-1079Google Scholar This observation closely relates to a broader challenge for preventive therapies, as "there is no glory in prevention." To further OA prevention, we need to align our efforts and knowledge with experts from behavioral research. How can we motivate individuals at risk for OA risk factors to modify their lifestyle, if there is no positive feedback from that actual intervention? After all, these individuals do not have any joint symptoms, so they cannot experience any relief of symptoms to keep them motivated to adhere to an intervention. Are individuals at risk for OA risk factors willing to consider medical interventions or should we aim for nonpharmacologic interventions only? How should we educate these individuals regarding their future risk of OA in order to motivate them to get into action, rather than demoralizing them by presenting a future with a chronic condition? These questions highlight some of the current knowledge gaps in OA prevention. When designing a preventive intervention, the presence of a (modifiable) risk factor for OA might help to overcome the lack of motivation for preventive measures among the target population. For instance, among those with overweight/obesity, tracking the body weight over time to illustrate their weight loss will provide participants with a measure of their progress during the intervention. Still, we know that achieving sustainable lifestyle changes among subjects with overweight/obesity is very hard, and adherence to these interventions remains a challenge.37Runhaar J. de Vos B.C. van Middelkoop M. et al.Prevention of incident knee osteoarthritis by moderate weight loss in overweight and obese females.Arthritis Care Res (Hoboken). 2016; 68: 1428-1433Google Scholar, 38Runhaar J. van Middelkoop M. Reijman M. et al.Prevention of knee osteoarthritis in overweight females: the first preventive randomized controlled trial in osteoarthritis.Am J Med. 2015; 128: 888-895 e4Google Scholar, 39Kohl 3rd, H.W. Craig C.L. Lambert E.V. et al.The pandemic of physical inactivity: global action for public health.Lancet. 2012; 380: 294-305Google Scholar Similarly, targeting individuals with a history of joint trauma might facilitate the willingness for preventive interventions, as these individuals have a strong preference to keep physically active but also often fear for a reinjury.40Filbay S.R. Crossley K.M. Ackerman I.N. Activity preferences, lifestyle modifications and re-injury fears influence longer-term quality of life in people with knee symptoms following anterior cruciate ligament reconstruction: a qualitative study.J Phys. 2016; 62: 103-110Google Scholar Unfortunately, little is known about the mechanisms through which joint injuries lead to the early onset of OA.41Whittaker J.L. Roos E.M. A pragmatic approach to prevent post-traumatic osteoarthritis after sport or exercise-related joint injury.Best Pract Res Clin Rheumatol. 2019; 33: 158-171Google Scholar,42Kramer W.C. Hendricks K.J. Wang J. Pathogenetic mechanisms of posttraumatic osteoarthritis: opportunities for early intervention.Int J Clin Exp Med. 2011; 4: 285-298Google Scholar A recently developed framework for an intervention for managing knee OA risk factors after ACL injuries does show that the first steps toward OA prevention after knee joint injuries are currently being taken.43Davies AM, Wong R, Steinhart K, et al., Development of an Intervention to Manage Knee Osteoarthritis Risk and Symptoms Following Anterior Cruciate Ligament Injury. Osteoarthritis Cartilage, 2021. (in press).Google Scholar The presence of an OA risk factor does not always facilitate the process of OA prevention. Participating in high-impact sports puts individuals at risk for hip OA development, and high occupational loading is known to increase the risk for hand and hip OA. Nevertheless, targeting these risk factors to prevent the subsequent onset of OA will be challenging. How to motivate athletes to change the sport they participate in toward one with less/no risk for OA development? Also, most employees with high occupational loadings will require retraining in order to take on new jobs, are likely to have a preference for their current job, and might lack a track-record to be competitive when applying for another and less burdensome job. Given the lack of preventive trials in OA research, the selection of effective interventions for the prevention of OA is very hard.3Runhaar J. Zhang Y. Can we prevent OA? Epidemiology and public health insights and implications
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