1 INTRODUCTION Osteoarthritis (OA) once considered a consequence of aging; OA could be found in moving joints, especialy affect the large weight-bearing joints such as the knee, hip and spine When OA with clinical symptoms, such as pain, physical disability and limiting daily activities, which makes the patients have to see a doctor regularly and be treated Therefore, this affects the quality of their life and causes economically costly According to a survey conducted in USA, more than 80% of over 55 year-old people show signs of OA on X-ray, in which 10 - 20% of people have limited mobility Especially, a few hundred thousands of the people are not self-serviced due to hip OA and the cost of treating one patient with drugs was amounted to USD 141.98 in 30 days In France, OA accounts for about 28.6% of the musculoskeletal disorder, each year about 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 more elderly people are the more severe disease are This disease does not directly threaten to the patients’ life so patients and the community has not paid adequate attention to it, especially manual labors in rural areas If this disease is detected and treated late, the result of treatment is not effective as expected, associated with leaving jobs, reducing labor productivity and limit daily activities, even leading to lifelong disability Therefore, the role of community health workers is very important in the early detection, proper treatment and counseling for the people In Vietnam, there have been research works on the clinical characteristics and treatments on knee OA in a number of hospitals, but epidemiological assessment of knee osteoarthritis and diagnose as well as treatments and counseling for knee OA patients in the community still received 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 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 Assess on the effectiveness of intervention model to improve diagnosis and management capabilities of knee OA of community health workers in Hai Duong province NEW CONTRIBUTIONS OTHE THESIS Describe the real situation of knee OA in people aged 40 above from 02 communes in Gia Loc district, Hai Duong province Assess on the effectiveness of intervention models to improve diagnostic and management capabilities of knee OA by community health workers in Hai Duong province THESIS STRUCTURE This thesis is 137 pages thick excluding appendices, including chapters, 35 tables, 10 charts, 191 references in domestic and abroad The outline of the thesis consists of Introduction (2 pages), overview (48 pages), materials and research methodology (16 pages), results (34 pages), discussion (page 34), conclusions (2 pages) and recommendations (1 page) and articles related to the thesis published CHAPTER 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 the bottom loop under the tibia tuberosity Knee is divided into two areas by the 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, and patella with the face of patella of femur This is a complex joint with very wide synovial fluid, easily swollen and distended Knee joints in prone 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 the epicoldyle of femur, tibia, and the back patella Articular cartilage with physiological functions is to protect the epiphyseal of the bones and spread out the weight bearing on the entire joint surface Normally, articular cartilage is glossy, wet, very hard and strong elastic The articular cartilage ensures sliding motion among the articular surfaces occurring with a very low coefficient of friction, as a buffer layer helps to reduce compression Articular cartilage has no blood vessels and nerves The basic composition comprises the cartilage cells, collagen fibers and basic chemicals, and arranged and form different layers 1.2 Osteoarthritis 1.2.1 Definition Osteoarthritis is the dysfunction of articular cartilage, the main manifestation of this disease is the phenomenon of wear and tear of articular cartilage in relation to minimizing the mechanical operation of the joint OA is the result of the mechanical and biological proccess, which causes the imbalance between synthesis and destruction of cartilage and subchondral bone (the spine and intervertebral discs) 1.2.2 Epidemiology of osteoarthritis Osteoarthritis is a common musculoskeletal disease Among the elderly, knee OA is a leading cause of chronic disability in the developed countries Several hundred thousand people in the U.S are unable to walk independently from bed to the bathroom because of knee or hip OA Under the age of 55, the distribution of this disease in men and women 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 yellow discoloration, dull, dry, soft, loss of smoothness, elastic reduction, thinness and cracks Initial cartilage damage is small cracked areas; the cracks can be column form, gray and grainy The damage will spread and deepen over time This situation progresses down deeply and spreads vertically and in some cases, some cracks will spread to the subchondral bones There may be ulcers; loss of cartilage exposes the subchondral bone Besides the cracks of the surface cartilage, articular cartilages in older adults become thinner than articular cartilage in children and adolescents  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 by macrophages cells, so it promotes inflammation proccess - Stage III: widespread inflammatory process, because the synovial membrane cells afected to release protease and cytokines, that promote catabolism 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 a rest, 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 the patella slots - pulley, - ball pulley; signs of wood shavings; bony enlargement 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, mobility maintaining, minimizing the disability  Medical treatments: - Using of non-pharmacological methods, avoiding the overloading for the knee joint due to movement and weight - Pain relievers and anti-inflammatory drugs, such as acetaminophen, non-steroid anti-inflammatory drugs and corticosteroids (intra joint injections) - Supplement, including Glucosamine Sulfate, Chondroitin Sulfate, etc - IL inhibitor, such as artrodar; - Stem cell therapies  Surgical treatments: - Treatment under arthroscopy - Wedge approach to joint, bone chisels - Joint replacement surgery or arthroplasty 1.3 Factors related to osteoarthritis Degradation of articular cartilage and intervertebral discs is due to many causes, which are mostly aging and mechanical factors to promote the accelerated degradation, mechanical factors that increase downforce on a surface area of joints and intervertebral discs are also called overloading phenomenon The mechanical factors including congenital malformations, deformations, trauma, increasing body weight, increasing payload 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 The nearest and most accessible health care services are CHCs The strengthening activities as well as improving the quality of medical facilities, especially CHCs are necessary to improve people's access to health facilities and ensure equity in health care for all citizens However, primary medical activities have not currently been comprehensive, the quality of health care at community health centers have not improved remarkably The attractiveness of the CHCs in health care is low; people 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 when they are ill, is very low despite a large team of health workers The situations about the capacity of the health workers is still a matter needed to be concerned Most medical workers in CHCs are still lack of knowledge and skills, especially the ability to examine and detect common 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 of people in Vietnam, musculoskeletal diseases, especially knee OA is common, the more elderly people are the more severe the diseases are After the age of 40-50, manifestation of the disease may appear, and women easily get down this disease twice as often as men If being detected and treated late, the treating effect is not as expected It is associated with leaving jobs, reducing labor productivity and limit daily activities, even to lifelong disability Therefore, the role of health workers at the grassroots levels is vital in the early detection, proper treatment and counseling for people Whether medical workers have sufficient knowledge, detection skills, diagnosis and early treatment for knee OA in the community or not is an issue that needs to be addressed According to a survey in Malaysia, most primary doctors order unnecessary tests for the diagnosis of OA X-ray images can help in the diagnosis and severity of illness, but not always parallel with the clinical manifestations, in some cases people with X-ray evident of OA but no clinical symptoms In the diagnosis proccess to identify OA, blood tests are not worthy much, however, more than 50% of physicians at CHCs ordered to specify blood tests, such as rheumatoid factor, uric acid, ANA, etc to diagnose the OA This can easily lead to misdiagnosis as rheumatoid arthritis or lupus if the RF tests or antinuclear antibodies (ANA) are positive Therefore, the authors strongly recommends that training for primary care physicians focus on the diagnosis and management of OA, and paying more attention to the musculoskeletal disorder in the training program at university and guiding OA management for primary care physicians CHAPTER 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 Duong province - For objective 2: Medical doctors and assistant physicians are working in 263 CHCs in Hai Duong province 2.2 Methods: 2.2.1 Design of study: - Cross-sectional study: to determine the incidence, clinical symptoms, X-ray of the knee osteoarthritis and some related factors in 02 communes of Gia Loc district, Hai Duong province Besides, we initial commented on the diagnosis and management of knee osteoarthritis in the community - Intervention study: basing on cross-sectional study results, implementing interventions and evaluating its effectiveness for community health workers is to improve knowledge on diagnosis, treatment and counseling for the knee OA patients, which also contributes 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, Xray and a number of related factors to the knee OA in people aged 40 years or older in 02 communes of Gia Loc district, Hai Duong province, applying the formula of the sample size for cross-sectional descriptive study: Z12−α / pq n= x2 ( εp ) n: number of individuals in the study sample p: estimated propotion of OA (p = 0.3 estimated by the study of Nguyen Thi Nga) q: the offset to of p (q = - p) Z1- α/2: Critical values of the standard distribution, apply to the significance level In this study α = 0.05 → Z1- α/2 = 1.96 εp: relative accuracy (ε: relative accuracy coefficient = 0.1) Applying the formula above, the sample size for the random sample, 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 communes is 2153 We investigate 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 and assistant physicians): selecting all the medical doctors and assistant physicians 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 had participated in cross-sectional study 2.2.3 Intervention Providing the training programme for health workers about knee OA, focusing on the diagnosis, treatment and counseling for the knee OA patients by musculoskeletal specialist doctor of Bach Mai Hospital 2.2.4 Data collecting techniques - Questionnaire designing - Training collaborators to data collecting information by rheumatology specialtist doctor of Bach Mai Hospital - Conducting a pilot survey and completing questionnaires - Data Collecting 2.2.5 Data analysis: Data was processed and analysed by SPSS program 7.5 The research results are calculated and presented in numbers and percentage (for qualitative variables), the average value (for quantitative variables) Comparison was done before and after the intervention by statistical hypothesis testing (p value) and considers the magnitude of the efective indicators 2.3 Research Ethics: The proposal must be approved and decided by the commitee of Hanoi Medical University and Ministry of Education and Training CHAPTER 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 27,1% 72,9% Knee OA Non Knee OA 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%) Figure 3.2: Site of knee OA Comments: Of the 584 participants with knee OA, there were 78.9% painful in both knee joints, while the number of patients suffering pain in one knee joint accounted for 21.1% Table 3.1: Relationship between knee OA and age groups Knee OA based Not enough on physical symptoms of knee Total Age group examination OA on physical findings examination n % n % n % 40 - 49 103 16,7 513 83,3 616 100 50 - 59 161 26,9 438 73,1 599 100 60 - 69 133 33,2 268 66,8 401 100 ≥ 70 187 34,8 350 65,2 537 100 p